Maria Picchio - Academia.edu (original) (raw)
Papers by Maria Picchio
Radiotherapy and Oncology, 2018
European Journal of Nuclear Medicine and Molecular Imaging
To explore the role of fully hybrid 68Ga-DOTATOC PET/MR imaging and radiomic parameters in predic... more To explore the role of fully hybrid 68Ga-DOTATOC PET/MR imaging and radiomic parameters in predicting histopathological prognostic factors in patients with pancreatic neuroendocrine tumours (PanNETs) undergoing surgery. One hundred eighty-seven consecutive 68Ga-DOTATOC PET/MRI scans (March 2018–June 2020) performed for gastroenteropancreatic neuroendocrine tumour were retrospectively evaluated; 16/187 patients met the eligibility criteria (68Ga-DOTATOC PET/MRI for preoperative staging of PanNET and availability of histological data). PET/MR scans were qualitatively and quantitatively interpreted, and the following imaging parameters were derived: PET-derived SUVmax, SUVmean, somatostatin receptor density (SRD), total lesion somatostatin receptor density (TLSRD), and MRI-derived apparent diffusion coefficient (ADC), arterial and late enhancement, necrosis, cystic degeneration, and maximum diameter. Additionally, first-, second-, and higher-order radiomic parameters were extracted from both PET and MRI scans. Correlations with several PanNETs’ histopathological prognostic factors were evaluated using Spearman’s coefficient, while the area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to evaluate parameters’ predictive performance. Primary tumour was detected in all 16 patients (15/16 by 68Ga-DOTATOC PET and 16/16 by MRI). SUVmax and SUVmean resulted good predictors of lymphnodal (LN) involvement (AUC of 0.850 and 0.783, respectively). Second-order radiomic parameters GrayLevelVariance and HighGrayLevelZoneEmphasis extracted from T2 MRI demonstrated significant correlations with LN involvement (adjusted p = 0.009), also showing good predictive performance (AUC = 0.992). This study demonstrates the role of the fully hybrid PET/MRI tool for the synergic function of imaging parameters extracted by the two modalities and highlights the potentiality of imaging and radiomic parameters in assessing histopathological features of PanNET aggressiveness.
Cancers, 2022
The aims of this systematic review were to (1) assess the utility of PSMA-PET and choline-PET in ... more The aims of this systematic review were to (1) assess the utility of PSMA-PET and choline-PET in the assessment of response to systemic and local therapy, and to (2) determine the value of both tracers for the prediction of response to therapy and survival outcomes in prostate cancer. We performed a systematic literature search in PubMed/Scopus/Google Scholar/Cochrane/EMBASE databases (between January 2010 and October 2021) accordingly. The quality of the included studies was evaluated following the “Quality Assessment of Prognostic Accuracy Studies” tool (QUAPAS-2). We selected 40 articles: 23 articles discussed the use of PET imaging with [68Ga]PSMA-11 (16 articles/1123 patients) or [11C]/[18F]Choline (7 articles/356 patients) for the prediction of response to radiotherapy (RT) and survival outcomes. Seven articles (three with [68Ga]PSMA-11, three with [11C]Choline, one with [18F]Choline) assessed the role of PET imaging in the evaluation of response to docetaxel (as neoadjuvant t...
Clinical Nuclear Medicine, 2022
Aim The assessment of deep myometrial invasion (MI) and lymph node involvement is of utmost impor... more Aim The assessment of deep myometrial invasion (MI) and lymph node involvement is of utmost importance in the preoperative staging of endometrial cancer (EC). Imaging parameters derived respectively from MRI and PET have shown good predictive value. The main aim of the present study is to assess the diagnostic performance of hybrid 18F-FDG PET/MRI in EC staging, with particular focus on MI and lymphnodal involvement detection. Patients and Methods Prospective monocentric study including 35 patients with biopsy-proven EC undergoing preoperative 18F-FDG PET/MRI (December 2018–March 2021) for staging purpose. Histological examination was the reference standard. PET (SUVmax, SUVmean with a threshold of 40% of SUVmax–SUVmean40, metabolic tumor volume, total lesion glycolysis) and MRI (volume index [VI], total tumor volume, tumor volume ratio [TVR], mean apparent diffusion coefficient, minimum apparent diffusion coefficient) parameters were calculated on the primary tumor, and their role in predicting EC risk group, the presence of lymphovascular space invasion (LVSI), and MI was assessed. Receiver operating characteristics analysis was used to assess the predictive value of PET and MRI parameters on EC characteristics. Results Patients' median age was 66.57 years (SD, 10.21 years). 18F-FDG PET/MRI identified the primary tumor in all patients. Twenty-two of 35 patients had high-risk EC and 13/35 low-risk disease; 13/35 presented LVSI, 22/35 had deep MI at histological examination, and 13/35 had p53 hyperexpression. PET/MRI was able to detect lymphnodal involvement with high accuracy and high specificity (sensitivity of 0.8571, specificity of 0.9286, accuracy of 0.9143), also showing a high negative predictive value (NPV) for lymphnodal involvement (NPV of 0.9630, positive predictive value [PPV] of 0.7500). The assessment of deep MI using PET/MRI correctly staged 27 patients (77.1%; sensitivity of 0.7273, specificity of 0.8462, accuracy of 0.7714), with also a good PPV (PPV of 0.8889, NPV of 0.647). MRI-derived total tumor volume, VI, and TVR were significant in predicting EC groups (high-risk vs low-risk patients) (P = 0.0059, 0.0235, 0.0181, respectively). MRI-derived volume, VI, TVR, and PET-derived metabolic tumor volume and total lesion glycolysis were able to predict LVSI (P = 0.0023, 0.0068, 0.0068, 0.0027, 0.01394, respectively). Imaging was not able to predict grading, presence of deep MI, nor hyperexpression of p53. Conclusions 18F-FDG PET/MRI has good accuracy in preoperative staging of EC; PET and MRI parameters have synergic role in preoperatively predicting LVSI, with MRI parameters being also predictive for EC risk group.
