Concurrent chemoradiotherapy represents one of the most used strategies in the curative treatment of patients with head and neck (HNC) cancer. Locoregional failure is the predominant recurrence pattern. Tumor hypoxia belongs to the main cause of treatment failure. Positron emission tomography (PET) using hypoxia radiotracers has been studied extensively and has proven its feasibility and reproducibility to detect tumor hypoxia. A number of studies confirmed that the uptake of FMISO in the recurrent region is significantly higher than that in the non-recurrent region. The escalation of dose to hypoxic tumors may improve outcomes. The technical feasibility of optimizing radiotherapeutic plans has been well documented. To define the hypoxic tumour volume, there are two main approaches: dose painting by contour (DPBC) or by number (DPBN) based on PET images. Despite amazing technological advances, precision in target coverage, and surrounding tissue sparring, radiation oncology is still not considered a targeted treatment if the "one dose fits all" approach is used. Using FMISO and other hypoxia tracers may be an important step for individualizing radiation treatment and together with future radiomic principles and a possible genome-based adjusting dose, will move radiation oncology into the precise and personalized era.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

BACKGROUND Determination of prognosis based on ischemia detection, using single‑photon emission computed tomography myocardial perfusion imaging (SPECT‑MPI), can be challenging in patients with multiple affected coronary arteries. AIMS The aim of the study was to examine the outcomes of SPECT‑MPI combined with the coronary artery calcium score (CACS) to identify predictors of adverse cardiac events (ACEs) in patients for whom ischemia detection may be difficult using SPECT‑MPI. METHODS The study group included 195 patients with a history of chronic kidney disease, suspected ischemic cardiomyopathy, or left bundle branch block. All patients underwent SPECT‑MPI and CACS evaluation. During the follow‑up, ACEs were recorded. Perfusion and functional parameters as well as the CACS were analyzed to find the predictors of ACEs. RESULTS The ACEs were recorded in 58 individuals (29.7%) and were significantly associated with ischemia (P <0.001), abnormal functional parameters (P = 0.04), and higher CACSs (P <0.001). The optimal cutoff value of the CACS to predict an ACE was 530. Cox proportional hazards models revealed that age, mild and severe ischemia, functional abnormalities, and a CACS of 530 or higher were significant predictors of ACEs. In the subgroup of individuals without ischemia, a CACS of 530 or higher was significantly associated with poor outcome, while we recorded only 3 ACEs in these patients when the CACS was lower than 530. CONCLUSIONS The addition of the CACS to SPECT‑MPI improves the identification of patients at higher risk for ACEs, even in individuals for whom SPECT‑MPI is challenging.

Objective: An arteriovenous graft (AVG) is indicated in hemodialysis patients with failed arteriovenous access. Early treatment of AVG infection is important because an advanced prosthetic infection leads to the removal of the prosthesis. The aim of this study was to evaluate the benefits of 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT in early detection of AVG infections. Subjects and Methods: Fifty-one AVGs were evaluated. 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT studies were performed at intervals of 10, 20-30, and 40-50 weeks after AVG insertion. Agreement between the imaging methods and reference parameters (i.e. clinical presentation, C-reactive protein and microbiological findings on the hemodialysis cannula extracted after hemodialysis from AVG) was evaluated. Results: The study results showed that focal accumulation of the radiopharmaceuticals can be considered a sign of AVG infection. At 10 weeks after AVG implantation, the focal 18F-FDG findings showed the best agreement with the reference parameters (agreement coefficients AC1 - clinical status: 0.693, CRP: 0.605, cannula microbiology: 0.518, respectively). At 20 to 30 weeks after AVG implantation, the diagnostic value of focal 99mTc-HMPAO-WBC accumulation increased (AC1 coefficients: 0.658, 0.658, 0.408) and was similar to that of focal 18F-FDG uptake (AC1s: 0.656, 0.570, 0.409). Between 40 and 50 weeks since AVG implantation, the diagnostic significance of focal 99mTc-HMPAO-WBC accumulation (AC1 coefficients: 0.771, 0.811, 0.611) slightly exceeded the diagnostic value of focal 18F-FDG accumulation (AC1 coefficients: 0.524, 0.456, 0.569). Conclusion: 18F-FDG PET/CT and 99mTc-HMPAO-WBC SPECT/CT can both serve as important tools contributing to early diagnosis of AVG infection.

