Cancer Treatment Today » Imaging

How to follow Diffuse Large Cell Lymphoma after completing treatment

M Levin, MD — Fri, 07 Sep 2012 22:20:18 +0000

Athough CT remains the gold standard for the staging and follow-up of malignant lymphomas, 18F-FDG PET has a potential role in accurately staging disease and in predicting response to therapy. On the other, guidelines do not recommend MRI for surveillance. The most common lymphoma is Diffuse Large B0cell Lymphoma(DLBCL). 2012 NCCN Guidelines for DLBCL on p. BCEL-4 recommend CT no more often than every 6 months for 2 years after completion of treatment, then only as clinically indicated. In contrast to the North American guidelines, the European Society of Medical Oncology (ESMO) in 2007 specifically advises against routine imaging except to evaluate residual disease. These guidelines recommend:

PET scan at end of treatment, if available
Minimal radiologic examinations in patients with DLBCL at 6, 12, and 24 months after end of treatment, when indicated by site of disease
In regard to followup, a recent study showed that a negative PET scan after completion of therapy does not exclude the presence of residual microscopic disease and does not indicate complete remission. The majority of studies evaluating FDG-PET in lymphoma include patients with diffuse large B-cell non-Hodgkin’s lymphoma (NHL) or Hodgkin’s disease. There are limited data available on the role of PET in other histologies.

A negative PET scan at the end of therapy appears to provide favorable prognostic information. Persistently positive PET scans at the end of therapy, or in follow-up, warrant close follow-up or additional diagnostic procedures, since some of those patients may remain in prolonged remission.

The Imaging Subcommittee of the International Harmonization Project (IHP) in Lymphoma developed guidelines for performing and interpreting positron emission tomography (PET) for treatment assessment in patients with lymphoma. The new recommendations, targeting both clinical practice and clinical trials, are published in the January 22 Early Release issue of the 2007 al of Clinical Oncology. They are based on experts’ consensus and not randomized evidence.

Specific recommendations related to followup are:

After treatment completion, PET should be performed at least 3 weeks, and preferably 6 to 8 weeks, after chemotherapy or chemoimmunotherapy, and 8 to 12 weeks after radiation or chemoradiotherapy. Noncontrast PET/CT can be used instead of contrast-enhanced diagnostic CT to follow-up patients with lymphoma, although patients with hepatic or splenic involvement should continue to receive contrast-enhanced diagnostic CT. Attenuation-corrected PET is much preferred over nonattenuation-corrected scans.

For professional version see here

MRI for back pain – pro

M Levin, MD — Fri, 07 Sep 2012 19:43:01 +0000

The American College of Physicians (ACP) and the American Pain Society (APS) have issued a comprehensive joint clinical practice guideline for the diagnosis and treatment of low back pain, which is published in the October 2, 2007 issue of the Annals of Internal Medicine.

For patients with nonspecific low back pain, clinicians should not routinely order imaging studies, including radiographs, computerized tomography (CT) scans, magnetic resonance imaging (MRI), or other diagnostic tests. These tests should be used to evaluate only those patients who have severe or progressive neurologic deficits or who are suspected to have cancer, infection, or other underlying condition as the cause of their low back pain.

For patients with nonspecific low back pain, clinicians should not routinely perform imaging studies, including radiographs, CT scans, and MRI, or other diagnostic tests (strong recommendation; moderate-quality evidence).

Patients with severe or progressive neurologic deficits, or in whom history and physical examination suggest cancer, infection, or other underlying condition as the cause of their low back pain, should undergo imaging studies and other appropriate diagnostic tests (strong recommendation; moderate-quality evidence).

Patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis should undergo MRI or CT only if positive results would potentially lead to surgery or epidural steroid injection for suspected radiculopathy. In choosing an imaging procedure, MRI is preferred to CT (strong recommendation; moderate-quality evidence).

Ann Intern Med. 2007;147:478-491.

Davis PC, Wippold FJ II, Brunberg JA, Cornelius RS, De La Paz RL, Dormont D, Gray L, Jordan JE, Mukherji SK, Seidenwurm DJ, Turski PA, Zimmerman RD, Sloan MA, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® low back pain. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 7 p.

