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Aujourd’hui, aucun element fiable ne permet de predire correctement la reponse tumorale a un traitement. La surveillance de l’evolution tumorale sous traitement reste donc primordiale. En routine clinique, les dosages sanguins de marqueurs tumoraux et l’imagerie anatomique sont les plus utilises mais presentent des limites non negligeables. La tomographie par emission de positons (TEP) au 18F-fluoro-desoxyglucose (18F-FDG), qui est une modalite d’imagerie moleculaire et fonctionnelle, constitue de ce fait une methode de choix pour l’evaluation de la reponse. Son role pourrait etre encore plus important dans le suivi des tumeurs traitees par therapies ciblees. Le developpement de nouveaux traceurs permet de pallier certaines limitations de la TEP au 18F-FDG. Le role de la TEP dans le suivi de la reponse therapeutique ne peut donc que croitre dans les prochaines annees.

Table of contents A1 68Ga-PSMA PET/CT in staging and restaging of Prostate Cancer Patients: comparative study with 18F-Choline PET/CT W Langsteger, A Rezaee, W Loidl, HS Geinitz, F Fitz, M Steinmair, G Broinger, L Pallwien-Prettner, M Beheshti A2 F18 Choline PET – CT: an accurate diagnostic tool for the detection of parathyroid adenoma? L Imamovic, M Beheshti, G Rendl, D Hackl, O Tsybrovsky, M Steinmair, K Emmanuel, F Moinfar, C Pirich, W Langsteger A3 [18F]Fluoro-DOPA-PET/CT in the primary diagnosis of medullary thyroid carcinoma A Bytyqi, G Karanikas, M Mayerhöfer, O Koperek, B Niederle, M Hartenbach A4 Variations of clinical PET/MR operations: An international survey on the clinical utilization of PET/MRI T Beyer, K Herrmann, J Czernin A5 Standard Dixon-based attenuation correction in combined PET/MRI: Reproducibility and the possibility of Lean body mass estimation I Rausch, P Rust, MD DiFranco, M Lassen, A Stadlbauer, ME Mayerhöfer, M Hartenbach, M Hacker, T Beyer A6 High resolution digital FDG PET/MRI imaging for assessment of ACL graft viability K Binzel, R Magnussen, W Wei, MU Knopp, DC Flanigan, C Kaeding, MV Knopp A7 Using pre-existing hematotoxicity as predictor for severe side effects and number of treatment cycles of Xofigo therapy A Leisser, M Nejabat, M Hartenbach, G Kramer, M Krainer, M Hacker, A Haug A8 QDOSE – comprehensive software solution for internal dose assessment Wencke Lehnert, Karl Schmidt, Sharok Kimiaei, Marcus Bronzel, Andreas Kluge A9 Clinical impact of Time-of-Flight on next-generation digital PET imaging of Yttrium-90 radioactivity following liver radioembolization CL Wright, K Binzel, J Zhang, Evan Wuthrick, Piotr Maniawski, MV Knopp A10 Snakes in patients! Lessons learned from programming active contours for automated organ segmentation M Blaickner, E Rados, A Huber, M Dulovits, H Kulkarni, S Wiessalla, C Schuchardt, RP Baum, B Knäusl, D Georg A11 Influence of a genetic polymorphism on brain uptake of the dual ABCB1/ABCG2 substrate [11C]tariquidar M Bauer, B Wulkersdorfer, W Wadsak, C Philippe, H Haslacher, M Zeitlinger, O Langer A12 Outcome prediction of temporal lobe epilepsy surgery from P-glycoprotein activity. Pooled analysis of (R)-[11C]-verapamil PET data from two European centres M Bauer, M Feldmann, R Karch, W Wadsak, M Zeitlinger, MJ Koepp, M-C Asselin, E Pataraia, O Langer A13 In-vitro and in-vivo characterization of [18F]FE@SNAP and derivatives for the visualization of the melanin concentrating hormone receptor 1 M Zeilinger, C Philippe, M Dumanic, F Pichler, J Pilz, M Hacker, W Wadsak, M Mitterhauser A14 Reducing time in quality control leads to higher specific radioactivity of short-lived radiotracers L Nics, B Steiner, M Hacker, M Mitterhauser, W Wadsak A15 In vitro 11C-erlotinib binding experiments in cancer cell lines with epidermal growth factor receptor mutations A Traxl, Thomas Wanek, Kushtrim Kryeziu, Severin Mairinger, Johann Stanek, Walter Berger, Claudia Kuntner, Oliver Langer A16 7-[11C]methyl-6-bromopurine, a PET tracer to measure brain Mrp1 function: radiosynthesis and first PET evaluation in mice S Mairinger, T Wanek, A Traxl, M Krohn, J Stanek, T Filip, M Sauberer, C Kuntner, J Pahnke, O Langer A17 18F labeled azidoglucose derivatives as “click” agents for pretargeted PET