Publications by authors named "Roberta Zanca"

7 Publications

  • Page 1 of 1

Role of Multimodal Imaging in Patients With Suspected Infections After the Bentall Procedure.

Front Cardiovasc Med 2021 1;8:745556. Epub 2021 Dec 1.

Department of Translational Research and New Technology in Medicine and Surgery, Regional Center of Nuclear Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.

This study aimed to assess the diagnostic performances of multimodal imaging [i.e., white blood cell single-photon emission computed tomography/CT (Tc-HMPAO-WBC SPECT/CT) and 18-fluoride-fluorodeoxyglucose positron emission tomography/CT ([F]FDG PET/CT)] in patients with suspected infection after the Bentall procedure, proposing new specific diagnostic criteria for the diagnosis. Between January 2009 and December 2019, we selected within a cardiovascular infections registry, 76 surgically treated patients (27 women and 49 men, median 66 years, and range 29-83 years). All the patients underwent molecular imaging for a suspected infection after the replacement of the aortic valve and ascending aorta according to the Bentall procedure. We analyzed 98 scans including 49 Tc-WBC and 49 [F]FDG PET/CT. A total of 22 patients with very early/early suspected infection (<3 months after surgery) were imaged with both the techniques. Positive imaging was classified according to the anatomical site of increased uptake: to the aortic valve (AV), to both the AV and AV tube graft (AVTG) or to the TG, to surrounding tissue, and/or to extracardiac sites (embolic events or other sites of concomitant infection). Standard clinical workup included in all the patients having echocardiography/CT, blood culture, and the Duke criteria. Pretest probability and positive/negative likelihood ratio were calculated. Sensitivity and specificity of Tc labeled hexamethylpropylene amine oxime-WBC SPECT/CT (Tc-HMPAO-WBC SPECT/CT) and [F]FDG PET/CT imaging were calculated by using microbiology ( = 35) or clinical follow-up ( = 41) as final diagnosis. Tc-HMPAO-WBC scintigraphy and [F]FDG PET/CT findings were compared with 95% CIs by using the McNemar test to those of echocardiography/CT, blood culture, and the Duke criteria. Sensitivity, specificity, and accuracy of Tc-HMPAO-WBC were 86, 92, and 88%, respectively, with a slightly higher sensitivity for tube graft infection (TGI) as compared to isolated AV and combined AVTG. Overall, sensitivity, specificity, and accuracy of [F]FDG PET/CT were 97, 73, and 90%, respectively. In 22 patients with suspected very early and early postsurgical infections, the two imaging modalities were concordant in 17 cases [10 true positive (TP) and 7 true negative (TN)]. [F]FDG PET/CT presented a higher sensitivity than Tc-HMPAO-WBC scan. Tc-HMPAO-WBC scan correctly classified as negative three false-positive (FP) PET/CT findings. Our findings supported the use of Tc-HMPAO-WBC SPECT/CT and [F]FDG PET/CT in patients with suspicion infection after the Bentall procedure early in the course of the disease onset to confirm the diagnosis and provide a comprehensive assessment of disease burden through the proposed criteria.
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http://dx.doi.org/10.3389/fcvm.2021.745556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8671629PMC
December 2021

[F]FMCH PET/CT biomarkers and similarity analysis to refine the definition of oligometastatic prostate cancer.

EJNMMI Res 2021 Nov 27;11(1):119. Epub 2021 Nov 27.

Nuclear Medicine, Department of Translational Research and Advanced Technology in Medicine and Surgery University of Pisa, Pisa University Hospital, Via Roma 67, 56123, Pisa, Italy.

Background: The role of image-derived biomarkers in recurrent oligometastatic Prostate Cancer (PCa) is unexplored. This paper aimed to evaluate [F]FMCH PET/CT radiomic analysis in patients with recurrent PCa after primary radical therapy. Specifically, we tested intra-patient lesions similarity in oligometastatic and plurimetastatic PCa, comparing the two most used definitions of oligometastatic disease.