Background: Frontline therapy of Hodgkin lymphoma (HL) is strictly stage-adapted. Staging systems used are based on historical variables which only indirectly reflects tumor load (Ann Arbor stage) or lymphoma cytokine activity (systemic symptoms, erytrocyte sedimentation rate). With new, abbreviated interim PET-tailored chemotherapy schemes (2+2) and reduced radiotherapy protocols, there is a clinical need for precise staging tools. Last years have brought new insight into the prognostic role of metabolic quantitative PET parameters and HL-associated biomarkers. Total metabolic tumor volume (TMTV) measured using fluoro-deoxyglucose PET (FDG-PET) was found to be a predictor of therapy failure after frontline treatment (Kanoun 2014). Interestingly, TMTV was found capable of identifying poor responders within one (intermediate) staging group (Akhtari, 2018; Cottereau 2018). Serum concentrations of thymus and activation-regulated chemokine (TARC) and other cytokines have been proved to have prognostic significance in the patients treated both in the frontline and relapse setting (Moskowitz, 2015; Guidetti 2017). A relationship between pretreatment TMTV, baseline cytokines levels, and current staging systems has not been analyzed yet.

Background Mucosal melanoma is a rare form of melanoma presenting variably as sores or unexplained bleeding located mainly in the head and neck region, anorectal region or female genital tract. Mucosal melanoma is usually diagnosed at an advanced stage and is characterized by an aggressive behavior. Surgery represents the mainstay of treatment for early stage melanomas, but for advanced disease there have been until recently very limited treatment options. Ipilimumab, a human monoclonal antibody directed against the cytotoxic T lymphocyte antigen 4, was the first treatment modality to demonstrate survival benefit in advanced malignant melanoma. Method Description of a new case and review of the literature. Results We present here a patient with mucosal melanoma with aggressive biological behavior and documented late response to ipilimumab. Conclusions Ipilimumab represents an effective treatment option in selected patients with mucosal melanoma.

The topic of pheochromocytomas is becoming increasingly popular as a result of major advances in different medical fields, including laboratory diagnosis, genetics, therapy, and particularly in novel advances in imaging techniques. The present review article discusses current clinical, biochemical, genetic and histopathological aspects of the diagnosis of pheochromocytomas and planning of pre-surgical preparation and subsequent surgical treatment options. The main part of the paper is focused on the role of morphological imaging methods (primarily computed tomography and magnetic resonance imaging) and functional imaging (scintigraphy and positron emission tomography) in the diagnosis and staging of pheochromocytomas.

Hybrid pulmonary imaging in the present day has seen a fusion of various uses of CT scans, including angiography (CTAG), diagnostic CT, low dose CT (LDCT), and perfusion or ventilation scintigraphy in tomographic or planar imaging. Determining the most effective individualized test for the complete diagnostics of patients with pulmonary symptoms for various groups of patients is a major issue. The aim of the present study was to assess the effectiveness of the implementation of hybrid imaging in current methods of nuclear medicine in differential diagnostics of pulmonary embolism (PE). 326 patients were examined for symptomatology of PE. Patients were initially examined with SPECT perfusion scintigraphy. SPECT finding without sub-segmental or segmental defects was considered unproven PE but the finding of more segments or sub-segments in various lung parts was considered nearly proven PE. In the case of unclear findings, LDCT was added and in the case of a higher suspicion of PE, a ventilation examination was applied. It was possible to determine 83% of patients with the occurrence or exclusion of PE only on the basis of the perfusion SPECT examination and an X-ray or LDCT. LDCT was determined with 26% of the patients. With 41% of them, the use of LDCT resulted in an alternative diagnosis, explaining perfusion abnormalities. The research proved that use of SPECT/LDCT for differential diagnosis of lung symptoms brings about improvement in the diagnosis of pulmonary embolism or the identification of other lung diseases when lung perfusion abnormalities are recorded.