imaging D Svatunek, C Denk, M Wilkovitsch, T Wanek, T Filip, C Kuntner-Hannes, J Fröhlich, H Mikula A18 Bioorthogonal tools for PET imaging: development of radiolabeled 1,2,4,5-Tetrazines C Denk, D Svatunek, T Wanek, S Mairinger, J Stanek, T Filip, J Fröhlich, H Mikula, C Kuntner-Hannes A19 Preclinical evaluation of [18F]FE@SUPPY- a new PET-tracer for oncology T Balber, J Singer, J Fazekas, C Rami-Mark, N Berroterán-Infante, E Jensen-Jarolim, W Wadsak, M Hacker, H Viernstein, M Mitterhauser A20 Investigation of Small [18F]-Fluoroalkylazides for Rapid Radiolabeling and In Vivo Click Chemistry C Denk, D Svatunek, B Sohr, H Mikula, J Fröhlich, T Wanek, C Kuntner-Hannes, T Filip A21 Microfluidic 68Ga-radiolabeling of PSMA-HBED-CC using a flow-through reactor S Pfaff, C Philippe, M Mitterhauser, M Hartenbach, M Hacker, W Wadsak A22 Influence of 24-nor-ursodeoxycholic acid on hepatic disposition of [18F]ciprofloxacin measured with positron emission tomography T Wanek, E Halilbasic, M Visentin, S Mairinger, B Stieger, C Kuntner, M Trauner, O Langer A23 Automated 18F-flumazenil production using chemically resistant disposable cassettes P Lam, M Aistleitner, R Eichinger, C Artner A24 Similarities and differences in the synthesis and quality control of 177Lu-DOTA-TATE, 177Lu -HA-DOTA-TATE and 177Lu-DOTA-PSMA (PSMA-617) H Eidherr, C Vraka, A Haug, M Mitterhauser, L Nics, M Hartenbach, M Hacker, W Wadsak A25 68Ga- and 177Lu-labelling of PSMA-617 H Kvaternik, R Müller, D Hausberger, C Zink, RM Aigner A26 Radiolabelling of liposomes with 67Ga and biodistribution studies after administration by an aerosol inhalation system U Cossío, M Asensio, A Montes, S Akhtar, Y te Welscher, R van Nostrum, V Gómez-Vallejo, J Llop A27 Fully automated quantification of DaTscan SPECT: Integration of age and gender differences F VandeVyver, T Barclay, N Lippens, M Troch A28 Lesion-to-background ratio in co-registered 18F-FET PET/MR imaging – is it a valuable tool to differentiate between low grade and high grade brain tumor? L Hehenwarter, B Egger, J Holzmannhofer, M Rodrigues-Radischat, C Pirich A29 [11C]-methionine PET in gliomas - a retrospective data analysis of 166 patients N Pötsch, I Rausch, D Wilhelm, M Weber, J Furtner, G Karanikas, A Wöhrer, M Mitterhauser, M Hacker, T Traub-Weidinger A30 18F-Fluorocholine versus 18F-Fluorodeoxyglucose for PET/CT imaging in patients with relapsed or progressive multiple myeloma: a pilot study T Cassou-Mounat, S Balogova, V Nataf, M Calzada, V Huchet, K Kerrou, J-Y Devaux, M Mohty, L Garderet, J-N Talbot A31 Prognostic benefit of additional SPECT/CT in sentinel lymph node mapping of breast cancer patients S Stanzel, G Pregartner, T Schwarz, V Bjelic-Radisic, B Liegl-Atzwanger, R Aigner A32 Evaluation of diagnostic value of TOF-18F-FDG PET/CT in patients with suspected pancreatic cancer S Stanzel, F Quehenberger, RM Aigner A33 New quantification method for diagnosis of primary hyperpatahyroidism lesions and differential diagnosis vs thyropid nodular disease in dynamic scintigraphy A Koljević Marković, Milica Janković, V Miler Jerković, M Paskaš, G Pupić, R Džodić, D Popović A34 A rare case of diffuse pancreatic involvement in patient with merkel cell carcinoma detected by 18F-FDG MC Fornito, D Familiari A35 TSH-stimulated 18F-FDG PET/CT in the diagnosis of recurrent/metastatic radioiodine-negative differentiated thyroid carcinomas in patients with various thyroglobuline levels P Koranda, H Polzerová, I Metelková, L Henzlová, R Formánek, E Buriánková, M Kamínek A36 Breast Dose from lactation following I131 treatment WH Thomson, C Lewis A37 A new concept for performing SeHCAT studies with the gamma camera WH Thomson, J O’Brien, G James, A Notghi A38 Whole body F-18-FDG-PET and tuberculosis: sensitivity compared to x-ray-CT H Huber, I Stelzmüller, R Wunn, M Mandl, F Fellner, B Lamprecht, M Gabriel A39 Emerging role 18F-FDG PET-CT in the diagnosis and follow-up of the infection in heartware ventricular assist system (HVAD) MC Fornito, G Leonardi A40 Validation of Poisson resampling software WH Thomson, J O’Brien, G James A41 Protection of PET nuclear medicine personnel: problems in satisfying dose limit requirements J Hudzietzová, J Sabol, M Fülöp

