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Primary pancreatic lymphoma (PPL) represents less than 0.5% of all pancreatic neoplasms. Clinical manifestations are non-specific and diagnosis is delayed in the majority of patients.85-year-old woman reporting accidental fall at home 20-days earlier, was admitted with diagnosed of acute abdomen from suspected two-stage rupture of the spleen. The patient complained of pain in the upper abdomen. Blood-chemical tests did not show anemia and leukocytosis, but showed increased CA19.9, CA125, LDH and beta2- microglobulin. Contrast-enhanced CT showed left pleural, perisplenic, perihepatic, and Douglas blood effusion, a neoformation of the body-tail of the pancreas with peri-pancreatic blood layer, splenomegaly due to the presence of a hypodense area as from intraparenchymal hematoma, with an apparently undamaged splenic capsule. The patient underwent emergency exploratory laparotomy, that revealed the presence of modest free serohematic effusion from oozing of the pancreatic neoformation. The local spread of the disease prevented any attempt at surgical resection. Bleeding was checked with the addition of topical hemostats (Tabotamp®) and biopsy sampling of the pancreatic mass was performed. A final histological diagnosis of large cell NHL of centro-follicular origin, double expressor for the CMYC and BCL2 protein, was achieved. The age of the patient, the poor general conditions, the associated pathologies, the locally advanced spread of the disease and the histological aggressiveness, were contraindications to chemo-radiotherapy treatments.The initial misdiagnosis was due to the history of recent trauma, the uncommon clinical presentation, the underestimation of the serum increase in markers and the interpretation of the CT.Acute Abdomen, Hemoperitoneum, Primary Pancreatic Lymphoma.Il linfoma pancreatico primitivo (PPL) rappresenta meno dello 0.5% di tutte le neoplasie pancreatiche. Le manifestazioni cliniche di esordio non sono specifiche e la diagnosi è tardiva nella maggioranza dei pazienti. OSSERVAZIONE PERSONALE: Donna di 85 anni, ricoverata presso l’Ospedale Universitario “A. Fiorini” di Terracina- Polo Pontino, con diagnosi di addome acuto da sospetta rottura in due tempi della milza. Al ricovero la pz lamentava dolore a carico dei quadranti addominali superiori e riferiva caduta accidentale in casa avvenuta 20 giorni prima. Presentava esami ematochimici negativi per anemia e leucocitosi (Hb12.7g/dl; GB9.8x10/UL), significativo incremento del CA19.9 (196 U/ml), del CA125 (138 U/ml), delle LDH (1044 U/L) e della beta2-microglobulina. La CT torace-addome-pelvi con mdc mostrava versamento a densità ematica in sede pleurica sinistra, perisplenica, periepatica e nel Douglas e una neoformazione del corpo-coda pancreas con falda ematica peripancreatica. La milza appariva di dimensioni notevolmente aumentate, con presenza di area ipodensa di 12.5x10.6 cm di diametro come da ematoma intraparenchimale, con capsula splenica apparentemente indenne. La pz veniva sottoposta a laparotomia esplorativa urgente per sospetto emoperitoneo. All’apertura della cavità peritoneale si dimostrava la presenza di modesto versamento libero sieroematico da stillicidio della neoformazione pancreatica. La diffusione locale della malattia impediva ogni tentativo di resezione chirurgica. Si procedeva a controllo del sanguinamento con apposizione di emostatici topici (Tabotamp®) e a prelievo bioptico dalla neoformazione pancreatica. Si poneva diagnosi istologica finale di Linfoma Non-Hodgkin a grandi cellule di origine centro- follicolare, doppio espressore per la proteina CMYC e BCL2 all’immunoistochimica. L’età della pz, le scadenti condizioni generali, le patologie associate in trattamento poli-farmacologico, la diffusione localmente avanzata della malattia e l’aggressività istologica controindicavano il trattamento chemioradioterapico. CONCLUSIONE: La diagnosi di PPL è molto difficile e tardiva nella maggioranza dei pz, poichè le manifestazioni cliniche di esordio sono di solito aspecifiche; così come nel caso da noi riportato in cui il sanguinamento intraretro- peritoneale era difficilmente riconducibile ad una malattia pancreatica. I riferito trauma addominale, la sintomatologia clinica aspecifica, la CT in cui non erano state evidenziate le alterazioni caratteristiche dei linfomi extranodali, la sottovalutazione dell’aumento dei livelli plasmatici dei marcatori CA19-9 e CA125, delle LDH e della beta2- microglobulina, sono state nel nostro caso la causa di errata diagnosi e indicazione al trattamento chirurgico in urgenza.

Background and Aims: The Diverticular Inflammation and Complication Assessment (DICA) endoscopic classification of diverticulosis and diverticular disease (DD) is currently available. It scores severity of the disease as DICA 1, DICA 2 and DICA 3. Our aim was to assess the agreement on this classification in an international endoscopists community setting. Methods: A total of 96 doctors (82.9% endoscopists) independently scored a set of DD endoscopic videos. The percentages of overall agreement on DICA score and a free-marginal multirater kappa (κ) coefficient were reported as statistical measures of interrater agreement. Results: Overall agreement in using DICA was 91.8% with a free-marginal kappa of 88% (95% CI 80-95). The overall agreement levels were: DICA 1, 85.2%; DICA 2, 96.5%; DICA 3, 99.5%. The free marginal κ was: DICA 1 = 0.753, DICA 2 = 0.958, DICA 3 = 0.919. The agreement about the main endoscopic items was 83.4% (k 67%) for diverticular extension, 62.6% (k 65%) for number of diverticula for each district, 86.8% (k 82%) for presence of inflammation, and 98.5 (k 98%) for presence of complications. Conclusions: The overall interrater agreement in this study ranges from good to very good. DICA score is a simple and reproducible endoscopic scoring system for diverticulosis and DD.

Pancreatic neuroendocrine tumors (PNETs) are uncommon, representing5% of all pancreatic neoplasms, divided into functioning PNETs with secreted hormone cause of specific symptoms, and non-functioning PNETs (nf- PNETs) characterized by delayed diagnosis with metastases and clinical manifestations of compressive effects. Surgical approach is recommended for functioning and nf-PNETs2 cm in diameter.A 76-year-old woman was admitted to the UOC-University-Surgery Hospital "A. Fiorini" in Terracina for nausea and pain in the upper abdominal quadrants with dorso-lumbar irradiation, arising after the evening meal. After the haematochemistry tests and the instrumental investigations, the diagnosis of acute, severe halitiasic pancreatitis was made. Conventional US, CCT, CE-MRI and EUS showed a 2.8cm diameter lesion in the head-body junction of the pancreas. FNA-cytological examination did not found the presence of atypical pancreatic cells. Total-body scintigraphy with Octreoscan® documented a pathological hypercaptation area located in correspondence with the neoformation. The patient underwent a body-tail spleno-pancreatectomy. The histological examination showed an intermediate grade (G2) nf-PNET infiltrating the lienal vein and stenosing the Wirsung duct, with perilesional pancreatitis. Immunohistochemistry showed CAM 5.2, Synaptophysin (95%) and Chromogranin (60%) positive immunophenotype, with negative intratumoral Somatostatin expression.Although rarely, nf-PNETS may be the cause of severe non-biliary acute pancreatitis from pancreatic ductal system compression. In cases where PET/CT68Ga cannot be performed, total-body scintigraphy with Octreoscan® remains the most widely used method for the diagnosis of PNETs and the identification of extra-pancreatic lesions. Chromogranin and Synaptophysin are confirmed as specific markers of neuroendocrine differentiation.Acute pancreatitis, Chromogranin, Pancreatic neuroendocrine tumor, Synaptophysin, Somatostatin.I tumori neuroendocrini del pancreas (PNET) sono rari, e rappresentano5% di tutte le neoplasie pancreatiche, suddivisi in PNET funzionanti con secrezione ormonale responsabile di sintomi specifici e PNET non funzionanti (nf-PNET) generalmente di diagnosi tardiva per la comparsa di metastasi o manifestazioni cliniche per effetti compressivi. L’approccio chirurgico è il trattamento di scelta per PNETs funzionanti, non-funzionanti di diametro superiore a 2 cm o sintomatici per disturbi da compressione. Osservazione personale. Donna di 76 anni ricoverata presso la UOC-Università-Chirurgia Ospedale “A. Fiorini” di Terracina per nausea e dolore ai quadranti addominali superiori con irradiazione dorso-lombare, insorti dopo un pasto serale. Dopo gli esami ematochimici e le indagini strumentali, è stata fatta la diagnosi di pancreatite acuta severa. Gli US convenzionali, CCT, CE-MRI ed EUS hanno mostrato una lesione di 2,8 cm di diametro nella giunzione testa-corpo del pancreas. L’esame citologico FNA non ha rilevato la presenza di cellule pancreatiche atipiche. La scintigrafia total body con Octreoscan® ha documentato un’area di ipercaptazione patologica situata in corrispondenza della neoformazione. La paziente è stata sottoposta a spleno-pancreasectomia corpo-coda. L’esame istologico ha dimostrato un nf-PNET di grado intermedio (G2) stenosante il vena lienale e stenosante il dotto di Wirsung, con pancreatite perilesionale. L’immunoistochimica ha mostrato un immunofenotipo positivo per CAM5.2, sinaptofisina (95%) e cromogranina (60%), con espressione di somatostatina intratumorale negativa. CONCLUSIONE: Sebbene raramente un nf-PNETS può essere la causa di grave pancreatite acuta non biliare da compressione del sistema duttale pancreatico. Nei casi in cui la PET / CT68Ga non può essere eseguita, la scintigrafia total body con Octreoscan® rimane il metodo più utilizzato per la diagnosi dei PNET e l’identificazione delle eventuali lesioni extra-pancreatiche. La cromogranina e la sinaptofisina sono confermate come marcatori specifici del differenziamento neuroendocrino.