For Lay version see here

How long to follow after remission of diffuse large cell lymphoma – pro

M Levin, MD — Fri, 07 Sep 2012 19:40:19 +0000

Although CT remains the gold standard for the staging and follow-up of malignant lymphomas, 18F-FDG PET has a potential role in accurately staging disease and in predicting response to therapy. On the other hand, guidelines do not recommend PET routinely for surveillance. NCCN Guidelines for DLBCL on p. BCEL-4 recommend CT no more often than every 6 months for 2 years after completion of treatment, then only as clinically indicated. In contrast to the North American guidelines, the European Society of Medical Oncology (ESMO) in 2007 specifically advises against routine imaging except to evaluate residual disease. These guidelines recommend:

Specific recommendations related to followup are:

As noted, guidelines do not recommend PET for surveillance after that point.

Barrington SF, Kluge R. FDG PET for therapy monitoring in Hodgkin and non-Hodgkin lymphomas. Eur J Nucl Med Mol Imaging. 2017;44(Suppl 1):97-110.

Freudenberg LS, Antoch G, Schutt P, et al. FDG-PET/CT in re-staging of patients with lymphoma. Eur J Nucl Med Mol Imaging. 2004;31:325–329

Yuliya S. Jhanwar and David J. Straus The Role of PET in Lymphoma Journal of Nuclear Medicine Vol. 47 No. 8 1326-1334, 2006

Lavely WC, Delbeke D, Greer JP,

NCCN, NHL, BCEL-4, 2018

J. W. Fletcher, B. Djulbegovic, H. P. Soares, B. A. Siegel, V. J. Lowe, G. H. Lyman, R. E. Coleman, R. Wahl, J. C. Paschold, N. Avril, et al.
Recommendations on the Use of 18F-FDG PET in Oncology
J. Nucl. Med., March 1, 2008; 49(3): 480 – 508.

Zelenetz A, Abramson JS, Advani A, et al. NCCN Clinical Practice Guidelines in Oncology: Non-Hodgkin’s Lymphomas. Version 2, 2011. Available at: http://www.nccn.org/professionals/physician_gls/pdf/nhl.pdf.

Jost L. Newly diagnosed large B-cell non-Hodgkin’s lymphoma: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol 2007;18(Suppl 2):ii55–ii56

Followup for renal cell carcinoma – pro

M Levin, MD — Fri, 07 Sep 2012 19:36:59 +0000

The guidelines recommend CT for routine followup of renal cel carcinoma patients on active treatment. Some guidelines recommend PET as well as an alternative or to supplement CT; however, CT remains the standard imaging modality for restaging.
In regard to PET/CT, little reliable information exists. There is currently limited experience with FDG-PET and renal cell carcinoma. One of the first studies evaluating 29 patients with solid renal masses demonstrated a sensitivity of 77% (20 of 26 patients with renal cancer)and 3 false positives (angiomyolipoma, pericytoma and pheochromocytoma). In another 3 patients, FDG-PET detected regional nodal metastases.
A second study evaluating factors in the degree of FDG uptake in renal cell carcinoma (n = 11) demonstrated that patients with higher grade tumors had positive FDG-PET studies. The fact that many renal cell carcinomas are lower in grade may explain the relatively low sensitivity.

Another limitation with FDG-PET evaluation of renal cell carcinoma is the fact that FDG is excreted by the kidneys. Thus, variable degrees of increased uptake are normally seen in the renal parenchyma and collecting system, making detection of focal increased uptake in a tumor difficult. PET scanning has been shown to be potentially useful in differentiating benign from malignant hepatic lesions, but limitations include false-positive and false-negative results. Its sensitivity for detecting metastatic lesions is better than for determining the presence of cancer in the renal primary site.