Rationale: It was hypothesised that Iniparib or 4-iodo-3-nitrobenzamide acts as an irreversible inhibitor of PARP1 and possibly other enzymes. It has shown successively promising then confusing results in MTNBC in combination with chemotherapy. To date, its mechanism of action has not been completely elucidated but since 1992, inhibition of glycolysis by iniparib and subsequent necrotic cell death has been described. We hypothesised that early inhibition of glycolysis evidenced by in-vivo imaging with 2-((18)F)Fluoro-2-Deoxy-D-Glucose Positron-Emission Tomography (18FDG-PET) may be a predictor of efficacy to iniparib, as it was previously reported for other anticancer drugs. Objectives: To detect metabolic pharmacodynamic effect of iniparib plus chemotherapy by means of 18FDG PET and proof the concept of its use as an early predicitive tool of Iniparib efficacy in MTNBC. Patients & Methods: From March to November 2011, 8 pts were included in our institution in a randomized phase II study comparing bi-weekly versus weekly iniparib treatement in combination with gemcitanine and carboplatin. All patients had 18FDG-PET at baseline, at day 7 (D7). The maximum value of standardized uptake value (SUVmax) of all measurable metastatic lesions was measured and the median SUVmax was calculated for all patients at baseline and D7. The metabolic response was defined as the percentage of reduction of SUVmax (SUVmax Baseline — SUVmax D7) / SUVmax Baseline and the median SUVmax response was correlated to RECIST 1.1 response at six weeks and to disease-free survival (DFS). Results: The median decrease in SUVmax of evaluable lesions measured at D7 was predictive of RECIST 1.1 response at six weeks and was correlated to the best obtained response during the treatment phase. Furthermore, it showed a linear correlation with DFS (y = −0,0007x - 0,1325; R2 = 0,3402). Conclusion: Metabolic pharmacodynamic effect as evidenced by 18FDG PET as soon as one week of treatement act as an early predicitive tool of Iniparib plus chemotherapy efficacy in MTNBC. Considering the lack of a predicitive biomarker of response and if confirmed on larger study, 18FDG PET could be used as a surrogate predictive biomarker is this setting. These results may be considered as an in-vivo proof of concept for the inhibition of glycolysis by iniparib. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-10-01.

Ce chapitre porte sur la prise en charge diagnostique et therapeutique d’une recidive intramammaire homolaterale isolee d’un cancer du sein ayant eu initialement un traitement conservateur. Il exclut la surveillance apres traitement de la recidive locale. La recidive locale isolee homolaterale est definie comme une recidive intramammaire dans le sein traite (y compris avec atteinte de la peau par contiguite ou nodule isole sur la cicatrice initiale mais exclut les nodules de permeation et les recidives associees a une localisation ganglionnaire ou metastatique). La tumeur initiale et la recidive peuvent etre un cancer in situ et/ ou invasif.

Summary Background: Occult invasive disease could be found at definitive histology in patients initially diagnosed with large ductal carcinoma in situ (DCIS). Sentinel lymph node (SLN) biopsy is a reliable and minimally invasive procedure providing axillary information and avoiding a second operation in this particular group of patients. The aim of our study was to assess the value of SLN biopsy in patients with large DCIS who are at highest risk for being upstaged to invasive carcinoma. Patients and methods: The study included 195 patients diagnosed with DCIS upon initial core biopsy and undergoing SLN biopsy. Many features were correlated with the presence of unsuspected invasive disease and positive SLN biopsy using univariate and multivariate analyses. Results: Of the 110 patients with pure DCIS, seven patients (6%) had a metastatic lymph node; 31 patients (16%) were found to have invasive disease upon final histology. Univariate analysis of predictors of unsuspected invasive carcinoma showed that patients having a preoperative biopsy that indicated DCIS with microinvasion (DCISM) or large DCIS were at a higher risk of invasive carcinoma after histological examination of the operative specimen. Of the 31 patients who were upstaged to invasive carcinoma at final histology, seven patients (22%) had a positive SLN biopsy. The analysis of predictors of positive SLN in our study shows that diffuse DCIS requiring mastectomy is the main risk factor for SLN metastasis. Conclusion: There are no real predictive factors for invasive disease in patients with an initial diagnosis of DCIS or DCISM. Our study supports the value of SLN biopsy in patients with a preoperative DCISM biopsy or patients with a large pure DCIS biopsy requiring mastectomy.

During the last half of century considerable research on radiosensitivity biomarkers has been published. However, to date there is no non-invasive marker of cellular radiosensitivity identified for clinical routinely use. In this review, the main functional and metabolic imaging isotopic techniques for tumor radiosensitivity that have been explored over the last years are being described. This indirect evaluation fall into 3 topics associated with tumor proliferation rate or apoptosis, tumor hypoxic fraction, neoangiogenesis and the intrinsic radiosensitivity of clonogenic tumor cells. The final objective of the radiosensitivity monitoring during radiotherapy would be to adapt treatment strategy for overcoming the identified radioresistance mechanism such as hypoxia by the addition of radiosensitisers for example. This would allow better tumor control rather than continue inefficient and costly treatment delivery, which in addition could compromise outcome.

