Publications by authors named "Geoffrey B Johnson"

85 Publications

PSMA as a Theranostic Target in Hepatocellular Carcinoma: Immunohistochemistry and Ga-PSMA-11 PET Using Cyclotron-Produced Ga.

Hepatol Commun 2021 Nov 15. Epub 2021 Nov 15.

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

Prostate-specific membrane antigen (PSMA) is a validated target for molecular diagnostics and targeted radionuclide therapy. Our purpose was to evaluate PSMA expression in hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and hepatic adenoma (HCA); investigate the genetic pathways in HCC associated with PSMA expression; and evaluate HCC detection rate with Ga-PSMA-11 positron emission tomography (PET). In phase 1, PSMA immunohistochemistry (IHC) on HCC (n = 148), CCA (n = 111), and HCA (n = 78) was scored. In a subset (n = 30), messenger RNA (mRNA) data from the Cancer Genome Atlas HCC RNA sequencing were correlated with PSMA expression. In phase 2, Ga-PSMA-11 PET was prospectively performed in patients with treatment-naïve HCC on a digital PET scanner using cyclotron-produced Ga. Uptake was graded qualitatively and semi-quantitatively using standard metrics. On IHC, PSMA expression was significantly higher in HCC compared with CCA and HCA (P < 0.0001); 91% of HCCs (n = 134) expressed PSMA, which principally localized to tumor-associated neovasculature. Higher tumor grade was associated with PSMA expression (P = 0.012) but there was no association with tumor size (P = 0.14), fibrosis (P = 0.35), cirrhosis (P = 0.74), hepatitis B virus (P = 0.31), or hepatitis C virus (P = 0.15). Overall survival tended to be longer in patients without versus with PSMA expression (median overall survival: 4.2 vs. 1.9 years; P = 0.273). FGF14 (fibroblast growth factor 14) mRNA expression correlated positively (rho = 0.70; P = 1.70 × 10 ) and MAD1L1 (Mitotic spindle assembly checkpoint protein MAD1) correlated negatively with PSMA expression (rho = -0.753; P = 1.58 × 10 ). Of the 190 patients who met the eligibility criteria, 31 patients with 39 HCC lesions completed PET; 64% (n = 25) lesions had pronounced Ga-PSMA-11 standardized uptake value: SUV (median [range] 9.2 [4.9-28.4]), SUV 4.7 (2.4-12.7), and tumor-to-liver background ratio 2 (1.1-11). Conclusion: Ex vivo expression of PSMA in neovasculature of HCC translates to marked tumor avidity on Ga-PSMA-11 PET, which suggests that PSMA has the potential as a theranostic target in patients with HCC.
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http://dx.doi.org/10.1002/hep4.1861DOI Listing
November 2021

Phase II Evaluation of Stereotactic Ablative Radiotherapy (SABR) and Immunity in C-Choline-PET/CT-Identified Oligometastatic Castration-Resistant Prostate Cancer.

Clin Cancer Res 2021 Sep 30. Epub 2021 Sep 30.

Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota.

Purpose: Outcomes for resistant metastatic castration-resistant prostate cancer (CRPC) are poor. Stereotactic ablative radiotherapy (SABR) induces antitumor immunity in clinical and preclinical studies, but immunologic biomarkers are lacking.

Patients And Methods: Eighty-nine patients with oligometastatic CRPC were identified by C-Choline-PET (Choline-PET) from August 2016 to December 2019 and treated with SABR. Prespecified coprimary endpoints were 2-year overall survival (OS) and PSA progression. Secondary endpoints included 2-year SABR-treated local failure and 6-month adverse events. Correlative studies included peripheral blood T-cell subpopulations before and after SABR.

Results: 128 lesions in 89 patients were included in this analysis. Median OS was 29.3 months, and 1- and 2-year OS were 96% and 80%, respectively. PSA PFS was 40% at 1 year and 21% at 2 years. Local PFS was 84.4% and 75.3% at 1 and 2 years, respectively, and no grade ≥3 AEs were observed. Baseline high levels of tumor-reactive T cells (T; CD8CD11a) predicted superior local, PSA, and distant PFS. Baseline high levels of effector memory T cells (T; CCR7CD45RA) were associated with improved PSA PFS. An increase in T at day 14 from baseline was associated with superior OS.

Conclusions: This is the first comprehensive effector T-cell immunophenotype analysis in a phase II trial before and after SABR in CRPC. Results are favorable and support the incorporation of immune-based markers in the design of future randomized trials in patients with oligometastatic CRPC treated with SABR.
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http://dx.doi.org/10.1158/1078-0432.CCR-21-2510DOI Listing
September 2021

Prevalence of Transthyretin Amyloid Cardiomyopathy in Heart Failure With Preserved Ejection Fraction.

JAMA Cardiol 2021 Nov;6(11):1267-1274

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Importance: Heart failure (HF) with preserved ejection fraction (HFpEF) is common, is frequently associated with ventricular wall thickening, and has no effective therapy. Transthyretin amyloid cardiomyopathy (ATTR-CM) can cause the HFpEF clinical phenotype, has highly effective therapy, and is believed to be underrecognized.

Objective: To examine the prevalence of ATTR-CM without and with systematic screening in patients with HFpEF and ventricular wall thickening.

Design, Setting, And Participants: This population-based cohort study assessed ATTR-CM prevalence in 1235 consecutive patients in southeastern Minnesota with HFpEF both without (prospectively identified cohort study) and with (consenting subset of cohort study, n = 286) systematic screening. Key entry criteria included validated HF diagnosis, age of 60 years or older, ejection fraction of 40% or greater, and ventricular wall thickness of 12 mm or greater. In this community cohort of 1235 patients, 884 had no known ATTR-CM, contraindication to technetium Tc 99m pyrophosphate scanning, or other barriers to participation in the screening study. Of these 884 patients, 295 consented and 286 underwent scanning between October 5, 2017, and March 9, 2020 (community screening cohort).

Exposures: Medical record review or technetium Tc 99m pyrophosphate scintigraphy and reflex testing for ATTR-CM diagnosis.

Main Outcomes And Measures: The ATTR-CM prevalence by strategy (clinical diagnosis or systematic screening), age, and sex.