Hybrid pulmonary imaging in the present day has seen a fusion of various uses of CT scans, including angiography (CTAG), diagnostic CT, low dose CT (LDCT), and perfusion or ventilation scintigraphy in tomographic or planar imaging. Determining the most effective individualized test for the complete diagnostics of patients with pulmonary symptoms for various groups of patients is a major issue. The aim of the present study was to assess the effectiveness of the implementation of hybrid imaging in current methods of nuclear medicine in differential diagnostics of pulmonary embolism (PE). 326 patients were examined for symptomatology of PE. Patients were initially examined with SPECT perfusion scintigraphy. SPECT finding without sub-segmental or segmental defects was considered unproven PE but the finding of more segments or sub-segments in various lung parts was considered nearly proven PE. In the case of unclear findings, LDCT was added and in the case of a higher suspicion of PE, a ventilation examination was applied. It was possible to determine 83% of patients with the occurrence or exclusion of PE only on the basis of the perfusion SPECT examination and an X-ray or LDCT. LDCT was determined with 26% of the patients. With 41% of them, the use of LDCT resulted in an alternative diagnosis, explaining perfusion abnormalities. The research proved that use of SPECT/LDCT for differential diagnosis of lung symptoms brings about improvement in the diagnosis of pulmonary embolism or the identification of other lung diseases when lung perfusion abnormalities are recorded.

Kudlackova S, Kral M, Koranda P, Student V. 18-F cholin PET CT v primodiagnostice karcinomu prostaty. Cil: Zjistit přinos 18F-fluorocholinoveho PET/CT (18F-FCH PET/CT) pro cilenou biopsii prostaty u pacientů s opakovaně negativnimi biopsiemi a trvajicim podezřenim na přitomnost karcinomu prostaty. Soubor pacientů a metoda: Od ledna 2013 do května 2015 jsme provedli 18-F-FCH PET/CT cholinove PET CT vysetřeni u 30 pacientů. Indikacnim kriteriem bylo PSA nad 10 ng/ml a prodělani vice než tři biopsii prostaty, vcetně biopsie saturacni. Pokud to bylo možne, pak pacienti předem prodělali sestitýdenni kůru ATB terapie Doxycyklinem 100 mg 2x denně k eliminaci zanětu, a tim možným falesně pozitivnim nalezům na 18F-FCH PET/CT. Pote bylo provedeno PET/CT vysetřeni a nasledně s odstupem byla provedena cilena biopsie ložisek popsaných na 18F-FCH PET/CT. Cilena biopsie byla provedena pod sonografickou kontrolou transrektalně za pomoci kognitivni fuze PET/CT obrazu s real-time sonografickým zaznamem. Byly odebirany jen vzorky z ložisek popsaných na PET/CT. Výsledky: Od ledna 2013 do května 2015 absolvovalo 18F-FCH PET/CT 30 pacientů. Průměrný věk pacientů byl 66 let v rozmezi 57-75 let. U 14 z nich jsme potvrdili karcinom prostaty, což cini 46% zachyt ve skupině rebiopsii. Vsichni tito pacienti měli Gleasonovo skore vyssi než sedm a PSA vyssi než 20 ng/ml. Zavěr: V nasem souboru jsme prokazali přinos 18F-FCH PET/CT u pacientů s opakovaně negativnimi biopsiemi a pokracujici elevaci PSA, u kterých nebyl karcinom prostaty standardnim způsobem detekovan. Ložisko vyznacene pomoci 18F-cholinufluorocholinu umožnilo cilenou biopsii pod sonografickou kontrolou. V soucasnosti neni jednoznacne doporuceni, jak postupovat u pacientů, u kterých mame opakovaně negativni biopsie prostaty a trva podezřeni na přitomnost karcinomu. Využiti 18F-FCH PET/CT se jevi jako jedna z možnosti.

