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At least 865 records · Page 48

Computer-Aided Diagnosis of Lung Nodules in Computed Tomography by Using Phylogenetic Diversity, Genetic Algorithm, and SVM

Lung cancer is pointed as the major cause of death among patients with cancer throughout the world. This work is intended to develop a methodology for diagnosis of lung nodules using images from the Image Database Consortium and Image Database Resource Initiative (LIDC-IDRI). The proposed methodology uses image processing and pattern recognition techniques. In order to differentiate between the patterns of malignant and benign nodules, we used phylogenetic diversity by means of particular indexes, that are: intensive quadratic entropy, extensive quadratic entropy, average taxonomic distinctness, total taxonomic distinctness, and pure diversity indexes. After that, we applied the genetic algorithm for selection of the best model. In the tests’ stage, we applied the proposed methodology to 1405 (394 malignant and 1011 benign) nodules. The proposed work presents promising results at the classification into malignant and benign, achieving accuracy of 92.52%, sensitivity of 93.1% and specificity of 92.26%. The results demonstrated a good rate of correct detections using texture features. Since a precocious detection allows a faster therapeutic intervention, thus a more favorable prognostic to the patient, we propose herein a methodology that contributes to the area in this aspect.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

CLMcrop yields and water requirements: avoided impacts by choosing RCP 4.5 over 8.5

Here, we perform CLMcrop simulations of the 20th and 21st centuries to assess potential avoided impacts in (a) crop yield losses and (b) water demand increases if humanity were to choose the representative concentration pathway (RCP) 4.5 instead of 8.5. RCP 8.5 imposes more extreme climatic changes on CLMcrop, while simultaneously exposing the crops to higher CO2 fertilization than RCP 4.5. As a result CLMcrop simulates global to regional scale changes in yield and water requirements for RCP 8.5 that exceed and sometimes more than double the RCP 4.5 changes relative to today. Under RCP 4.5 then, human societies may confront easier adaptation to changes in crop yields and water requirements. Under both RCPs, CLMcrop projects declining global yields for C3 crops (e.g., wheat, soybean, rice) without CO 2 fertilization and C4 crops (corn, sugarcane) without irrigation. Yield declines of 3 t ha -1 stand out in parts of tropical and subtropical Africa and South America (presently areas of rapid agricultural expansion) and are due to increasing plant respiration and decreasing soil moisture, both due to rising temperatures. Irrigation and CO 2 fertilization mitigate yield losses and in some cases lead to gains, so irrigation may help maintain or increase current yields through the 21st century. However, simulated global irrigation requirements increase: as much as 23 % for C4 crops without CO 2 fertilization under RCP 8.5 and as little as 3 % for C4 crops with CO 2 fertilization under RCP4.5. Nitrogen fertilized crops display greater vulnerability to climate and environmental change than unfertilized crops in our simulations; still relative to unfertilized crops, they deliver significantly higher yields and remain indispensable in supporting a more populous and affluent humanity. These CLMcrop results broadly agree with previously published outcomes for the 21st century. We describe in this article a new version of CLMcrop that represents prognostic crop behavior not only in the mid-latitudes but also the tropics.

54 ENVIRONMENTAL SCIENCES↗

Quantification of PET Myocardial Blood Flow

Purpose of Review: The aim of this review is to provide an update on quantification of myocardial blood flow (MBF) with positron emission tomography (PET) imaging. Technical and clinical aspects of flow quantification with PET are reviewed. Recent Findings: The diagnostic and prognostic values of myocardial flow quantification have been established in numerous studies and in various populations. MBF quantification has also shown itself to be particularly useful in the assessment of coronary microvascular dysfunction and in evaluation of cardiac allograft vasculopathy. Overall, myocardial flow reserve (MFR) and hyperemic MBF can lead to improved risk stratification by providing information complementary to that of other markers of disease severity, such as fractional flow reserve. Summary: Flow quantification enhances MPI’s ability to detect both significant epicardial disease and microvascular dysfunction. With recent technological and methodological advances, flow quantification with PET is no longer restricted to cyclotron-equipped academic centers.