Methods: PCa patients eligible for [F]FMCH PET/CT presenting biochemical failure after first-line curative treatments were invited to participate in this prospective observational trial. PET/CT images of 92 patients were visually and quantitatively analyzed. Each patient was classified as oligometastatic or plurimetastatic according to the total number of detected lesions (up to 3 and up to 5 or > 3 and > 5, respectively). Univariate and intra-patient lesions' similarity analysis were performed.

Results: [F]FMCH PET/CT identified 370 lesions, anatomically classified as regional lymph nodes and distant metastases. Thirty-eight and 54 patients were designed oligometastatic and plurimetastatic, respectively, using a 3-lesion threshold. The number of oligometastic scaled up to 60 patients (thus 32 plurimetastatic patients) with a 5-lesion threshold. Similarity analysis showed high lesions' heterogeneity. Grouping patients according to the number of metastases, patients with oligometastatic PCa defined with a 5-lesion threshold presented lesions heterogeneity comparable to plurimetastic patients. Lesions within patients having a limited tumor burden as defined by three lesions were characterized by less heterogeneity.

Conclusions: We found a comparable heterogeneity between patients with up to five lesions and plurimetastic patients, while patients with up to three lesions were less heterogeneous than plurimetastatic patients, featuring different cells phenotypes in the two groups. Our results supported the use of a 3-lesion threshold to define oligometastatic PCa.
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http://dx.doi.org/10.1186/s13550-021-00858-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8627538PMC
November 2021

What to Trust, PSA or [Ga]Ga-PSMA-11: Learn from Experience.

Res Rep Urol 2021 20;13:597-601. Epub 2021 Aug 20.

Regional Center of Nuclear Medicine, Department of Translational Research and New Technology in Medicine, University of Pisa, Pisa, Italy.

Brain metastases from prostate cancer typically occur in the more advanced stages of the disease. Clinically, the early diagnosis of visceral disease is crucial, impacting on patient's management and prognosis. Although magnetic resonance imaging (MRI) is the modality of choice for the detection of brain metastases, it is not routinely performed in the surveillance of prostate cancer patients unless neurological manifestations appear. Prostate-specific membrane antigen (PSMA) is a glycoprotein, a membrane-bound metallopeptidase, overexpressed in more than 90% of prostate cancer cells. This molecular target is a suitable tissue biomarker for prostate cancer functional imaging. We present a case of a 73-year gentleman diagnosed with prostate adenocarcinoma and surgically treated (pT3bN1Mx, Gleason Score of 9) in February 2016. Subsequently, he underwent androgen deprivation therapy because of the occurrence of a bone metastasis. Between 2016 and January 2019 PSA levels were maintained under control. Starting from September 2019, it progressively raised up to 0.85 ng/mL with a doubling time of 3.3 months. Therefore, he performed a [Ga]Ga-PSMA-11 PET/CT which showed a focal radiopharmaceutical uptake in the right temporal lobe corresponding to the presence of a rounded cystic lesion on brain MRI. The subsequent excisional biopsy diagnosed a prostate adenocarcinoma metastasis. PSMA expression has been reported in brain parenchyma after ischemic strokes and in some brain tumors including gliomas, meningiomas, and neurofibromas. In our case, the lack of symptoms and the relatively low PSA level raised questions about the nature of the lesion, posing the differential diagnosis between brain metastases and primary brain tumor. Finally, our case shows the capability of [Ga]Ga-PSMA-11 PET/CT to detect metachronous distant brain metastases in a low biochemical recurrent asymptomatic prostate cancer patient, indicating that proper acquisition - from the vertex to thigh - should be always considered, regardless of the PSA level.
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http://dx.doi.org/10.2147/RRU.S316446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384575PMC
August 2021

Artificial intelligence and hybrid imaging: the best match for personalized medicine in oncology.

Eur J Hybrid Imaging 2020 Dec 9;4(1):24. Epub 2020 Dec 9.

Regional Center of Nuclear Medicine, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy.

