Primary thyroid follicular lymphoma (FL) is exceedingly rare with frequently low fluorine-18-fluorodeoxyglucose (18F-FDG) avidity, challenging accurate staging. We report the case of a 49-year-old female who underwent left thyroid lobectomy for a thyroid imaging reporting and data system (TI-RADS) 4a nodule, with histopathology confirming low-grade FL. Postoperative 18F-FDG positron emission tomography/computed tomography (PET/CT) showed only mild uptake at the surgical bed and cervical lymph nodes, interpreted as reactive change. A subsequent aluminum fluoride-18-1,4,7-triazacyclononane-1,4,7-triacetic acid-Pentixather (Al18F-NOTA-Pentixather) C-X-C chemokine receptor type 4 (CXCR4)-targeted PET/CT, however, revealed multiple intensely avid cervical and abdominal nodal lesions and spleen involvement. This imaging discrepancy underscores the limitations of 18F-FDG in low-grade lymphomas and suggests that CXCR4-targeted PET/CT may offer a more accurate reflection of disease burden, with potential implications for staging and therapeutic management.
Systematic cardiovascular risk assessment and stratification across the entire cancer care continuum is essential among cancer patients, largely due to potential cardiotoxic effects of oncologic therapeutic regiments. Prior to initiation of cancer therapy, cardiotoxicity risk assessment should include comprehensive evaluation of baseline cardiovascular status and baseline measurement of cardiac biomarkers. Patient-related factors should be integrated with therapy-related risks associated with specific oncologic regiments and/or radiotherapy. During cancer treatment, continuous cardiovascular surveillance is necessary to detect early or subclinical myocardial dysfunction. Monitoring strategies involve periodic clinical evaluation, serial echocardiographic assessment and biomarker measurements. Surveillance protocols should be adapted according to the cardiotoxic potential of the administered regimen; as early detection of cardiotoxicity allows prompt cardioprotective interventions and adjustment of oncologic treatments. Cardiovascular assessment after cancer therapy is crucial due to potential delayed cardiotoxic effects. During the first year, post-treatment, structured follow-up is recommended to identify persistent or emerging cancer therapy-related cardiotoxicities. Long-term surveillance is also particularly important for cancer survivors exposed to cardiotoxic agents, given their increased risk of chronic cardiovascular complications. Digitalization improves cardio-oncology risk assessment through artificial intelligence, electronic health records, and remote monitoring enabling earlier detection and personalized cardiovascular surveillance. A multidisciplinary cardio-oncology approach and structured surveillance across the entire cancer care continuum is crucial to reduce cardiovascular morbidity and improve long-term outcomes.
Quantitative imaging in nuclear medicine has evolved from simple photon counting to the estimation of absolute physical quantities such as activity concentration. This transition enhances diagnostic accuracy and supports personalized treatment planning. The present work reviews the principles of quantitative imaging in SPECT and PET, highlighting major degrading factors and correction techniques. Emphasis is placed on clinical applications including dosimetry, theranostics, and functional organ assessment, as well as on dynamic imaging approaches. Finally, current developments and future perspectives toward standardized and automated quantification are discussed.
OBJECTIVE:Prostate-Specific Membrane Antigen (PSMA) PET/CT has rapidly become the preferred first-line imaging modality for primary staging of unfavourable intermediate-risk, high-risk, and very high-risk prostate cancer, and for restaging at biochemical recurrence. The objective of this review is to provide nuclear medicine physicians with a comprehensive and practical framework for PSMA PET/CT interpretation, structured reporting, and clinical decision integration, with emphasis on primary staging evidence, biochemical recurrence (BCR) detection rates, imaging pitfalls, and the PSMA-RADS reporting system. METHODS:A narrative review of published evidence was performed, encompassing landmark randomised controlled trials and guideline documents from the EAU, EANM, and NCCN. Key trials reviewed included proPSMA, OSPREY, PRIMARY, CONDOR, and VISION. RESULTS:PSMA PET/CT demonstrated diagnostic accuracy (AUC) of 0.92 versus 0.38 for conventional imaging in primary staging (proPSMA). Detection rates in BCR ranged from 38% at PSA <0.2ng/mL to 97% at PSA >2ng/mL. In a phase 3 RCT, 18F-PSMA-1007 demonstrated superiority over 18F-Choline (84% vs 69%, OR 2.53, p<0.001). CONCLUSION:PSMA PET/CT provides superior staging accuracy, enables detection of recurrence at low PSA levels, guides oligometastasis-directed therapy, and serves as the mandatory gatekeeper for 177Lu-PSMA-617 theranostic eligibility. Structured reporting using PSMA-RADS and rigorous CT correlation - particularly to exclude unspecific bone uptakes (UBUs) with 18F-PSMA-1007 - are core professional competencies of the nuclear medicine physician.