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PET/CT for Diagnosis and Management of Large-Vessel Vasculitis

Purpose of Review: This review aims to discuss the use of fluorodeoxyglucose (FDG) positron emission tomography (PET/CT) for diagnosis and management of patients with large-vessel vasculitis (LVV). Recent Findings: Incidence of LVV is likely underestimated, in part due to its non-specific symptoms. Nevertheless, early diagnosis of LVV is essential to initiate timely therapy in order to prevent vascular complications, such as stenoses and aneurysms. FDG PET/CT imaging has the ability to detect LVV during the acute phase, prior to edema and other vascular structural changes, with its high sensitivity for inflammatory activity. FDG PET/CT was shown to be a powerful prognostic marker by allowing identification of patients at risk of vascular complications. Additionally, preliminary data support the use of FDG PET/CT to follow therapy efficacy. Summary: FDG PET/CT allows early detection of inflammation, before morphological and irreversible vascular changes can be observed, allowing prompt diagnosis and treatment of LVV.

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Evaluation of Hypertrophic Cardiomyopathy: Newer Echo and MRI Approaches

Purpose of Review: This review discusses the basic and evolving echocardiographic and cardiac magnetic resonance (CMR) approaches in the diagnosis and management of patients with hypertrophic cardiomyopathy (HCM). Recent Findings: Newer imaging technologies and techniques in both echocardiography and CMR have proved to add incremental value to our understanding of HCM. 3D reconstruction in echocardiography and CMR allows for more accurate morphological and volumetric assessment of the left ventricle. Echocardiographic and CMR-based left atrial assessment, including for its mechanical properties, has been shown to be correlated to outcomes and development of atrial fibrillation. Tissue characterization and scar burden quantification by late gadolinium enhancement on CMR has revolutionized our understanding of fibrotic processes in HCM and their contribution to disease severity and clinical outcomes. Summary: Cardiac imaging plays a crucial role in HCM patients. Using echocardiography and CMR as complementary modalities allows for improved diagnostics, optimization of treatment, and better prognostication.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Characteristics and impact of programmed death-ligand 1 expression, CD8+ tumor-infiltrating lymphocytes, and p16 status in head and neck squamous cell carcinoma

Background: No predictive biomarker of immune checkpoint inhibitors in head and neck squamous cell carcinoma (HNSCC) has been well established. The impact of programmed death-ligand 1 (PD-L1) expression, CD8+ tumor-infiltrating lymphocytes (TILs), and p16 status in HNSCC is unclear and may vary according to ethnicity. Methods: HNSCC patients treated between 2007 and 2013 were reviewed. Archival tissues were retrieved for PD-L1, CD8+ TILs, and p16 analyses. PD-L1 expression was evaluated by using the validated SP142 assay on the VENTANA platform. CD8+ TILs were defined by using semiquantitative scoring. Results: A total of 203 patients were analyzed. PD-L1 expression was observed in 80% of patients and was significantly associated with older age (P < 0.001). A high CD8+ TIL score (≥ 6) was significantly associated with never-smoking (P = 0.020), oral cavity cancer (P < 0.001), and stage M0 at presentation (P = 0.025). The p16 status was positive in 12% of patients. Patients with a high TIL score had a significantly longer OS (P = 0.032). Patients with PD-L1 expression of 1–49% and ≥ 50% were associated with a significantly shorter OS compared with those with PD-L1 < 1% (P = 0.027 and P = 0.011, respectively). Multivariate analysis showed that PD-L1 ≥ 50% was significantly associated with a poor OS. (HR 2.98 [95% CI 1.2–7.39]; P = 0.019.) Conclusions: A high prevalence of PD-L1 expression was observed in HNSCC using the validated SP142 assay. PD-L1 expression was associated with older age, while highly PD-L1 expression (≥ 50%) was an independent prognostic factor for poor OS in anti-PD1/PD-L1 untreated HNSCC patients.

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Correlation between the magnitude of best tumor response and patient survival in nivolumab therapy for metastatic renal cell carcinoma