Challenges in the diagnosis of polypoid gallbladder lesion (PLG) is due to the low sensibility (SE) of ultrasound scan (US), and the selection criteria of patients with PLG to be addressed to surgical treatment or followup are not yet fully defined.Retrospective observational study was conducted on 2631 patients, 1175(44.6%) M, mean age 56 years, 1456(55.4%) F, mean age 46 years, who underwent laparoscopic and open cholecystectomy.The US diagnosis for PLG was placed in 38/2631(1.4%) patients. On histological examination (HE) the polyps were identified in 68/2631(2.6%) patients and it was associated with biliary lithiasis in 28/2631 (1.1%) cases. From the US and HE comparison, the ultrasound diagnosis was burdened by false positives (8/38; 21%) and false negatives (38/2631;1.45%), with SE 44% (95% c.i.:32.2-55.7). The histological incidence of gall bladder cancer (GBC) was 0.38%(10/2631).US survey underestimated the incidence of PLG compared to the histological finding (p=0.021). Female gender has been shown to be a specific risk factor for benign and malignant PLG and non-polypoid mucosal lesions (p=0.041). The parietal lesion size0.5cm does not exclude the neoplastic nature. Currently the prevention and diagnosis of GBC is based on the early detection and treatment of potentially evolutionary polypoid lesions over a period of about 15 years.It is probably that early cholecystectomy in all the patients with PLG of diameter1cm, isolated or associated with lithiasis, symptomatic and asymptomatic, can contribute to the reduction of the incidence of GBC.Cholecystectomy, Gallbladder polyps, Gallbladder cancer, Ultrasound scan.La diagnosi ultrasonografica (US) delle lesioni polipoidi della colecisti (PLG) è difficile per la bassa sensibilità (SE) della metodica. Non sono stati ancora completamenti definiti i criteri di selezione dei pazienti con PLG da indirizzare al trattamento chirurgico o al follow-up. L’indagine istopatologica (EI) rappresenta il gold standard per la diagnosi di polipi non-neoplastici (colesterolotici, infiammatori, fibroepiteliali, adenomiomatosici), di polipi neoplastici (carcinomi, carcinoidi), di lesioni precancerose non polipoidi (displasia di basso ed alto grado, metaplasia intestinale di tipo muciparo, metaplasia gastrica di tipo pilorico) e di irregolarità nodulari parietali della colecistite xanto-granulomatosa. Gli scopi dello studio sono stati quelli di valutare in un campione di pazienti sottoposti a colecistectomia, la prevalenza dei polipi non neoplastici e neoplastici e la sensibilità dell’US tradizionale trans-addominale rispetto all’EI nell’identificazione delle PLG.Studio osservazionale retrospettivo, condotto su un campione di 2631 pazienti, sottoposti a colecistectomia laparoscopica e open, in elezione e in urgenza, identificati mediante il codice ICD-9-CM 51.2, nel periodo Aprile 2005 - Marzo 2018, presso l’ospedale universitario “A. Fiorini” di Terracina - Polo Pontino, “Sapienza” Università di Roma. Tutti i pazienti erano stati sottoposti a US.Il campione esaminato era costituito da 1175(44.6%) M, età media 56 anni, range 25-95 anni, 1456(55.4%) F, età media 46anni, range 17-90 anni. La diagnosi US di PLG veniva posta in 38/2631(1.4%) pazienti. All’esame istologico i polipi erano identificati in 68/2631(2.6%) pazienti, associati a litiasi biliare in 28/2631 (1.1%) casi. Dal confronto US e EI la diagnosi ecografica risultava gravata da falsi positivi (FP) (8/38; 21%) e falsi negativi (FN) (38/2631; 1.45%), con SE 44% (95% c.i.:32.2-55.7). L’incidenza istologica di PLG neoplastiche è stata dello 0.38% (10/2631), 3M e 7F, età media 64 anni, (range 49-80 anni). In 3 casi le neoplasie erano state identificate all’US (3/10; 30 % VP); nei restanti 7 casi costituivano reperto istologico incidentale (7/10; 70 % FN), di cui 5 con diametro1cm nel contesto di un quadro clinico di colecistite acuta litiasica e 2 con diametro1cm in un quadro di litiasi non complicata.L’US tradizionale trans-addominale sottostimava l’incidenza delle PLG rispetto all’EI (p=0.021) e i FP per PLG isolate sono stati causa di errata indicazione al trattamento chirurgico. Il confronto fra diagnosi US ed EI conferma la bassa SE della metodica ecografica nell’identificazione delle PLG, sia in presenza che in assenza di litiasi biliare. Il sesso femminile si è dimostrato specifico fattore di rischio per PLG benigne e maligne e lesioni mucosali non polipoidi (p=0.041). Nel nostro studio, probabilmente, le cause della mancata identificazione US delle irregolarità parietali maligne erano l’oscuramento della lesione dall’esordio clinico della neoplasia in colecistite acuta litiasica (in 5 pazienti) e le dimensioni1cm in presenza di litiasi non complicata (in 2 pazienti). La dimensione della lesione parietale0.5cm non escludeva la loro natura neoplastica. Attualmente la prevenzione e la diagnosi di GBC è basata sul precoce riscontro e trattamento delle lesioni polipoidi potenzialmente evolutive nell’arco di circa 15 anni.Probabilmente la colecistectomia precoce in tutti i pz con PLG di diametro1cm, isolate o associate a calcoli, sintomatici e asintomatici, può contribuire alla riduzione dell’incidenza del GBC.

Purpose: Ovarian cancer is the eighth most common malignancy among women and has a high mortality rate. Prognostic factors able to drive an effective therapy are essential. 18F-Fluoro-2-deoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) has been investigated in patients with epithelial ovarian cancer and showed promise in diagnosing, staging, detecting recurrent lesions and monitoring treatment response. Conversely, its prognostic role remains unclear. We aimed at assessing the prognostic value of 18F-FDG PET/CT performed in the restaging process in a multicentre study. Methods: We evaluated 168 patients affected by ovarian carcinoma, who underwent a restaging 18F-FDG PET/CT. The presence of local recurrences, lymph node involvement and distant metastasis was recorded as well as lesion dimensions, maximum and mean standardized uptake values (SUVmax and SUVmean, respectively). Progression-free survival (PFS) and overall survival (OS) at 3 and 4Âyears were computed by using Kaplan-Meier curves. Increased odds ratio was assessed using Cox regression analysis testing all lesion parameters measured by PET/CT. Results: PFS was significantly longer in patients with a negative than a positive restaging PET/CT study (3- and 4-year PFS 64 and 53Â% vs 23 and 12Â%, respectively; p < 0.001). Similarly, a negative study was associated with a significantly higher OS rate after 4Âyears of follow-up (67 vs 25Â% in negative and positive groups, respectively; p < 0.001). Lymph node or distant involvement were also independently associated with an increased risk of disease progression [hazard ratio (HR) 1.6 and 2.2, respectively; p = 0.003]. Moreover, PET/CT showed an incremental prognostic value compared to the International Federation of Gynecology and Obstetrics (FIGO) staging system. In the analysis of patient subsets, individuals with the same FIGO stage I–II but with negative PET had a significantly better 4-year OS than patients with low FIGO stage but positive PET. This implies that patients with the same FIGO stage can be further prognostically stratified using PET (p = 0.01). At receiver-operating characteristic (ROC) analysis, no thresholds for semiquantitative parameters were predictive of a worse outcome. Conclusion: 18F-FDG PET/CT has an important prognostic value in assessing the risk of disease progression and mortality rate. An efficacious therapy planning might therefore effectively rely on 18F-FDG PET/CT findings. Semiquantitative data were not proven to be an effective tool to predict disease progression.

Our aims were to assess the real life effectiveness and safety of the new bismuth-containing quadruple therapy in a large population of patients infected by Helicobacter pylori.Consecutive dyspeptic H. pylori-positive patients were enrolled, both naïve for treatment and already unsuccessfully treated. Patients were treated with Pylera® 3 capsules 4 times/daily plus omeprazole 20 mg or esomeprazole 40 mg 2 times/daily for 10 days. Eradication was confirmed using a urea-breath test (at least 30 days after the end of the treatment). Efficacy and safety were assessed.A total of 349 patients were treated. H. pylori eradication was achieved in 316 (90.5%, 95% CIs 80.8-1.0) patients in the intention-to-treat population, and in 93.5% (95% CIs 83.5-1.0) in the per-protocol population. No difference in the eradication rate was found between naïve and previously treated patients (91.3 vs. 90.0%, p = 0.901). Adverse events occurred in 55 patients (15.8%, 95% CIs 11.9-20.1). Five patients discontinued treatment: 2 patients suffered from severe abdominal pain, one patient from headache, one patient from diarrhea, and one patient from diffuse urticarial rush.Pylera® achieved a remarkable eradication rate in real life both as first treatment and as a rescue therapy, with a good safety profile.

Aim. Aim of the study was to quantify the economic impact of PET/CT and contrast enhanced (c.e.) CT performed in a single session examination vs. stand-alone modalities in oncological patients. Methods. One-hundred-forty-five cancer patients referred to both PET/CT and c.e. CT, to either stage (N.=46) or re-stage (N.=99) the disease, were included. Seventy-two/145 performed both studies in a single session (innovative method) and 73/145 in two different sessions (traditional method). The cost-minimization analysis was performed by evaluating: 1) institutional costs, data obtained by hospital accountability (staff, medical materials, equipment maintenance and depreciation, departments utilities); 2) patients costs, data obtained by a specific survey provided to patients (travel, food, accommodation costs, productivity loss). Results. Economic data analysis showed that the costs for innovative method was lower than those of traditional method, both for Institution (106 (sic) less per test) and for patient (21 (sic) less per patient). The loss of productivity for patient and caregivers resulted lower for the innovative method than the traditional method (3 work-hour less per person). Conclusion. PET/CT and c.e. CT performed in a single session is more cost-effective than stand-alone modalities, by reducing both Institutional and patients costs. These advantages are mainly due to lower Institutional cost (single procedure) and to lower cost related to travel and housing.