Non-melanoma skin cancer (NMSC) is one of the most frequently diagnosed malignancies worldwide, especially among fair-skinned individuals. Basal cell carcinoma (BCC) is the predominant subtype, whereas squamous cell carcinoma (SCC) accounts for a smaller but increasing proportion of cases. The incidence of these tumors continues to rise due to aging populations, cumulative ultraviolet exposure and improved detection. Lesions are commonly located on cosmetically sensitive regions such as the face, scalp and neck, where treatment may significantly affect both function and appearance. Conventional therapeutic approaches include surgery, radiotherapy, cryotherapy and topical agents; however, these treatments may be associated with recurrence, cosmetic impairment or prolonged treatment duration. Rhenium-188 skin cancer therapy is a topical radionuclide-based treatment designed for superficial lesions. Owing to the limited tissue penetration of beta radiation, it can deliver high doses to the lesion while preserving surrounding healthy tissues. Published clinical evidence suggests high local control rates, good cosmetic outcomes and acceptable toxicity profiles. Therefore, Rhenium-188 may represent a valuable alternative for carefully selected patients with superficial NMSC.
The aim of the presented study was to evaluate the efficacy and safety of 177Lu-PSMA radioligand therapy in patients with metastatic castration-resistant prostate cancer (mCRPC) in a hospital clinical setting.
Radioembolization (SIRT) was initially introduced in the early 21st century as a whole-liver, primarily palliative treatment, for hepatocellular carcinoma (HCC) and liver metastatic colorectal cancer (mCRC). Over time, its application expanded to include other primary and secondary liver tumors. Clinical experience and emerging studies have demonstrated a clear relationship between higher tumor-absorbed radiation doses and improved tumor response. Such dose escalation can be achieved through advanced, more precise, and synchronous dosimetric approaches (personalized dosimetry), or in selected cases, through targeted treatments such as segmentectomy or lobectomy. These strategies have been associated with improved survival outcomes and, in certain cases, have enabled a shift toward curative treatment intent.
Genetic predisposition contributes significantly to the development of specific gynecologic cancers, particularly ovarian and endometrial malignancies. Germline pathogenic variants in BRCA1 and BRCA2 genes account for a considerable proportion of hereditary ovarian cancer cases, while mismatch repair gene alterations underlie Lynch syndrome, strongly associated with endometrial cancer. Current international guidelines recommend universal genetic testing for all patients with ovarian cancer and systematic screening for mismatch repair deficiency in endometrial tumors. These molecular alterations directly impact therapeutic decisions, including the use of poly (ADP-ribose) polymerase inhibitors and immune checkpoint inhibitors, while enabling preventive strategies through cascade testing in relatives. The integration of genetic data with nuclear medicine imaging enhances disease characterization and treatment monitoring. Multidisciplinary collaboration is essential for the effective implementation of precision medicine in gynecologic oncology.
The low mortality of papillary thyroid carcinoma (PTC) has led to progressively less aggressive therapeutic approaches according to the latest 2025 guidelines. However, morbidity associated with persistent disease and cervical lymph node metastases remains a significant clinical challenge. The presence of undetected "occult" metastases and the occurrence of nodal recurrences following apparently adequate treatment raise concerns regarding the effectiveness of current diagnostic and therapeutic strategies. Improving preoperative diagnostic accuracy in assessing both the extent and aggressiveness of the disease could play a decisive role in selecting the most appropriate surgical approach and the need for adjuvant radioactive iodine (RAI) therapy. Precise topographical localization of the tumor represents an additional risk factor that should be incorporated into therapeutic decision-making.