Results: A total of 1235 patients participated in the study, including a community cohort (median age, 80 years; interquartile range, 72-87 years; 630 [51%] male) and a community screening cohort (n = 286; median age, 78 years; interquartile range, 71-84 years; 149 [52%] male). In the 1235 patients in the community cohort without screening group, 16 patients (1.3%; 95% CI, 0.7%-2.1%) had clinically recognized ATTR-CM. The prevalence was 2.5% (95% CI, 1.4%-4.0%) in men and 0% (95% CI, 0.0%-0.6%) in women. In the 286 patients in the community screening cohort, 18 patients (6.3%; 95% CI, 3.8%-9.8%) had ATTR-CM. Prevalence increased with age from 0% in patients 60 to 69 years of age to 21% in patients 90 years and older (P < .001). Adjusting for age, ATTR-CM prevalence differed by sex, with 15 of 149 men (10.1%; 95% CI, 5.7%-16.1%) and 3 of 137 women (2.2%; 95% CI, 0.4%-6.3%) having ATTR-CM (P = .002).

Conclusions And Relevance: In this cohort study based in a community-based setting, ATTR-CM was present in a substantial number of cases of HFpEF with ventricular wall thickening, particularly in older men. These results suggest that systematic evaluation can increase the diagnosis of ATTR-CM, thereby providing therapeutically relevant phenotyping of HFpEF.
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http://dx.doi.org/10.1001/jamacardio.2021.3070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8387947PMC
November 2021

Atypical Metastases in the Abdomen and Pelvis From Biochemically Recurrent Prostate Cancer: C-Choline PET/CT With Multimodality Correlation.

AJR Am J Roentgenol 2021 Nov 17:1-10. Epub 2021 Nov 17.

Department of Radiology, Mayo Clinic, 200 First St SW, Charlton 1, Rochester, MN 55905.

PET with targeted radiotracers has become integral to mapping the location and burden of recurrent disease in patients with biochemical recurrence (BCR) of prostate cancer (PCa). PET with C-choline is part of the National Comprehensive Cancer Network and European Association of Urology guidelines for evaluation of BCR. With advances in PET technology, increasing use of targeted radiotracers, and improved survival of patients with BCR because of novel therapeutics, atypical sites of metastases are being increasingly encountered, challenging the conventional view that prostate cancer rarely metastasizes beyond bones or lymph nodes. The purpose of this article is to describe such atypical metastases in the abdomen and pelvis on C-choline PET (including metastases to the liver, pancreas, genital tract, urinary tract, peritoneum, abdominal wall, and perineural spread) and to present multimodality imaging features and relevant imaging pitfalls. Given atypical metastases' inconsistent relationship with the serum PSA level and the nonspecific presenting symptoms, atypical metastases are often first detected on imaging. Awareness of their imaging features is important because their detection affects clinical management, patient counseling, prognosis, and clinical trial eligibility. Such awareness is particularly critical because the role of radiologists in the imaging and management of BCR will continue to increase given the expanding regulatory approvals of other targeted and theranostic radiotracers.
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http://dx.doi.org/10.2214/AJR.21.26426DOI Listing
November 2021

Frequency and Characteristics of Nodal and Deltoid FDG and C-Choline Uptake on PET Performed After COVID-19 Vaccination.

AJR Am J Roentgenol 2021 Nov 19;217(5):1206-1216. Epub 2021 May 19.

Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

COVID-19 vaccination may trigger reactive lymphadenopathy, confounding imaging interpretation. There has been limited systematic analysis of PET findings after COVID-19 vaccination. The purpose of this study was to evaluate the frequency and characteristics of abnormal FDG and C-choline uptake on PET performed after COVID-19 vaccination. This retrospective study included 67 patients (43 men and 24 women; mean [± SD] age, 75.6 ± 9.2 years) who underwent PET examination between December 14, 2020, and March 10, 2021, after COVID-19 vaccination and who had undergone prevaccination PET examination without visible axillary node uptake. A total of 52 patients received the BNT162b2 mRNA COVID-19 vaccine (Pfizer-BioNTech; hereafter referred to as the Pfizer-BioNTech vaccine), and 15 received the SARS-CoV-2 mRNA-1273 vaccine (Moderna; hereafter referred to as the Moderna vaccine). Sixty-six of the patients underwent PET/CT, and one underwent PET/MRI. Fifty-four PET examinations used FDG, and 13 used C-choline. PET was performed a median of 13 and 10 days after vaccination for patients who had received one ( = 44) and two ( = 23) vaccine doses, respectively. Two nuclear medicine physicians independently reviewed images and were blinded to injection laterality and the number of days since vaccination. Lymph node or deltoid SUV greater than the blood pool SUV was considered positive. Interreader agreement was assessed, and the measurements made by the more experienced physician were used for subsequent analysis. Positive axillary lymph node uptake was observed in 10.4% (7/67) of patients (7.4% [4/54] of FDG examinations and 23.1% [3/13] of C-choline examinations); of the patients with positive axillary lymph nodes, four had received the Pfizer vaccine, and three had received the Moderna vaccine. Injection laterality was documented for five of seven patients with positive axillary lymph nodes and was ipsilateral to the positive node in all five patients. PET was performed within 24 days of vaccination for all patients with a positive node. One patient showed extraaxillary lymph node uptake (ipsilateral supraclavicular uptake on FDG PET). Ipsilateral deltoid uptake was present in 14.5% (8/55) of patients with documented injection laterality, including 42.9% (3/7) of patients with positive axillary lymph nodes. Interreader agreement for SUV measurements (expressed as intraclass correlation coefficients) ranged from 0.600 to 0.988. Increased axillary lymph node or ipsilateral deltoid uptake is occasionally observed on FDG or C-choline PET performed after COVID-19 vaccination with the Pfizer-BioNTech or Moderna vaccine. Interpreting physicians should recognize characteristics of abnormal uptake on PET after COVID-19 vaccination to guide optimal follow-up management and reduce unnecessary biopsies.
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http://dx.doi.org/10.2214/AJR.21.25928DOI Listing
November 2021

F-fluorodeoxyglucose positron emission tomography/computed tomography of giant cell arteritis with lower extremity involvement in association with polymyalgia rheumatica.

World J Nucl Med 2021 Jan-Mar;20(1):90-92. Epub 2020 Oct 2.

Department of Radiology, Mayo Clinic, Rochester, MN, USA.