Purpose: To report a retrospective study concerning the impact of fused 18F-fluoro-deoxy- d -glucose (FDG)-hybrid positron emission tomography (PET) and CT images on three-dimensional conformal radiotherapy planning for patients with non–small-cell lung cancer. Methods and Materials: A total of 101 patients consecutively treated for Stage I–III non–small-cell lung cancer were studied. Each patient underwent CT and FDG-hybrid PET for simulation treatment in the same treatment position. Images were coregistered using five fiducial markers. Target volume delineation was initially performed on the CT images, and the corresponding FDG-PET data were subsequently used as an overlay to the CT data to define the target volume. Results: 18F-fluoro-deoxy- d -glucose-PET identified previously undetected distant metastatic disease in 8 patients, making them ineligible for curative conformal radiotherapy (1 patient presented with some positive uptake corresponding to concomitant pulmonary tuberculosis). Another patient was ineligible for curative treatment because the fused PET-CT images demonstrated excessively extensive intrathoracic disease. The gross tumor volume (GTV) was decreased by CT-PET image fusion in 21 patients (23%) and was increased in 24 patients (26%). The GTV reduction was ≥25% in 7 patients because CT-PET image fusion reduced the pulmonary GTV in 6 patients (3 patients with atelectasis) and the mediastinal nodal GTV in 1 patient. The GTV increase was ≥25% in 14 patients owing to an increase in the pulmonary GTV in 11 patients (4 patients with atelectasis) and detection of occult mediastinal lymph node involvement in 3 patients. Of 81 patients receiving a total dose of ≥60 Gy at the International Commission on Radiation Units and Measurements point, after CT-PET image fusion, the percentage of total lung volume receiving >20 Gy increased in 15 cases and decreased in 22. The percentage of total heart volume receiving >36 Gy increased in 8 patients and decreased in 14. The spinal cord volume receiving at least 45 Gy (2 patients) decreased. Multivariate analysis showed that tumor with atelectasis was the single independent factor that resulted in a significant effect on the modification of the size of the GTV by FDG-PET: tumor with atelectasis (with vs. without atelectasis, p = 0.0001). Conclusion: The results of our study have confirmed that integrated hybrid PET/CT in the treatment position and coregistered images have an impact on treatment planning and management of non–small-cell lung cancer. However, FDG images using dedicated PET scanners and respiration-gated acquisition protocols could improve the PET-CT image coregistration. Furthermore, the impact on treatment outcome remains to be demonstrated.

Resume Objectif de l'etude. – Evaluer dans une serie retrospective l'impact du recalage d'images de tomographie par emission de positons (TEP) au 18 fluorodeoxyglucose ([18F]-FDG) et detection en coincidence (TEDC) par gamma-camera et d'images de simulation virtuelle par tomodensitometrie pour la radiotherapie conformationnelle des cancers bronchiques non a petites cellules. Patients et methodes. – Les dossiers de cent un patients consecutifs atteints d'un cancer bronchique non a petites cellules de stades I a III ont ete etudies. Tous les patients ont eu une tomographie par emission de positons au [18F]-FDG et detection en coincidence et une simulation virtuelle par tomodensitometrie dans la meme position de traitement. Cinq reperes cutanes ont permis la mise en correspondance des images tomographiques par emission de positons et tomodensitometriques de maniere semi-automatique. Dans un premier temps, le volume cible a ete defini par imagerie tomodensitometrique seule. Dans un deuxieme temps, les contours du volume cible ont ete redefinis sur les deux types d'images simultanement affichees a l'ecran de la console d'imagerie. Resultats. – La tomographie par emission de positons au [18F]-FDG a permis d'identifier des metastases a distance occultes chez huit patients (dont un faux-positif pour une partie des images d'hyperfixation dans les parenchymes pulmonaires correspondant a une tuberculose pulmonaire concomitante), et un patient est devenu egalement ineligible pour une radiotherapie conformationnelle a visee curative par l'importance du volume tumoral apres fusion d'images. Apres fusion d'images tomographiques par emission de positons et tomodensitometriques, le volume tumoral macroscopique (GTV) a ete reduit chez 21 patients (23 %) et augmente chez 24 patients (26 %). La reduction du volume tumoral macroscopique etait superieure ou egale a 25 % dans sept cas, par reduction du volume tumoral macroscopique pulmonaire dans six cas, dont trois avec atelectasie, et par reduction du volume tumoral macroscopique ganglionnaire mediastinal dans un cas. L'augmentation du volume tumoral macroscopique etait superieure ou egale a 25 % dans 14 cas, par detection d'une atteinte ganglionnaire mediastinale dans trois cas, et par augmentation du volume tumoral macroscopique pulmonaire dans 11 cas, dont quatre avec atelectasie. Sur 81 patients ayant recu une dose superieure ou egale a 60 Gy au point ICRU, le pourcentage de volume pulmonaire sain recevant plus de 20 Gy a ete augmente dans 15 cas et reduit dans 22 cas. Le pourcentage de volume cardiaque recevant au moins 36 Gy a ete augmente chez huit patients et reduit chez 14 patients. Le volume de moelle epiniere recevant au moins 45 Gy (deux patients) a ete diminue. Apres analyse multifactorielle, un seul facteur independant a eu un impact significatif sur la modification du volume tumoral macroscopique : la presence d'une atelectasie ( p = 0,0001). Conclusion. – Notre etude confirme que la fusion d'images tomographiques par emission de positons au [18F]-FDG et detection en coincidence et d'images de simulation virtuelle par tomodensitometrie pour la radiotherapie conformationnelle de cancer bronchique non a petites cellules a non seulement un impact sur la strategie therapeutique, mais aussi sur la planification de la radiotherapie. L'imagerie par tomographie par emission de positons–tomodensitometrie dediee, utilisant une methode de recalage d'images elastique, tenant compte des mouvements de la cage thoracique lies a la respiration avec un protocole de controle des mouvements respiratoires, devrait ameliorer la precision de la technique de recalage d'images metaboliques et anatomiques. Cependant, l'interet de ces techniques demanderait a etre confirme par controle histopathologique et l'impact sur le controle tumoral local et la survie reste a demontrer.