The correlation between the magnitudes of best tumor response (bTR) and patient survival in immune checkpoint inhibitor therapy for metastatic renal cell carcinoma (mRCC) remains unclear. In this article, we retrospectively investigated the prognostic association of the magnitude of bTR in nivolumab therapy for mRCC. Fifty-five patients treated with nivolumab after failure of at least one molecular-targeted therapy were evaluated. Assessment of the magnitude of bTR was based on the Response Evaluation Criteria in Solid Tumors (RECIST) v.1.1. Endpoints were progression-free survival (PFS) and overall survival (OS) after the initiation of nivolumab therapy. In regard to the magnitude of bTR, complete response, partial response, stable disease, and progressive disease were observed in three (5.46%), 15 (27.3%), 19 (34.5%), and 18 (32.7%) patients, respectively. PFS and OS were significantly correlated with the magnitude of bTR (median PFS: not reached (N.R.) [95% confidence interval (CI) 16.8–N.R.] vs. 13.0 [8.38–56.0] vs. 5.95 [4.27–7.30] vs. 1.92 [0.53–3.91] months, p < 0.0001; OS: N.R. [N.R.–N.R.] vs. N.R. [21.4–N.R.] vs. 23.3 [23.3–N.R.] vs. 7.36 [1.41–N.R.] months, p < 0.0001). In addition, multivariate analyses show that the magnitude of bTR was an independent factor for PFS (p < 0.0001) and OS (p = 0.0010). In conclusion, this retrospective study shows the significant correlation between the magnitude of bTR and patient survival in nivolumab therapy for mRCC. The magnitude of bTR can be an effective surrogate marker for survival.

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Identification of important invasion and proliferation related genes in adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is an end‐stage hormonal syndrome. Although profound attempts have been made to illuminate the pathogenesis, the molecular mechanisms of ACC remain to be clarified. To identify the important genes in the progression of ACC, microarray datasets GSE19775 was downloaded from the gene expression omnibus database. The differentially-expressed genes (DEGs) were identified, and pathway and GO enrichment analyses were performed. The protein–protein interaction (PPI) network was constructed and the module analysis was performed using the protein interaction network analysis and Cytoscape. Also constructed target genes–miRNA regulatory network and target genes–TF regulatory network. Correlation of the hub genes were analyzed in The Cancer Genome Atlas. The prognostic values of hub genes were further validated by online tool UALCAN. Mutation analysis was done by online tool CBio Cancer Genomics Portal. A total of 884 DEGs were identified, with 441 in up regulation and 443 in down regulation. Pathways in catecholamine biosynthesis, aldosterone synthesis and secretion, pyrimidine deoxyribonucleosides salvage and systemic lupus erythematosus were the most significantly enriched for DEGs (up and down regulated). Blood vessel morphogenesis and cell cycle phase transition were the most significantly enriched term in biological processes, while extracellular matrix and chromosome, centromeric region were in cellular component and heparin binding and protein dimerization activity were in molecular function. Among the PPI networks and its module, target genes–miRNA regulatory network and target genes–TF regulatory network, hub genes were YWHAZ, FN1, GRK5, VCAM1, GATA6, TXNIP, HSPA1A, and F11R. Hub genes such as YWHAZ, STAT1, ICAM1, SH3BP5, CD83, FN1, TK1, HIST1H1C, CABLES1, and MCM3 were associated with poor overall survival, while hub genes such as STAT1, ICAM1, CD83, FN1, TK1, HIST1H1C, and MCM3 were highly expressed in stage 4. In conclusion, DEGs and hub genes diagnosed in this study may deepen our understanding of molecular mechanisms underlying the progression of ACC, and provide important targets for diagnosis and treatment of ACC.

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MPC-1 expression in myeloma cells is associated with the efficacy of bortezomib therapy

The use of bortezomib in the clinic has significantly improved outcomes for patients with multiple myeloma (MM), even those harboring high-risk cytogenetic abnormalities or those classified in the high-risk category according to the International Staging System (ISS). In this study, we analyzed the association between immunophenotyping on myeloma cells and the clinical outcomes of patients who received bortezomib-based regimens as first-line therapy. Immunophenotypic analysis before bortezomib therapy was performed by flow cytometry, and whether the immunophenotyping results influenced the clinical outcomes of the patients was investigated. Seventy-four newly diagnosed patients with MM were included in this study. We found that the expression of MPC-1 significantly predicted the time to next therapy (TNT), with a longer TNT in the MPC-1 positive group (p = 0.005), whereas it did not affect overall survival (OS; p = 0.773). In addition, we found that CD45-positivity was associated with shorter TNT (p = 0.0432). Following ISS assessment at treatment initiation, patients who were classified as stage I showed a slightly longer OS compared to those at stage II or III; however, these results were not significant (p = 0.0987). Furthermore, multivariate analysis revealed the prognostic significance of MPC-1 expression, as MPC-1-negativity was associated with a worse TNT. The combination of MPC-1 and CD45 status more sensibly predicted the TNT for bortezomib therapy. Our results demonstrate the clinical importance of immunophenotyping on myeloma cells to determine patient prognoses in this era of novel therapeutic agents.