Purpose: The aim of this work was the assessment of the physical performance of the new hybrid PETCT system: Discovery-690. Methods: The Discovery-690 combines a lutetium-yttrium-orthosilicate (LYSO) block detector designed PET tomograph with a 64-slice CT scanner. The system is further characterized by a dedicated powerful computing platform implementing fully 3D-PET iterative reconstruction algorithms. These algorithms can account for time of flight (TOF) information andor a 3D model of the PET point spread function (PSF). PET physical performance was measured following NEMA NU-2-2007 procedures. Furthermore, specific tests were used: (i) to measure the energy and timing resolution of the PET system and (ii) to evaluate image quality, by using phantoms representing different clinical conditions (e.g., brain and whole body). Data processing and reconstructions were performed as required by standard procedures. Further reconstructions were carried out to evaluate the performance of the new reconstruction algorithms. In particular, four algorithms were considered for the reconstruction of the PET data: (i) HD = standard configuration, without TOF and PSF, (ii) TOF = HD + TOF, (iii) PSF = HD + PSF, and (iv) TOFPSF = HD+TOF+PSF. Results: The transverse (axial) spatial resolution values were 4.70 (4.74) mm and 5.06 (5.55) mm at 1 cm and 10 cm off axis, respectively. Sensitivity (average between 0 and 10 cm) was 7.5 cpskBq. The noise equivalent count rate (NECR) peak was 139.1 kcps at 29.0 kBqml. The scatter fraction at the NECR peak was 37%. The correction accuracy for the dead time losses and random event counts had a maximum absolute error below the NECR peak of 2.09%. The average energy and timing resolution were 12.4% and 544.3 ps, respectively. PET image quality was evaluated with the NEMA IEC Body phantom by using four reconstruction algorithms (HD, TOF, PSF, and TOFPSF), as previously described. The hot contrast (after 3 iterations and for a lesionbackground activity ratio of 4:1) for the spheres of 10, 13, 17, and 22 mm was (HD) 29.8, 45.4, 55.4, and 68.1%; (TOF) 39.9, 53.5, 62.7, and 72.2%; (PSF) 28.3, 47.3, 60.4, and 71.8%; (TOFPSF) 43.8, 62.9, 70.6, and 76.4%. The cold contrast for the spheres of 28 and 37 mm was (HD) 62.4 and 65.2%; (TOF) 77.1 and 81.4%; (PSF) 62.0 and 65.2%; (TOFPSF) 77.3 and 81.6%. Similar hot and cold contrast trends were found during the analyses of other phantoms representing different clinical conditions (brain and whole body). Nevertheless, the authors observed a predominant role of either TOF or PSF, depending on the specific characteristics and dimensions of the phantoms. Conclusions: Discovery-690 shows very good PET physical performance for all the standard NEMA NU-2-2007 measurements. Furthermore, the new reconstruction algorithms available for PET data (TOF and PSF) allow further improvements of the D-690 image quality performance both qualitatively and quantitatively. © 2011 American Association of Physicists in Medicine.

Purpose: To describe the degradation effects produced by respiratory organ and lesion motion on PET/CT images and to define the role of respiratory gated (RG) 4D-PET/CT techniques to compensate for such effects. Methods: Based on the literature and on our own experience, technical recommendations and clinical indications for the use of RG 4D PET/CT have been outlined. Results: RC 4D-PET/CT techniques require a state of the art PET/CT-scanner, a respiratory monitoring system and dedicated acquisition and processing protocols. Patient training is particularly important to obtain a regular breathing pattern. An adequate number of phases has to be selected to balance motion compensation and statistical noise. RG 4D PET/CT motion free images may be clinically useful for tumour tissue characterization, monitoring patient treatment and target definition in radiation therapy planning. Conclusions: RG 4D PET/CT is a valuable tool to improve image quality and quantitative accuracy and to assess and measure organ and lesion motion for radiotherapy planning. 2010 European Society for Therapeutic Radiology and Oncology and European Association of Nuclear Medicine. Published by Elsevier Ireland Ltd. All rights reserved. 96 (2010) 311-316

Molecular imaging techniques, such as positron emission tomography (PET), may be of help in management treatment planning. In particular, in prostate cancer patients, PET and PET-computed tomography (PET-CT) can be successfully used in treatment planning at different steps, including: 1) tumor characterization and staging, to define the most appropriate primary treatment; 2) re-staging, to define a second line therapy on the site of possible recurrences; and 3) monitoring the disease and the efficacy of treatment. Although the most commonly used PET tracer, [(18)F]Fluorodeoxyglucose ([(18)F]FDG), presents limitations in imaging prostate cancer patients, several alternative PET tracers have been proposed to evaluate by PET these patients, with promising RESULTS: Optimal treatment for prostate cancer depends on the accuracy in tumor characterization and staging. In fact, localized primary tumor can be treated with radical prostatectomy, while metastatic tumor is usually treated with systemic therapeutic regimen. Different PET tracers, including [(11)C]Choline, [(18)F]Choline and [(11)C]Acetate, have been successfully reported. Howe-ver, further studies in large population of patients are still necessary to establish their final clinical role in the primary detection and staging of prostate cancer. The information on the site of possible recurrences is also important for therapeutic strategies. Several PET tracers have been proposed to re-stage prostate cancer patients. In particular, [11C]Choline PET has now been established as a clinical procedure to non-invasively re-stage, in a single session, prostate cancer patients presenting an increase of prostate specific antigen (PSA) after radical treatment. The role of PET and PET-CT in monitoring the disease and the effects of treatment are under investigation and still to be defined. In the present review, we focused on the use of several PET tracers in different clinical indications aimed at the treatment planning of prostate cancer patients.

We performed a prospective study to evaluate the effect of antibiotic prophylaxis (AP) on the incidence of infection in elective laparoscopic cholecystectomy (LC).All patients were at low-medium anesthetic and infectious risk and underwent LC for benign disease. At induction of anesthesia 41 patients received ampicillin-sulbactam 3g, 40 patients received ciprofloxacin 400mg intravenously, and 53 patients received no AP.Postoperative infection was observed in 11 patients (8.2%) in the entire study group. All ob served infections were superficial surgical site infections (SSIs), always located at the umbilical incision. Infection occurred in 3 patients (7.3%) in ampicillin-sulbactam group, in 3 patients (7.5%) in ciprofloxacin group and in 5 patients (9.4%) in nonantibiotic group (p=0.916). Univariate analysis showed that duration of operation, placement of a drain and postoperative hospital stay were significantly associated with the development of SSIs. At multivariate analysis, only duration of operation was statistically significant in predicting SSIs.The present study did not show any advantage in the use of AP, although in case of difficult surgery the risk of SSIs is increased, in particular in the umbilical incision. In all patients, the bile culture was sterile, then the infection of the umbilical site is not due to bacterial infection from the gallbladder.AP in elective LC should not be routinely performed. A particular attention to the preoperative cleaning and topical antibiotic therapy of the umbilical area is advised.In letteratura c’è un crescente consenso nell’evitare l’utilizzo della profilassi antibiotica (PA) nella colecistectomia per via laparoscopica elettiva (CLE). Tuttavia, la PA è ancora ampiamente utilizzata allo scopo di ridurre l’incidenza di infezioni postoperatorie. Abbiamo eseguito uno studio prospettico di comparazione tra utilizzo di ampicilina-sulbactam, ciprofloxacina e assenza di PA nei pazienti a basso-medio rischio anestesiologico (ASA I-III) e infettivo (patologie croniche in buon compenso) sottoposti a CLE per patologia benigna (litiasi e polipi). A 41 pazienti sono stati somministrati 3g di ampicillina- sulbactam e.v., 40 pazienti hanno assunto 400mg di ciprofloxacina e.v. e 53 pazienti non hanno effettuato nessuna PA. Nell’intero gruppo di studio si sono registrati 11 casi (8,2%) di infezione postoperatoria. Tutte le infezioni hanno coinvolto unicamente il sito chirurgico e, in particolare, l’incisione ombelicale. L’infezione si è verificata in 3 pazienti (7,3%) nel gruppo ampicilina-sulbactam, in 3 pazienti (7,5%) nel gruppo ciprofloxacina e in 5 pazienti (9,4%) nel gruppo non sottoposto a PA (p=0.916). All’analisi statistica univariata la durata dell’intervento chirurgico, il posizionamento di un drenaggio e la degenza ospedaliera, si sono dimostrati significativamente associati all’insorgenza di infezioni postoperatorie. All’analisi statistica multivariata unicamente la durata dell’intervento chirurgico è risultato significativamente associato all’insorgenza di infezioni del sito chirurgico. La PA nella CLE non è consigliabile. In caso di difficoltà durante l’intervento chirurgico, il rischio di infezione del sito chirurgico è aumentato, in particolare nella sede dell’incisione ombelicale. Si raccomanda una particolare attenzione alla disinfezione preoperatoria dell’area ombelicale anche con l’utilizzo di antibiotici per via topica.

Aim. To prospectively evaluate the impact of coregistered positron emission tomography (PET) and computed tomography (CT) in 3D conformal radiotherapy (3D-CRT) planning in patients with non-small lung cancer (NSCLC). Methods. Twenty-one patients (median age: 57 years; range: 42-80 years) referred to 3D-CRT for NSCLC were recruited. Positron emission tomography with F-18-fluorodeoxyglucose ([F-18]FDG-PET) and conventional CT images were coregistered (PET/CT images) using a commercial software package based on surface matching technique. Neoplastic areas were contoured on [F-18]FDG-PET images with the aid of the correspondent CT image by a nuclear medicine physician. CT images and their relative PET contours were then transferred to treatment planning system. A radiation oncologist firstly contoured clinical target volumes (CTV) on CT scan alone (CTV-CT), and then on coregistered PET/CT images (CTV-PET/CT). CTV-CT and CTV-PET/CT were compared for each patient; a difference higher than 25% was considered of clinical relevance. Results. Three patients were shifted to pallative radiotherapy for metastatic disease or very large tumor size, showed by [F-18]FDG-PET. Of the remaining 18 patients a CTV change, after inclusion of PET/CT data, was observed in 10/18 cases (55%): larger in 7/18 (range 33279%) and smaller in 3/18 patients (range 26-34%), mainly due to inclusion or exclusion of lymph-nodal disease and to better definition of tumor extent. CTV changes smaller than 25% occurred in the remaining 8/18 patients. Conclusion. [F-18]FDG-PET and CT images co-registration in radiotherapy treatment planning led to a change in CTV definition in the majority of our patients, which may significantly modify management and radiation treatment modality in these patients.

Primitive NHL represents 9% of testis tumours and the 85% is diagnosed in patient older thant 60 years old. Usually pain and a testis mass are the main manifestations. The Authors report the case of a 82 years-old man with bilateral hydrocele causing severe alteration in the deambulation. The cytology did not show blood cells or neoplastic cell in the FNAB. The US showed a complete modification in the testis. The patient underwent to surgery intervention of vaginalis tunic eversion and resection with the aim of control the symptoms. The histology on multiple biopsy of testis and epidydims bilaterally showed a large B-cell lymphoma. The patient was treated with 6 chemotheray cycles (Rituximab, Vincristine, Cyclophosphamide, Prednisone). Bilateral hydrocele is a rare clinical presentation of testis NHL. In this patient, blood and neoplastic cell absence in the cytology made difficult the differential diagnosis between inflammatory pathology and neoplasia. Hystopathologic study and immunologic pattern can make a certain diagnosis.