Purpose. Assessment of deep myometrial invasion (MI) and lymphovascular space invasion (LVSI) is ... more Purpose. Assessment of deep myometrial invasion (MI) and lymphovascular space invasion (LVSI) is of utmost importance in preoperative staging of endometrial cancer (EC). Imaging parameters derived respectively from MRI and PET have shown good predictive value. Aim of the present study is to assess the diagnostic performance of hybrid 18F-FDG PET/MRI in EC staging, with particular focus on MI and LVSI detection.Methods. Prospective monocentric study including 35 patients with biopsy-proven EC undergoing preoperative 18F-FDG PET/MRI for staging purpose. Histological examination was the reference standard. PET (SUVmax, SUVmean40, MTV40, TLG40) and MRI (volume index-VI, total tumor volume-TTV, tumor volume ratio-TVR, ADCmean, ADCmin) parameters were calculated on the primary tumor, and their role in predicting histological findings (grade, high- vs. low-risk groups, LVSI, MI, p53 hyper-expression) was assessed through a ROC analysis.Results. 18F-FDG-PET/MRI identified the primary tumor ...
Cancers, 2021
Simple Summary Pancreatic cancer (PC) has a severe prognosis and even after radical surgery, rela... more Simple Summary Pancreatic cancer (PC) has a severe prognosis and even after radical surgery, relapse rate is very high (70–80%). The impact of PET/CT in PC clinical management has been increasingly investigated in the last decades. As regards localized and potentially resectable disease, the role of PET/CT is still controversial and international guidelines do not recommend its routine use. Despite this, PET may play a role in assessing PC stage and grade and potential resectability after neoadjuvant treatment. Aim of this review is to discuss the current use for staging and disease response assessment and future developments of PET/CT in resectable PC. Abstract Pancreatic Cancer (PC) has a poor prognosis, with a 5-year survival rate of only 9%. Even after radical surgical procedures, PC patients have poor survival rates, with a high chance of relapse (70–80%). Imaging is involved in all aspects of the clinical management of PC, including detection and characterization of primary tu...
European Journal of Nuclear Medicine and Molecular Imaging, 2021
To present the state-of-art of radiomics in the context of pancreatic neuroendocrine tumors (PanN... more To present the state-of-art of radiomics in the context of pancreatic neuroendocrine tumors (PanNETs), with a focus on the methodological and technical approaches used, to support the search of guidelines for optimal applications. Furthermore, an up-to-date overview of the current clinical applications of radiomics in the field of PanNETs is provided. Original articles were searched on PubMed and Science Direct with specific keywords. Evaluations of the selected studies have been focused mainly on (i) the general radiomic workflow and the assessment of radiomic features robustness/reproducibility, as well as on the major clinical applications and investigations accomplished so far with radiomics in the field of PanNETs: (ii) grade prediction, (iii) differential diagnosis from other neoplasms, (iv) assessment of tumor behavior and aggressiveness, and (v) treatment response prediction. Thirty-one articles involving PanNETs radiomic-related objectives were selected. In regard to the grade differentiation task, yielded AUCs are currently in the range of 0.7–0.9. For differential diagnosis, the majority of studies are still focused on the preliminary identification of discriminative radiomic features. Limited information is known on the prediction of tumors aggressiveness and of treatment response. Radiomics is recently expanding in the setting of PanNETs. From the analysis of the published data, it is emerging how, prior to clinical application, further validations are necessary and methodological implementations require optimization. Nevertheless, this new discipline might have the potential in assisting the current urgent need of improving the management strategies in PanNETs patients.
Radiotherapy and Oncology, 2020
Purpose: To assess the value of 18F-Fluorodeoxyglucose (18F-FDG) PET Radiomic Features (RF) in pr... more Purpose: To assess the value of 18F-Fluorodeoxyglucose (18F-FDG) PET Radiomic Features (RF) in predicting Distant Relapse Free Survival (DRFS) in patients with Locally Advanced Pancreatic Cancer (LAPC) treated with radio-chemotherapy. Materials & Methods: One-hundred-ninety-eight RF were extracted using an IBSI (Image Biomarker Standardization Initiative) consistent software from pre-radiotherapy images of 176 LAPC patients, treated with moderate hypo-fractionation (44.25Gy, 2.95Gy/fr). Tumors were segmented by applying a previously validated semi-automatic method. One-hundred-twenty-six RF were excluded due to poor reproducibility and/or repeatability and/or inter-scanner variability. The original cohort was randomly split in a training (n=116) and a validation (n=60) group. Multi-variable Cox regression was applied on the training group, including only independent RF in the model. The resulting radiomic index was tested in the validation cohort. The impact of selected clinical variables was also investigated. Results: The resulting Cox model included two RF of first order: Center of Mass Shift (COMshift) and 10 th Intensity percentile (P10) (p=0.0005, HR=2.72, 95%CI=1.54-4.80), showing worse outcome for patients with lower COMshift and higher P10. Once stratified by quartile values (< lowest quartile vs > highest quartile vs the remaining), the index properly stratified patients according to their DRFS (p=0.0024, log-rank test). Performances were confirmed in the validation cohort (p=0.03, HR=2.53, 95%CI=0.96-6.65). The addition of clinical factors did not significantly improve models' performances. Conclusions: A radiomic-based index including only two robust PET-RF predicted DRFS of LAPC patients after radio-chemotherapy. Current results could find relevant applications in treatment personalization of LAPC. A multi-institution independent validation has currently been planned.
