BACKGROUND

Since the publication of the European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis (LVV) in 2009, several relevant randomised clinical trials and cohort analyses have been published, which have the potential to change clinical care and therefore supporting the need to update the original recommendations.

METHODS

Using EULAR standardised operating procedures for EULAR-endorsed recommendations, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 13 countries. We modified existing recommendations and created new recommendations.

RESULTS

Three overarching principles and 10 recommendations were formulated. We recommend that a suspected diagnosis of LVV should be confirmed by imaging or histology. High dose glucocorticoid therapy (40-60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active giant cell arteritis (GCA) or Takayasu arteritis (TAK). We recommend adjunctive therapy in selected patients with GCA (refractory or relapsing disease, presence of an increased risk for glucocorticoid-related adverse events or complications) using tocilizumab. Methotrexate may be used as an alternative. Non-biological glucocorticoid-sparing agents should be given in combination with glucocorticoids in all patients with TAK and biological agents may be used in refractory or relapsing patients. We no longer recommend the routine use of antiplatelet or anticoagulant therapy for treatment of LVV unless it is indicated for other reasons.

CONCLUSIONS

We have updated the recommendations for the management of LVV to facilitate the translation of current scientific evidence and expert opinion into better management and improved outcome of patients in clinical practice.

https://ard.bmj.com/content/annrheumdis/79/1/19.full.pdf

2018 Update of the EULAR recommendations for the management of large vessel vasculitis.

These joint practice guidelines, or procedure standards, were developed collaboratively by the European Association of Nuclear Medicine (EANM), the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the European Association of Neurooncology (EANO), and the working group for Response Assessment in Neurooncology with PET (PET-RANO). Brain PET imaging is being increasingly used to supplement MRI in the clinical management of glioma. The aim of these standards/guidelines is to assist nuclear medicine practitioners in recommending, performing, interpreting and reporting the results of brain PET imaging in patients with glioma to achieve a high-quality imaging standard for PET using FDG and the radiolabelled amino acids MET, FET and FDOPA. This will help promote the appropriate use of PET imaging and contribute to evidence-based medicine that may improve the diagnostic impact of this technique in neurooncological practice. The present document replaces a former version of the guidelines published in 2006 (Vander Borght et al. Eur J Nucl Med Mol Imaging. 33:1374-80, 2006), and supplements a recent evidence-based recommendation by the PET-RANO working group and EANO on the clinical use of PET imaging in patients with glioma (Albert et al. Neuro Oncol. 18:1199-208, 2016). The information provided should be taken in the context of local conditions and regulations.

/pdf/joint-eanm-eano-rano-practice-guidelines-snmmi-procedure-53kgqvkini.pdf

Joint EANM/EANO/RANO practice guidelines/SNMMI procedure standards for imaging of gliomas using PET with radiolabelled amino acids and [18F]FDG: version 1.0.

Large vessel vasculitis (LVV) is defined as a disease mainly affecting the large arteries, with two major variants, Takayasu arteritis (TA) and giant cell arteritis (GCA). GCA often coexists with polymyalgia rheumatica (PMR) in the same patient, since both belong to the same disease spectrum. FDG-PET/CT is a functional imaging technique which is an established tool in oncology, and has also demonstrated a role in the field of inflammatory diseases. Functional FDG-PET combined with anatomical CT angiography, FDG-PET/CT(A), may be of synergistic value for optimal diagnosis, monitoring of disease activity, and evaluating damage progression in LVV. There are currently no guidelines regarding PET imaging acquisition for LVV and PMR, even though standardization is of the utmost importance in order to facilitate clinical studies and for daily clinical practice. This work constitutes a joint procedural recommendation on FDG-PET/CT(A) imaging in large vessel vasculitis (LVV) and PMR from the Cardiovascular and Inflammation & Infection Committees of the European Association of Nuclear Medicine (EANM), the Cardiovascular Council of the Society of Nuclear Medicine and Molecular Imaging (SNMMI), and the PET Interest Group (PIG), and endorsed by the American Society of Nuclear Cardiology (ASNC). The aim of this joint paper is to provide recommendations and statements, based on the available evidence in the literature and consensus of experts in the field, for patient preparation, and FDG-PET/CT(A) acquisition and interpretation for the diagnosis and follow-up of patients with suspected or diagnosed LVV and/or PMR. This position paper aims to set an internationally accepted standard for FDG-PET/CT(A) imaging and reporting of LVV and PMR.