An 80-year-old man presented with new-onset pain in the shoulders and lower extremities and elevated serum inflammatory markers. A clinical diagnosis of polymyalgia rheumatica (PMR) was made, but there was a suboptimal response to glucocorticoid therapy, prompting further evaluation. F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) revealed intense FDG uptake in the arteries of the bilateral lower extremities, head, and neck, but sparing the aorta, suggestive of an uncommon pattern of giant cell arteritis (GCA). There were also imaging signs consistent with PMR, including FDG uptake in the synovium of large joints. This case highlights the uncommon manifestation of GCA with lower extremity involvement and sparing of the aorta. The combination of FDG PET imaging features and elevated serum markers obviated the need for invasive biopsy. One might also conclude that standard FDG PET/CT imaging protocols covering orbits/vertex to thighs incompletely evaluate the extent of arterial distribution of GCA.
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http://dx.doi.org/10.4103/wjnm.WJNM_102_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034796PMC
October 2020

Accuracy of F-Fluorocholine PET for the Detection of Parathyroid Adenomas: Prospective Single-Center Study.

J Nucl Med 2021 Nov 5;62(11):1511-1516. Epub 2021 Mar 5.

Department of Surgery, University of California San Francisco, San Francisco, California;

The purpose of this prospective study was to determine the correct localization rate (CLR) of F-fluorocholine PET for the detection of parathyroid adenomas in comparison to Tc-sestamibi imaging. This was a single-arm prospective trial. Ninety-eight patients with biochemical evidence of primary hyperparathyroidism were imaged before parathyroidectomy using F-fluorocholine PET/MRI. Tc-sestamibi imaging performed separately from the study was evaluated for comparison. The primary endpoint of the study was the CLR on a patient level. Each imaging study was interpreted by 3 masked readers on a per-region basis. Lesions were validated by histopathologic analysis of surgical specimens. Of the 98 patients who underwent F-fluorocholine PET, 77 subsequently underwent parathyroidectomy and 60 of those had Tc-sestamibi imaging. For F-fluorocholine PET in patients who underwent parathyroidectomy, the CLR based on the masked reader consensus was 75% (95% CI, 0.63-0.82). In patients who underwent surgery and had an available Tc-sestamibi study, the CLR increased from 17% (95% CI, 0.10-0.27) for Tc-sestamibi imaging to 70% (95% CI, 0.59-0.79) for F-fluorocholine PET. In this prospective study using masked readers, the CLR for F-fluorocholine PET was 75%. In patients with a paired Tc-sestamibi study, the use of F-fluorocholine PET increased the CLR from 17% to 70%. F-fluorocholine PET is a superior imaging modality for the localization of parathyroid adenomas.
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http://dx.doi.org/10.2967/jnumed.120.256735DOI Listing
November 2021

Radiologic and clinicopathologic characteristics of thyroid nodules with focal 68Ga-DOTATATE PET activity.

Nucl Med Commun 2021 May;42(5):510-516

Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic.

Objective: Our aim was to determine the radiologic and clinicopathologic characteristics of thyroid nodules with focal 68Ga-DOTATATE activity.

Methods: In this retrospective study of 1927 consecutive 68Ga-DOTATATE PET scans, 85 patients with incidental and nonincidental focal 68Ga-DOTATATE avid thyroid nodules were identified, of which 31 patients with 33 thyroid nodules underwent fine-needle aspiration (FNA) or surgery. These 33 nodules were reviewed for Krenning score and SUVmax of the thyroid nodule, contralateral thyroid lobe and left atrium.

Results: Cytology/histopathology included 58% (19/33) with benign findings, 18% (6/33) medullary thyroid carcinoma (MTC), 9% (3/33) atypia or follicular lesion of undetermined significance (AUS/FLUS), 9% (3/33) suspicious for follicular neoplasm and Hurthle cell adenoma (SFN/HCA) and 6% (2/33) nondiagnostic cytology. Median serum calcitonin was 1156 pg/mL (range, 460-1828) in MTC and was <5.0 pg/mL (<5.0-12.5) in patients with benign nodules. Nodules had Krenning score of 1, 2 and 3 in 46% (15/33), 27% (9/33) and 27% (9/33). The majority of MTC and AUS/FLUS nodules had a Krenning score of 3, and there was substantial intragroup variation in Krenning score among the benign nodules. The mean SUVmax for the entire cohort was 5.5 ± 2.9 (mean ± SD), and the range was 2.0-13.0. There was overlap in the nodule/contralateral thyroid SUVmax ratios between groups. The MTC and AUS/FLUS nodules tended to have a higher nodule/blood pool SUVmax ratio than the other pathologic groups.

Conclusion: There was considerable variation in radiologic characteristics among benign thyroid nodules. The ratio of thyroid nodule SUVmax/blood pool SUVmax may be useful to differentiate pathologic groups, but larger studies are needed to investigate this further. Given the potential for malignancy in thyroid nodules with focal 68Ga-DOTATATE activity, further evaluation with serum calcitonin and FNA may be considered.Video Abstract: http://links.lww.com/NMC/A186.
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http://dx.doi.org/10.1097/MNM.0000000000001356DOI Listing
May 2021

FDG PET/CT and MRI Features of Pathologically Proven Schwannomas.

Clin Nucl Med 2021 04;46(4):289-296

From the Departments of Radiology.

Purpose: The aim of this study was to examine the MRI and FDG PET/CT imaging features of pathologically proven schwannomas.

Patients And Methods: This institutional review board-approved retrospective study examined biopsy-proven schwannomas that underwent FDG PET/CT and/or MRI at our institution between January 1, 2002, and April 1, 2018. PET/CT features analyzed included SUVmax, metabolic ratios, volumetric metabolic measures, presence of calcification, and pattern of FDG activity. MRI features included T1/T2 signal, enhancement pattern, margins, perilesional edema, presence of muscular denervation, and size.

Results: Ninety-five biopsy-proven schwannomas were identified (40 with both PET and MRI, 35 with PET only, and 20 with MRI only), 46 females and 49 males, average age of 57.7 ± 15.3 years. The average largest dimension was 4.6 ± 2.7 cm, the average SUVmax was 5.4 ± 2.7, and lesion SUVmax/liver SUVmean was 2.2 ± 1.2. Eleven (15%) of 75 lesions had SUVmax greater than 8.1, 26/75 (35%) had SUVmax greater than 6.1, and 14/75 (19%) had lesion SUVmax/liver SUVmean greater than 3.0. On MRI, 29/53 (55%) demonstrated internal nonenhancing areas. Twenty-eight (70%) of 40 lesions with both MRI and PET demonstrated at least 1 imaging feature concerning for malignant peripheral nerve sheath tumor (irregular margins, internal nonenhancement, perilesional edema, heterogeneous FDG uptake, or SUVmax >8.1). Lesions with heterogeneous FDG activity had higher SUVmax (6.5 ± 0.5 vs 4.7 ± 0.4, P = 0.0031) and more frequent internal nonenhancement on MRI (P = 0.0218).