JAMA Oncology, 2020
To the Editor In a recent Viewpoint, Connor et al 1 discussed diagnosis and risk classification i... more To the Editor In a recent Viewpoint, Connor et al 1 discussed diagnosis and risk classification in men with oligometastatic prostate cancer. They hypothesized that the diagnostic superiority of novel targeted imaging in detection of metastatic disease would allow early identification of oligometastatic prostate cancer, generating a stage migration and a so-called Will Rogers phenomenon for the survival of these patients. It should be recalled that choline positron emission tomography/computed tomography (PET/CT) and prostatespecific membrane antigen (PSMA) PET/CT were investigated mainly for recurrences at the nodal/bone level after previous radical treatments. 2,3 Their sensitivity and specificity on a per-patient basis are similar, with PSMA PET/CT performing better at low (but not low enough for very early salvage radiotherapy) prostate-specific antigen levels. 2,3 In addition, the results must be interpreted with caution given the possibility of false-positive results. 4 Moreover, as the NRG Oncology/Radiation Therapy Oncology Group (RTOG) 0534 Short-Term Androgen Deprivation With Pelvic Lymph Node or Prostate Bed Only Radiotherapy (SPPORT) trial 5 demonstrated, the prostate bed is still the main site of relapse after prostatectomy. Pollack et al 5 observed, in a randomized trial of salvage radiotherapy performed on 1792 patients who had undergone prostatectomy, that 5 years after the treatment, progression-free survival rates were 71.1% for prostate bed-only radiotherapy, 82.7% for prostate bed radiotherapy plus short-term (4-6 months) androgen deprivation therapy, and 89.1% for prostate bed radiotherapy plus short-term androgen deprivation therapy and pelvic lymph node radiotherapy. The optimal results of the RTOG 0534 trial were obtained using standard imaging. 5 Thus, some patients with oligometastatic disease were not diagnosed, but pelvic lymph node radiotherapy and short-term androgen deprivation therapy contributed to disease control in these patients. The opposite is not valid, and the results of metastasis-directed therapy are scarce in this setting. In other words, the RTOG 0534 trial demonstrated that at the first relapse after prostatectomy, early salvage prostate bed radiotherapy should be performed, being the site of relapse in the majority of patients; PET/CT resolution for microscopic disease does not allow the exclusion of prostate bed radiotherapy. Second, short-term androgen deprivation therapy should be prescribed; the objective cannot be androgen deprivation-free survival. Third, pelvic lymph node radiotherapy should be added, increasing biochemical and distant metastasisfree survival; here, the novel targeted imaging could probably improve the definition of the lymph nodes presenting the relapse, which could be boosted for better local control. At the second relapse, waiting for PET/CT positivity would not worsen the results, as it would for the first relapse. Thus, we can have a dawn for patients treated until recently with palliative hormonal therapy. Otherwise, because of the abovementioned limitations, we would witness the sunset of metastasis-directed therapy, also owing to increasingly efficacious systemic therapies.
Clinical and Translational Imaging, 2020
High-grade gliomas are aggressive primitive brain tumors presenting aberrant vasculature, regiona... more High-grade gliomas are aggressive primitive brain tumors presenting aberrant vasculature, regional necrosis, and areas of hypoxia. Tumor hypoxia is associated with resistance to conventional treatment and worse prognosis. [18F]-fluoromisonidazole (18F-FMISO) is the most extensively investigated radiotracer for the evaluation of hypoxia. However, the use of 18F-FMISO in clinical practice has been hampered mainly due to the slow clearance of the unbound tracer from normoxic tissue and its low tumor-to-background ratio (TBR). The research community has therefore investigated other radiotracers to overcome the drawbacks of 18F-FMISO. This mini-review aims to present an update on the most relevant PET studies published in the last 15 years evaluating the utility of radiotracers for hypoxia imaging other than 18F-FMISO in high-grade glioma (HGG) patients. A comprehensive computer literature search of studies was carried out in PubMed/MEDLINE database to identify the most relevant studies published in the last 15 years which investigated the utility of hypoxia PET tracers other than 18F-FMISO in the assessment of tumor hypoxia in patients with HGG. 18F-flouroazomycin arabinoside (18F-FAZA) has been proposed as a valid alternative to 18F-FMISO for the assessment of hypoxia, due to its improved biodistribution and enhanced tumor-to-background ratio. Also 1-(2-[18F]fluoro-1[hydroxymethyl]ethoxy)methyl-2-nitroimidazole(18F-FRP170) seems a valuable hypoxia tracer in patients with brain tumor. The value of copper-diacetyl-bis(N4-methylthiosemicarbazone)(Cu-ATSM) seems controversial. Few evidences still exist regarding the utility of 18F-2-(2-nitro-1H-imidazol-1-yl)-N-(2,2,3,3,3-pentafluoropropyl)-acetamide (18F-EF5). Hypoxia PET imaging has the potential to provide useful information for the clinicians and to guide hypoxia tailored treatments. According to the present literature, the most promising hypoxic tracer seems to be 18F-FAZA, but well-designed and wide trials to validate hypoxia radiotracers and evaluate their clinical utility in daily practice are still lacking.
Clinical nuclear medicine, 2017
A 57 year-old man underwent MRI with dynamic susceptibility contrast and dynamic contrast-enhance... more A 57 year-old man underwent MRI with dynamic susceptibility contrast and dynamic contrast-enhanced perfusion for neurological symptoms suggesting the diagnosis of high-grade glioma. A F-FAZA PET/CT was performed because of the enrollment in a prospective clinical trial. Subsequent radiotherapy treatment has been planned based on conventional imaging; moreover, a F-FAZA PET/CT-guided treatment planning highlighting hypoxic regions has been simulated. After radiotherapy treatment, the man underwent MRI and F-FAZA PET/CT, showing partial response.
Radiotherapy and Oncology, 2017
Conclusion Tumor voxel metabolic ratio determined us ing multiple FDG PET images can be used to a... more Conclusion Tumor voxel metabolic ratio determined us ing multiple FDG PET images can be used to assess tumor voxel dose response, SF2, which shows an excellent predictive value for tumor local radioresistance and failure. Our results demonstrate that a heterogeneous dose distribution in tumor should be prescribed to optimize cancer radiotherapy. Tumor voxel TMR determined at the early treatment will be good bio-parametric matrix to determine a new tumor dose prescription function at the voxel level for the treatment of adaptive dose-paintingby-number. PO-0886 Early changes of FDG-PET markers predict the outcome after chemo-radiotherapy for pancreatic cancer
European Urology Supplements, 2012
INTRODUCTION AND OBJECTIVES: The aim of this study was to prospectively evaluate the accuracy of ... more INTRODUCTION AND OBJECTIVES: The aim of this study was to prospectively evaluate the accuracy of integrated [(11)C]choline-PET/CT in the diagnosis of lymph-node recurrence in patients previously treated with radical prostatectomy (RP) who experience PSA relapse. METHODS: The study included 71 patients with biochemical recurrence (BCR) and pathologic nodal [(11)C]choline-uptake at PET/CT scan suggestive of nodal recurrence. All patients were treated with either bilateral pelvic salvage lymph node dissection (sLND) alone (n 16; 22.5%) or with a combination of pelvic retroperitoneal sLND (n 55; 77.5%) between October 2002 and July 2011 at a single tertiary referral center. BCR was defined as a PSA value 0.2 ng/ml. All patients had complete clinical and pathological data, including PSA at surgery, number of lymph nodes removed, number of positive lymph nodes as well as laterality and site of nodal metastases at sLND. For the purpose of the study, LN sites were stratified in: right pelvic, left pelvic and retroperitoneal, respectively. We analyzed sensitivity, specificity, positive and negative predictive value as well as accuracy of the [(11)C]choline-PET/CT in predicting presence of nodal metastases at sLND. All the analyses were performed in the e overall patient population and after stratifying according to PSA (namely, 2 versus 2 ng/ml) and androgen deprivation therapy (ADT) status at sLND. RESULTS: The mean number of removed and positive nodes at sLND were 30.4 (median 29; range: 4-87) and 9.2 (range: 0-66), respectively. Fifty-nine out of the 71 patients (83%) with positive [(11)C]choline-PET/CT had histologically proven nodal metastases of PCa at sLND. A per-site based analysis showed that sensitivity, specificity, positive predictive value, negative predictive value and accuracy of [(11)C]choline-PET/CT in predicting nodal recurrence were 75.5%, 77.9%, 78.5%, 74.7%, and 76.6%, respectively. Table 1 shows the performance characteristics of [(11)C]choline-PET/CT after stratification according to ADT status and PSA values at sLND. CONCLUSIONS: [(11)C]Choline-PET/CT represents an accurate diagnostic tool for the detection of lymph-node metastases of clinical recurrent prostate cancer, regardless of ADT status at sLND.