/pdf/fdg-pet-ct-a-imaging-in-large-vessel-vasculitis-and-3e7scwtlhr.pdf

FDG-PET/CT(A) imaging in large vessel vasculitis and polymyalgia rheumatica: joint procedural recommendation of the EANM, SNMMI, and the PET Interest Group (PIG), and endorsed by the ASNC

https://www.europeanurology.com/article/S0302-2838(13)00382-5/pdf/The+Role+of+11C-Choline+and+18F-Fluorocholine+Positron+Emission+Tomography+%28PET%29+and+PET/CT+in+Prostate+Cancer%3A+A+Systematic+Review+and+Meta-analysis

The role of 11C-choline and 18F-fluorocholine positron emission tomography (PET) and PET/CT in prostate cancer: a systematic review and meta-analysis.

Prostate cancer is biologically and clinically a heterogeneous disease that makes imaging evaluation challenging. The role of imaging in prostate cancer should include diagnosis, localization, and characterization (indolent vs. lethal) of the primary tumor, determination of extracapsular spread, guidance and evaluation of local therapy in organ-confined disease, staging of locoregional lymph nodes, detection of locally recurrent and metastatic disease in biochemical relapse, planning of radiation treatment, prediction and assessment of tumor response to salvage and systemic therapy, monitoring of active surveillance and definition of a trigger for definitive therapy, and prognostication of time to hormone refractoriness in castrate disease and overall survival. To address these tasks effectively, imaging needs to be tailored to the specific phases of the disease in a patient-specific, risk-adjusted manner. In this article, I review the preclinical and clinical evidence on the potential and emerging role of PET with the 3 most commonly studied radiotracers in prostate cancer, namely 18F-FDG, 18F- or 11C-acetate, and 18F- or 11C-choline.

https://jnm.snmjournals.org/content/jnumed/52/1/81.full.pdf

Prostate Cancer: PET with 18F-FDG, 18F- or 11C-Acetate, and 18F- or 11C-Choline

Introduction. Glucocorticosteroids (GC) are the standard treatment for large-vessel vasculitis, but some patients are refractory. Cyclophosphamide (CYC) has been shown to be effective in autoimmune diseases. Methods. The study consisted of a retrospective analysis of 10 patients with active large-vessel arteritis who received pulse CYC after failure of GC or because of organ threatening stenosis. CYC pulse therapy was started with a dose of 750mg/m 2 body surface every 3 weeks and increased if necessary. Clinical response was assessed by the Birmingham Vasculitis Activity Score (BVAS), the C-reactive protein and the erythrocyte sedimentation rate (ESR). PET/CT was performed at baseline and during treatment to determine disease activity. Results. The median BVAS at the time of the initial PET/CT was 6.5 (5―13). The median ESR was 42mm/h (6―94mm/h), and the medium CRP was 4.6mg/dl (0.18―11.8mg/dl). All but one patient experienced a complete clinical remission during CYC treatment after a median of 10 cycles. PET/CT confirmed the efficacy of the treatment by normalisation of FDG uptake during therapy. One patient with persisting inflammation was lost to follow-up. One patient experienced a relapse after 21 months. The remaining 8 patients are still in remission with low-dose GC and a maintenance therapy (azathioprine, methotrexate or mycophenolate) after a median follow-up of 45 months. Conclusion. Pulse cyclophosphamide is effective in patients with large-vessel vasculitis resistant to glucocorticosteroids. The high rate of sustained response in our patients suggests that treatment decisions based on clinical parameters combined with PET/CT may have a beneficial effect on the clinical outcome.

Cyclophosphamide for large vessel vasculitis: assessment of response by PET/CT.

UNLABELLED
Aim of this study was to compare the diagnostic accuracy of positron emission tomography and computed tomography with (11)C-Choline (Cho-PET/CT) and whole body magnetic resonance imaging (WB-MRI) for diagnostic work-up of prostate cancer.


PATIENTS, METHODS
We evaluated retrospectively 42 patients with untreated prostate cancer (n = 17), or increasing levels of prostate-specific antigen (PSA) after curative therapy (n = 25) who had been investigated by both Cho-PET/CT and WB-MRI. MRI, CT, and PET images were separately analyzed by experienced radiologists or nuclear medicine experts, followed by consensus reading. Validation was established by histology, follow-up, or consensus reading.


