Nicola Mulholland

There is limited research into the impact of active brown adipose tissue (aBAT) in patients with phaeochromocytomas and paragangliomas (PPGLs). A small body of evidence has shown that patients with PPGL patients can exhibit a high prevalence for aBAT recognized as ranging between 8 - 28% without specific correlation to germline mutations. Furthermore, it has been suggested that aBAT may be linked to increased mortality. Systematic searches of the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL), EudraCT, ClinicalTrials.gov, medRvix CINAHL and Scopus databases were conducted. Our study was registered with PROSPERO international registry for systematic reviews with ID: CRD42021276073. Furthermore, we conducted a retrospective cohort study evaluating our records for patients between 2013-2021 with PPGLs who had an 18F-FDG PET/CT and metabolically aBAT. Meta-analytical calculations were performed using R software and SPSS was used for analyses of variables from our retrospective cohort study. Our systematic search produced 4 studies, the data of which were pooled into a meta-analysis including the data from our study. Our meta-analysis demonstrated a significant correlation between 18F-FDG PET/CT avidity and concentration of plasma metanephrines and normetanephrines using a random effect model (Pr=0.822, P=0.012) was observed. A statistically significant difference in metadrenaline levels between mutational status clusters (Kruskal-Wallis statistic = 11.435, df = 2, P=0.003) with post-hoc analysis suggesting significant difference between clusters 1 (SDH/VHL) and 2 (MEN/RET), as well as between cluster 1 and control group. Patients with PPGLs exhibit a high prevalence of BAT activation on 18F-FDG PET/CT.

Andrea Kuhnl, Claire Roddie, Amy A Kirkwood, Tobias Menne, Maria Mar Cuadrado, Maria A. V. Marzolini, Wendy Osborne, Robin Sanderson, Maeve O'Reilly, William M

We describe the use of Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) in the investigation and diagnosis of Charcot neuroarthropathy (CN) in patients with a hot swollen foot but normal radiographs and clinical suspicion of CN, usually termed Stage 0. This was a retrospective cohort review of 46 diabetes patients who underwent 3 phase bone scintigraphy with “High Resolution” SPECT/CT. The imaging demonstrated that Stage 0 Charcot foot has a distinct bone pathology, which can be classified into three groups: (1) fractures on Computed Tomography (CT) with accompanying focal uptake of tracer on SPECT, (2) bony abnormalities apart from fracture on CT with focal uptake of tracer on SPECT, and (3) normal CT but focal bony uptake of tracer on SPECT. The CT component of SPECT/CT detected bony fractures in 59% of patients. Early treatment with below knee cast and follow-up for 24 months showed only 4 patients who developed Stage 1 Eichenholtz Charcot foot. Our findings support the use of 3 phase bone scintigraphy with SPECT/CT in the characterization and early diagnosis of CN. Stage 0 Charcot foot has a distinct bone pathology which requires urgent treatment to prevent progression to Stage 1 Eichenholtz Charcot foot. If SPECT/CT is unavailable, CT alone will detect bone fracture in 59% patients.

We report on a case of a 68-year-old female, currently a dialysis-dependant patient with disseminated metastatic neuroendocrine tumour, treated with ¹⁷⁷Lu-Dotatate. As ¹⁷⁷Lu-Dotatate is cleared predominantly by the kidneys, there are concerns regarding the treatment plan strategy to avoid increased radiation exposure compared with patients with normal renal function. For this purpose, personalized dosimetry was used to calculate the safe administered activity using whole-body scans. Employing this strategy allowed us to adjust the administered activity for the third fraction. The whole-body doses calculated were not significantly different from those received by patients with normal renal function. The radiological follow-up showed a stable disease, suggesting effective treatment. We found negligible radiation protection problems involved with this procedure.

In November 2014 the International Myeloma Working Group (IMWG) revised the definition of multiple myeloma, such that asymptomatic patients with newly diagnosed multiple myeloma without any of the traditional ‘CRAB’ (hypercalcaemia, renal impairment, anaemia, bone disease) end organ damage criteria but with one of three new criteria would be recommended to start treatment. Previously, the standard of care for such patients was expectant management. These three new criteria are: greater than 60% clonal plasma cells on bone marrow biopsy, a serum free light chain (sFLC) ratio of >100 (the involved sFLC must be >100 mg/l) and greater than one unequivocal focal lesion on advanced imaging (low dose whole body computerized tomography, magnetic resonance imaging, ¹⁸F fluorodeoxyglucose positron emission tomography). Although this would appear to affect a small number of patients, the impact of these changes are broad, leading to an increased use of advanced imaging, a debate around the management of patients previously diagnosed with smouldering myeloma, changed terminology and clinical trial design and an extension of the use of biomarkers. For the first time the philosophy of treatment in myeloma will change from treatment initiation only being triggered by overt end organ damage to an era where sub clinical risk factors will also be taken into account.

¹³¹Iodine (I131)-metaiodobenzylguanidine (mIBG) is a radionuclide-based treatment option for metastatic gastrointestinal-pancreatic neuroendocrine tumours (GEP NET). This study aimed at identifying prognostic indicators of long-term outcome based on initial evaluation following a first mIBG treatment (7400 MBq) in a patient cohort with such tumours, with a secondary aim of evaluating progression-free survival (PFS) and overall survival (OS) following mIBG therapy. Retrospective review of the hospital records was performed to identify a cohort of 38 adult patients who underwent ¹³¹Iodine-mIBG therapy over a 9-year period for metastatic GEP NETs and neuroendocrine tumours with an unknown primary. Treatment response was evaluated based on radiological criteria (RECIST1.1), biochemical markers [serum Chromogranin A (CgA)/urinary 5HIAA] and symptomatic response at clinical follow-up, all evaluated at 3–6 months from first mIBG treatment. Progression-free survival (PFS) and overall survival (OS) from the first mIBG treatment were recorded. At 3–6 months following a single mIBG therapy, 75 %, 67 %, and 63 % of patients showed either a partial response (PR) or stable disease (SD) on radiological, biochemical, and symptomatic criteria, respectively. Complete response (CR) was not seen in any patient. OS from the date of diagnosis and from the first therapy was 8 years +/−1.1 (95 % CI 5.7 to 10.2 years) and 4 years+/−0.69 (95 % CI 2.6–5.3 years), respectively. Twenty-nine percent of patients were alive at 10 years. Significant survival advantage was seen in patients with SD/PR as compared to those who had progressive disease (PD) for each of these three criteria. Biochemical, radiological (RECIST 1.1) and symptomatic assessment of disease status at 3 to 6 months after first I131-mIBG therapy stratifies patients with a poor prognosis. This can be used to identify patients who may benefit from alternative strategies of treatment.