Journal of Nuclear Medicine, 2016
Recurrence of prostate cancer is suspected when an increase in the prostate-specific antigen leve... more Recurrence of prostate cancer is suspected when an increase in the prostate-specific antigen level is detected after radical treatment; the recurrence could be local relapse, distant relapse, or both. Differentiation between the two patterns of relapse is critical for choosing the proper treatment strategy. Choline PET/CT could be of help in discriminating patients with local, lymph node, and bone recurrences, thus having an impact on patient management.
Revista española de medicina nuclear e imagen molecular, 2013
The quarterly journal of nuclear medicine and molecular imaging : official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the Society of Radiopharmaceutical Chemistry and Biology, 2012
High risk prostate cancer patients have a significant risk to develop regional lymph node metasta... more High risk prostate cancer patients have a significant risk to develop regional lymph node metastases, and this represent a major cause of biochemical failure. Although pelvic lymphadenectomy is the gold standard to assess the status of pelvic lymph nodes, a diagnostic imaging tool to non-invasively explore patients and to detect metastases, both in staging and in re-staging phase, would be of particular help in clinical management. In staging phase, while choline PET/CT specificity has been reported to be fairly high in lymph nodal detection, its sensitivity is not adequate due to its spatial resolution. Its role in the evaluation of patients with biochemical relapse or with suspected relapse has been successfully documented. In particular, choline PET/CT has great potential as a single step whole body diagnostic procedure to evaluate lymph nodal and bone metastatic involvement. Salvage lymph nodal dissection was recently listed as a possible experimental option for patients with no...
The quarterly journal of nuclear medicine and molecular imaging : official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the Society of Radiopharmaceutical Chemistry and Biology, 2010
This paper focuses on acquisition and processing methods in positron emission tomography/computed... more This paper focuses on acquisition and processing methods in positron emission tomography/computed tomography (PET/CT) for radiotherapy (RT) applications. The recent technological evolutions of PET/CT systems are described. Particular emphasis is dedicated to the tools needed for the patient positioning and immobilization, to be used in PET/CT studies as well as during RT treatment sessions. The effect of organ and lesion motion due to patient's respiration on PET/CT imaging is discussed. Breathing protocols proposed to minimize PET/CT spatial mismatches in relation to respiratory movements are illustrated. The respiratory gated (RG) 4D-PET/CT techniques, developed to measure and compensate for organ and lesion motion, are then introduced. Finally a description is provided of different acquisition and data processing techniques, implemented with the aim at improving: i) image quality and quantitative accuracy of PET images, and ii) target volume definition and treatment planning ...
Revista Española de Medicina Nuclear e Imagen Molecular, 2012
18 F-FDG-PET/CT is widely employed to evaluate lymphoma patients. False positive results are quit... more 18 F-FDG-PET/CT is widely employed to evaluate lymphoma patients. False positive results are quite frequent, generally due to active phase of inflammation. We describe an unusual PET/CT presentation of a sarcoid-like reaction (SLR) in a patient monitored for Hodgkin Lymphoma characterized by an intense uptake in lymph nodes and multiple bone foci in a PET/CT study. The final diagnosis was obtained by biopsy. This study draws attention to the fact that multifocal bone marrow uptakes due to a sarcoideal reaction may be a possible cause of false positive results in 18 F-FDG-PET/CT studies in oncology patients.
Nuclear Medicine Communications, 2010
The purpose of this study was to assess the value of 2-[F]fluoro-2-deoxy-D-glucose positron emiss... more The purpose of this study was to assess the value of 2-[F]fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography ([F]FDG PET/CT) in the primary staging of high-risk endometrial cancer patients. This retrospective study was conducted on 32 consecutive patients with histological diagnosis of primary high-risk endometrial cancer, who underwent PET/CT with [F]FDG in addition to conventional clinical and instrumental staging procedures. After surgery, [F]FDG PET/CT findings were correlated with pathological findings on a patient-by-patient basis. The diagnostic accuracy of [F]FDG PET/CT for primary cancer detection, lymph nodal involvement and distant metastases was assessed. [F]FDG PET/CT could correctly detect primary tumor in 29 of the 32 high-risk patients, with a sensitivity of 90.6%. The overall [F]FDG PET/CT patient-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 57.1, 100.0, 100.0, 86.4, and 88.5%, respectively, for revealing lymph nodal neoplastic involvement, and 100.0, 96.0, 87.5, 100.0, 96.9%, respectively, for detecting distant metastases. In particular, while the suspicion of distant metastases was documented by conventional imaging in only two patients, [F]FDG PET/CT correctly identified metastatic lesions in seven patients (21.9% of cases). The major benefit provided in high-grade tumor patients by the use of [F]FDG PET/CT in the primary staging of endometrial cancer is its ability to accurately detect distant metastases in the abdomen and extra-abdominal regions. [F]FDG PET/CT adds relevant information that may influence patient management.