Hepatocellular carcinoma is a main challenge in oncologic care. Surgery is the mainstay of treatment. Transarterial chemoembolization is the most widely used palliative treatment for hepatocellular carcinoma. The Authors present a case report of a 61-year old man with hepatocellular carcinoma, belonging to Child-Pugh class A. The advanced age and the previous history of bladder carcinoma made the patient not suitable for liver transplantation. The patient refused hepatic resection so that transarterial chemoembolization was proposed. During 14-year follow-up there was intrahepatic progression of the tumor after the first treatment, followed by reduction in size and number of the lesions after subsequent treatments. In spite of the ominous prognosis of hepatocellular carcinoma, in this case-report transarterial chemoembolization allowed us to achieve a unique long-term survival.

Splenic infarction is a rare cause of acute abdomen. It must be suspected in patient with hematologic diseases or thromboembolic conditions. The most common onset symptom is left-upper quadrant abdominal pain. Additional symptoms include fever and anemia. Laboratory may show elevated white blood cell and platelet counts.A 97-year-old female with a past history of atrial fibrillation presented with left-upper quadrant abdominal pain and fever since 20 days. Laboratory showed elevated white blood cell and platelet counts, increased C-reactive protein and lactate dehydrogenase. Both ultrasonographic and tomographic scans showed a large hypodense area of the spleen. The patient received intravenous antibiotic therapy, which led to significant clinical improvement with discharge 16 days after admission.The diagnosis of splenic infarction is based both on clinical presentation and imaging studies. Angio-computed tomography is the diagnostic procedure of choice. Ultrasonography and conventional radiology are useful in the differential diagnosis with other abdominal and thoracic diseases mimicking splenic infarction. In our case the management was conservative, because the patient was hemodynamically stable and antibiotic therapy could control the sepsis. Moreover, advanced age and poor cardiac and respiratory conditions contraindicated surgery.In our case splenic infarction was probably due to a thromboembolic event secondary to atrial fibrillation. In accordance with the literature, we suggest initial conservative therapy. Surgery is indicated only in the presence of complications.

Gallstone ileus is a rare complication of cholecystolithiasis. It causes 1-3% of the mechanical obstructions of the small bowel. It often affects patients between 63 and 85 years old. Pre-operative diagnosis is usually delayed 1-10 days because there is not a specific symptomatology.The authors report the case of a 50 year-old man with diagnosis of mechanical obstruction of the small bowel caused by a voluminous gallstone. Ileal occlusion was showed by CT. The patient underwent to one-stage emergency surgery with enterolithotomy, cholecystectomy and duodenal fistula repair. Patient's recovery was regular and he was discharged fourteen days after surgery.In our case gallstone ileus was diagnosed with a delay of 5 days. Ultrasonography was not able to show the gallbladder. Diagnosis was made by CT, which is the diagnostic gold standard.Patient's performance status influences surgical strategy. In our experience, the patient underwent one-stage surgery because he was considered at low risk. Instead staged procedure with enterolithotomy and delayed cholecystectomy and fistula repair, is performed only in patients at high risk.

We report a case of acute relapsing pancreatitis associated with pancreas divisum, who underwent major papilla sphincterotomy after failed minor papilla cannulation. Long-term results were satisfactory. The possible explanations of the efficacy of major papilla endoscopic resection in this particular case are discussed.

Gallbladder polypoid lesions occur in 1.3%-6.9% of cases. The preoperative diagnosis between benign, malignant and potentially malignant lesions is difficult. Therefore it is not possible any.The Authors describe three cases. The case 1 was a gallbladder diffuse adenomyomatosis; the ultrasound and the CT were of little help in defining preoperatively the nature and the gravity of the thickening. Case 2 was an adenomyomatosis of the fundus: the ultrasound examinations were not able to establish preoperatively lesion's nature, site and dimensions. In the case 3, ultrasounds showed polypoid lesions and calculi concrections not found in colecistectomy.The ultrasound is the most widely used diagnostic tool in the evaluation of gallbladder polypoid lesions; its accuracy is only 66%. CT, which has an accuracy level of 75%, must be carried out there is any possibility of malignant degeneration of the polyp. If doubts persist, a MR, 93% accuracy, is indicated. In selected cases, PET can be of further help.The preoperative diagnosis of the nature of gallbladder polypoid lesions is "difficult" and this justifies the lack of consensus on treatment. However, the adenoma-carcinoma sequence, widely discussed in literature, can justifies to the use of CT, MR, PET and surgical treatment after an ultrasound examination.

Umbilical endometriosis is a very rare disease. We report a case of spontaneous umbilical endometriosis in a 36-year old female. Endometriosis was suspected because of the presence of the typical cyclic bleeding and swelling. Abdominal CT excluded the presence of other endometriotic localizations. The umbilical mass was widely excised together with the umbilicus, fascia and peritoneum. The ensuing defect was primarily closed without using prosthetic mesh. Postoperative recovery was uneventful. Histological examination of the specimen showed the presence of endometrial glands with a stromal component, compatible with the diagnosis of endometriosis. At one-year follow-up the results of surgery were satisfactory with no sign of endometriosis recurrence and or parietal defect occurrence. We suggest that surgical excision should be wide in order to prevent local recurrence, and prosthetic materials should not be used to repair the ensuing umbilical defect.

Uterine carcinosarcoma is a highly aggressive neoplasm with tendency to early recurrence and/or metastasis. The neoplasia has both epithelial and stromal malignant components. Clinically, it is characterized by a postmenopausal metrorrhagia, associated sometimes with abdominal pain. The Authors describe a case of carcinosarcoma in a 82-year old woman with a vaginal bleeding since 10 months and an ingravescent hypochromic anemia. The RMN of the abdomen and pelvis showed a mass occupying the whole uterine lumen, without signs of pelvic diffusion. A bilateral hystero-oophorectomy was performed; the patient's critical conditions and a high anaesthesiological risk advised us not to perform a bilateral pelvic lymphadenectomy with aortic sampling. Six months after operation, a clinical follow-up with a total-body CT didn't show any sign of local recurrence and/or distant metastasis. From the analysis of this case report and from the data of the literature some important considerations can be done: a) gynecologic check up in post-menopausal women with associated risk factors (obesity and hypertension) can allow an early diagnosis also in asymptomatic patients; b) sovrapubic and transvaginal US, abdomino-pelvic CT and MRI are essential for a correct clinical staging; c) surgical excision followed by the histological examination of the specimen is mandatory to establish a correct diagnosis.

The diagnostic specificity of recombinant 21-hydroxylase autoantibodies (21OH-Ab) for Addison's disease was tested in adult patients with either Graves' disease (GD), insulin-dependent diabetes mellitus (IDDM), or polyendocrinopathy, as well as in healthy controls. Using a radiobinding assay with in vitro translated recombinant human 21-hydroxylase, we found 21OH-Ab in 24/28 (86%) idiopathic Addison patients, and using an immunofluorescence assay we found adrenal cortex autoantibodies (ACA) in 12/28 (43%) patients (P = 0.002). All the 12 ACA-positive sera were also positive for 21OH-Ab and ACA were found in 11/15 (73%) patients with less than 15 years and in 1/13 (8%) patients with 15-38 years of disease duration (P = 0.002). 21OH-Ab were present in 3/92 (3%) patients with GD, in 1/180 (0.6%) with IDDM and in 0/106 healthy subjects. The 21OH-Ab-positive GD and IDDM patients were also positive for ACA. None of 17 patients with polyendocrinopathy, but without Addison's disease, had 21OH-Ab. None of the 180 Belgian IDDM patients had Addison' s disease or developed an adrenal insufficiency at follow up. In two out of three Graves patients, the presence of 21OH-Ab was associated with clinical and biochemical signs of adrenal insufficiency. Of the 89 21OH-Ab-negative patients with GD none had Addison's disease at the time of blood sampling, and 79 were followed up for 5.6-7.5 years and none developed clinical signs of adrenal insufficiency. We conclude that the presence of 21OH-Ab in patients with endocrine autoimmune diseases is highly specific for Addison's disease.

The incidence of cancer of the cardia is increasing. Surgical treatment, in a small percentage of patients in early stage, consists in esophagectomy and total gastrectomy, followed by colon interposition. The operation can be performed through the thorax or by an abdominal and cervical approach. From 1982 to 1989 twenty-five patients were operated on. Between 1980 and 1982 the cancer was resected opening the thorax in 9 patients (group A), while from 1983 to 1989 the esophagus was removed through diaphragmatic hiatus in 16 patients (group B). All cases were analyzed as for histology, staging and resection margin. Average clinical follow-up was 22 +/- 32.7 months (range 1-102). Morbidity was 77.7% in group A and 68% in group B. Mortality dropped to 14% in the last 7 patients. Mean survival time was 23 +/- 34 months in group A and 11.2 +/- 13.7 months in group B (p = N.S.). Follow-up controls showed that all patients, in whom the esophagus was replaced with colon, were able to feed adequately.

Aim. This study was aimed at assessing the clinical performances of a NaI(Tl) crystal 3D PET scanner, C-PET (ADAC-UGM), using a multi-ring 2D BGO PET scanner (multi-ring PET), as a reference. Methods. Thirty-seven oncological patients were studied in sequence with multi-ring PET and C-PET, within 30 days of a CT study. in order to assess the behaviour of CPET in relation to acquisition count rate, patients were divided into 3 groups according to the count rate at the time of the C-PET scan acquisition. Group A (n=21): 3000-5000 kcounts/sec (recommended count rate range); Group B (n=8): 5000 Kcounts/sec. Results. The number of lesions detected by multi-ring PET and C-PET, classified according to size, was compared. For Group A and Group B there was a good agreement between C-PET and multi-ring PET in terms of lesion detectability (relative sensitivity: 99.9% and 96.0%. respectively), while for Group C the relative sensitivity of C-PET was 61.9%. Conclusion. Optimal performances of the C-PET scanner can thus be obtained at a count rate within or below the recommended range. Despite a lower lesion/background contrast resulting from a high scatter and random noise, the sensitivity of C-PET in detecting hypermetabolic lesions is comparable to that of multi-ring PET. These findings are discussed in relation to the physical performance of the two scanners and particularly in relation to the 3D vs 2D acquisition modality.