RESULTS
88/103 detected lesions were considered as malignant: 44 bone metastases, 22 local tumor, 15 lymph node metastases, 3 lung, and 3 brain metastases. One further lesion was located in the adrenal gland, which was a second tumor. Overall sensitivity, specificity and accuracy for Cho-PET/CT were 96.6%, 76.5%, and 93.3%, resp., and for WB-MRI 78.4%, 94.1%, and 81.0%, resp. 3 vertebral metastases had initially been missed by Cho-PET/CT and were found retrospectively. MRI identified 2 bone metastases and 1 lymph node metastasis after being informed about the results of Cho-PET/CT.


CONCLUSIONS
Cho-PET/CT and WB-MRI both presented high accuracy in the detection of bone and lymph node metastases. The strength of MRI is excellent image quality providing detailed anatomical information whereas the advantage of Cho-PET/CT is high image contrast of pathological foci.

Comparison of 11C-Choline-PET/CT and whole body-MRI for staging of prostate cancer

Purpose: In patients with peritoneal carcinomatosis (PC), cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is an evolving therapeutic approach with curative intention. The differentiation between posttherapeutic findings after HIPEC and relapse of PC is challenging. We evaluated the diagnostic value of F-18-FDG-PET/CT in patients with relapse of PC after HIPEC. Materials and Methods: 36 patients with recurring PC after HIPEC were examined on a whole-body PET/CT system (44 examinations). The examination included 3 D F-18-FDG-PET and contrast-enhanced CT. Images were assessed by two experienced readers regarding the presence and the extent of PC using the peritoneal carcinomatosis index (PCI). Imaging results were correlated with surgical findings or follow-up. Results: Relapse was suspected in 40 of 44 examinations. Relapse was missed by F-18-FDG PET/CT in 4 patients and significantly underestimated in 8 patients. The diagnostic accuracy for the detection of PC on a patient basis was 91 %, the sensitivity was 91 % and the positive predictive value was 100 %. The mean PCI was 11.4 ± 11.9 for PET/CT, 8.4 ± 10.3 for CT and 16.6 ± 15.0 in the case of surgical exploration. The extent of PC was underestimated by PET/CT and even more by CT alone (p  Conclusion: The diagnostic value of F-18-FDG PET/CT after cytoreductive surgery and HIPEC in the detection of recurring PC is superior to contrast-enhanced CT. However, the quantification of the extent of PC is limited due to post-therapeutic tissue alterations. Key Points:
 • Imaging of recurrent PC after HIPEC is challenging due to posttherapeutic tissue alterations. • The extent of recurrent PC after HIPEC is systematically underestimated by F-18-FDG PET/CT. • F-18-FDG PET/CT provides improved sensitivity for recurrent PC compared to contrast-enhanced CT. • The correlation of the extent of recurrent PC depicted by F-18-FDG PET/CT and surgical exploration is better than that of contrast-enhanced CT and surgical exploration. Citation Format:
 • Klumpp B, Schwenzer N F, Gatidis S et al. Assessment of Relapse in Patients with Peritoneal Carcinomatosis after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy using F-18-FDG-PET/CT. Fortschr Rontgenstr 2014; 186: 359 – 366

/pdf/assessment-of-relapse-in-patients-with-peritoneal-4vcouszgmw.pdf

Assessment of relapse in patients with peritoneal carcinomatosis after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy using F-18-FDG-PET/CT.

126 Objectives To compare the diagnostic performance of 68Ga-DOTATOC-PET/CT and whole-body (wb) MRI for staging of neuroendocrine tumors (NET). Methods In 51 patients (25 f, 26 m, mean 57 yrs) with histologically proven NET and suspicion of metastatic spread 68Ga-DOTATOC-PET/CT and wbMRI were performed within Results 41 of 51 (80%) NET patients had 593 metastatic lesions (lung: 54, liver: 266, bone: 131, lymph node (LN): 99, other: 43). 68Ga-DOTATOC-PET was false negative in 5/41 (12%) of patients due to lack of SSTR expression. Of all 593 detected lesions, PET identified 370 (62%) true positive lesions, CT 482 (81%), PET/CT 545 (92%) and wbMRI 54 (91%). Comparison of organ-based detection rates between PET/CT and wbMRI revealed significantly higher sensitivity of PET/CT in detecting metastatic LN (100% vs 73%; p Conclusions PET/CT and wbMRI showed comparable overall detection rates for metastatic involvement in NET but significantly differed in organ-based detection rates with superiority of PET/CT for LN and pulmonary lesions and of wbMRI for liver and bone metastases

Comparison of 68Ga-DOTATOC-PET/CT and whole-body MRI in staging of neuroendocrine tumors

Diagnosis of vasculitis with F-18 FDG-PET/CT: Quantification of arterial wall activity in vasculitis patients and controls

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