The Journal of Urology, 2012
Radiotherapy and Oncology, 2018
European Journal of Nuclear Medicine and Molecular Imaging
To explore the role of fully hybrid 68Ga-DOTATOC PET/MR imaging and radiomic parameters in predic... more To explore the role of fully hybrid 68Ga-DOTATOC PET/MR imaging and radiomic parameters in predicting histopathological prognostic factors in patients with pancreatic neuroendocrine tumours (PanNETs) undergoing surgery. One hundred eighty-seven consecutive 68Ga-DOTATOC PET/MRI scans (March 2018–June 2020) performed for gastroenteropancreatic neuroendocrine tumour were retrospectively evaluated; 16/187 patients met the eligibility criteria (68Ga-DOTATOC PET/MRI for preoperative staging of PanNET and availability of histological data). PET/MR scans were qualitatively and quantitatively interpreted, and the following imaging parameters were derived: PET-derived SUVmax, SUVmean, somatostatin receptor density (SRD), total lesion somatostatin receptor density (TLSRD), and MRI-derived apparent diffusion coefficient (ADC), arterial and late enhancement, necrosis, cystic degeneration, and maximum diameter. Additionally, first-, second-, and higher-order radiomic parameters were extracted from both PET and MRI scans. Correlations with several PanNETs’ histopathological prognostic factors were evaluated using Spearman’s coefficient, while the area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to evaluate parameters’ predictive performance. Primary tumour was detected in all 16 patients (15/16 by 68Ga-DOTATOC PET and 16/16 by MRI). SUVmax and SUVmean resulted good predictors of lymphnodal (LN) involvement (AUC of 0.850 and 0.783, respectively). Second-order radiomic parameters GrayLevelVariance and HighGrayLevelZoneEmphasis extracted from T2 MRI demonstrated significant correlations with LN involvement (adjusted p = 0.009), also showing good predictive performance (AUC = 0.992). This study demonstrates the role of the fully hybrid PET/MRI tool for the synergic function of imaging parameters extracted by the two modalities and highlights the potentiality of imaging and radiomic parameters in assessing histopathological features of PanNET aggressiveness.
Cancers, 2022
The aims of this systematic review were to (1) assess the utility of PSMA-PET and choline-PET in ... more The aims of this systematic review were to (1) assess the utility of PSMA-PET and choline-PET in the assessment of response to systemic and local therapy, and to (2) determine the value of both tracers for the prediction of response to therapy and survival outcomes in prostate cancer. We performed a systematic literature search in PubMed/Scopus/Google Scholar/Cochrane/EMBASE databases (between January 2010 and October 2021) accordingly. The quality of the included studies was evaluated following the “Quality Assessment of Prognostic Accuracy Studies” tool (QUAPAS-2). We selected 40 articles: 23 articles discussed the use of PET imaging with [68Ga]PSMA-11 (16 articles/1123 patients) or [11C]/[18F]Choline (7 articles/356 patients) for the prediction of response to radiotherapy (RT) and survival outcomes. Seven articles (three with [68Ga]PSMA-11, three with [11C]Choline, one with [18F]Choline) assessed the role of PET imaging in the evaluation of response to docetaxel (as neoadjuvant t...
Clinical Nuclear Medicine, 2022
Aim The assessment of deep myometrial invasion (MI) and lymph node involvement is of utmost impor... more Aim The assessment of deep myometrial invasion (MI) and lymph node involvement is of utmost importance in the preoperative staging of endometrial cancer (EC). Imaging parameters derived respectively from MRI and PET have shown good predictive value. The main aim of the present study is to assess the diagnostic performance of hybrid 18F-FDG PET/MRI in EC staging, with particular focus on MI and lymphnodal involvement detection. Patients and Methods Prospective monocentric study including 35 patients with biopsy-proven EC undergoing preoperative 18F-FDG PET/MRI (December 2018–March 2021) for staging purpose. Histological examination was the reference standard. PET (SUVmax, SUVmean with a threshold of 40% of SUVmax–SUVmean40, metabolic tumor volume, total lesion glycolysis) and MRI (volume index [VI], total tumor volume, tumor volume ratio [TVR], mean apparent diffusion coefficient, minimum apparent diffusion coefficient) parameters were calculated on the primary tumor, and their role in predicting EC risk group, the presence of lymphovascular space invasion (LVSI), and MI was assessed. Receiver operating characteristics analysis was used to assess the predictive value of PET and MRI parameters on EC characteristics. Results Patients' median age was 66.57 years (SD, 10.21 years). 18F-FDG PET/MRI identified the primary tumor in all patients. Twenty-two of 35 patients had high-risk EC and 13/35 low-risk disease; 13/35 presented LVSI, 22/35 had deep MI at histological examination, and 13/35 had p53 hyperexpression. PET/MRI was able to detect lymphnodal involvement with high accuracy and high specificity (sensitivity of 0.8571, specificity of 0.9286, accuracy of 0.9143), also showing a high negative predictive value (NPV) for lymphnodal involvement (NPV of 0.9630, positive predictive value [PPV] of 0.7500). The assessment of deep MI using PET/MRI correctly staged 27 patients (77.1%; sensitivity of 0.7273, specificity of 0.8462, accuracy of 0.7714), with also a good PPV (PPV of 0.8889, NPV of 0.647). MRI-derived total tumor volume, VI, and TVR were significant in predicting EC groups (high-risk vs low-risk patients) (P = 0.0059, 0.0235, 0.0181, respectively). MRI-derived volume, VI, TVR, and PET-derived metabolic tumor volume and total lesion glycolysis were able to predict LVSI (P = 0.0023, 0.0068, 0.0068, 0.0027, 0.01394, respectively). Imaging was not able to predict grading, presence of deep MI, nor hyperexpression of p53. Conclusions 18F-FDG PET/MRI has good accuracy in preoperative staging of EC; PET and MRI parameters have synergic role in preoperatively predicting LVSI, with MRI parameters being also predictive for EC risk group.