Resume Objectif de l'etude. – Evaluer l'impact de la fusion d'images de tomographie par emission de positons (TEP) au 18fluorodeoxyglucose ([18F]-FDG) et detection en coincidence par gamma camera et d'images de simulation virtuelle par tomodensitometrie pour la radiotherapie conformationnelle des cancers de l'œsophage. Patients et methodes. – Les dossiers de 34 patients consecutifs atteints d'un cancer de l'œsophage ont ete etudies. Tous les patients ont eu une TEP au [18F]-FDG avec detection en coincidence et une simulation virtuelle par tomodensitometrie dans la meme position de traitement. Cinq reperes cutanes ont permis la mise en correspondance des images TEP et tomodensitometriques de maniere semi-automatique. Dans un premier temps, le volume cible a ete defini par imagerie tomodensitometrique seule. Dans un deuxieme temps, les contours du volume cible ont ete redefinis sur les deux types d'images simultanement affichees a l'ecran de la console d'imagerie. Resultats. – La TEP au [18F]-FDG a permis d'identifier des metastases a distance occultes chez deux patients devenus ineligibles pour une radiotherapie conformationnelle a visee curative. Apres fusion d'images TEP et tomodensitometriques, le volume tumoral macroscopique (GTV) a ete reduit chez 12 patients (35 %) et augmente chez sept patients (20,5 %). La reduction du volume tumoral macroscopique etait superieure ou egale a 25 % dans quatre cas par reduction de la longueur de la tumeur œsophagienne. L'augmentation du volume tumoral macroscopique etait superieure ou egale a 25 % dans deux cas par detection d'une atteinte ganglionnaire mediastinale occulte dans un cas et par augmentation de la longueur de la tumeur œsophagienne dans un autre cas. Les modifications du volume tumoral macroscopique ont change le volume cible previsionnel (PTV) dans 18 cas. Cependant, les modifications de la delimitation du volume tumoral macroscopique et du deplacement de l'isocentre du volume cible previsionnel apres TEP au [18F]-FDG ont change le pourcentage de volume de parenchyme pulmonaire sain recevant plus de 20 Gy chez 25 patients (73,5 %) avec une reduction dans 12 cas et une augmentation dans 13 cas. Conclusion. – Dans notre etude, la fusion d'images TEP et tomodensitometriques a eu un impact sur la strategie therapeutique et sur la planification de la radiotherapie des cancers de l'œsophage liee a une modification de la definition du volume tumoral macroscopique. L'impact sur le controle tumoral reste a demontrer.

Resumen Se presenta el caso de una paciente de 67 anos con un tumor neuroendocrino tipo carcinoide de intestino delgado, que tras tres intervenciones quirurgicas para la exeresis del tumor primario y sus metastasis, se tiene la sospecha de una nueva recidiva. En el TAC se observa una lesion suprarrenal izquierda. La PET 18F-FDG fue negativa y la gammagrafia con 111In-pentetreotido mostro depositos en higado y cupula diafragmatica izquierda. La PET 18F-FDOPA mostro los depositos descritos en la exploracion con pentetreotido asi como otros de gran intensidad en suprarrenal izquierda, area retrovesical junto con varios de pequeno tamano en region abdomino-pelvica, sugestivos de carcinomatosis peritoneal. La PET 18F-FDOPA fue la primera tecnica que mostro toda esta extension, seis meses antes de que fuera confirmada por TAC. Los tumores neuroendocrinos forman un grupo heterogeneo de neoplasias y su estudio se realiza mediante tecnicas radiologicas convencionales y tecnicas funcionales de medicina nuclear. Este caso ilustra la necesidad de utilizar las diferentes tecnicas y trazadores segun las caracteristicas del tumor a estudiar para mejorar asi la precision diagnostica y pronostica.

Positron Emission Tomography (PET) is a several decade old imaging technique that has more recently demonstrated its utility in clinical applications. The imaging agents used for PET contain a positron emmiter coupled to a molecule that drives the radionuclide to target organs or to tissues performing the targetted biological function. PET is then part of functional imaging. As compared to conventional scintigraphy that uses gamma photons, the coincidence emission of two 511 keV annihilation photons in opposite direction that finally results from by beta plus decay makes it possible for PET to get rid of the collimators that greatly contribute to the poor resolution of scintigraphy. In this article, the authors describe the basics of physics for PET imaging and report on the clinical performances of the most commonly used PET tracer: [ 18 F]-fluorodeoxyglucose (FDG). A recent and promising development in this field is fusion of images coming from different imaging modalities. New PET machines now include a CT and this fusion is therefore much easier.

Coincidence detection using a cornantional gamma-camera (CDET) has been proposed for almost a year by several firms with the aim of positron imaging. Namely 18 F-FDG scanning, in nuclear medicine departements. The authors obtained a CDET machine in June 1997. This first article is a survey or the principles of this technique, the optimisations which are required and the choices made by the builder and the users. The consequences of these adaptations on the quality of conventional scintiscans perfomed on the CDET machine are finally adressed

Authors report on their expenence of FDG scintigraphy using a camera with coincidence detec tion (CDET) in cancer patients. FDG scintigraphy has been performed in 215 patients since July 1997 in three main indications in which histological evidence has been regularly obtained: lung tumours, suspicion of colorectal cancer recurrence. and renal tumours. In these three types of tumours, the results appeared not to be different from those already published using PET machines.