NCCN recommends chest and abdominal CT 4- 6 months, then as indicated. A recent guideline states: “FDG PET, whole body may have a role when CT and/or bone scan findings are equivocal.” ACR recommends: ”

For T1 tumors. As the risk of metastases is low, most surveillance protocols recommend that history, physical examination, laboratory tests, and a chest radiograph be obtained every 6 to 12 months for 3 years and then yearly until year 5. Others have suggested no imaging if the tumor is <2.5 cm. Most protocols do not recommend surveillance with abdominal computed tomography (CT) for patients with T1 tumors.
For T2 primary tumors. Most protocols recommend that history, physical examination, laboratory tests and a chest radiograph be obtained annually or every 6 months for 3 years, then annually thereafter till year 5. Protocols vary widely regarding the use of abdominal CT. Some do not recommend CT at all, while others recommend CT at year 2 and year 5. Still others recommend a CT every other year, or annually for 3 years following surgical removal, then annually thereafter.
For T3 or T4 primary tumors. Most protocols recommend that history, physical examination, laboratory tests, and a chest radiograph be obtained every 6 months for a few years, then annually thereafter. The vast majority of protocols recommend abdominal CT, with most recommending more frequent (every 3 to 6 months) CT imaging for 3 years after surgery and less frequently (yearly or every other year) thereafter. “

D. Soulières, MD MSc, Review of guidelines on the treatment of metastatic renal cell carcinoma
Curr Oncol. 2009 May; 16(Supplement 1): S67–S70.

Urological Tumours National Working Group. Renal cell carcinoma. Utrecht, The Netherlands: Association of Comprehensive Cancer Centres (ACCC); 2006 Oct 23. 108 p. [442 references]
Casalino DD, Francis IR, Baumgarten DA, Bluth EI, Bush WH Jr, Curry NS, Israel GM, Jafri SZ, Kawashima A, Papanicolaou N, Remer EM, Sandler CM, Spring DB, Fulgham P, Expert Panel on Urologic Imaging. Follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2007. 5 p. [60 references]

Delbeke D, Martin WH, Sandler MP, Chapman WC, Wright JK Jr, Pinson CW. Evaluation of benign vs malignant hepatic lesions with positron emission tomography. Arch Surg. 1998;133:510-515.

Motzer RJ, Hutson TE, Tomczak P, et al. Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med. 2007;356(2):115-124.

Dilhuydy MS, Durieux A, Pariente A, de Clermont H, Pasticier G, Monteil J, Ravaud A.. PET scans for decision-making in metastatic renal cell carcinoma: a single-institution evaluation.Oncology. 2006;70(5):339-44

Ak I, Can C..F-18 FDG PET in detecting renal cell carcinoma.Acta Radiol. 2005 Dec;46(8):895-9

clinical practice guidelines: B. Escudier, V. Kataja, and On behalf of the ESMO Guidelines Working GroupRenal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann Oncol (2010) 21(suppl 5): v137-v139

Casalino DD, Francis IR, Arellano RS, Baumgarten DA, Curry NS, Dighe M, Fulgham P, Israel GM, Leyendecker JR, Papanicolaou N, Prasad S, Ramchandani P, Remer EM, Sheth S, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria® follow-up of renal cell carcinoma. [online publication]. Reston (VA): American College of Radiology (ACR); 2009. 6 p. [62 references]

UPTODATE, 2019
Surveillance for metastatic disease after definitive treatment for renal cell carcinoma
Authors:Brian Shuch, MDAllan J Pantuck, MD, MS, FACSIzak Faiena, MDSection Editor:Jerome P Richie, MD, FACSDeputy Editor:Sadhna R Vora, MD

Magnetic Resonance Imaging Spectroscopy in cancer – pro

M Levin, MD — Fri, 07 Sep 2012 19:31:34 +0000

The combination of magnetic resonance spectroscopy (MRS) and imaging (MRI) has led to mapping metabolites from normal and neoplastic tissue within the time limits of a routine study. MRSI (magnetic resonance spectroscopy imaging) detects metabolites that contain protons, phosphorus, fluorine, or other nuclei. This allows radiologists and oncologists to apply MRSI as an assessment of function (uptake) to supplement anatomic information in research and clinical practice.Magnetic resonance spectroscopy may be useful in some circumstances, such as assessing patient responses to neoadjuvant chemotherapy when resection has not yet been performed. It is not yet widely accepted that it can be used to successfully survey pateints at a high risk or relapse.