Purpose. Assessment of deep myometrial invasion (MI) and lymphovascular space invasion (LVSI) is ... more Purpose. Assessment of deep myometrial invasion (MI) and lymphovascular space invasion (LVSI) is of utmost importance in preoperative staging of endometrial cancer (EC). Imaging parameters derived respectively from MRI and PET have shown good predictive value. Aim of the present study is to assess the diagnostic performance of hybrid 18F-FDG PET/MRI in EC staging, with particular focus on MI and LVSI detection.Methods. Prospective monocentric study including 35 patients with biopsy-proven EC undergoing preoperative 18F-FDG PET/MRI for staging purpose. Histological examination was the reference standard. PET (SUVmax, SUVmean40, MTV40, TLG40) and MRI (volume index-VI, total tumor volume-TTV, tumor volume ratio-TVR, ADCmean, ADCmin) parameters were calculated on the primary tumor, and their role in predicting histological findings (grade, high- vs. low-risk groups, LVSI, MI, p53 hyper-expression) was assessed through a ROC analysis.Results. 18F-FDG-PET/MRI identified the primary tumor ...
Cancers, 2021
Simple Summary Pancreatic cancer (PC) has a severe prognosis and even after radical surgery, rela... more Simple Summary Pancreatic cancer (PC) has a severe prognosis and even after radical surgery, relapse rate is very high (70–80%). The impact of PET/CT in PC clinical management has been increasingly investigated in the last decades. As regards localized and potentially resectable disease, the role of PET/CT is still controversial and international guidelines do not recommend its routine use. Despite this, PET may play a role in assessing PC stage and grade and potential resectability after neoadjuvant treatment. Aim of this review is to discuss the current use for staging and disease response assessment and future developments of PET/CT in resectable PC. Abstract Pancreatic Cancer (PC) has a poor prognosis, with a 5-year survival rate of only 9%. Even after radical surgical procedures, PC patients have poor survival rates, with a high chance of relapse (70–80%). Imaging is involved in all aspects of the clinical management of PC, including detection and characterization of primary tu...
European Journal of Nuclear Medicine and Molecular Imaging, 2021
To present the state-of-art of radiomics in the context of pancreatic neuroendocrine tumors (PanN... more To present the state-of-art of radiomics in the context of pancreatic neuroendocrine tumors (PanNETs), with a focus on the methodological and technical approaches used, to support the search of guidelines for optimal applications. Furthermore, an up-to-date overview of the current clinical applications of radiomics in the field of PanNETs is provided. Original articles were searched on PubMed and Science Direct with specific keywords. Evaluations of the selected studies have been focused mainly on (i) the general radiomic workflow and the assessment of radiomic features robustness/reproducibility, as well as on the major clinical applications and investigations accomplished so far with radiomics in the field of PanNETs: (ii) grade prediction, (iii) differential diagnosis from other neoplasms, (iv) assessment of tumor behavior and aggressiveness, and (v) treatment response prediction. Thirty-one articles involving PanNETs radiomic-related objectives were selected. In regard to the grade differentiation task, yielded AUCs are currently in the range of 0.7–0.9. For differential diagnosis, the majority of studies are still focused on the preliminary identification of discriminative radiomic features. Limited information is known on the prediction of tumors aggressiveness and of treatment response. Radiomics is recently expanding in the setting of PanNETs. From the analysis of the published data, it is emerging how, prior to clinical application, further validations are necessary and methodological implementations require optimization. Nevertheless, this new discipline might have the potential in assisting the current urgent need of improving the management strategies in PanNETs patients.
Radiotherapy and Oncology, 2020
Purpose: To assess the value of 18F-Fluorodeoxyglucose (18F-FDG) PET Radiomic Features (RF) in pr... more Purpose: To assess the value of 18F-Fluorodeoxyglucose (18F-FDG) PET Radiomic Features (RF) in predicting Distant Relapse Free Survival (DRFS) in patients with Locally Advanced Pancreatic Cancer (LAPC) treated with radio-chemotherapy. Materials & Methods: One-hundred-ninety-eight RF were extracted using an IBSI (Image Biomarker Standardization Initiative) consistent software from pre-radiotherapy images of 176 LAPC patients, treated with moderate hypo-fractionation (44.25Gy, 2.95Gy/fr). Tumors were segmented by applying a previously validated semi-automatic method. One-hundred-twenty-six RF were excluded due to poor reproducibility and/or repeatability and/or inter-scanner variability. The original cohort was randomly split in a training (n=116) and a validation (n=60) group. Multi-variable Cox regression was applied on the training group, including only independent RF in the model. The resulting radiomic index was tested in the validation cohort. The impact of selected clinical variables was also investigated. Results: The resulting Cox model included two RF of first order: Center of Mass Shift (COMshift) and 10 th Intensity percentile (P10) (p=0.0005, HR=2.72, 95%CI=1.54-4.80), showing worse outcome for patients with lower COMshift and higher P10. Once stratified by quartile values (< lowest quartile vs > highest quartile vs the remaining), the index properly stratified patients according to their DRFS (p=0.0024, log-rank test). Performances were confirmed in the validation cohort (p=0.03, HR=2.53, 95%CI=0.96-6.65). The addition of clinical factors did not significantly improve models' performances. Conclusions: A radiomic-based index including only two robust PET-RF predicted DRFS of LAPC patients after radio-chemotherapy. Current results could find relevant applications in treatment personalization of LAPC. A multi-institution independent validation has currently been planned.