Differentes conferences de consensus et recommandations nationales et internationales ont tente de definir les indications des traitements neoadjuvants des cancers du sein [1, 2, 3, 4]. Nous aborderons ici essentiellement les indications et modalites de ces traitements en excluant une partie de la question des traitements antihormonaux neoadjuvants pour lesquels a ce jour le niveau de preuve d’interet reste moindre malgre un interet en recherche [1, 2, 3] clinique [5]. Les dernieres recommandations pour la pratique clinique de Nice Sain-Paul-de-Vence ont permis d’etablir trois indications qui sont [6] : les tumeurs initialement inoperables d’emblee d’un point de vue carcinologique; les tumeurs initialement operables mais non accessibles a un traitement chirurgical conservateur d’emblee; l’utilisation de l’approche neoadjuvante comme modele de recherche clinique pour la personnalisation des traitements medicaux.

En l’absence de mise a jour des Standards Options et Recommandations (SOR) concernant les indications de la tomographie par emission de positons (TEP) au (18-F)-fluorodesoxyglucose (FDG) couplee a la tomodensitometrie (TDM) dans le domaine du cancer du sein, la derniere mise a jour par veille bibliographique, en date de novembre 2005 publiee en janvier 2006 reste la reference1. Certes, il aurait ete aise et rapide de se retrancher derriere ces recommandations toujours en vigueur et se contenter de les rappeler, mais plusieurs publications sont parues durant l’intervalle de temps allant de janvier 2006 a la date de la tenue du 11e cours francophone superieur sur le cancer du sein a Nice-Saint-Paul-de-Vence.

PET with fluoroethylthyrosine (FET), amino-acid analogue, has been performed in Germany since the beginning of the decade for molecular and metabolic imaging of brain tumours, since FDG, the glucose analogue which is the reference tracer for clinical PET, has this drawback to be taken-up intensely by cerebral cortex. We report on our preliminary results on the comparison of PET/CT with FET and FDG in 10 evaluable patients presenting with a brain lesion either at diagnosis or after treatment. In an attempt to optimise specificity, FET PET/CT has been acquired as a static image 1h after injection, while the most current practice is a dynamic 40 min acquisition starting at FET injection. With our acquisition protocol, diagnostic performance of FET was 88% sensitivity and 80% accuracy vs 13% and 30% respectively for FDG.FET is a radiopharmaceutical with clinical usefulness for the diagnosis, delineation and monitoring of brain tumours. Association with FDG allows identification of high-grade lesions or components, but it could be avoided providing that acquisition and quantification procedures of FET PET/CT would have been better optimised and standardised.

Dermatomyositis is an idiopathic inflammatory myopathy that may be associated with malignancies. The technique of 18-F fluorodeoxyglucose (FDG)-positron emission tomography (PET) is an important tool to investigate underlying malignancy in patients with a possible paraneoplastic syndrome. We report two consecutive patients with dermatomyositis in whom 18-F FDG-PET revealed unsuspected infections. Physicians should be aware that a positive 18-F FDG-PET is not specific for malignancy and may reveal other conditions including an infectious disorder.

Occult invasive disease could be found at definitive histology in patients initially diagnosed with large ductal carcinoma in situ (DCIS). Sentinel lymph node (SLN) biopsy is a reliable and minimally invasive procedure providing axillary information and avoiding a second operation in this particular group of patients. The aim of our study was to assess the value of SLN biopsy in patients with large DCIS who are at highest risk for being upstaged to invasive carcinoma.The study included 195 patients diagnosed with DCIS upon initial core biopsy and undergoing SLN biopsy. Many features were correlated with the presence of unsuspected invasive disease and positive SLN biopsy using univariate and multivariate analyses.Of the 110 patients with pure DCIS, seven patients (6%) had a metastatic lymph node; 31 patients (16%) were found to have invasive disease upon final histology. Univariate analysis of predictors of unsuspected invasive carcinoma showed that patients having a preoperative biopsy that indicated DCIS with microinvasion (DCISM) or large DCIS were at a higher risk of invasive carcinoma after histological examination of the operative specimen. Of the 31 patients who were upstaged to invasive carcinoma at final histology, seven patients (22%) had a positive SLN biopsy. The analysis of predictors of positive SLN in our study shows that diffuse DCIS requiring mastectomy is the main risk factor for SLN metastasis.There are no real predictive factors for invasive disease in patients with an initial diagnosis of DCIS or DCISM. Our study supports the value of SLN biopsy in patients with a preoperative DCISM biopsy or patients with a large pure DCIS biopsy requiring mastectomy.

Malignant lymphomas are lymphoproliferative disorders arising in both lymphoid tissue and non-lymphoid organ systems. Treatment rarely is surgical, and currently relies on a combination of chemotherapy and radiation therapy. The role of imaging is to determine the spread of the disease, to identify targets and to assess therapeutic response. Imaging techniques mainly use morphological criteria, and may underestimate infiltrative disease, as observed in bones. The frequent presence of residual masses after treatment usually prevents classification of patients as complete response. Over time, positron emission tomography (PET) with F18-fluorodeoxyglucose (FDG) has become a prominent part of the workup at diagnosis and during follow-up. Recently, PET has been integrated in the revised response criteria for malignant lymphoma.