The aim of this paper was to assess the prognostic role of pretherapy partial volume corrected (PVC) 18F-fluorodeoxyglucose mean standardized uptake value (SUV) in breast cancer (BC).Forty oncological patients, BC diagnosed by biopsy, with breast tumor mass diameter1 cm measured to the mammography, designed for surgical intervention, underwent a pretherapy semi-quantitative 18F-FDG positron emission tomography/computed tomography (18F-FDG PET/CT) whole-body study for tumor staging. Mean Body-Weight Standardized Uptake Value with Correction for Partial Volume effect (PVC- SUVBW-mean) was calculated in all mammary detected lesions. Excised tissues from primitive BC were sectioned and classified according to the WHO guidelines, evaluating biological features. Univariate (Mann-Withney/Kruskal-Wallis) and multivariate (linear regression, hierarchical clustering) statistical tests were performed between PVC-SUVBW-mean and biological indexes. ROC analysis was performed. PVC-SUVBW-mean thresholds were derived allowing to distinguish groups of BC patients with different biological characteristics. Specificity and Sensitivity were also calculated.Statistical and multiple correlations between pretherapy 18F-FDG PET PVC-SUVBW-mean and histological type, grade, ER/PgR hormone receptors and Mib-1 cellular proliferation index were found. In our samples, PVC-SUVBW-mean≈4 g/cc was found correlated to BC patients with Invasive Lobular Carcinoma (ILC) or well differentiated Invasive Ductal Carcinoma (IDC), a positive expression of ER and PgR and a negative expression of MiB-1, while PVC-SUVBW-mean≈7.00 is associated to BC patients with moderately and poorly differentiated IDC, negative expression of ER and PgR and a positive expression of MiB-1.Pretherapy PVC 18F-FDG PET PVC-SUVBW-mean measurement correlates with prognostic factors in BC and could be used to stratify patients before intervention.

Aims and background Evaluation of the metabolic response to radiotherapy in non-small cell lung cancer patients is commonly performed about three months after the end of radiotherapy. The aim of the present study was to assess with positron emission tomography/computed tomography (PET/CT) and [18F]fluorodeoxyglucose changes in glucose metabolism during and after radiotherapy in non-small cell lung cancer patients. Methods and study design In 6 patients, PET/CT scans with [18F]fluorodeoxyglucose were performed before (PET0), during (PET1; at a median of 14 days before the end of radiotherapy) and after the end of radiotherapy (PET2 and PET3, at a median of 28 and 93 days, respectively). The metabolic response was scored according to visual and semiquantitative criteria. Results Standardize maximum uptake at PET1 (7.9 ± 4.8), PET2 (5.1 ± 4.1) and PET3 (2.7 ± 3.1) were all significantly (P 0 (16.1 ± 10.1). Standardized maximum uptake at PET1 was significantly higher than at both PET2 and PET3. There were no significant differences in SUVmax between PET2 and PET3. PET3 identified 4 complete and 2 partial metabolic responses, whereas PET1 identified 6 partial metabolic responses. Radiotherapy-induced increased [18F]fluorodeoxyglucose uptake could be visually distinguished from tumor uptake based on PET/CT integration and was less frequent at PET1 (n = 2) than at PET3 (n = 6). Conclusions In non-small cell lung cancer, radiotherapy induces a progressive decrease in glucose metabolism that is greater 3 months after the end of treatment but can be detected during the treatment itself. Glucose avid, radiotherapy-induced inflammation is more evident after the end of radiotherapy than during radiotherapy and does not preclude the interpretation of [18F]fluorodeoxyglucose images, particularly when using PET/CT.

AIM: Anti-androgenic hormonal therapy in prostate cancer patients with concomitant meningioma may result in tumor growth and development of neurological symptoms. Positron emission tomography/computed tomography (PET/CT) with [(11)C]choline is used for restaging prostate cancer patients with biochemical failure. In vitro and in vivo data support altered choline metabolism in meningiomas. METHODS: During a retrospective study in prostate cancer patients with biochemical failure referred to our institution between November 2004 and Ja-nuary 2007, encephalic focal uptake of [(11)C]choline was incidentally noted in 4 patients, 2 of which had been taking luteinizing hormone-releasing hormone analogs. RESULTS: Subsequent to the incidental finding, one patient underwent surgical removal of the meningioma; strict neuroradiological follow-up was planned for the 3 other patients. CONCLUSIONS: We suggest that in prostate cancer patients candidate for anti-androgenic therapy the whole body [(11)C]choline PET/CT scan should include the whole skull to check for the possible presence of meningiomas. This could help to identify patients at risk for the development of neurological symptoms during anti-androgenic therapy and help the referring urologist in the clinical management of these patients.

To evaluate the incidence of SSI and systemic infectious complications in a consecutive series of patients undergoing thyroid surgery in the absence of prophylactic antibiotic (NO-AP).Prospective observational study including 77 patients who underwent total thyroidectomy and completion of previous hemithyroidectomy in NO-AP. The surgical intervention was performed by surgeons who were experienced in the procedure, and involved the use of Ligasure Harmonic Ethicon®, absorbable hemostat in oxidized regenerated cellulose (Tabotamp®), and skin incision suture device Skin Stapler®. The following risk factors were assessed: gender, age, BMI, alcohol consumption, habitual smoking, co-morbidities, ASA score, indication to surgery, duration of anesthesia and procedure lenght, type of surgical procedure, fever, white blood cells count, dosage of the pre-operative C Reactive Protein in the five first post-operative day, and histological diagnosis. The data were collected and processed using IBM SPSS software v.23.0.No factors of increased infectious risk have been identified. No infectious surgical and systemic complications have been reported causes of prolongation of the length of the hospital stay.Fever, neutrophilic leukocytosis and increased PCR cannot be assessed as predictive factors of infectious complication in thyroid surgery. The cutaneous antisepsis of the operative field with chlorhexidine gluconate, the improvement of the surgical technique, the protection of the cutaneous margins of incision, the use of new devices, the accurate hemostasis and the reduction of surgery time lead to a lack of SSIs and systemic infection complications in all patients undergoing thyroid surgery in NO-AP.Antibiotic prophylaxis, Surgical site infections, Thyroid surgery, Thyroidectomy.Le infezioni del sito chirurgico (SSIs) e le complicanze infettive sistemiche dopo chirurgia tiroidea sono di non comune riscontro. La profilassi antibiotica nei pazienti a basso rischio infettivo (ASA ≤3) sembra priva di significativi vantaggi sull’incidenza delle SSIs e delle complicanze settiche sistemiche. Scopo dello studio è stato quello di valutare l’incidenza delle SSI e delle complicanze infettive sistemiche in una serie consecutiva di pazienti sottoposti a chirurgia della tiroide in assenza di profilassi antibiotica (NO-AP).Lo studio di tipo osservazionale prospettico includeva 77 pazienti (57 F; età media 57.1 anni; 20 M; età media 56.8) sottoposti a chirurgia tiroidea nel periodo Gennaio 2018-Dicembre 2019 presso l’ospedale universitario “ A. Fiorini” di Terracina. Nessun paziente veniva sottoposto a profilassi antibiotica. L’intervento chirurgico era eseguito da chirurghi esperti della procedura e prevedeva l‘utilizzo del Ligasure Harmonic Ethicon®, di emostatico riassorbibile in cellulosa ossidata e rigenerata (Tabotamp®) e dispositivo di sutura dell’incisione cutanea Skin Stapler®. Venivano valutati i seguenti fattori di rischio: sesso, età, BMI, consumo di alcool, fumo abituale, comorbilità, ASA score, indicazione all’intervento, durata dell’anestesia e dell’intervento chirurgico, procedura chirurgica adottata, febbre, conta dei globuli bianchi e dosaggio della Proteina C Reattiva pre-op e in I,II,III,IV,V giornata p.o, diagnosi istologica. I dati venivano raccolti ed elaborati mediante software IBM SPSS v.23.0.Una tiroidectomia totale è stata eseguita in 72 pz, completamento di pregressa emitiroidectomia in 5 pz, linfoadenectomia del compartimento centrale di ”necessità” in 11 pz. In tutti i casi l’indicazione al trattamento chirurgico era rappresentata da gozzo multinodulare funzionante in 19 (24,6%) pz, non funzionante in 58(75.3%) pz, endotoracico 10(12.9%) pz. Non sono state riportate complicanze infettive del sito chirurgico e sistemiche causa di prolungamento della durata della degenza clinica. Pertanto la febbre, la leucocitosi neutrofila e l’aumento della PCR non possono essere valutati come fattori predittivi di complicanza infettiva.Non sono stati identificati fattori di aumentato rischio infettivo. L’antisepsi del campo operatorio con Clorexidina gluconato, il miglioramento della tecnica chirurgica, la protezione dei margini cutanei di incisione, l’utilizzo dei nuovi devices, l’emostasi accurata e la riduzione dei tempi operatori si sono associati al mancato riscontro di SSIs e di complicanze infettive sistemiche in tutti i pz sottoposti a chirurgia tiroidea in assenza di profilassi antibiotica.

Carcinosarcoma is a rare tumor of the uterus with a poor prognosis. We present a case of uterine carcinosarcoma in an 82-year-old woman who suffered from pervaginal bleeding for ten months duration with progressive anemia. Abdominopelvic nuclear magnetic resonance (NMR) imaging showed the presence of an intrauterine mass, infiltrating the myometrium and reaching the cervix. The patient was submitted to total abdominal hysterectomy with bilateral salpingo-oophorectomy. The carcinosarcoma, arising from the lumen of the uterus, infiltrated the inner one-third of the myometrial layer (pT1b, pNx, pMx; FIGO Stage 1B). A CT of the total body performed six months after surgery showed no signs of recurrent and/or metastatic tumor. The clinicopathological features, treatment options and prognosis of this aggressive neoplasm are reviewed.

The authors report a case of epidermoid carcinoma of the anal margin with repeated metachronous metastases in the inguinal lymph nodes. The treatment of synchronous ad metachronous metastases is briefly discussed through a literature review.

Purpose: To present the state-of-art of radiomics in the context of pancreatic neuroendocrine tumors (PanNETs), with a focus on the methodological and technical approaches used, to support the search of guidelines for optimal applications. Furthermore, an up-to-date overview of the current clinical applications of radiomics in the field of PanNETs is provided. Methods: Original articles were searched on PubMed and Science Direct with specific keywords. Evaluations of the selected studies have been focused mainly on (i) the general radiomic workflow and the assessment of radiomic features robustness/reproducibility, as well as on the major clinical applications and investigations accomplished so far with radiomics in the field of PanNETs: (ii) grade prediction, (iii) differential diagnosis from other neoplasms, (iv) assessment of tumor behavior and aggressiveness, and (v) treatment response prediction. Results: Thirty-one articles involving PanNETs radiomic-related objectives were selected. In regard to the grade differentiation task, yielded AUCs are currently in the range of 0.7–0.9. For differential diagnosis, the majority of studies are still focused on the preliminary identification of discriminative radiomic features. Limited information is known on the prediction of tumors aggressiveness and of treatment response. Conclusions: Radiomics is recently expanding in the setting of PanNETs. From the analysis of the published data, it is emerging how, prior to clinical application, further validations are necessary and methodological implementations require optimization. Nevertheless, this new discipline might have the potential in assisting the current urgent need of improving the management strategies in PanNETs patients.