Conclusions: Schwannomas may be large, be intensely FDG avid, and demonstrate significant heterogeneity, features typically associated with malignant peripheral nerve sheath tumors. A significant proportion exhibit FDG activity above cutoff levels previously thought useful in differentiating malignant from benign peripheral nerve sheath tumors.
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http://dx.doi.org/10.1097/RLU.0000000000003485DOI Listing
April 2021

123I Scan With Whole-Body Retention Measurement at 48 Hours for Simplified Dosimetry Before 131I Treatment of Metastatic Thyroid Cancer.

Clin Nucl Med 2021 03;46(3):e151-e153

From the Department of Radiology, Mayo Clinic, Rochester, MN.

Abstract: A previously published model (Atkins) allows for calculation of 131I maximum tolerated activity on the basis of 48-hour whole-body retention of 131I on a pretherapy diagnostic scan. Our practice uses iodine 123I for diagnostic imaging of metastatic thyroid cancer for staging before 131I therapy, with images typically acquired 24 hours after administration of the radiopharmaceutical. We explored the feasibility of an additional 123I whole-body scan and retention measurement at 48 hours, with application of the model to estimate maximum tolerated activity of radioiodine before 131I treatment of metastatic thyroid cancer.
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http://dx.doi.org/10.1097/RLU.0000000000003464DOI Listing
March 2021

Positron emission tomography objective parameters for assessment of left ventricular assist device infection using F-FDG PET/CT.

Am J Nucl Med Mol Imaging 2020 15;10(6):301-311. Epub 2020 Dec 15.

Department of Radiology, Mayo Clinic College of Medicine and Science Rochester, MN, USA.

Left ventricular assist device (LVAD) is a life-saving therapy, but it poses a substantial infection risk. Current evaluation of LVAD infection with F-FDG PET/CT is predominately subjective. We present qualitative and semi-quantitative F-FDG PET/CT parameters for early detection of LVAD infection and site localization. We retrospectively reviewed all 25 LVAD patients at our institution who had undergone F-FDG PET/CT imaging between 2014 and 2018. LVADs were subdivided into five assessed regions: driveline exit site, subcutaneous driveline, LVAD pump, LVAD inflow, and LVAD outflow cannulae. Ultimate diagnosis of LVAD infection was determined by a multidisciplinary primary care team. Qualitative and semi-quantitative analysis of PET/CT data were performed, including calculation of the standardized uptake value maximum, mean, and peak (SUV, SUV, and SUV, respectively), as well as metabolic tumor volume (MTV), and total lesion glycolysis (TLG). A total of 14 patients presented with symptoms of infection, and LVAD infection was ultimately diagnosed in 19 of the 25 cases. All cases were correctly identified on F-FDG PET/CT with no false positive and no false negative cases, corresponding to a sensitivity and specificity of 100%. The mean SUV range at noninfected sites was 2.5-3.4, and the range was 5.7-8.1 at infected sites, resulting in a significant difference ( < 0.01) at all LVAD regions. F-FDG PET/CT is a useful adjunctive tool for assessment of LVAD infection and infection localization, which is crucial for clinical management. A cut-off SUV 5 is recommended to help diagnose LVAD infection.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7724280PMC
December 2020

How We Do It: A Multidisciplinary Approach to Lu DOTATATE Peptide Receptor Radionuclide Therapy.

Radiology 2021 02 24;298(2):261-274. Epub 2020 Nov 24.

From the Division of Nuclear Medicine, Department of Radiology (B.J.B., A.D., J.R.Y., A.T.P., G.B.J., D.N.G., C.M.P., A.T.K.), and Department of Medical Oncology (T.R.H., R.A.E.), Mayo Clinic, 200 First St SW, Rochester, MN 55905.

Lutetium 177 (Lu) DOTA-0-Tyr3-Octreotate (DOTATATE) peptide receptor radionuclide therapy (PRRT) is an effective treatment for advanced gastroenteropancreatic neuroendocrine tumors. This review presents a clinical practice workflow that has been successful since Lu DOTATATE PRRT was approved by the U.S. Food and Drug Administration. The workflow relies heavily on the input of a multidisciplinary team and involves a nuclear medicine consultation service, tumor board, and specific preparations in advance of therapy and day-of-therapy procedures. A systematic checklist designed to ensure appropriate selection of treatment candidates and identification of any concerns to address to safely administer PRRT is provided. All patients were evaluated with gallium 68 DOTATATE PET/CT, and in cases of high-grade tumors, they were also evaluated with fluorine 18 fluorodeoxyglucose PET/CT, with imaging findings reviewed as part of the systematic checklist before PRRT. Adverse effects are discussed and imaging follow-up regimens are reviewed, including alternative diagnostic contrast materials. Approaches to multiple challenging patient scenarios are illustrated through case examples. Finally, alternative theranostic radionuclides and treatment strategies are discussed.
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http://dx.doi.org/10.1148/radiol.2020201745DOI Listing
February 2021

Pulmonary nodules in patients with primary Sjögren's syndrome: Causes, clinico-radiologic features, and outcomes.

Respir Med 2020 Nov - Dec;174:106200. Epub 2020 Oct 22.

Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA. Electronic address:

Background: Primary Sjögren's Syndrome (pSS) is characterized by an immune-mediated lymphoplasmacytic infiltration of the salivary and lacrimal glands. Pulmonary nodules are not uncommonly encountered in these patients.

Methods: We conducted a retrospective computer-assisted search for patients with pSS who were encountered at our institution between 1999 and 2018 and had histologically characterized pulmonary nodule(s)/mass (es) (PNs).

Results: Of 41 patients with pSS and PNs, median age was 67 years (IQR, 56-74), 94% were women, and 39% had a smoking history. The PNs proved to be non-Hodgkin lymphoma (NHL) in 16 patients (39%), lung carcinoma in 11 patients (27%), other malignancies in 2 patients (5%), and benign diseases in remaining 12 patients (29%), including 7 with amyloidomas. Patients with NHL were younger (p = 0.006) while smoking exposure was more prevalent in patients with lung carcinoma (p = 0.022). Patients with NHL had a higher number of PNs and more often manifested random distribution, cysts, ground-glass changes and consolidations. Upper and/or mid-lung location, spiculated borders, solitary nodule, increasing size, and higher SUV on FDG-PET scan were associated with lung carcinoma. At the end of follow-up (median 5.9 years), 8 patients (20%) had died and included 5 patients with lung carcinoma; no deaths were observed in the NHL group.