http://radiology.rsnajnls.org/cgi/reprint/174/3/847.pdf

Jaffe, C. Carl Response Assessment in Clinical Trials: Implications for Sarcoma Clinical Trial Design Oncologist 2008 13: 14-18

Vaidya SJ, Payne GS, Leach MO, Pinkerton CR. Potential role of magnetic resonance spectroscopy in assessment of tumour response in childhood cancer. Eur J Cancer 2003;39:728–735

Prostascint – pro

M Levin, MD — Fri, 07 Sep 2012 19:29:55 +0000

PROSTASCINT is the first monoclonal antibody-based agent that targets prostate-specific membrane antigen (PSMA) to image the extent and spread of prostate cancer. The study that supports its use, “Capromab pendetide (ProstaScint) imaging with central abdominal uptake: poor outcomes for prostate cancer patients,” by Haseman, et al., was presented at the 2007 Annual Meeting of the American Urological Association taking place May 19-24, 2007 in Anaheim, California. PROSTASCINT consists of Cytogen’s proprietary PSMA-targeting monoclonal antibody, 7E11-C5, linked to the imaging radioisotope Indium-111. By targeting PSMA, the PROSTASCINT molecular imaging procedure can detect the extent and spread of prostate cancer using a standard gamma camera.

Emerging data from several sources using the superimposition, or fusion, of the PROSTASCINT functional study upon an anatomic image such as Computed Tomography (CT) Imaging or Magnetic Resonance Imaging (MRI), have generated renewed interest in the clinical value of PROSTASCINT imaging. In January 2007, the National Comprehensive Cancer Network, or NCCN, updated its clinical practice guidelines and expanded PROSTASCINT’s role to include recurrent disease. The expanded NCCN guidelines reflect the growing awareness of the potential for PROSTASCINT fusion imaging to assess disease and plan individualized treatment regimens. ProstaScint scans are US Food and Drug Administration approved for pretreatment evaluation of metastatic disease in high-risk patients. They are also approved for post-prostatectomy assessment of recurrent disease in patients with a rising prostate-specific antigen level.

Schettino CJ, Kamer EL, Noz ME, et al. Impact of fusion of indium-111 capromab pendetide volume data sets with those from MRI or CT in patients with recurrent prostate cancer. AJR. 2004; 183:519-524.

Wong, Terence Z., Turkington, Timothy G., Polascik, Thomas J., Coleman, R. Edward
ProstaScint (Capromab Pendetide) Imaging Using Hybrid Gamma Camera-CT Technology
Am. J. Roentgenol. 2005 184: 676-680

Rodney J Ellis, Edward Kim, Ryan FoorRole of ProstaScint® for brachytherapy in localized prostate adenocarcinoma Expert Review of Molecular Diagnostics
July 2004, Vol. 4, No. 4, Pages 435-441

Imaging and radiological surveillance for hystiocytosis – pro

M Levin, MD — Fri, 07 Sep 2012 19:25:45 +0000

Histiocytosis is a rare disease that involves hystiocytes. The disease can range from limited involvement that spontaneously regresses to progressive multiorgan involvement that can be chronic and debilitating. In some cases, the disease can be life-threatening.It is approximated that histiocytosis affects 1 in 200,000 children born each year in the United States. The disease us rare and not much is known securely about how to treat it. Because of its rarity, prospective studies are not possible.

Chest xray is ususally done. CAT may be appropriate in initial work-up of lung invovement. High-resolution CT scanning may be required if lung involvement is suspected based on radiography findings of pulmonary infiltrates or a cystic appearance. Skeletal survey may show osteolytic lesions. CT scanning or MRI of the hypothalamic-pituitary region may reveal abnormalities of these organs. In particular, magnetic resonance spectroscopy may be valuable in the early detection and evaluation of the neurodegenerative component.

There is no evidence that routine CT surveillance is of benefit.