Aim To explore the potentiality of radiomics analysis, performed on 68Ga-DOTATOC and fluorine-18-fluorodeoxyglucose (18F-FDG) PET/computed tomography (CT) images, in predicting tumour aggressiveness and outcome in patients candidate to surgery for pancreatic neuroendocrine neoplasms (PanNENs). Patients and methods Retrospective study including 61 patients who underwent 68Ga-DOTATOC and 18F-FDG PET/CT before surgery for PanNEN. Semiquantitative variables [SUVmax and somatostatin receptor density (SRD) for 68Ga-DOTATOC PET; SUVmax and MTV for 18F-FDG PET] and texture features [intensity variability, size zone variability (SZV), zone percentage, entropy; homogeneity, dissimilarity and coefficient of variation (Co-V)] have been analysed to evaluate their possible role in predicting tumour characteristics. Principal component analysis (PCA) was firstly performed and then multiple regression analyses were performed by using the extracted principal components. Results Regarding 68Ga-DOTATOC PET, SZV, entropy, intensity variability and SRD were predictive for tumour dimension. Regarding 18F-FDG PET, intensity variability, SZV, homogeneity, SUVmax and MTV were predictive for tumour dimension. Four principal components were extracted from PCA: PC1 correlated with all 18F-FDG variables, while PC2, PC3 and PC4 with 68Ga-DOTATOC variables. PC1 was the only significantly predicting angioinvasion (P = 0.0222); PC4 was the only one significantly predicting lymph nodal involvement (P = 0.0151). All principal components except PC4 significantly predicted tumour dimension (P

We present the current clinical applications of radiomics in the context of prostate cancer (PCa) management. Several online databases for original articles using a combination of the following keywords: “(radiomic or radiomics) AND (prostate cancer or prostate tumour or prostate tumor or prostate neoplasia)” have been searched. The selected papers have been pooled as focus on (i) PCa detection, (ii) assessing the clinical significance of PCa, (iii) biochemical recurrence prediction, (iv) radiation-therapy outcome prediction and treatment efficacy monitoring, (v) metastases detection, (vi) metastases prediction, (vii) prediction of extra-prostatic extension. Seventy-six studies were included for qualitative analyses. Classifiers powered with radiomic features were able to discriminate between healthy tissue and PCa and between low- and high-risk PCa. However, before radiomics can be proposed for clinical use its methods have to be standardized, and these first encouraging results need to be robustly replicated in large and independent cohorts.

Deep learning (DL) strategies applied to magnetic resonance (MR) images in positron emission tomography (PET)/MR can provide synthetic attenuation correction (AC) maps, and consequently PET images, more accurate than segmentation or atlas-registration strategies. As first objective, we aim to investigate the best MR image to be used and the best point of the AC pipeline to insert the synthetic map in. Sixteen patients underwent a 18F-fluorodeoxyglucose (FDG) PET/computed tomography (CT) and a PET/MR brain study in the same day. PET/CT images were reconstructed with attenuation maps obtained: (1) from CT (reference), (2) from MR with an atlas-based and a segmentation-based method and (3) with a 2D UNet trained on MR image/attenuation map pairs. As for MR, T1-weighted and Zero Time Echo (ZTE) images were considered; as for attenuation maps, CTs and 511 keV low-resolution attenuation maps were assessed. As second objective, we assessed the ability of DL strategies to provide proper AC maps in presence of cranial anatomy alterations due to surgery. Three 11C-methionine (METH) PET/MR studies were considered. PET images were reconstructed with attenuation maps obtained: (1) from diagnostic coregistered CT (reference), (2) from MR with an atlas-based and a segmentation-based method and (3) with 2D UNets trained on the sixteen FDG anatomically normal patients. Only UNets taking ZTE images in input were considered. FDG and METH PET images were quantitatively evaluated. As for anatomically normal FDG patients, UNet AC models generally provide an uptake estimate with lower bias than atlas-based or segmentation-based methods. The intersubject average bias on images corrected with UNet AC maps is always smaller than 1.5%, except for AC maps generated on too coarse grids. The intersubject bias variability is the lowest (always lower than 2%) for UNet AC maps coming from ZTE images, larger for other methods. UNet models working on MR ZTE images and generating synthetic CT or 511 keV low-resolution attenuation maps therefore provide the best results in terms of both accuracy and variability. As for METH anatomically altered patients, DL properly reconstructs anatomical alterations. Quantitative results on PET images confirm those found on anatomically normal FDG patients.

The statements produced by the Chairmen and Speakers of the 3rd International Symposium on Diverticular Disease, held in Madrid on April 11th-13th 2019, are reported. Topics such as current and evolving concepts on the pathogenesis, the course of the disease, the news in diagnosing, hot topics in medical and surgical treatments, and finally, critical issues on the disease were reviewed by the Chairmen who proposed 39 statements graded according to level of evidence and strength of recommendation. Each topic was explored focusing on the more relevant clinical questions. The vote was conducted on a 6-point scale and consensus was defined a priori as 67% agreement of the participants. The voting group consisted of 124 physicians from 18 countries, and agreement with all statements was provided. Comments were added explaining some controversial areas.

Background: Conventional imaging (CI) techniques are inadequate for lymph node (LN) staging in prostate cancer (PCa). Objectives: To assess the accuracy of C-11-Choline positron emission tomography/computerized tomography (PET/CT) for LN staging in intermediate-risk and high-risk PCa and to compare it with two currently used nomograms. Design, Setting, and Participants: From January 2007 to September 2007, 57 PCa patients at intermediate risk (n = 27) or high risk (n = 30) were enrolled at two academic centres. All patients underwent preoperative PET/CT and radical prostatectomy with extended pelvic LN dissection (PLND). Risk of LN metastasis (LNM) was assessed using available nomograms. Measurements: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and number of correctly recognized cases for LNM detection at PET/CT were assessed. The accuracy of PET/CT for LNM detection was compared with the accuracy of nomograms for LNM prediction by using receiver operating characteristic (ROC) analysis. Results and Limitations: Fifteen patients (26%) had LNMs, and a total of 41 LNMs were identified. on a patient analysis, sensitivity, specificity, PPV, NPV, and number of correctly recognized cases at PET/CT were 60.0%, 97.6%,90.0%, 87.2%, and 87.7% while, on node analysis, these numbers were 41.4%, 99.8%, 94.4%, 97.2%, and 97.1%. The mean diameter (in mm) of the metastatic deposit of true-positive LNs was significantly higher than that of false-negative LNs (9.2 vs 4.2; p = 0.001). PET/CT showed higher specificity and accuracy than the nomograms; however, in pairwise comparison, the areas under the curve (AUCs) were not statistically different (all p values >0.05). Conclusions: In patients with intermediate-risk and high-risk PCa, C-11-Choline PET/CT has quite a low sensitivity for LNM detection but performed better than clinical nomograms, with equal sensitivity and better specificity. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved. Background: Conventional imaging (CI) techniques are inadequate for lymph node (LN) staging in prostate cancer (PCa). Objectives: To assess the accuracy of C-11-Choline positron emission tomography/computerized tomography (PET/CT) for LN staging in intermediate-risk and high-risk PCa and to compare it with two currently used nomograms. Design, Setting, and Participants: From January 2007 to September 2007, 57 PCa patients at intermediate risk (n = 27) or high risk (n = 30) were enrolled at two academic centres. All patients underwent preoperative PET/CT and radical prostatectomy with extended pelvic LN dissection (PLND). Risk of LN metastasis (LNM) was assessed using available nomograms. Measurements: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and number of correctly recognized cases for LNM detection at PET/CT were assessed. The accuracy of PET/CT for LNM detection was compared with the accuracy of nomograms for LNM prediction by using receiver operating characteristic (ROC) analysis. Results and Limitations: Fifteen patients (26%) had LNMs, and a total of 41 LNMs were identified. on a patient analysis, sensitivity, specificity, PPV, NPV, and number of correctly recognized cases at PET/CT were 60.0%, 97.6%,90.0%, 87.2%, and 87.7% while, on node analysis, these numbers were 41.4%, 99.8%, 94.4%, 97.2%, and 97.1%. The mean diameter (in mm) of the metastatic deposit of true-positive LNs was significantly higher than that of false-negative LNs (9.2 vs 4.2; p = 0.001). PET/CT showed higher specificity and accuracy than the nomograms; however, in pairwise comparison, the areas under the curve (AUCs) were not statistically different (all p values >0.05). Conclusions: In patients with intermediate-risk and high-risk PCa, C-11-Choline PET/CT has quite a low sensitivity for LNM detection but performed better than clinical nomograms, with equal sensitivity and better specificity. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Purpose: To evaluate, in prostate cancer (PCa) patients the potential of 11C-choline PET/CT as a guide to helical tomotherapy (HTT) of lymph-node (LN) relapses with simultaneous integrated boost (SIB). The efficacy and feasibility of HTT in terms of acute toxicity were assessed. Methods: We enrolled 83 PCa patients (mean age 68 years, range 51 - 82 years) with biochemical recurrence after radical primary treatment (mean serum PSA 7.61 ng/ml, range 0.37 - 187.00 ng/ml; PSA0) who showed pathological findings on 11C-choline PET/CT only at the LN site. 11C-Choline PET/CT was performed for restaging and then for radiation treatment planning (PET/CT0). Of the 83 patients, 8 experienced further LN relapse, of whom 5 were retreated once and 3 were retreated twice (total 94 radiotherapy treatments). All pelvic and/or abdominal LNs positive on PET/CT0 were treated with high doses using SIB. Doses were in the range 36 - 74 Gy administered in 28 fractions. After the end of HTT (mean 83 days, range 16 - 365 days), serum PSA was measured in all patients (PSA 1) and compared with PSA0 to evaluate early biochemical response. In 47 patients PET/CT was repeated (PET/CT1) to assess metabolic responses at the treated areas. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) were used to assess acute toxicity. Results: PET/CT0 revealed pathological LNs in the pelvis in 49 patients, pathological LNs in the abdomen in 15 patients pathological LNs in both the pelvis and abdomen in 18 patients, and pathological LNs in the pelvis or abdomen and other sites in 12 patients. All these sites were treated with HTT. With respect to PSA0, PSA1 (mean 6.28 ng/ml, range 0.00 - 220.46 ng/ml) showed a complete biochemical response after 66 of the 94 HTT treatments, a partial response after 12 treatments, stable disease after 1 treatment and progression of disease after 15 treatments. Of the 47 patients receiving PET/CT1, 20 showed a complete metabolic response at the treated area, 22 a partial metabolic response, 3 progression of disease and 2 stable disease. HTT with SIB was well tolerated in all patients. Grade 3 acute toxicity in the genitourinary tract was observed in two patients. Conclusion: 11C-Choline PET/CT is a valuable tool for planning and monitoring HTT in LN relapse after primary treatment. High-dose hypofractionated 11C-choline PET/CT-guided HTT with SIB is well tolerated and is associated with a high early biochemical response rate. © 2014 Springer-Verlag.