JAMA Oncology, 2020
To the Editor In a recent Viewpoint, Connor et al 1 discussed diagnosis and risk classification i... more To the Editor In a recent Viewpoint, Connor et al 1 discussed diagnosis and risk classification in men with oligometastatic prostate cancer. They hypothesized that the diagnostic superiority of novel targeted imaging in detection of metastatic disease would allow early identification of oligometastatic prostate cancer, generating a stage migration and a so-called Will Rogers phenomenon for the survival of these patients. It should be recalled that choline positron emission tomography/computed tomography (PET/CT) and prostatespecific membrane antigen (PSMA) PET/CT were investigated mainly for recurrences at the nodal/bone level after previous radical treatments. 2,3 Their sensitivity and specificity on a per-patient basis are similar, with PSMA PET/CT performing better at low (but not low enough for very early salvage radiotherapy) prostate-specific antigen levels. 2,3 In addition, the results must be interpreted with caution given the possibility of false-positive results. 4 Moreover, as the NRG Oncology/Radiation Therapy Oncology Group (RTOG) 0534 Short-Term Androgen Deprivation With Pelvic Lymph Node or Prostate Bed Only Radiotherapy (SPPORT) trial 5 demonstrated, the prostate bed is still the main site of relapse after prostatectomy. Pollack et al 5 observed, in a randomized trial of salvage radiotherapy performed on 1792 patients who had undergone prostatectomy, that 5 years after the treatment, progression-free survival rates were 71.1% for prostate bed-only radiotherapy, 82.7% for prostate bed radiotherapy plus short-term (4-6 months) androgen deprivation therapy, and 89.1% for prostate bed radiotherapy plus short-term androgen deprivation therapy and pelvic lymph node radiotherapy. The optimal results of the RTOG 0534 trial were obtained using standard imaging. 5 Thus, some patients with oligometastatic disease were not diagnosed, but pelvic lymph node radiotherapy and short-term androgen deprivation therapy contributed to disease control in these patients. The opposite is not valid, and the results of metastasis-directed therapy are scarce in this setting. In other words, the RTOG 0534 trial demonstrated that at the first relapse after prostatectomy, early salvage prostate bed radiotherapy should be performed, being the site of relapse in the majority of patients; PET/CT resolution for microscopic disease does not allow the exclusion of prostate bed radiotherapy. Second, short-term androgen deprivation therapy should be prescribed; the objective cannot be androgen deprivation-free survival. Third, pelvic lymph node radiotherapy should be added, increasing biochemical and distant metastasisfree survival; here, the novel targeted imaging could probably improve the definition of the lymph nodes presenting the relapse, which could be boosted for better local control. At the second relapse, waiting for PET/CT positivity would not worsen the results, as it would for the first relapse. Thus, we can have a dawn for patients treated until recently with palliative hormonal therapy. Otherwise, because of the abovementioned limitations, we would witness the sunset of metastasis-directed therapy, also owing to increasingly efficacious systemic therapies.
Clinical and Translational Imaging, 2020
High-grade gliomas are aggressive primitive brain tumors presenting aberrant vasculature, regiona... more High-grade gliomas are aggressive primitive brain tumors presenting aberrant vasculature, regional necrosis, and areas of hypoxia. Tumor hypoxia is associated with resistance to conventional treatment and worse prognosis. [18F]-fluoromisonidazole (18F-FMISO) is the most extensively investigated radiotracer for the evaluation of hypoxia. However, the use of 18F-FMISO in clinical practice has been hampered mainly due to the slow clearance of the unbound tracer from normoxic tissue and its low tumor-to-background ratio (TBR). The research community has therefore investigated other radiotracers to overcome the drawbacks of 18F-FMISO. This mini-review aims to present an update on the most relevant PET studies published in the last 15 years evaluating the utility of radiotracers for hypoxia imaging other than 18F-FMISO in high-grade glioma (HGG) patients. A comprehensive computer literature search of studies was carried out in PubMed/MEDLINE database to identify the most relevant studies published in the last 15 years which investigated the utility of hypoxia PET tracers other than 18F-FMISO in the assessment of tumor hypoxia in patients with HGG. 18F-flouroazomycin arabinoside (18F-FAZA) has been proposed as a valid alternative to 18F-FMISO for the assessment of hypoxia, due to its improved biodistribution and enhanced tumor-to-background ratio. Also 1-(2-[18F]fluoro-1[hydroxymethyl]ethoxy)methyl-2-nitroimidazole(18F-FRP170) seems a valuable hypoxia tracer in patients with brain tumor. The value of copper-diacetyl-bis(N4-methylthiosemicarbazone)(Cu-ATSM) seems controversial. Few evidences still exist regarding the utility of 18F-2-(2-nitro-1H-imidazol-1-yl)-N-(2,2,3,3,3-pentafluoropropyl)-acetamide (18F-EF5). Hypoxia PET imaging has the potential to provide useful information for the clinicians and to guide hypoxia tailored treatments. According to the present literature, the most promising hypoxic tracer seems to be 18F-FAZA, but well-designed and wide trials to validate hypoxia radiotracers and evaluate their clinical utility in daily practice are still lacking.
Clinical nuclear medicine, 2017
A 57 year-old man underwent MRI with dynamic susceptibility contrast and dynamic contrast-enhance... more A 57 year-old man underwent MRI with dynamic susceptibility contrast and dynamic contrast-enhanced perfusion for neurological symptoms suggesting the diagnosis of high-grade glioma. A F-FAZA PET/CT was performed because of the enrollment in a prospective clinical trial. Subsequent radiotherapy treatment has been planned based on conventional imaging; moreover, a F-FAZA PET/CT-guided treatment planning highlighting hypoxic regions has been simulated. After radiotherapy treatment, the man underwent MRI and F-FAZA PET/CT, showing partial response.
Radiotherapy and Oncology, 2017
Conclusion Tumor voxel metabolic ratio determined us ing multiple FDG PET images can be used to a... more Conclusion Tumor voxel metabolic ratio determined us ing multiple FDG PET images can be used to assess tumor voxel dose response, SF2, which shows an excellent predictive value for tumor local radioresistance and failure. Our results demonstrate that a heterogeneous dose distribution in tumor should be prescribed to optimize cancer radiotherapy. Tumor voxel TMR determined at the early treatment will be good bio-parametric matrix to determine a new tumor dose prescription function at the voxel level for the treatment of adaptive dose-paintingby-number. PO-0886 Early changes of FDG-PET markers predict the outcome after chemo-radiotherapy for pancreatic cancer
European Urology Supplements, 2012
INTRODUCTION AND OBJECTIVES: The aim of this study was to prospectively evaluate the accuracy of ... more INTRODUCTION AND OBJECTIVES: The aim of this study was to prospectively evaluate the accuracy of integrated [(11)C]choline-PET/CT in the diagnosis of lymph-node recurrence in patients previously treated with radical prostatectomy (RP) who experience PSA relapse. METHODS: The study included 71 patients with biochemical recurrence (BCR) and pathologic nodal [(11)C]choline-uptake at PET/CT scan suggestive of nodal recurrence. All patients were treated with either bilateral pelvic salvage lymph node dissection (sLND) alone (n 16; 22.5%) or with a combination of pelvic retroperitoneal sLND (n 55; 77.5%) between October 2002 and July 2011 at a single tertiary referral center. BCR was defined as a PSA value 0.2 ng/ml. All patients had complete clinical and pathological data, including PSA at surgery, number of lymph nodes removed, number of positive lymph nodes as well as laterality and site of nodal metastases at sLND. For the purpose of the study, LN sites were stratified in: right pelvic, left pelvic and retroperitoneal, respectively. We analyzed sensitivity, specificity, positive and negative predictive value as well as accuracy of the [(11)C]choline-PET/CT in predicting presence of nodal metastases at sLND. All the analyses were performed in the e overall patient population and after stratifying according to PSA (namely, 2 versus 2 ng/ml) and androgen deprivation therapy (ADT) status at sLND. RESULTS: The mean number of removed and positive nodes at sLND were 30.4 (median 29; range: 4-87) and 9.2 (range: 0-66), respectively. Fifty-nine out of the 71 patients (83%) with positive [(11)C]choline-PET/CT had histologically proven nodal metastases of PCa at sLND. A per-site based analysis showed that sensitivity, specificity, positive predictive value, negative predictive value and accuracy of [(11)C]choline-PET/CT in predicting nodal recurrence were 75.5%, 77.9%, 78.5%, 74.7%, and 76.6%, respectively. Table 1 shows the performance characteristics of [(11)C]choline-PET/CT after stratification according to ADT status and PSA values at sLND. CONCLUSIONS: [(11)C]Choline-PET/CT represents an accurate diagnostic tool for the detection of lymph-node metastases of clinical recurrent prostate cancer, regardless of ADT status at sLND.