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Programmed death-1 receptor (PD-1) and PD-ligand-1 (PD-L1) expression in non-small cell lung cancer and the immune-suppressive effect of anaerobic glycolysis

The microenvironment of a tumor may regulate the anti-tumor immune response. Intratumoral acidosis and hypoxia may suppress lymphocyte proliferation and migration, and this may have important implications in modern immunotherapy. The expression of PD-L1 by cancer cells and of PD-1 by tumor infiltrating lymphocytes (TILs) was assessed in tissue specimens from 98 operable NSCLC patients. Their prognostic role and their association with makers of glycolysis and anaerobic metabolism were assessed. Strong cytoplasmic/membrane PD-L1 expression was noted in 45/98 cases. Intense presence of TILs was noted in 42/98 cases (high TIL-score), and intense presence of PD-1 expressing TILs (high PIL-score) in 17/98 cases. PD-L1 expression was directly correlated with high PIL-score (p = 0.005). A significant inverse relationship was found between lactate dehydrogenase LDH5 expression and PIL-score (p = 0.008). Similarly, low PIL-score was significantly linked with high-hexokinase HXKII and monocarboxylate transporter MCT2 expression (p < 0.04). Cases with both intense TIL-score and PIL-score had significantly better survival (p < 0.05). For patients with high TIL-score or high PIL-score, PD-L1 overexpression defined significantly poorer survival (p = 0.01 and p = 0.03, respectively). In multivariate analysis, stage (p = 0.002, HR 3.33, 95%CI 1.4–4.5) and TIL-score (p = 0.02, HR 2.12, 95%CI 1.1–4.0) were independent predictive variables of death events. Given the low specificity of PD-L1 as a biomarker for anti-PD-1/PD-L1 immunotherapy, a combined assessment of TIL, PD-L1, PD-1, and LDH5 provides a tool for an immunological/metabolic classification of NSCLC tumors, with a different prognosis and different expected response to anti-PD-1/PD-L1 immunotherapy, which should be considered in relevant clinical trials.

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Impact of circulating tumour cells on survival of eribulin-treated patients with metastatic breast cancer

Several clinical studies have examined circulating tumour cells (CTCs). However, the application of CTCs as a predictive/prognostic marker for breast cancer patients has yet to be established, particularly the selection of suitable markers for detecting CTCs. We recently investigated CTCs, including mesenchymal status, from metastatic breast cancer patients who had received eribulin-based treatment. We found that assessment of both mesenchymal and epithelial CTCs might be important for predicting eribulin responsiveness. In the current study, we followed up the outcomes of these patients after eribulin treatment and investigated the possibility of CTC analysis results serving as prognostic markers for this patient population. Twenty-one patients were enrolled and peripheral blood samples were collected before eribulin-based treatments. CTCs were then examined using a Microfluidic Chip device. CTCs positive for vimentin and pan-cytokeratin were defined as mesenchymal and epithelial CTCs, respectively. Overall survival (OS) was assessed in relation to the number of CTCs and clinicopathological factors. During the observation period, 13 patients (62%) died due to breast cancer and the median OS was 18 months. Patients with high-grade tumours and a high total number of CTCs showed significantly shorter OS than those with low-grade tumours and smaller CTC burdens (p = 0.026 and 0.037, respectively). Patients who received eribulin as the first chemotherapy for metastatic disease showed longer OS (p = 0.006). Our data suggest that determining numbers of both mesenchymal and epithelial CTCs might predict survival for patients receiving eribulin.

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Can synthetic lethality approach be used with DNA repair genes for primary and secondary MDS?