High risk prostate cancer patients have a significant risk to develop regional lymph node metastases, and this represent a major cause of biochemical failure. Although pelvic lymphadenectomy is the gold standard to assess the status of pelvic lymph nodes, a diagnostic imaging tool to non-invasively explore patients and to detect metastases, both in staging and in re-staging phase, would be of particular help in clinical management. In staging phase, while choline PET/CT specificity has been reported to be fairly high in lymph nodal detection, its sensitivity is not adequate due to its spatial resolution. Its role in the evaluation of patients with biochemical relapse or with suspected relapse has been successfully documented. In particular, choline PET/CT has great potential as a single step whole body diagnostic procedure to evaluate lymph nodal and bone metastatic involvement. Salvage lymph nodal dissection was recently listed as a possible experimental option for patients with nodal recurrent prostate cancer, even in the absence of solid prospective data. Radiation treatment for lymph-node recurrence is a therapeutic option evaluated in several studies, in particular by using stereotactic treatment or whole pelvic lymph-nodal irradiation plus a boost on choline PET/CT positive lymph nodes. In the present review an analysis of the specific role of choline PET/CT in guiding a specific treatment on lymph nodal site in prostate cancer patients is reported.

EAU guidelines on prostate cancer. Part II: Treatment of advanced, relapsing, and castration-resistant prostate cancer.

Context: Choline positron emission tomography (PET)/computed tomography (CT) is a currently used diagnostic tool in restaging prostate cancer (PCa) patients with increasing prostate-specific antigen (PSA) after either radical prostatectomy (RP) or external-beam radiation therapy (EBRT). However, no final recommendations have been made on the use of this modality for patient management. Objective: To critically analyse the current evidence for the use of choline PET/CT scanning in the management of patients with a progressive increase in PSA after radical treatment for PCa, evaluating its diagnostic accuracy in the detection of recurrences, the clinical predictors of positive PET/CT examinations, and the modalities' role as a guide for tailored therapeutic strategies. Evidence acquisition: Data on recently published (2003-2010) original articles, review articles, and editorials concerning the role of choline PET/CT in this scenario were analysed. Evidence synthesis: The diagnostic accuracy of choline PET in detecting sites of PCa relapse has been investigated by several authors, and the overall reported sensitivity ranges between 38% and 98%. It has been demonstrated that choline PET technology's positive detection rate improves with increasing PSA values. The routine use of choline PET/CT cannot be recommended for PSA values

Aims To (a) assess the accuracy of F-18-FDG PET/CT in distinguishing malignant from benign pelvic lesions, compared to transvaginal ultrasonography (TVUS) and (b) to establish the role of whole-body F-18-FDG PET/CT, compared to contrast enhanced computed tomography (CT), in staging patients with ovarian cancer. final pathological staging in 22/32 (69%) patients while CT results were concordant in 17/32 (53%) patients. CT incorrectly down-staged four out of six stage IV patients by missing distant metastasis in the liver, pleura, mediastinum, and in left supraclavicular lymph nodes, which were correctly detected by F-18-FDG PET/CT. Patients Fifty consecutive patients with a pelvic lesion, already scheduled for surgery on the basis of physical examination, TVUS, and serum Ca125 levels, were enrolled in the study. Patients' age ranged between 23 and 89 years (mean 64). All patients underwent TVUS including a colour Doppler study followed by a thorax and abdominal CT scan, and whole-body F-18-FDG PIET/CT within 2 weeks prior to surgery. Histological findings obtained at surgery were taken as the 'gold standard' to compare F-18-FDG PET/CT and TVUS, and F-18-FDG PET/CT vs. CT. When tissue analysis showed ovarian cancer, the accuracy of F-18-FDG PET/CT and CT were compared for the purpose of obtaining a precise staging. Results At surgery, the ovarian lesions were malignant in 32/50 patients (64%) and benign in the remaining 18/50 patients (36%). The sensitivity, specificity, NPV, PPV and accuracy of F-18-FDG PET/CT were 87%,100%, 81 %, 100% and 92%, respectively, compared with 90%, 61%, 78%, 80% and 80%, respectively, for TVUS. In staging ovarian cancer, 18F-FDG PET/CT results were concordant with Conclusion PET/CT with 18F-FDG provides additional value to TVUS for the differential diagnosis of benign from malignant pelvic lesions, and to CT for the staging of ovarian cancer patients. Nucl Med Commun 28:589-595 (c) 2007 Lippincott Williams & Wilkins.

Purpose\ud To assess the value of 18F-Fluorodeoxyglucose (18F-FDG) PET Radiomic Features (RF) in predicting Distant Relapse Free Survival (DRFS) in patients with Locally Advanced Pancreatic Cancer (LAPC) treated with radio-chemotherapy.\ud \ud Materials & methods\ud One-hundred-ninety-eight RFs were extracted using IBSI (Image Biomarker Standardization Initiative) consistent software from pre-radiotherapy images of 176 LAPC patients treated with moderate hypo-fractionation (44.25 Gy, 2.95 Gy/fr). Tumors were segmented by applying a previously validated semi-automatic method. One-hundred-twenty-six RFs were excluded due to poor reproducibility and/or repeatability and/or inter-scanner variability. The original cohort was randomly split into a training (n = 116) and a validation (n = 60) group. Multi-variable Cox regression was applied to the training group, including only independent RFs in the model. The resulting radiomic index was tested in the validation cohort. The impact of selected clinical variables was also investigated.\ud \ud Results\ud The resulting Cox model included two first order RFs: Center of Mass Shift (COMshift) and 10th Intensity percentile (P10) (p = 0.0005, HR = 2.72, 95%CI = 1.54–4.80), showing worse outcomes for patients with lower COMshift and higher P10. Once stratified by quartile values (highest quartile vs the remaining), the index properly stratified patients according to their DRFS (p = 0.0024, log-rank test). Performances were confirmed in the validation cohort (p = 0.03, HR = 2.53, 95%CI = 0.96–6.65). The addition of clinical factors did not significantly improve the models’ performance.\ud \ud Conclusions\ud A radiomic-based index including only two robust PET-RFs predicted DRFS of LAPC patients after radio-chemotherapy. The current results could find relevant applications in the treatment personalization of LAPC. A multi-institution independent validation has been planned.

ObjectiveTo investigate the predictive value of the Diverticular Inflammation and Complication Assessment (DICA) classification and to develop and validate a combined endoscopic-clinical score predicting clinical outcomes of diverticulosis, named Combined Overview on Diverticular Assessment (CODA).DesignA multicentre, prospective, international cohort study.Setting43 gastroenterology and endoscopy centres located in Europe and South America.Participants2215 patients (2198 completing the study) at the first diagnosis of diverticulosis/diverticular disease were enrolled. Patients were scored according to DICA classifications.InterventionsA 3-year follow-up was performed.Main outcome measuresTo predict the acute diverticulitis and the surgery according to DICA classification. Survival methods for censored observation were used to develop and validate a novel combined endoscopic-clinical score for predicting diverticulitis and surgery (CODA score).ResultsThe 3-year cumulative probability of diverticulitis and surgery was of 3.3% (95% CI 2.5% to 4.5%) in DICA 1, 11.6% (95% CI 9.2% to 14.5%) in DICA 2 and 22.0% (95% CI 17.2% to 28.0%) in DICA 3 (p10% and >2.5% in CODA C, respectively. The CODA score showed optimal discrimination capacity in predicting the risk of surgery in the development (c-statistic: 0.829; 95% CI 0.811 to 0.846) and validation cohort (c-statistic: 0.943; 95% CI 0.905 to 0.981).ConclusionsDICA classification has a significant role in predicting the risk of diverticulitis and surgery in patients with diverticulosis, which is significantly enhanced by the CODA score.Trial registration numberNCT02758860.

Purpose: The aim of this study was to investigate the role of 18F-FDG PET/CT in predicting pathological prognostic factors, including tumor type and International Federation of Gynecology and Obstetrics (FIGO) score, in gestational trophoblastic disease (GTD). Methods: Retrospective monocentric study including 24 consecutive patients who underwent to 18F-FDG PET/CT from May 2005 to March 2021 for GTD staging purpose. The following semiquantitative PET parameters were measured from the primary tumor and used for the analysis: maximum standardized uptake value (SUVmax), SUVmean, metabolic tumor volume (MTV) and total lesion glycolisis (TLG). Statistical analysis included Spearman correlation coefficient to evaluate the correlations between imaging parameters and tumor type (nonmolar trophoblastic vs postmolar trophoblastic tumors) and risk groups (high vs low, defined according to the FIGO score), whereas area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to assess the predictive value of the PET parameters. Mann-Whitney U test was used to further describe the parameter's potential in differentiating the populations. Results: SUVmax and SUVmean resulted fair (AUC, 0.783; 95% confidence interval [CI], 0.56-0.95) and good (AUC, 0.811; 95% CI, 0.59-0.97) predictors of tumor type, respectively, showing a low (ρ = 0.489, adjusted P = 0.030) and moderate (ρ = 0.538, adjusted P = 0.027) correlation. According to FIGO score, TLG was instead a fair predictor (AUC, 0.770; 95% CI, 0.50-0.99) for patient risk stratification. Conclusions: 18F-FDG PET parameters have a role in predicting GTD pathological prognostic factors, with SUVmax and SUVmean being predictive for tumor type and TLG for risk stratification.