Conclusions: The majority of biopsied PNs in patients with pSS were malignant, most commonly lymphomas. Smoking exposure, solitary nodule, and high FDG avidity were more frequently associated with lung carcinoma. The clinical context, CT and FDG-PET are complementary in the evaluation and management of PNs in patients with pSS.
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http://dx.doi.org/10.1016/j.rmed.2020.106200DOI Listing
June 2021

Novel imaging techniques using F-florbetapir PET/MRI can guide fascicular nerve biopsy in amyloid multiple mononeuropathy.

Muscle Nerve 2021 01 4;63(1):104-108. Epub 2020 Nov 4.

Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.

Background: Multiple mononeuropathy is a rare presentation of primary (AL) amyloidosis and nerve biopsy is usually needed for diagnosis. Conventional imaging is useful to identify proximal nerve involvement but may be inadequate. We report a patient with multiple mononeuropathy whose presentation was suggestive of AL amyloid neuropathy and in whom repeated tissue biopsies were negative for amyloid (including two sensory nerves and one muscle).

Methods: The patient underwent magnetic resonance imaging (MRI) and whole body F-florbetapir positron emission tomography (PET)/MRI.

Results: Whole body F-florbetapir PET/MRI revealed abnormal low-level florbetapir uptake in the right proximal tibial and peroneal nerves, which provided a target for a sciatic bifurcation fascicular nerve biopsy that was diagnostic of AL amyloidosis.

Conclusions: F-florbetapir PET/MRI imaging is a promising diagnostic tool for patients with suspected peripheral nerve amyloidosis (including multiple mononeuropathy) in whom conventional imaging and nerve and muscle biopsies miss the pathology.
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http://dx.doi.org/10.1002/mus.27100DOI Listing
January 2021

Borderline Resectable and Locally Advanced Pancreatic Cancer: FDG PET/MRI and CT Tumor Metrics for Assessment of Pathologic Response to Neoadjuvant Therapy and Prediction of Survival.

AJR Am J Roentgenol 2021 09 21;217(3):730-740. Epub 2020 Oct 21.

Department of Radiology, Mayo Clinic, 200 First St SW, Charlton 1, Rochester, MN 55905.

Imaging biomarkers of response to neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDA) are needed to optimize treatment decisions and long-term outcomes. The purpose of this study was to investigate metrics from PET/MRI and CT to assess pathologic response of PDA to NAT and to predict overall survival (OS). This retrospective study included 44 patients with F-FDG-avid borderline resectable or locally advanced PDA on pretreatment PET/MRI who also underwent post-NAT PET/MRI before surgery between August 2016 and February 2019. Carbohydrate antigen 19-9 (CA 19-9) level, metabolic metrics from PET/MRI, and morphologic metrics from CT ( = 34) were compared between pathologic responders (College of American Pathologists scores 0 and 1) and nonresponders (scores 2 and 3). AUCs were measured for metrics significantly associated with pathologic response. Relation to OS was evaluated with Cox proportional hazards models. Among 44 patients (22 men, 22 women; mean age, 62 ± 11.6 years), 19 (43%) were responders, and 25 (57%) were nonresponders. Median OS was 24 months (range, 6-42 months). Before treatment, responders and nonresponders did not differ in CA 19-9 level, metabolic metrics, or CT metrics ( > .05). After treatment, responders and nonresponders differed in complete metabolic response (CMR) (responders, 89% [17/19]; nonresponders, 40% [10/25]; = .04], mean change in SUV (ΔSUV; responders, -70% ± 13%; nonresponders, -37% ± 42%; < .001), mean change in SUV corrected to serum glucose level (ΔSUV) (responders, -74% ± 12%; nonresponders, -30% ± 58%; < .001), RECIST response on CT (responders, 93% [13/14]; nonresponders, 50% [10/20]; = .02)], and mean change in tumor volume on CT (ΔTvol) (responders, -85% ± 21%; nonresponders, 57% ± 400%; < .001). The AUC of CMR for pathologic response was 0.75; ΔSUV, 0.83; ΔSUV, 0.87; RECIST, 0.71; and ΔTvol 0.86. The AUCs of bivariable PET/MRI and CT models were 0.83 (CMR and ΔSUV), 0.87 (CMR and ΔSUV), and 0.87 (RECIST and ΔTvol). OS was associated with CMR ( = .03), ΔSUV ( = .003), ΔSUV ( = .003), and RECIST ( = .046). Unlike CA 19-9 level, changes in metabolic metrics from PET/MRI and morphologic metrics from CT after NAT were associated with pathologic response and OS in patients with PDA, warranting prospective validation. Imaging metrics associated with pathologic response and OS in PDA could help guide clinical management and outcomes for patients with PDA who undergo emergency therapeutic interventions.
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http://dx.doi.org/10.2214/AJR.20.24567DOI Listing
September 2021

PET Imaging of Tumor Perfusion: A Potential Cancer Biomarker?

Semin Nucl Med 2020 11 7;50(6):549-561. Epub 2020 Aug 7.

Department of Radiology, Mayo Clinic, Rochester, MNDepartment of Neurology, Mayo Clinic, Rochester, MN.

Perfusion, as measured by imaging, is considered a standard of care biomarker for the evaluation of many tumors. Measurements of tumor perfusion may be used in a number of ways, including improving the visual detection of lesions, differentiating malignant from benign findings, assessing aggressiveness of tumors, identifying ischemia and by extension hypoxia within tumors, and assessing treatment response. While most clinical perfusion imaging is currently performed with CT or MR, a number of methods for PET imaging of tumor perfusion have been described. The inert PET radiotracer O-water PET represents the recognized gold standard for absolute quantification of tissue perfusion in both normal tissue and a variety of pathological conditions including cancer. Other cancer PET perfusion imaging strategies include the use of radiotracers with high first-pass uptake, analogous to those used in cardiac perfusion PET. This strategy produces more visually pleasing high-contrast images that provide relative rather than absolute perfusion quantification. Lastly, multiple timepoint imaging of PET tracers such as F-FDG, are not specifically optimized for perfusion, but have advantages related to availability, convenience, and reimbursement. Multiple obstacles have thus far blocked the routine use of PET imaging for tumor perfusion, including tracer production and distribution, image processing, patient body coverage, clinical validation, regulatory approval and reimbursement, and finally feasible clinical workflows. Fortunately, these obstacles are being overcome, especially within larger imaging centers, opening the door for PET imaging of tumor perfusion to become standard clinical practice. In the foreseeable future, it is possible that whole-body PET perfusion imaging with O-water will be able to be performed in a single imaging session concurrent with standard PET imaging techniques such as F-FDG-PET. This approach could establish an efficient clinical workflow. The resultant ability to measure absolute tumor blood flow in combination with glycolysis will provide important complementary information to inform prognosis and clinical decisions.
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http://dx.doi.org/10.1053/j.semnuclmed.2020.07.001DOI Listing
November 2020

Targeting of the Hedgehog/GLI and mTOR pathways in advanced pancreatic cancer, a phase 1 trial of Vismodegib and Sirolimus combination.