MRI for traumatic knee injury – pro

M Levin, MD — Fri, 07 Sep 2012 19:24:06 +0000

Some sources:

Pavlov H, Saboeiro GR, Campbell SE, Dalinka MK, Daffner RH, DeSmet AA, El-Khoury GY, Kneeland JB, Manaster BJ, Morrison WB, Rubin DA, Schneider R, Steinbach LS, Weissman BN, Haralson RH III, Expert Panel on Musculoskeletal Imaging. Acute trauma to the knee [online publication], Reston (VA): American College of Radiology (ACR); 2005. 9p. [97 references]

American College of Radiology Practice Guideline for the Performance and Interpretation of Magnetic Resonance Imaging (MRI) of the Knee, 10/01/05.

Wilkinson ID, Paley MNJ. Magnetic resonance imaging: basic principles. In: Grainger RC, Allison D, Adam, Dixon AK, eds. Diagnostic Radiology: A Textbook of Medical Imaging. 5th ed. New York, NY: Churchill Livingstone; 2008:chap 5.

Edwin H.G. Oei et al, MRI for Traumatic Knee Injury: A Review

Seminars in Ultrasound, CT, and MRI

Volume 28, Issue 2, April 2007, Pages 141-157

Sodium fluoridePET – pro

M Levin, MD — Fri, 07 Sep 2012 19:16:51 +0000

18F-Fluoride is a different kind of PET scan, which uses sodium fluoride instead of technetium. It is more PET avid than FDG PET. Society of Nuclear Medicine says this: ” No appropriateness criteria have been developed to date for this procedure. PET/CT 18F bone scans may be used to identify skeletal metastases, including localization and determination of the extent of disease. Insufficient information exists to recommend the following indications in all patients, but may be appropriate in certain individuals…..”

http://www.snm.org/docs/Practice%20Guideline%20NaF%20PET%20V1.1.pdf

National Health and Medical Research Council (Australia). A systematic review of the efficacy and safety of fluoridation [PDF]. 2007. ISBN 1-86496-415-4. Summary: Yeung CA. A systematic review of the efficacy and safety of fluoridation. Evid Based Dent. 2008;9(2):39–43. doi:10.1038/sj.ebd.6400578. PMID 18584000. Lay summary: NHMRC, 2007.

de Arcocha M, Portilla-Quattrociocchi H, Medina-Quiroz P, Carril JM.
Current status of the use of 18F-sodium fluoride in bone disease.
Rev Esp Med Nucl. 2012 Jan-Feb;31(1):51-7. Epub 2011 Jul 26.

PET in cervical cancer – pro

M Levin, MD — Tue, 04 Sep 2012 13:17:41 +0000

Lay Summary: PET has become an accepted tool for determining the extent of newly diagnosed cervical cancer and for following effects of treatment

NCCN recently (8/07) revised its staging recomendations and lists PET as a recommended staging modlity. Positron-emission tomography (PET) scan is no longer optional for ≥ stage IB2 disease and is now recommended as part of the workup. Whole-body positron emission tomography (PET) completed after cervical cancer treatment predicts outcome in a recent study.

Grigsby PW, Siegel BA, Dehdashti F. Lymph node staging by positron emission tomography in patients with carcinoma of the cervix. Journal of Clinical Oncology. 19(17), 3745-3749, Sept. 1, 2001

http://www.nccn.org/professionals/physician_gls/PDF/cervical.pdf

Schwarz JK, Siegel BA, Dehdashti F, Grigsby PW. Association of posttherapy positron emission tomography with tumor response and survival in cervical carcinoma. JAMA. 2007 Nov 21;298(19):2289-95.

JHuang KG, Ng KK, Tang SG, Chang YC, Hsueh S, Tsai CS, Hong JH, Lin CT, Chao A, Ma SY, Lin WJ, Fu YK, Fan CC, Lai CH. Defining the priority of using 18F-FDG PET for recurrent cervical cancer.Yen TC, See LC, Chang TC, Nucl Med. 2004 Oct;45(10):1632-9.Comment in:
J Nucl Med. 2004 Oct;45(10):1602-4.