Artificial intelligence (AI) refers to a field of computer science aimed to perform tasks typically requiring human intelligence. Currently, AI is recognized in the broader technology radar within the five key technologies which emerge for their wide-ranging applications and impact in communities, companies, business, and value chain framework alike. However, AI in medical imaging is at an early phase of development, and there are still hurdles to take related to reliability, user confidence, and adoption. The present narrative review aimed to provide an overview on AI-based approaches (distributed learning, statistical learning, computer-aided diagnosis and detection systems, fully automated image analysis tool, natural language processing) in oncological hybrid medical imaging with respect to clinical tasks (detection, contouring and segmentation, prediction of histology and tumor stage, prediction of mutational status and molecular therapies targets, prediction of treatment response, and outcome). Particularly, AI-based approaches have been briefly described according to their purpose and, finally lung cancer-being one of the most extensively malignancy studied by hybrid medical imaging-has been used as illustrative scenario. Finally, we discussed clinical challenges and open issues including ethics, validation strategies, effective data-sharing methods, regulatory hurdles, educational resources, and strategy to facilitate the interaction among different stakeholders. Some of the major changes in medical imaging will come from the application of AI to workflow and protocols, eventually resulting in improved patient management and quality of life. Overall, several time-consuming tasks could be automatized. Machine learning algorithms and neural networks will permit sophisticated analysis resulting not only in major improvements in disease characterization through imaging, but also in the integration of multiple-omics data (i.e., derived from pathology, genomic, proteomics, and demographics) for multi-dimensional disease featuring. Nevertheless, to accelerate the transition of the theory to practice a sustainable development plan considering the multi-dimensional interactions between professionals, technology, industry, markets, policy, culture, and civil society directed by a mindset which will allow talents to thrive is necessary.
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http://dx.doi.org/10.1186/s41824-020-00094-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8218106PMC
December 2020

[F]Fluorocholine PET/CT-guided stereotactic body radiotherapy in patients with recurrent oligometastatic prostate cancer.

Eur J Nucl Med Mol Imaging 2020 01 16;47(1):185-191. Epub 2019 Oct 16.

Nuclear Medicine, Pisa University Hospital, Via Roma 67, 56123, Pisa, Italy.

Background: In the last years, functional imaging has given a significant contribution to the clinical decision-making of biochemically relapsed prostate cancer (PCa). Hereby, we present a prospective study aiming to validate the role of [F]Fluoro-Methyl Choline ([F]FMCH) PET/CT in the selection of PCa patients suitable for stereotactic body radiotherapy (SBRT).

Methods: Patients with biochemical recurrence limited up to three lesions revealed by [F]FMCH PET/CT were enrolled in the present study and treated with SBRT on all active lesions. Systemic therapy-free survival since the [F]FMCH PET/CT was considered as the primary endpoint.

Results: Forty-six patients were evaluated, and a total of 67 lesions were treated. After a median follow-up of 28.9 months, systemic therapy was started in 30 patients (65.2%) and median systemic therapy-free survival was 39.1 months (95% CI 6.5-68.6); 6, 12, and 24-month ratios were 93.5%, 73.9%, and 63.1%, respectively. At univariate Cox regression analysis, Delta PSA demonstrated an impact on systemic therapy-free survival (p < 0.001).

Conclusions: Based on our findings, [F]FMCH PET/CT can identify oligometastatic prostate cancer patients suitable for SBRT, resulting in a systemic therapy-free survival of 39.1 months.
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http://dx.doi.org/10.1007/s00259-019-04482-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6885020PMC
January 2020

Ruptured Mycotic Aneurysm After Intravesical Instillation for Bladder Tumor.

Ann Vasc Surg 2019 Aug 22;59:310.e7-310.e11. Epub 2019 Feb 22.

Nuclear Medicine, Department of Translational Research and New Technology in Medicine, University of Pisa, Pisa, Italy.