Pancreatology 2020 Sep 14;20(6):1115-1122. Epub 2020 Jul 14.

Schulze Center for Novel Therapeutics, Division of Oncology Research, Department of Oncology, Mayo Clinic, Rochester, MN, USA; Department of Medical Oncology, Department of Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA. Electronic address:

Background/objectives: Preclinical data indicated a functional and molecular interaction between Hedgehog (HH)/GLI and PI3K-AKT-mTOR pathways promoting pancreatic ductal adenocarcinoma (PDAC). A phase I study was conducted of Vismodegib and Sirolimus combination to evaluate maximum tolerated dose (MTD) and preliminary anti-tumor efficacy.

Methods: Cohort I included advanced solid tumors patients following a traditional 3 + 3 design. Vismodegib was orally administered at 150 mg daily with Sirolimus starting at 3 mg daily, increasing to 6 mg daily at dose level 2. Cohort II included only metastatic PDAC patients. Anti-tumor efficacy was evaluated every two cycles and target assessment at pre-treatment and after a single cycle.

Results: Nine patient were enrolled in cohort I and 22 patients in cohort II. Twenty-eight patients were evaluated for dose-limiting toxicities (DLTs). One DLT was observed in each cohort, consisting of grade 2 mucositis and grade 3 thrombocytopenia. The MTD for Vismodegib and Sirolimus were 150 mg daily and 6 mg daily, respectively. The most common grade 3-4 toxicities were fatigue, thrombocytopenia, dehydration, and infections. A total of 6 patients had stable disease. No partial or complete responses were observed. Paired biopsy analysis before and after the first cycle in cohort II consistently demonstrated reduced GLI1 expression. Conversely, GLI and mTOR downstream targets were not significantly affected.

Conclusions: The combination of Vismodegib and Sirolimus was well tolerated. Clinical benefit was limited to stable disease in a subgroup of patients. Targeting efficacy demonstrated consistent partial decreases in HH/GLI signaling with limited impact on mTOR signaling. These findings conflict with pre-clinical models and warrant further investigations.
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http://dx.doi.org/10.1016/j.pan.2020.06.015DOI Listing
September 2020

Recent updates and developments in PET imaging of prostate cancer.

Abdom Radiol (NY) 2020 12;45(12):4063-4072

Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA.

A number of positron emission tomography (PET) radiotracers have been developed to improve the sensitivity and specificity of imaging for prostate cancer. These radiotracers include the bone-seeking agent NaF as well as more tumor-specific compounds such as C-choline and F-fluciclovine. In this review, we will discuss the advantages and disadvantages of these PET radiotracers for the imaging of men with prostate cancer across a range of clinical contexts. We will also touch upon radiotracers in late clinical development that have not gained regulatory approval, including those targeted against prostate-specific membrane antigen (PSMA) and gastrin-releasing peptide receptor (GRPR).
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http://dx.doi.org/10.1007/s00261-020-02570-yDOI Listing
December 2020

A 48-Year-Old South African Woman with Rheumatoid Arthritis and Lung Nodules.

Chest 2020 05;157(5):e151-e155

Division of Pulmonology, Department of Medicine, Tygerberg Academic Hospital, Stellenbosch University, Stellenbosch University, Cape Town, Western Cape, South Africa.

Case Presentation: We present the case of a 48-year-old South African woman with no smoking history, and seropositive rheumatoid arthritis diagnosed in 2001. She was treated with chloroquine (150 mg, 4 times per week) and methotrexate (30 mg weekly) with well-controlled symptoms until 2015, when she developed a disease flare. Her treatment regimen was changed to leflunomide (20 mg daily) monotherapy with subsequent symptom control. Biologic agents were not accessible because of cost constraints.
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http://dx.doi.org/10.1016/j.chest.2019.10.052DOI Listing
May 2020

ACR Appropriateness Criteria® Occupational Lung Diseases.

J Am Coll Radiol 2020 May;17(5S):S188-S197

Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Ordering the appropriate diagnostic imaging for occupational lung disease requires a firm understanding of the relationship between occupational exposure and expected lower respiratory track manifestation. Where particular inorganic dust exposures typically lead to nodular and interstitial lung disease, other occupational exposures may lead to isolated small airway obstruction. Certain workplace exposures, like asbestos, increase the risk of malignancy, but also produce pulmonary findings that mimic malignancy. This publication aims to delineate the common and special considerations associated with occupational lung disease to assist the ordering physician in selecting the most appropriate imaging study, while still stressing the importance of a multidisciplinary approach. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.022DOI Listing
May 2020

ACR Appropriateness Criteria® Acute Respiratory Illness in Immunocompromised Patients.

J Am Coll Radiol 2019 Nov;16(11S):S331-S339

Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

The immunocompromised patient with an acute respiratory illness (ARI) may present with fever, chills, weight loss, cough, shortness of breath, or chest pain. The number of immunocompromised patients continues to rise with medical advances including solid organ and stem cell transplantation, chemotherapy, and immunomodulatory therapy, along with the continued presence of human immunodeficiency virus and acquired immunodeficiency syndrome. Given the myriad of pathogens that can infect immunocompromised individuals, identifying the specific organism or organisms causing the lung disease can be elusive. Moreover, immunocompromised patients often receive prophylactic or empiric antimicrobial therapy, further complicating diagnostic evaluation. Noninfectious causes for ARI should also be considered, including pulmonary edema, drug-induced lung disease, atelectasis, malignancy, radiation-induced lung disease, pulmonary hemorrhage, diffuse alveolar damage, organizing pneumonia, lung transplant rejection, and pulmonary thromboembolic disease. As many immunocompromised patients with ARI progress along a rapid and potentially fatal course, timely selection of appropriate imaging is of great importance in this setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking, or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.05.019DOI Listing
November 2019

Molecular radionuclide imaging of pancreatic neoplasms.