Journal of Nuclear Medicine, 2016
Recurrence of prostate cancer is suspected when an increase in the prostate-specific antigen leve... more Recurrence of prostate cancer is suspected when an increase in the prostate-specific antigen level is detected after radical treatment; the recurrence could be local relapse, distant relapse, or both. Differentiation between the two patterns of relapse is critical for choosing the proper treatment strategy. Choline PET/CT could be of help in discriminating patients with local, lymph node, and bone recurrences, thus having an impact on patient management.
Revista española de medicina nuclear e imagen molecular, 2013
The quarterly journal of nuclear medicine and molecular imaging : official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the Society of Radiopharmaceutical Chemistry and Biology, 2012
High risk prostate cancer patients have a significant risk to develop regional lymph node metasta... more High risk prostate cancer patients have a significant risk to develop regional lymph node metastases, and this represent a major cause of biochemical failure. Although pelvic lymphadenectomy is the gold standard to assess the status of pelvic lymph nodes, a diagnostic imaging tool to non-invasively explore patients and to detect metastases, both in staging and in re-staging phase, would be of particular help in clinical management. In staging phase, while choline PET/CT specificity has been reported to be fairly high in lymph nodal detection, its sensitivity is not adequate due to its spatial resolution. Its role in the evaluation of patients with biochemical relapse or with suspected relapse has been successfully documented. In particular, choline PET/CT has great potential as a single step whole body diagnostic procedure to evaluate lymph nodal and bone metastatic involvement. Salvage lymph nodal dissection was recently listed as a possible experimental option for patients with no...
The quarterly journal of nuclear medicine and molecular imaging : official publication of the Italian Association of Nuclear Medicine (AIMN) [and] the International Association of Radiopharmacology (IAR), [and] Section of the Society of Radiopharmaceutical Chemistry and Biology, 2010
This paper focuses on acquisition and processing methods in positron emission tomography/computed... more This paper focuses on acquisition and processing methods in positron emission tomography/computed tomography (PET/CT) for radiotherapy (RT) applications. The recent technological evolutions of PET/CT systems are described. Particular emphasis is dedicated to the tools needed for the patient positioning and immobilization, to be used in PET/CT studies as well as during RT treatment sessions. The effect of organ and lesion motion due to patient's respiration on PET/CT imaging is discussed. Breathing protocols proposed to minimize PET/CT spatial mismatches in relation to respiratory movements are illustrated. The respiratory gated (RG) 4D-PET/CT techniques, developed to measure and compensate for organ and lesion motion, are then introduced. Finally a description is provided of different acquisition and data processing techniques, implemented with the aim at improving: i) image quality and quantitative accuracy of PET images, and ii) target volume definition and treatment planning ...
Revista Española de Medicina Nuclear e Imagen Molecular, 2012
18 F-FDG-PET/CT is widely employed to evaluate lymphoma patients. False positive results are quit... more 18 F-FDG-PET/CT is widely employed to evaluate lymphoma patients. False positive results are quite frequent, generally due to active phase of inflammation. We describe an unusual PET/CT presentation of a sarcoid-like reaction (SLR) in a patient monitored for Hodgkin Lymphoma characterized by an intense uptake in lymph nodes and multiple bone foci in a PET/CT study. The final diagnosis was obtained by biopsy. This study draws attention to the fact that multifocal bone marrow uptakes due to a sarcoideal reaction may be a possible cause of false positive results in 18 F-FDG-PET/CT studies in oncology patients.
Nuclear Medicine Communications, 2010
The purpose of this study was to assess the value of 2-[F]fluoro-2-deoxy-D-glucose positron emiss... more The purpose of this study was to assess the value of 2-[F]fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography ([F]FDG PET/CT) in the primary staging of high-risk endometrial cancer patients. This retrospective study was conducted on 32 consecutive patients with histological diagnosis of primary high-risk endometrial cancer, who underwent PET/CT with [F]FDG in addition to conventional clinical and instrumental staging procedures. After surgery, [F]FDG PET/CT findings were correlated with pathological findings on a patient-by-patient basis. The diagnostic accuracy of [F]FDG PET/CT for primary cancer detection, lymph nodal involvement and distant metastases was assessed. [F]FDG PET/CT could correctly detect primary tumor in 29 of the 32 high-risk patients, with a sensitivity of 90.6%. The overall [F]FDG PET/CT patient-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 57.1, 100.0, 100.0, 86.4, and 88.5%, respectively, for revealing lymph nodal neoplastic involvement, and 100.0, 96.0, 87.5, 100.0, 96.9%, respectively, for detecting distant metastases. In particular, while the suspicion of distant metastases was documented by conventional imaging in only two patients, [F]FDG PET/CT correctly identified metastatic lesions in seven patients (21.9% of cases). The major benefit provided in high-grade tumor patients by the use of [F]FDG PET/CT in the primary staging of endometrial cancer is its ability to accurately detect distant metastases in the abdomen and extra-abdominal regions. [F]FDG PET/CT adds relevant information that may influence patient management.
The Journal of Urology, 2012