Cancer-specific defects in DNA repair pathways create the opportunity to employ synthetic lethality approach. Recently, GEMA (gene expression and mutation analysis) approach detected insufficient expression of BRCA or NHEJ (non-homologous end joining) to predict PARP inhibitors response. We evaluated a possible role of DNA repair pathways using gene expression of single-strand break (XPA, XPC, XPG/ERCC5, CSA/ERCC8, and CSB/ERCC6) and double-strand break (ATM, BRCA1, BRCA2, RAD51, XRCC5, XRCC6, LIG4) in 92 patients with myelodysplastic syndrome (73 de novo, 9 therapy-related (t-MDS). Therapy-related MDS (t-MDS) demonstrated a significant downregulation of axis BRCA1-BRCA2-RAD51 comparing to normal controls (p = 0.048, p = 0.001, p = 0.001). XRCC6 showed significantly low expression in de novo MDS comparing to controls (p = 0.039) and for patients who presented chromosomal abnormalities (p = 0.047). Downregulation of LIG4 was consistently associated with poor prognostic markers in de novo MDS (hemoglobin < 8 g/dL (p = 0.040), neutrophils < 800/mm{sup 3} (p < 0.001), patients with excess of blasts (p = 0.001), very high (p = 0.002)/high IPSS-R (p = 0.043) and AML transformation (p < 0.001). We also performed an evaluation of GEPIA Database in 30 cancer types and detected a typical pattern of downregulation as here presented in primary or secondary MDS. All these results suggest synthetic lethality approach can be tested with DNA repair genes (beyond that of BRCA1/2 status) for de novo and therapy-related myelodysplastic syndrome and may encourage clinical trials evaluating the use of PARP1 inhibitors in MDS. Graphic Abstract: .

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Detection and quantitation of right ventricular reversible perfusion defects by stress SPECT myocardial perfusion imaging: A proof-of-principle study

Background: In patients with right dominant coronary circulation, the right ventricular (RV) myocardium and the inferior region of the left ventricular (LV) myocardium share a common source of blood flow. We hypothesized that stress/rest SPECT myocardial perfusion imaging (MPI) could detect reversible perfusion defects in the RV in some patients with LV inferior wall perfusion abnormalities. Material and Methods: We identified 2 groups of patients with LV inferior wall perfusion defects (with or without defects in other regions of LV myocardium) from our database. Patients in group 1 (n = 17) had reversible perfusion defects in the RV free wall by visual analysis, while patients in group 2 (n = 17) did not. The images were processed with filtered back projection and, separately, with iterative reconstruction. The images were then re-processed using an automated quantitative software that is specifically designed to include the RV in the region of interest. Results: There were 76% men in group 1 and 94% in group 2 (P <0.05). The mean age was 65±20 in group 1 vs. 63±18 years in group 2 (P < 0.05). The stress type was exercise in 30% in group 1 and 35% in group 2, with the remaining patients studied with pharmacological stress testing (P = NS). The presence of RV reversible perfusion defects using filtered back projection was more evident in 13 patients (75%), while it was better seen with iterative reconstruction in 4 patients (25%). By automated analysis, the RV reversible perfusion defect size was 19 ± 14% of RV myocardium. Conclusion: This proof-of-principle study demonstrates that reversible RV perfusion defects suggestive of ischemia can be detected by SPECT myocardial perfusion imaging in some patients with LV inferior ischemia by visual analysis and can be quantitated by automated programs. Further studies on the diagnostic and prognostic relevance of assessing RV ischemia on SPECT MPI are needed.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Patient page-sarcoidosis imaging

Optimizing our imaging capabilities for patients with cardiac sarcoidosis is critical as it has diagnostic, prognostic, and therapeutic implications. {sup 18}FDG PET/CT has the highest sensitivity for the detection of CS but requires specific dietary preparation that is difficult for patients to follow which may lead to ineffective suppression of physiologic {sup 18}FDG uptake. This may result in inconclusive scan results in up to 30% of patients undergoing {sup 18}FDG PET/CT imaging for CS. Therefore, it is imperative that we relay to our patients the importance of dietary preparation for CS PET imaging and then provide simple, easy to follow instructions for them. The current patient protocol is designed to achieve these two objectives.