Aim: To assess of the role of renal ultrasonography (US) and DMSA renal scintigraphy in the prediction of irreversible histological lesions of the upper pole in duplex system. Methods: A prospective cohort study based on data collected between 2005 and 2012 at our institution. The cohort consisted of 23 patients with ureteroceles and 28 patients with ectopic ureters who underwent upper pole nephrectomy. Preoperative recordings from ultrasound and nuclear renal scans were compared with the histological findings. Histological irreversible lesions were defined as the presence of dysplasia and/or severe chronic interstitial nephritis (CIN) in ≥ 90% of the specimen. ROC (Receiver Operating Characteristic) curves were used to investigate thresholds in order to identify irreversible lesions using various differential functions. The histology was correlated with the results of imaging. Results: Pathological findings were found in all histological samples. Histological lesions were irreversible in 20/23 patients (87.0%) with ureteroceles and in 14/28 patients (50.0%) with ectopic ureters. The model is able to predict irreversible lesions if an upper pole differential function is ≤ 3% in patients with ureteroceles, and ≤ 2% in the presence of ectopic ureters. Weak association between parenchymal thinning on ultrasonography and irreversible lesions was found in patients with ectopic ureters. Conclusion: DMSA renal scintigraphy provides a useful tool for the prediction of irreversible lesions in the upper pole. Low differential function (≤ 3% and ≤ 2%, respectively) indicates irreversible lesions, favoring heminephrectomy. Higher differential function indicates greater remaining biological potential of the parenchyma, favoring reconstruction of the upper pole.

Background: The increasing incidence of breast cancer worldwide raises the importance of improving imaging techniques for disease stratification after early lesion detection. SPECT/CT imaging is now widely available but its diagnostic potential is not fully utilized for more specific purposes including breast cancer patient stratification. Methods and Results: A Pubmed search for both original and review articles related to the value of SPECT/CT in breast cancer patients and comparison to other diagnostic methods. 62 articles were found using the key words SPECT/CT, Fusion Image and Breast Cancer. Development of a new generation of SPECT/CT systems and their introduction into practice has changed the old diagnostic algorithm. The increasing importance of SPECT/CT in the detection of bone metastases is confirmed. The diagnostic accuracy of new SPECT/CT instruments in the diagnostics of bone metastases is nearly comparable to PET/CT scans. SPECT/CT is more widely available and costs less than PET. It is able not only to identify a sentinel lymph nodes in atypical localizations but also to detect sentinel lymph nodes non visualized on previous planar scans. SPECT/CT offers precise anatomic localization of sentinel lymph nodes, thereby facilitating surgery. Knowledge of precise sentinel lymph node localization can also be applied in radiotherapy. Conclusions: The role of hybrid SPECT/CT imaging in breast cancer patients is changing. It is a powerful modality for skeletal and nodal staging in breast cancer patients with important impact on therapy.

Sklerotizace adenomu příštítného tělíska absolutním alkoholem -Percutaneous Ethanol Injection Therapy (PEIT) -pod ultrasonografickou kontrolou se individuálně používá jako alternativní postup při řešení primární hyperparatyreózy u polymorbidních pacientů vyššího věku, kteří mají zvýšené operační riziko

Background: The management of internal mammary nodes (IMNs) during multidisciplinary treatment of breast cancer has been debated for the last four decades without unequivocal conclusion. Patients and Methods: We retrospectively reviewed patients with breast cancer who underwent sentinel lymph node biopsy at our center from 2008 until 2012. IMN drainage was assessed as a potential risk factor for local and distant disease recurrence. Results: We identified 712 patients, with incidence of drainage to IMNs of 18.4%. No detrimental effect of the pattern of drainage to IMNs was found after a median follow-up of 58 months. A similar outcome was observed when drainage to IMNs was evaluated as a risk factor for patient survival. The potential risk factors for drainage to IMNs during sentinel lymph node biopsy were younger age (p=0.002) and tumor location in lower-outer, lower-inner, and upper-inner versus upper-outer quadrant (p<0.0001). Conclusion: The drainage to IMNs is unlikely to have a detrimental effect on patient outcome.