Initial staging of lung cancer is essential to determine the appropriate therapeutic strategy. 18F-FDG PET is currently considered to be the gold standard. 99mTc bisphonate bone scintigraphy has long been indicated to search for bone metastases but it is not know whether this exploration adds further information after an 18F-FDG PET scan. In order to answer this question, two observers unaware of the clinical situation reread PET scans and bone scintigraphies and results compared with other imaging findings. Between February 2001 and March 2004, 39 patients (13F, 26M, 62 +/- 11 yr) underwent 18FFDG PET and bone scintigraphy (mean interval 17 +/- 17 d). When the two explorations agreed for the diagnosis of bone extension, we considered that bone scintigraphy added nothing. When the two explorations were in disagreement, the other imaging examinations, the clinical features and laboratory results during the five-month minimal follow-up were used to establish the reference diagnosis. 18F-FDG PET and bone scintigraphy were in agreement in 29 patients (74%) with positive results in 12 (31%) and negative results in 17 (43%). The two explorations were in disagreement in 10 patients (26%). Among the five disagreement cases with positive bone scintigraphy and no bone anomaly on the 18F-FDG PET, the anomalies were benign and explained by clinical features (3 patients) or were not confirmed by the clinical course and laboratory results (2 patients). Among the 5 cases with a bone anomaly on the 18F FDG PET, no metastasis could be identified during clinical follow-up. Bone scintigraphy does not enable identification of any bone metastases which were not recognized on the PET scan and therefore should not be performed systematically. Using a computed tomography scan with the 18F-FDG PET could further limit the contribution of bone scintigraphy by providing more precision concerning foci identified on the PET scan.

During the last half of century considerable research on radiosensitivity biomarkers has been published. However, to date there is no non-invasive marker of cellular radiosensitivity identified for clinical routinely use. In this review, the main functional and metabolic imaging isotopic techniques for tumor radiosensitivity that have been explored over the last years are being described. This indirect evaluation fall into 3 topics associated with tumor proliferation rate or apoptosis, tumor hypoxic fraction, neoangiogenesis and the intrinsic radiosensitivity of clonogenic tumor cells. The final objective of the radiosensitivity monitoring during radiotherapy would be to adapt treatment strategy for overcoming the identified radioresistance mechanism such as hypoxia by the addition of radiosensitisers for example. This would allow better tumor control rather than continue inefficient and costly treatment delivery, which in addition could compromise outcome.

To report a retrospective study concerning the impact of fused 18F-fluorodeoxy-D-glucose (FDG)-hybrid positron emission tomography (PET) and computed tomography (CT) images on three-dimensional conformal radiation therapy (3D-CRT) planning for patients with non-small-cell lung cancer (NSCLC).One hundred and one patients consecutively treated for stages I-III NSCLC were studied. Each patient underwent CT and FDG-hybrid PET for simulation treatment in the same radiation treatment position. Images were coregistered using five fiducial markers. Target volume delineation was initially performed on the CT images and the corresponding FDG-PET data were subsequently used as an overlay to the CT data to define target volume.FDG-PET identified previously undetected distant metastatic disease in 8 patients making them ineligible for curative CRT (one patient presented some positive uptakes corresponding to concomitant pulmonary tuberculosis). Another patient was ineligible for curative treatment because fused CT/PET images demonstrated excessively extensive intrathoracic disease. The gross tumor volume (GTV) was decreased by CT/PET image fusion in 21 patients (23%) and was increased in 24 patients (26%). The GTV reduction wasor = 25% in 7 patients because CT/PET image fusion reduced pulmonary GTV in 6 patients (3 patients with atelectasis) and mediastinal nodal GTV in 1 patient. The GTV increase wasor = 25% in 14 patients due to an increase of the pulmonary GTV in 11 patients (4 patients with atelectasis) and detection of occult mediastinal lymph node involvement in 3 patients. Among 81 patients receiving a total doseor = 60 Gy at ICRU point, after CT/PET image fusion, the percentage of total lung volume receiving more than 20 Gy (VL20) increased in 15 cases and decreased in 22 cases. The percentage of total heart volume receiving more than 36 Gy increased in 8 patients and decreased in 14 patients. The spinal cord volume receiving at least 45 Gy (2 patients) decreased. After multivariate analysis, one single independent factor made significant effect of FDG/PET on the modification of the size of the GTV: tumor with atelectasis (P = 0.0001). Conclusion. - Our study confirms that integrated hybrid PET/CT in the treatment position and coregistered images have an impact on treatment planning and management of patients with NSCLC. FDG images using dedicated PET scanners with modern image fusion techniques and respiration-gated acquisition protocols could improve CT/PET image coregistration. However, prospective studies with histological correlation are necessary and the impact on treatment outcome remains to be demonstrated.