Lancet Gastroenterol Hepatol 2019 07;4(7):559-570

Department of Radiology, Mayo Clinic, Rochester, MN, USA. Electronic address:

Pancreatic neoplasms have high morbidity and dismal prognosis. Substantial progress in translational research and advances in scanner technology have resulted in rapid integration of molecular radionuclide imaging of pancreatic neoplasms into mainstream clinical practice. Metabolic imaging with F-FDG PET has extensive utility in the staging, assessment of treatment response, and follow-up of pancreatic ductal adenocarcinoma. Integrated PET/MRI has the potential to further expand this utility and lead to innovative applications. Somatostatin receptor PET imaging has had a profound effect on the evaluation and management of pancreatic neuroendocrine tumours. Peptide receptor radionuclide therapy is a new frontier in personalised medicine because it customises treatment to the unique biological features of a patient and the molecular signature of the patient's tumour. Further investigation is needed to optimise use of advanced molecular imaging techniques and novel radiotracers to achieve better outcomes for patients with pancreatic neoplasms.
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http://dx.doi.org/10.1016/S2468-1253(19)30081-0DOI Listing
July 2019

ACR Appropriateness Criteria Rib Fractures.

J Am Coll Radiol 2019 May;16(5S):S227-S234

Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Rib fractures are the most common thoracic injury after minor blunt trauma. Although rib fractures can produce significant morbidity, the diagnosis of injuries to underlying organs is arguably more important as these complications are likely to have the most significant clinical impact. Isolated rib fractures have a relatively low morbidity and mortality and treatment is generally conservative. As such, evaluation with standard chest radiographs is usually sufficient for the diagnosis of rib fractures, and further imaging is generally not appropriate as there is little data that undiagnosed isolated rib fractures after minor blunt trauma affect management or outcomes. Cardiopulmonary resuscitation frequently results in anterior rib fractures and chest radiographs are usually appropriate (and sufficient) as the initial imaging modality in these patients. In patients with suspected pathologic fractures, chest CT or Tc-99m bone scans are usually appropriate and complementary modalities to chest radiography based on the clinical scenario. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.02.019DOI Listing
May 2019

Tc-Tilmanocept Versus Tc-Sulfur Colloid in Lymphoscintigraphy: Sentinel Lymph Node Identification and Patient-Reported Pain.

J Nucl Med Technol 2019 Dec 24;47(4):300-304. Epub 2019 Apr 24.

Department of Diagnostic Radiology, Mayo Clinic, Rochester, Minnesota

Lymphoscintigraphy plays a vital role in sentinel lymph node (SLN) identification in oncologic breast surgery. The effectiveness of SLN localization and the degree of patient pain were compared between filtered Tc-sulfur colloid (Tc-SC) and Tc-tilmanocept. A retrospective review of patients undergoing lymphoscintigraphy for breast cancer using Tc-SC (June 1, 2010, to December 31, 2011) or Tc-tilmanocept (June 1, 2013, to January 31, 2014) was performed. SLN appearance time and uptake, SLN pathology, proportion of positive SLNs removed, and pain scores were compared for each radiopharmaceutical using the χ test, Fisher exact test, and unequal variance test, as appropriate. In total, 76 patients, with 86 evaluated axillae, underwent lymphoscintigraphy: 29 with Tc-SC and 47 with Tc-tilmanocept. The mean SLN appearance time was 11.0 min for Tc-SC and 19.3 min for Tc-tilmanocept ( = 0.003). There was no difference in the mean transit uptake percentage: 2.2% for Tc-SC and 1.9% for Tc-tilmanocept ( = 0.55). Tc-tilmanocept identified a greater proportion of intraoperative blue nodes than did Tc-SC ( = 0.03). There was no significant difference between Tc-SC and Tc-tilmanocept in the number of SLNs removed, number of patients with positive SLNs, or pain score. Tc-SC use in lymphoscintigraphy is an acceptable alternative to Tc-tilmanocept for SLN detection in breast cancer, on the basis of the similarity in intraoperative SLN identification and pain scores.
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http://dx.doi.org/10.2967/jnmt.118.225342DOI Listing
December 2019

Percutaneous Image-Guided Nodal Biopsy After 11C-Choline PET/CT for Biochemically Recurrent Prostate Cancer: Imaging Predictors of Disease and Clinical Implications.

Adv Radiat Oncol 2019 Jan-Mar;4(1):79-89. Epub 2018 Sep 5.

Department of Radiology, Mayo Clinic, Rochester, Minnesota.

Purpose: Management of recurrent prostate cancer necessitates timely diagnosis and accurate localization of the sites of recurrent disease. The purpose of this study was to assess predictors of histologic outcomes after 11C-choline positron emission tomography/computed tomography (CholPET) to increase the positive predictive value and specificity of CholPET in identifying imaging predictors of malignant and benign nodal disease to better inform clinical decision making regarding local therapy planning.

Materials And Methods: Retrospective review of patients undergoing CholPET followed by percutaneous core needle biopsy between January 1, 2010 and January 1, 2016. A total of 153 patients were identified who underwent 166 biopsy procedures. Patient, CholPET, procedural, and pathologic characteristics were recorded.

Results: A total of 157 biopsies were technically successful, and 110 (70.1%; 95% confidence interval, 62.2-77.1) yielded histologic results abnormal for metastatic prostate cancer. Lesion location, lesion maximum standardized uptake value (SUVmax), SUV ratio (calculated as the ratio of SUVmax to SUV mean in the right atrium), prostate-specific antigen, lesion short axis length, total Gleason score, and castration resistance were all associated with abnormal biopsy results ( values <.001, <.001, <.001, .02, .02, .02, and .015, respectively). External iliac, common iliac, and inguinal sites were associated with much lower rates of histologic positivity (mean [95% confidence interval], 51.2% [35.1-67.1], 46.2% [19.2-74.9], and 33.3% [7.5-70.1]), respectively.

Conclusions: In a cohort of patients in whom core needle biopsy was performed after CholPET, characteristics of choline localization including node location, SUVmax, lesion-to-blood pool SUV ratio, prostate-specific antigen, total Gleason score, and castration resistance were significantly associated with abnormal biopsy results for metastatic disease on CholPET. Relatively high false positive rates were found in common iliac, external iliac, and inguinal lymph node locations. Histologic confirmation of these sites should be strongly considered in the appropriate clinical scenario before designing additional local therapy plans.
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http://dx.doi.org/10.1016/j.adro.2018.08.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6349661PMC
September 2018

ACR Appropriateness Criteria Lung Cancer Screening.