Aim The assessment of deep myometrial invasion (MI) and lymph node involvement is of utmost importance in the preoperative staging of endometrial cancer (EC). Imaging parameters derived respectively from MRI and PET have shown good predictive value. The main aim of the present study is to assess the diagnostic performance of hybrid 18F-FDG PET/MRI in EC staging, with particular focus on MI and lymphnodal involvement detection. Patients and Methods Prospective monocentric study including 35 patients with biopsy-proven EC undergoing preoperative 18F-FDG PET/MRI (December 2018-March 2021) for staging purpose. Histological examination was the reference standard. PET (SUVmax, SUVmean with a threshold of 40% of SUVmax-SUVmean40, metabolic tumor volume, total lesion glycolysis) and MRI (volume index [VI], total tumor volume, tumor volume ratio [TVR], mean apparent diffusion coefficient, minimum apparent diffusion coefficient) parameters were calculated on the primary tumor, and their role in predicting EC risk group, the presence of lymphovascular space invasion (LVSI), and MI was assessed. Receiver operating characteristics analysis was used to assess the predictive value of PET and MRI parameters on EC characteristics. Results Patients' median age was 66.57 years (SD, 10.21 years). 18F-FDG PET/MRI identified the primary tumor in all patients. Twenty-two of 35 patients had high-risk EC and 13/35 low-risk disease; 13/35 presented LVSI, 22/35 had deep MI at histological examination, and 13/35 had p53 hyperexpression. PET/MRI was able to detect lymphnodal involvement with high accuracy and high specificity (sensitivity of 0.8571, specificity of 0.9286, accuracy of 0.9143), also showing a high negative predictive value (NPV) for lymphnodal involvement (NPV of 0.9630, positive predictive value [PPV] of 0.7500). The assessment of deep MI using PET/MRI correctly staged 27 patients (77.1%; sensitivity of 0.7273, specificity of 0.8462, accuracy of 0.7714), with also a good PPV (PPV of 0.8889, NPV of 0.647). MRI-derived total tumor volume, VI, and TVR were significant in predicting EC groups (high-risk vs low-risk patients) (P = 0.0059, 0.0235, 0.0181, respectively). MRI-derived volume, VI, TVR, and PET-derived metabolic tumor volume and total lesion glycolysis were able to predict LVSI (P = 0.0023, 0.0068, 0.0068, 0.0027, 0.01394, respectively). Imaging was not able to predict grading, presence of deep MI, nor hyperexpression of p53. Conclusions 18F-FDG PET/MRI has good accuracy in preoperative staging of EC; PET and MRI parameters have synergic role in preoperatively predicting LVSI, with MRI parameters being also predictive for EC risk group.

Purpose Several factors have been identified that predict positive fluorine-18-fluoromethylcholine (18F-FCH) PET/CT result in patients with prostate cancer undergoing PET/CT for biochemical failure. Among these factors, prostate-specific antigen (PSA) is the single factor most consistently associated with the prediction of positive 18F-FCH PET/CT. In this study, we wished to confirm this finding and expand it in a large series of patients. Patients and methods We retrospectively analyzed 192 patients with prostate cancer who were recruited from the Nuclear Medicine Department of the Sant'Andrea Hospital of La Spezia, Italy, from March 2013 to March 2018 and who underwent 18F-FCH PET/CT owing to biochemical failure after radical prostatectomy. Results Median trigger PSA was 2.57 ng/ml. The overall positive detection rate of 18F-FCH PET/CT was 60.9%. The percent of positive scans was 30.5% for PSA less than 1 ng/ml, 59.4% (38/64) for PSA between 1 and 5 ng/ml, and 88.4% for PSA greater than 5 ng/ml (P

BACKGROUND To investigate the correlation between 18F-labeled fluoroazomycinarabinoside (18F-FAZA) PET data and hypoxia immunohistochemical markers in patients with high-grade glioma (HGG). PATIENTS AND METHODS Prospective study including 20 patients with brain MRI suggestive for HGG and undergoing 18F-FAZA PET/CT before treatment for hypoxia assessment. For each 18F-FAZA PET scan SUVmax, SUVmean and 18F-FAZA tumour volume (FTV) at 40, 50 and 60% threshold of SUVmax were calculated; hypoxic volume was estimated by applying different thresholds (1.2, 1.3 and 1.4) to tumour/blood ratio. Seventeen patients were analysed. The immunohistochemical analysis assessed the following parameters: hypoxia-inducible factor 1α, carbonic anhydrase IX (CA-IX), glucose transporter-1, tumour vascularity and Ki-67. RESULTS 18F-FAZA PET showed a single lesion in 15/17 patients and multiple lesions in 2/17 patients. Twelve/17 patients had grade IV glioma and 5/17 with grade III glioma. Bioptic and surgical samples have been analysed separately. In the surgical subgroup (n = 7) a positive correlation was observed between CA-IX and SUVmax (P = 0.0002), SUVmean40 (P = 0.0058), SUVmean50 (P = 0.009), SUVmean60 (P = 0.0153), FTV-40-50-60 (P = 0.0424) and hypoxic volume1.2-1.3-1.4 (P = 0.0058). In the bioptic group (n = 10) tumour vascularisation was inversely correlated with SUVmax (P = 0.0094), SUVmean40 (P = 0.0107), SUVmean50 (P = 0.0094) and SUVmean60 (P = 0.0154). CONCLUSIONS The correlation of 18F-FAZA PET parameters with CD31 and CA-IX represents a reliable method for assessing tumour hypoxia in HGG. The inverse correlation between tumour vascularisation, SUVmax and SUVmean suggest that highly vascularized tumours might present more oxygen supply than hypoxia.

Background: The accurate detection of nodal invasion is an unmet need in the clinical staging of renal cancer. Positron emission tomography (PET) with 18F-fluoroazomycin arabinoside (18F-FAZA), a hypoxia specific tracer, is a non-invasive imaging method that detects tumour hypoxia. The aim of this work was to evaluate the role of 18F-FAZA PET/CT in the identification of lymph node metastases in renal cancer. Methods: A proof-of-concept phase 2 study including 20 kidney cancer patients (ClinicalTrials.gov Identifier: NCT03955393) was conducted. Inclusion criteria were one or more of the following three criteria: (1) clinical tumour size > 10cm, (2) evidence of clinical lymphadenopathies at preoperative CT scan and (3) clinical T4 cancer. Before surgery, 18F-FAZA PET/CT was performed, 2h after the intravenous injection of the radiotracer. An experienced nuclear medicine physician, aware of patient’s history and of all available diagnostic imaging, performed a qualitative and semi-quantitative analysis on 18F-FAZA images. Histopathological analysis was obtained in all patients on surgical specimen. Results: Fourteen/19 (74%) patients had a non-organ confined renal cell carcinoma (RCC) at final pathology (either pT3 or pT4). Median number of nodes removed was 12 (IQR 7–15). The rate of lymph node invasion was 16%. No patient with pN1 disease showed positive 18F-FAZA PET, thus suggesting the non-hypoxic behaviour of the lesions. In addition, neither primary tumour nor distant metastases presented a pathological 18F-FAZA uptake. No adverse events were recorded during the study. Conclusions: 18F-FAZA PET/CT scan did not detect RCC lymph neither nodal nor distant metastases and did not show any uptake in the primary renal tumour.

Background The aim of the present study is to explore the correlation between PET and MRI parameters of primary tumour and clinicopathological features and to determine their synergic predictive role in patients with endometrial cancer candidate to surgery. Methods Retrospective study including 27 patients with endometrial cancer and preoperative 18F-fluorodeoxyglucose (18F-FDG)-PET and MRI scan. The following parameters, calculated on the primary tumour, were used for analysis: maximum standardized uptake value (SUVmax), SUVmean, metabolic tumour volume (MTV) and total lesion glycolysis (TLG) for PET scans; mean apparent diffusion coefficient (ADCmean) and volume index for MRI scans. FIGO stage, grade, histotype, lymphovascular space invasion (LVSI) and myometrial invasion were the considered clinicopathological features. Results MRI volume index was a good predictor for deep myometrial invasion [area under the curve (AUC) = 0.85; P = 0.003] and for LVSI (AUC = 0.74; P = 0.039). A cutoff value of 9.555 for MRI volume index was predictive for deep myometrial invasion (sensitivity = 84.6%; specificity = 76.9%); a cutoff of 12.165 was predictive for LVSI (sensitivity = 69.2%; specificity = 83.3%). A TLG cutoff value of 26.03 was predictive for deep myometrial invasion (sensitivity = 84.6%; specificity = 76.9%). A high-direct correlation was found with MRI volume index (rho = 0.722; P < 0.001); low-direct correlation with SUVmax (rho = 0.484; P = 0.012), SUVmean (rho = 0.47; P = 0.015) and TLG (rho = 0.482; P = 0.013) were identified. The SUVmax/ADCmean ratio showed a low-direct correlation with percentage of myometrial invasion (rho = 0.467; P = 0.016). Conclusion Volume index, TLG and SUVmax/ADCmean ratio are associated with deep myometrial invasion. As myometrial invasion is the index used to predict lymph node involvement in endometrial cancer, the synergic use of these imaging parameters may be suggested to predict lymphnodal metastases.

The presence of hypoxia is a typical feature of solid tumors and has been identified in many neoplasms, favouring the survival of malignant cells in a hostile environment and the expression of an aggressive phenotype. Malignant brain tumors have large proportions of hypoxic tissue, thus contributing to resistance to radiation and chemotherapy. Positron emission tomography (PET) is an attractive technique to gain a non-invasive assessment of tumor hypoxia within the whole tumor, with 18F-fluoromisonidazole (18F-FMISO) and 18F-flouroazomycin arabinoside (18F-FAZA) being the most promising radiotracers. In this short review, we aim to discuss the available clinical studies focused on the use of 18F-FAZA PET/computed tomography in patients affected by high-grade glioma.

Objective: Several studies have reported about the performance of C-choline-PET/computed tomography (CT) (choline) in patients with biochemical recurrent (BCR) prostate cancer, but there is a lack of information regarding negative choline in the same clinical setting. Our aim was to retrospectively analyse negative choline in a cohort of BCR-patients with high prostate-specific antigen (PSA). Methods and results: We retrospectively analysed all choline-scans performed at two high-volume imaging centres between 2005 and 2018, selecting those of interest according to the following inclusion criteria: (1) proven prostate cancer treated either with radical prostatectomy or primary external beam radiation therapy (EBRT), (2) BCR after radical prostatectomy or EBRT, (3) PSA serum values >20 ng/mL at the time of scan and (4) scan reported as negative for active disease. Overall, among 5792 scans performed for BCR-prostate cancer, 14 matched the inclusion criteria and were classified as follows: 5/14(36%) inaccurate reports, 3/14(21%) questionable underestimation of positive findings, originally described as unclear, 6/14(43%) negatives. Choline showed a high detection rate in BCR-prostate cancer patients with PSA >20 ng/mL. Conclusions: Although negative reports can be found in this clinical setting, in our review various disease-relevant findings were identified in more than half of the cases originally reported as negative warranting a double reading in such cases to avoid false-negative reports.