We present the case of a 67 year old patient diagnosed of a neuroendocrine carcinoid tumour of the small intestine. The tumour and subsequent metastases were resected previously by surgery, but a new recurrence was suspected. CT showed left adrenal enlargement. 18F-FDG PET was normal and 111In pentetreotide scintigraphy showed liver and left diaphragmatic uptake. 18F-FDOPA PET showed uptake foci in liver and left diaphragm and also in left adrenal gland, retro urinary bladder area and multiple foci in abdominopelvic region, suggesting a peritoneal carcinomatosis. 18F-FDOPA PET was the first imaging modality to assess the extensiveness of the disease that was confirmed six month later by CT. Neuroendocrine tumors are a heterogeneous group of neoplasia. They are studied by conventional radiologic and functional techniques of nuclear medicine. This case illustrates the need to use the different techniques and tracers according to the characteristics of the tumor to be studied to thus improve the diagnostic and prognostic performance.

Although gynaecological cancers are not currently part of the clinical indications in the French registration for [18F]-fluoro-2-deoxyglucose (FDG), various studies indicate in this context a potential clinical benefit of imaging with this radiopharmaceutical and PET, a new imaging modality that can be performed either with a dedicated machine or with a "hybrid" gamma-camera (CDET). The potential indications of FDG-PET in mammary, ovarian or cervical cancers are reviewed according to the diagnostic phase: screening, tumour characterisation, staging, therapeutic follow-up and search for recurrence. By pooling the published results, the accuracy of FDG-PET could be estimated with a reasonable precision in various clinical settings: characterisation of a breast tumour (598/696 = 86%), lymph node invasion in breast cancer (525/602 = 87%), recurrence of breast cancer (114/127 = 90%), characterisation of adnexal masses (130/176 = 78%), recurrence of ovarian cancer (152/172 = 88%), lymph node invasion in cervical cancer (98/103 = 95%). Authors also present original data concerning their experience of recurrence detection with CDET in breast or ovarian cancers. In 44 patients suspicious of recurrence of breast cancer, FDG-CDET sensitivity was 94%, specificity 82% and accuracy 91%; in 18 patients suspicious of recurrence of ovarian cancer, specificity, sensitivity and accuracy were 100%. The impact of dedicated PET and CDET examinations performed by our team during year 2000, led, according to 63 forms returned to us, to a modification of stage in 48% of breast cancers, 36% of ovarian cancers, 43% of cervical cancers and above all induced a modification in patients' management in respectively 69%, 64% and 60% of cases, more than the average rate in cancer patients which was 50%. No significant difference was observed between clinical impact of dedicated PET and CDET examinations.

A FDG-CDET examination on a Picker gamma-camera equiped with coincidence detection and thick cristals was performed in 80 patients during the 2nd half of 1997. Sensitivity and specificity were both 100% for the detection of malignancy in primary lung tumours. Accuracy was 91% for the detection of hilar or mediastinal lymph nodes involvement vs 59% for CT; lymphangitic carcinomatosis, metastases and concomittant tumours were also successfully detected and confirmed. FDG-CDET contributed to significant management changes in 30% of the patients referred for lung abnormalities. FDG-CDET was also usefull in “occult” recurrence of colorectal cancer with an accuracy of 78% vs 42% for CT in this difficult indication; a longer follow-up is needed to be able to evaluate all the 25 patients whose management have been adequately modified in 60% of the cases. We conclude that the diagnostic performances of FDG-CDET derived from our current series cannot be distinguished from the corresponding results published with FDG-PET.

We tested a new schedule for follow up of anthracycline therapy using radionuclide angiography (RNA) in our hospital: just suspend the treatment for one cycle when the absolute LVEF 10% occured. Anthracycline treatment could then be restarted if the LVEF was retored, RNA being then performed at the beginning of each cycle. A remission was obtained in 25 cases. A complete remission could even be obtained in a patient whose LVEF was

Objectifs pedagogiques Rappeler le protocole d’examen IRM adequat. Rappeler les criteres diagnostiques essentiels du bilan d’extension. Discuter la valeur diagnostique de I’IRM par rapport aux autres techniques et a l’histologie. Connaitre les implications therapeutiques decoulant du bilan initial.

Resume La tomographie d’emission de positons (TEP) au [18-F]-fluorodesoxyglucose (18-FDG) possede desormais une place dans le diagnostic et le bilan d’extension des cancers broncho-pulmonaires. Par son approche metabolique et sa correlation a divers parametres biologiques tumoraux, elle pourrait apporter en outre des informations sur le pronostic et constituer un outil d’appreciation de la reponse therapeutique. Une revue des travaux publies montre que la TEP au 18-FDG possede une valeur pronostique independante lors du diagnostic initial des cancers bronchiques non a petites cellules (CBNPC). C’est une methode sensible pour mesurer in vivo les effets biologiques des therapeutiques anticancereuses sur les tumeurs qui trouve son application aussi bien dans les formes traitees par chimiotherapie seule ou association radio-chimiotherapie que dans les formes relevant d’un traitement multimodalite, apres chimiotherapie d’induction. Cependant, une meilleure standardisation des protocoles d’acquisition et des methodes de quantification ainsi qu’une experience plus large sont requises, ce qui justifie de reserver l’utilisation de la TEP au 18-FDG dans l’appreciation de la reponse precoce a la chimiotherapie des CBNPC a des essais cliniques prospectifs. Par ailleurs, l’avenement en TEP, de nouvelles molecules plus specifiques de certains parametres biologiques tumoraux tels que proliferation tumorale, apoptose ou encore hypoxie cellulaire, apparait tres prometteur.