Primarni hyperparatyreoza jako přicina hyperkalcemie u pacientů s non-Hodgkinovým lymfomem je poměrně vzacna a jeji přicinou býva nejcastěji solitarni adenom přistitneho těliska. V soucasnosti lze sledovat zvýsený výskyt jak primarni hyperparatyreozy, tak papilarniho karcinomu stitne žlazy jestě v pocatecnim, asymptomatickem stadiu nemoci. Tento trend je způsoben rozsiřenim laboratorniho screeningu a sirokou dostupnosti ultrasonografie ve vysetřovacim schematu onemocněni stitne žlazy. Vzacněji se lze setkat s koincidenci obou chorob. V kazuistice je prezentovan nalez adenomu přistitneho těliska a maleho papilarniho karcinomu stitne žlazy u pacientky s manifestnim non-Hodgkinovým lymfomem. V diagnostice byla využita kombinace vice zobrazovacich metod. Pro zdarne vyřeseni vsech diagnoz byla velmi důležita mezioborova spoluprace.

OBJECTIVECoronary artery disease (CAD) is highly prevalent in patients with end-stage renal disease (ESRD), owing to clustering of traditional and uremic-specific risk factors. However, in this population asymptomatic course of CAD is common and it has been reported that myocardial perfusion imaging (MPI) with single-photon emission tomography (SPET) has lower sensitivity. In the current study, we assessed the value of MPI gated-SPET and its combination with coronary artery calcium (CAC) score measurements in risk stratification of ESRD patients.MATERIALS AND METHODSMPI gated-SPET was performed with dual-headed SPET camera and CAC score measured by multi-detector computed tomography (MDCT) system.There were tested 77 ESRD individuals. During the follow-up study, cardiac events (CE) defined as cardiac death or nonfatal myocardial infarction (MI) or the necessity for coronary revascularization were recorded. Univariate and stepwise multivariable Cox proportional hazards-models were used to identify the predictors of CE.RESULTSEighteen CE were recorded during the follow-up. They were significantly associated with higher summed stress scores on MPI, higher percentage of ischaemic myocardium, higher occurrence of defects in multiple territories and higher CAC score (all with P<0.05). Univariate Cox proportional hazard-models showed that severe perfusion abnormalities as well as CAC score ≥1000 were significantly associated with cardiac events (P<0.0001, P=0.0056). In stepwise Cox proportional hazards-models considering age, gender, history of diabetes mellitus, post-stress left ventricular stunning, the degree of perfusion abnormality and CAC score, only severe perfusion abnormalities and CAC score ≥1000 were independent predictors of CE. There was no CE in patients with normal perfusion, normal function and zero CAC score.CONCLUSIONThis study suggests that combined evaluation of MPI and CAC can predict the outcome in ESRD individuals, while severe perfusion abnormality on gated-SPET and high CAC score ≥1000 are predictors of future cardiac events.

OBJECTIVEThe added value of coronary artery calcium (CAC) to SPET for identification of multivessel CAD has not been studied yet. The aim of this original study was to investigate CAC as an adjunct to gated single photon emission tomography (GSPET) in the detection of multivessel coronary artery disease (CAD).SUBJECTS AND METHODSThe study group consisted of 164 prospectively recruited patients without known CAD-123 (75%) men and 60 (37%) women, having diabetes type II, renal insufficiency, left ventricular dilatation and other cardiac problems (arrhythmia, necessity of pharmacological stress test, etc.). The mean age of these patients was 61±12 years (range 34-85 years). All these patients underwent GSPET imaging, CAC score measurement, and coronary angiography. The percentage of ischaemic myocardium, stress and rest left ventricular ejection fraction (LVEF), and transient ischaemic dilation (TID) ratio were measured.RESULTSPatients with multivessel CAD had more frequently reversible defects in multiple territories, severe ischaemia ≥10% of the left ventricle, stress worsening of the LVEF ≥5%, TID ratio ≥1.17, and CAC score >1000. In the detection of multivessel CAD, the sensitivity of combined assessment of perfusion, function, and CAC (i.e., multiple and/or ≥10% ischaemia, and/or worsening of the LVEF ≥5%, and/or TID ratio ≥1.17, and/or CAC score >1000) was significantly higher than the sensitivity of perfusion alone or perfusion and function alone (81% vs. 55% and 65%, respectively, P<0.05). Sensitivity of only CAC was low (41%).CONCLUSIONSensitivity of combined assessment of myocardial perfusion, function, and CAC was significantly higher than sensitivity of perfusion alone or perfusion and function alone, suggesting better identification of high-risk patients with CAD.