Background: Intravesical instillation of Bacillus Calmette-Guérin (BCG) is an effective and widely used treatment for patients with in situ bladder cancer. Major complications are quite uncommon, but a systemic dissemination of the attenuated strain of Mycobacterium bovis is possible. Few cases of aortic rupture caused by M bovis infection are described in literature.

Methods: A 70-year-old male, treated 3 months before with BCG instillation, presented to the emergency department because of a ruptured abdominal aortic aneurysm. The patient was hemodynamically stable, with a "hostile" abdomen. Therefore, an Endologix AFX endograft was deployed. During the postoperative period, his blood inflammatory markers increased, suspicious of a graft infection. Single-photon emission computed tomography (CT)/CT scan showed aortic increased uptake. Antibiotic therapy was continued, but after some days, the patient presented with hematemesis, and the CT scan showed an aortoenteric fistula. In emergency, the infected graft and aneurysm were removed, enteric fistula was closed, and an axillobifemoral bypass was performed. The patient died 25 days after endovascular aneurysm repair explantation.

Results: Despite the high suspicion of mycotic aortic aneurysm and graft infection by M bovis, there is no proof of this theory because of the absence of any positive culture test. M bovis is a slow-growing bacteria, and specific culture tests are required to identify it; indeed, all our blood and intraoperative samples were positive to other bacteria, probably the contaminant ones.

Conclusions: Mycotic aneurysm is an extremely rare complication of intravesical BCG therapy, but it must be taken into consideration in patients with rapidly growing aortic aneurysms or rupture of a normal aorta, who have been previously submitted to this kind of instillation.
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http://dx.doi.org/10.1016/j.avsg.2018.12.100DOI Listing
August 2019

Miniaturized Radiochemical Purity Testing for Tc-HMPAO, Tc-HMDP, and Tc-Tetrofosmin.

J Nucl Med Technol 2017 Sep 13;45(3):236-240. Epub 2017 Jul 13.

Regional Center of Nuclear Medicine, University of Pisa, Pisa, Italy; and

Quick methods are functional in clinical practice to ensure the fastest availability of radiopharmaceuticals. For this purpose, we investigated the radiochemical purity of the widely used Tc-hydroxymethylene diphosphonate, Tc-hexamethylpropyleneamine oxime, and Tc-tetrofosmin by reducing time as compared with the manufacturer's method. We applied a miniaturized chromatographic method with a reduced strip development from 18 cm to 9 cm for all 3 radiopharmaceuticals. The specific support medium and solvent system of the manufacturer's methods was kept unchanged for Tc-hydroxymethylene diphosphonate and Tc-tetrofosmin, whereas for Tc-hexamethylpropyleneamine oxime the instant thin-layer chromatography (ITLC) polysilicic gel (silicic acid [SA]) was replaced with a monosilicic gel (silicic gel [SG]) in the chromatographic system that uses methyl ethyl ketone as solvent. The method was applied and compared with the routine ITLC insert method in a total of 30 batches for each radiopharmaceutical. The precision of repeated tests was determined by comparison with the results of 10 replications on the same batch. Small volumes of concentrated TcO, and Tc-albumin nanocolloid were used to produce potential radiochemical impurities. Correlation between the quick methods and the insert methods was analyzed using a nonparametric 2-tailed test and a 2 × 2 contingency table with the associated Fisher exact test to evaluate sensitivity and specificity. A receiver-operating-characteristic analysis was performed to evaluate the best cutoff. The percentage radiochemical purity of the quick methods agreed with the standard chromatography procedures. We found that TcO and colloidal impurities are not the only common radiochemical impurities with Tc-tetrofosmin, and shortening of the ITLC strip with respect to the manufacturer's method will worsen system resolution and may produce inaccuracy. The miniaturized methods we described represent a fast and reliable alternative for Tc-exametazime and Tc-oxidronate quality control, with the upper cutoff for acceptable radiochemical purity values being 84% and 95%, respectively. For Tc-tetrofosmin radiochemical purity testing, a longer strip as described in the standard method is warranted.
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http://dx.doi.org/10.2967/jnmt.115.154484DOI Listing
September 2017
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