Clinical practice guidelines are indispensable tools for evidence-based decision-making, yet they are not inherently free of subjectivity and cannot replace clinical expertise or critical judgment. This is particularly relevant in differentiated thyroid cancer, where disease heterogeneity, overdiagnosis of low-risk tumors, and variability among available recommendations often complicate management, especially in relation to postoperative radioiodine administration. This review critically appraises contemporary guideline documents relevant to differentiated thyroid cancer, with emphasis on their evidence base, practical applicability, and implications for nuclear medicine practice. Major European recommendations from ESMO, ETA, and SNMMI/EANM were compared with the 2025 American Thyroid Association guidelines, focusing on risk stratification, radioiodine use, molecular testing, surveillance, and multidisciplinary implementation. Real-world applicability was also considered in light of published comparative analyses. Across the reviewed documents, a clear trend toward individualized, risk-adapted management was observed. Routine radioiodine ablation is increasingly discouraged in low-risk disease, while selective use is recommended in intermediate-risk patients and retained in high-risk settings. Dynamic reassessment, structured follow-up with ultrasound and thyroglobulin monitoring, and incorporation of molecular markers are now integral components of modern management frameworks. However, differences in terminology, structure, and implementation persist between European and American guidance. Overall, contemporary guidelines support a precision medicine approach to differentiated thyroid cancer while underscoring the need for contextual interpretation and critical appraisal. European recommendations offer a practical framework for everyday clinical use, whereas ATA 2025 contributes methodological refinement through dynamic reassessment. The findings highlight the importance of combining evidence-based recommendations with physician judgment to optimize individualized patient care.
18F-FDG PET/CT imaging has transformed the way lymphoma patients are managed, playing a pivotal role in diagnosis, staging, prognostication, and treatment response evaluation. PET/CT guided treatment is a reality in HL, having spared patients from unnecessary toxicities while maximizing responses. Advancements in imaging technology and methodologies, along with the development of artificial intelligence, are expected to revolutionize the evaluation of complex imaging data, enhancing the diagnostic and predictive power of PET in lymphoma.
OBJECTIVE:The aim of this retrospective study was to evaluate the clinical characteristics, treatment response and toxicity profile of patients treated withpeptide receptor radionuclidetherapy (PRRT) using 177Lu-DOTATATE at the Department of Nuclear Medicine at Theageneio Cancer Hospital. MATERIALS AND METHODS:Forty-nine patients with advanced somatostatin receptor-positive neuroendocrine tumors (NETs) and related neoplasms underwent treatment with 177Lu-DOTATATE between January 2022 and January 2026. Demographic, clinical, imaging and therapeutic data were retrospectively analyzed. Response assessment was performed according to RECIST 1.1 criteria. Toxicity evaluation included hematologic, renal and hepatic adverse effects. RESULTS:Pancreatic and small intestine NETs represented the most common primarytumors. Liver, lymph node and bone metastases were the predominant metastaticsites. Disease control was achieved in 81.3% of patients, with partial response observed in 27.1% and stable disease in 54.2% of patients, and most individuals completed the planned four treatment cycles. Hematologic toxicity was recorded in a minority of eight cases, while severe renal or hepatic toxicity remained uncommon. CONCLUSION:PRRT with 177Lu-DOTATATE appears to be an effective and generally well-tolerated therapeutic option in patients with advanced NETs, providing high disease control rates with acceptable toxicity.
The aim of this presentation is to transfer the experience of the Institute of Nuclear Medicine at University College London Hospital with prostate cancer theranostics as a leading clinical and academic centre in the UK as well as to open a discussion on the current state and potential future developments in this field.
Differentiated thyroid carcinoma (DTC) is the most frequent thyroid malignancy. It consists of papillary (85%), follicular (13%) with subtypes and anaplastic (<2%) thyroid cancer, derived from follicular dedifferentiation. DTC is typically associated with a favorable prognosis. However, a subset of patients progresses to a state of radioiodine (RAI) refractoriness (RAIR), necessitating complex multidisciplinary management. This article explores the diagnostic challenges, prognostic evaluation, and the evolving therapeutic landscape for RAIR-DTC, highlighting the importance of integrated oncology care.