62 RADIOLOGY AND NUCLEAR MEDICINE↗

Coronary risk equivalence of diabetes assessed by SPECT-MPI

Background: Several publications and guidelines designate diabetes mellitus (DM) as a coronary artery disease (CAD) risk equivalent. The aim of this investigation was to examine DM cardiac risk equivalence from the perspective of stress SPECT myocardial perfusion imaging (MPI). Methods and Results: We examined cardiovascular outcomes (cardiac death or nonfatal MI) of 17,499 patients referred for stress SPECT-MPI. Patients were stratified into four categories: non-DM without CAD, non-DM with CAD, DM without CAD, and DM with CAD, and normal or abnormal perfusion. Cardiac events occurred in 872 (5%), with event-free survival best among non-DM without CAD, worst in DM with CAD, and intermediate in DM without CAD, and non-DM with CAD. After multivariate adjustment, risk remained comparable between DM without CAD and non-DM with CAD [AHR 1.0 (95% CI 0.84–1.28), P =0.74]. Annualized event rates for normal subjects were 1.4% and 1.6% for non-DM with CAD and DM without CAD, respectively (P = 0.48) and 3.5% (P = 0.95) for both abnormal groups. After multivariate adjustment, outcomes were comparable within normal [AHR 1.4 (95% CI 0.98–1.96) P = 0.06] and abnormal [AHR 1.1 (95% CI 0.83–1.50) P = 0.49] MPI. Conclusions: Diabetic patients without CAD have comparable risk of cardiovascular events as non-diabetic patients with CAD after stratification by MPI results. These findings support diabetes as a CAD equivalent and suggest that MPI provides additional prognostic information in such patients.

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Relationship of left ventricular global longitudinal strain with cardiac autonomic denervation as assessed by {sup 123}I-mIBG scintigraphy in patients with heart failure with reduced ejection fraction submitted to cardiac resynchronization therapy

Background: Heart failure (HF) is associated with cardiac autonomic denervation (AD), which can be non-invasively assessed by {sup 123}I-metaiodobenzylguanidine ({sup 123}I-mIBG) scintigraphy and has prognostic implications. We aimed to study the relationship between myocardial contractility assessed by global longitudinal strain (GLS) and AD assessed by {sup 123}I-mIBG scintigraphy in advanced HF. Methods/Results: BETTER-HF is a prospective randomized clinical trial including HF patients (pts) submitted to cardiac resynchronization therapy (CRT) who are submitted to a clinical, echocardiographic, and scintigraphic assessment before and 6 months after CRT. 81 pts were included. An echocardiographic response (absolute increase in left ventricular ejection fraction ≥ 10%) was observed in 73.7% of pts. A higher baseline late heart-to-mediastinum ratio (HMR) was associated with a better echocardiographic response. There was a significant association between late HMR and GLS at baseline and 6 months. At baseline, GLS had an AUC of 0.715 for discrimination for a late HMR < 1.6. A GLS cut-off of − 9% maximized the likelihood of correctly classifying a pt as having severe AD (HMR < 1.6). Conclusion: Myocardial contractility as assessed by GLS is moderately correlated with AD as assessed by {sup 123}I-mIBG scintigraphy and has a good discrimination for the identification of severe cardiac denervation. GLS may allow for a more readily accessible estimation of the degree of AD in advanced HF pts.

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Advanced cardiovascular imaging for the evaluation of cardiac sarcoidosis

Cardiac sarcoidosis (CS) remains an intriguing infiltrating disorder and one of the most important forms of inflammatory cardiomyopathy. Identification of patients with CS is of extreme importance because they are at higher risk of sudden death, and heart-failure progression. And while it remains a diagnostic conundrum, a great amount of experience has been accumulated over the last decade with the advent of fluorine-18 fluorodeoxyglucose positron emission tomography and cardiac magnetic resonance with late gadolinium enhancement imaging. They have both proven to be advanced imaging techniques that provide important, and often complementary, diagnostic and prognostic information for the management of CS. However, they have also shown to have limitations, and, thus, there is a continued need for developing more specific imaging probes for identifying cardiac inflammation. The aim of the present manuscript is to provide the reader with a better understanding of the histopathology of the disease, how this potentially relates to noninvasive imaging detection, and the best strategies available for the diagnosis and management of patients with CS.

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Hybrid anatomo-functional imaging of coronary artery disease: Beneficial irrespective of its core components

Coronary artery disease (CAD) is the most common and important cause of ischemic heart disease, with major implications on global morbidity and mortality. Non-invasive testing is crucial in the diagnostic and prognostic work-up of patients with or at risk of CAD, and also to guide decision making in terms of pharmacologic and revascularization therapy. The traditional paradigm is to view anatomic (i.e., coronary computed tomography) and functional imaging (e.g., myocardial perfusion scintigraphy) tests as opposing alternatives. Such approach is too reductionist and does not capitalize on the strengths of each type of test while risking to overlook the inherent limitations. The combination of anatomic and functional tests in a logic of hybrid imaging holds the promise of overcoming the limitations inherent to anatomic and functional testing, enabling more accurate diagnosis, prognosis, and guidance for revascularization in patients with CAD.

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