J Am Coll Radiol 2018 Nov;15(11S):S341-S346

Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Lung cancer remains the leading cause of cancer death in both men and women. Smoking is the single greatest risk factor for the development of lung cancer. For patients between the age of 55 and 80 with 30 or more pack years smoking history who currently smoke or who have quit within the last 15 years should undergo lung cancer screening with low-dose CT. In patients who do not meet these criteria but who have additional risk factors for lung cancer, lung cancer screening with low-dose CT is controversial but may be appropriate. Imaging is not recommended for lung cancer screening of patient younger than 50 years of age or patients older than 80 years of age or patients of any age with less than 20 packs per year history of smoking and no additional risk factor (ie, radon exposure, occupational exposure, cancer history, family history of lung cancer, history of COPD, or history of pulmonary fibrosis). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.09.025DOI Listing
November 2018

Rheumatoid pulmonary nodules: clinical and imaging features compared with malignancy.

Eur Radiol 2019 Apr 4;29(4):1684-1692. Epub 2018 Oct 4.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Gonda 18 South, 200 First St. SW, Rochester, MN, 55905, USA.

Objectives: The objective of this study was to identify clinical and imaging features that distinguish rheumatoid lung nodules from malignancy.

Methods: We conducted a retrospective review of 73 rheumatoid patients with histologically-proven rheumatoid and malignant lung nodules encountered at Mayo Clinic, Rochester, MN (2001-2016). Medical records and imaging were reviewed including a retrospective blinded review of CT and PET/CT studies.

Results: The study cohort had a mean age of 67 ± 11 years (range 45-86) including 44 (60%) women, 82% with a smoking history, 38% with subcutaneous rheumatoid nodules, and 78% with rheumatoid factor seropositivity. Subjects with rheumatoid lung nodules compared to malignancy were younger (59 ± 12 vs 71 ± 9 years, p < 0.001), more likely to manifest subcutaneous rheumatoid nodules (73% vs 20%, p < 0.001) and rheumatoid factor seropositivity (93% vs 68%, p = 0.034) but a history of smoking was common in both groups (p = 0.36). CT features more commonly associated with rheumatoid lung nodules compared to malignancy included multiplicity, smooth border, cavitation, satellite nodules, pleural contact, and a subpleural rind of soft tissue. Optimal sensitivity (77%) and specificity (92%) (AUC 0.85, CI 0.75-0.94) for rheumatoid lung nodule were obtained with ≥ 3 CT findings (≥ 4 nodules, peripheral location, cavitation, satellite nodules, smooth border, and subpleural rind). Key FDG-PET/CT features included low-level metabolism (SUV 2.7 ± 2 vs 7.2 ± 4.8, p = 0.007) and lack of F-fluorodeoxyglucose (FDG)-avid draining lymph nodes.

Conclusion: Rheumatoid lung nodules have distinct CT and PET/CT features compared to malignancy. Patients with rheumatoid lung nodules are younger and more likely to manifest subcutaneous rheumatoid nodules and seropositivity.

Key Points: • Rheumatoid lung nodules have distinct clinical and imaging features compared to lung malignancy. • CT features of rheumatoid lung nodules include multiplicity, cavitation, satellite nodules, smooth border, peripheral location, and subpleural rind. • Key PET/CT features include low-level metabolism and lack of FDG-avid draining lymph nodes.
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http://dx.doi.org/10.1007/s00330-018-5755-xDOI Listing
April 2019

Clinical PET/MRI: 2018 Update.

AJR Am J Roentgenol 2018 08 27;211(2):295-313. Epub 2018 Jun 27.

1 Department of Radiology, Mayo Clinic, Charlton 1, 200 First St SW, Rochester, MN 55905.

Objective: The purpose of this article is to provide an update on clinical PET/MRI, including current and developing clinical indications and technical developments.

Conclusion: PET/MRI is evolving rapidly, transitioning from a predominant research focus to exciting clinical practice. Key technical obstacles have been overcome, and further technical advances promise to herald significant advancements in image quality. Further optimization of protocols to address challenges posed by this hybrid modality will ensure the long-term success of PET/MRI.
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http://dx.doi.org/10.2214/AJR.18.20001DOI Listing
August 2018

Tc-Sulfur Colloid Bone Marrow Scintigraphy in Diagnosis of Diffuse Pulmonary Extramedullary Hematopoiesis Secondary to Myelofibrosis.

J Nucl Med Technol 2018 Dec 8;46(4):368-372. Epub 2018 Jun 8.

Department of Radiology, Mayo Clinic in Arizona, Scottsdale, Arizona.

Our objective was to define the role of combined Tc-sulfur colloid bone marrow (SC BM) scintigraphy, SPECT or SPECT/CT, and chest CT in diagnosing diffuse pulmonary extramedullary hematopoiesis (PEMH) in patients with myelofibrosis. We retrospectively reviewed Tc-SC BM scintigraphy scans performed at our institution for the diagnosis of diffuse PEMH, as well as accompanying chest CT and SPECT/CT imaging findings. Relevant clinical information, including respiratory manifestations, pulmonary hypertension, and subjective response to whole-lung radiation therapy, was also summarized. Twenty-two myelofibrosis patients with 27 Tc-SC BM scintigraphy scans were diagnosed with diffuse PEMH. In 21 patients (95%) with accompanying chest CT and SPECT/CT scans, the most common CT findings were ground-glass opacity, interstitial infiltration, and pleural effusion. Of 20 patients (91%) who underwent 2-dimensional echocardiography studies, 12 (55%) were diagnosed with pulmonary hypertension. All 12 patients exhibited the aforementioned nonspecific CT imaging findings, with 8 (66%) of them presenting with respiratory symptoms, including dyspnea, shortness of breath, and cough. In the remaining 8 patients, without pulmonary hypertension, half had similar respiratory symptoms. Fourteen patients (64%) of this cohort received whole-lung radiation therapy, of whom 7 (50%) experienced symptom relief after therapy. Nonspecific respiratory symptoms should raise concern about pulmonary hypertension and diffuse PEMH in patients with advanced-stage myelofibrosis. Combined Tc-SC BM scintigraphy and SPECT/CT is a promising noninvasive imaging tool to diagnose this rare clinical entity. hematology; respiratory; SPECT/CT; pulmonary hematopoiesis; Tc-99m sulfur colloid scintigraphy; myelofibrosis.
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http://dx.doi.org/10.2967/jnmt.118.210534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6944180PMC
December 2018

Embrace Progress.

J Nucl Med 2018 07 26;59(7):1169. Epub 2018 Apr 26.

Oxford University Hospitals NHS Foundation Trust Oxford, OX3 7LE, U.K. E-mail:

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http://dx.doi.org/10.2967/jnumed.118.212761DOI Listing
July 2018
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