Nuclear medicine has progressed from an exploratory discipline, historically constrained by limited spatial resolution and qualitative interpretation, into a rigorously quantitative clinical specialty. This evolution represents a systematic conversion of uncertainty into actionable information. Uncertainty that was once implicit and observer-dependent is increasingly measured, modelled, and managed across the full imaging-therapy continuum. Early tracer work established the foundational diagnostic logic of assessing function before structure. Subsequent instrumentation advances, culminating in the contemporary deployment of long axial field-of-view total-body positron emission tomography (PET) and digital cadmium-zinc-telluride detectors, have compressed spatial ambiguity and enabled true dynamic, multi-organ kinetic modelling. Hybrid imaging further reduced uncertainty by coupling functional signals to anatomical context, while artificial intelligence has emerged as a transformative force, enabling synthetic attenuation correction, automated total tumour volume segmentation, and the deployment of 3D vision-language foundation models for multimodal analysis. Parallel progress in radiochemistry and target biology has shifted tracer development toward highly specific receptor and antigen ligands. This momentum catalysed the theranostics revolution, where diagnostic imaging serves as an explicit, quantitative gatekeeper for radiopharmaceutical therapy. As the field transitions into the "Alpha-Era"-characterized by the clinical maturation of targeted alpha therapies-dosimetry and radiobiology have become paramount. To harness this complexity, the discipline is adopting Theranostics Digital Twins, advanced computational frameworks that integrate physiologically-based radiopharmacokinetic models, radiobiological optimizers, and patient-specific multi-omics to predict dose-response and mitigate toxicity. Though modern nuclear medicine has not eliminated biological uncertainty, it has formalized its quantification, establishing a highly personalized and augmented therapeutic paradigm capable of overriding sub-clonal tumour resistance and redefining systemic oncology.
Parathyroid glands are the smallest organs in our body,that regulate calcium metabolism, by producing parathyroid hormone (PTH). They are four, at least, as they might be either supernumerary or ectopic, especially in patients with chronic renal failure. Hyperparathyroidism (HPT) is a common endocrine disease, characterized by hormone imbalance, which leads to increased secretion of PTH. Primary hyperparathyroidism (PHPT) is caused by hyperfunctioning parathyroid glands, mainly by a solitary parathyroid adenoma and less frequently by parathyroid hyperplasia or double parathyroid adenomas. The alteration in calcium homeostasis, that stimulates the excessive production of PTH is called secondary HPT. Diagnosis of HPT may be clinical or incidental on biochemical screening. Surgical removal of hyperfunctioning parathyroid gland is the only curative treatment available at the moment. Minimally invasive parathyroidectomy (MIP) seems to be the surgical procedure of choice, as it demonstrates multiple advantages, such as reduced duration of surgery shorter hospitalization, with better cosmetic outcome and fewer patient complications. Preoperative imaging is therefore essential for those patients who are going to be treated surgically.
Gastrointestinal cancer, poses a significant global health challenge, encompassing a spectrum of malignancies affecting various parts of the digestive system and account for a substantial portion of cancer-related morbidity and mortality worldwide. Cancers of the digestive tract can develop anywhere between the stomach and the intestinal canal, from the esophagus down to the anus. Most cancers that start in the digestive tract, start in the gland cells lining the gastrointestinal tract - adenocarcinomas. Tumor types such as melanomas, neuroendocrine tumors, gastrointestinal stromal tumors and sarcomas can also occur.
Personalized dosimetry is increasingly recognized as a key component of molecular radiotherapy. The aim of this study is to present recent advances in individualized dosimetry and to discuss current challenges in its clinical implementation. Quantitative imaging techniques, such as SPECT/CT, enable absorbed dose calculations, while voxel-based dosimetry offers improved precision in dose distribution, spatial resolution, and biological relevance compared to conventional organ-based methods. Clinical evidence supports the role of individualized dosimetry in improving therapeutic outcomes and reducing toxicity. However, routine clinical adoption remains limited due to workflow complexity, increased workload, and lack of standardization. Emerging artificial intelligence (AI) applications provide promising solutions for automation and optimization. Personalized dosimetry is expected to improve therapeutic efficacy while minimizing toxicity, supporting its integration into routine clinical practice.
Peptide Receptor Radionuclide Therapy (PRRT) has emerged as an established treatment modality for patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs), particularly in the second-line setting following progression on somatostatin analogs. Evidence from trials such as NETTER-1 and NETTER-2 has demonstrated significant improvements in progression-free survival and objective response rates, with expanding indications into first-line treatment and higher-grade disease. Emerging data from comparative and combination studies highlight the potential role of PRRT alongside targeted therapies and chemotherapy, although uncertainties remain regarding optimal sequencing and overall survival benefit. Retreatment strategies, special population considerations, and novel approaches including alpha-emitting radionuclides and somatostatin receptor antagonists further broaden the therapeutic landscape. Ongoing prospective trials are expected to refine patient selection and define the future role of PRRT across different tumor grades and clinical scenarios.
