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Reshma Jagsi, MD, DPhil; Kevin Kalinsky, MD, MS; Hope S. Rugo, MD, FASCO; Alastair Thompson, MD, MBChB, BSc (Hons), FRCS (Ed), FACS; Debu Tripathy, MD


Clinical Case Vignette Series™: 41st Annual Miami Breast Cancer Conference®

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For Satoshi Minoshima, M.D., Ph.D., the approval of new anti-amyloid treatments and emerging research on the use of blood-based biomarkers were key developments that fueled the 

recently updated appropriate use criteria (AUC)

 for brain positron emission tomography (PET) in patients with mild cognitive impairment (MCI)

, Dr. Minoshima noted that amyloid PET wasn’t recommended 10 years ago for patients who had an established diagnosis of Alzheimer’s disease. However, with the approvals of the anti-amyloid therapies lecanemab (Leqembi, Eisai/Biogen) and donanemab (Kisunia, Eli Lilly), Dr. Minoshima said amyoid PET enables clinicians to confirm target expression within the brain in these patients prior to treatment.

Additionally, in light of emerging evidence on the use of blood-based biomarkers, Dr. Minoshima notes the utility of amyloid PET imaging if cerebrospinal fluid (CSF) or other fluid biomarker results are uncertain or incongruent with the clinical diagnosis.

“I think maybe that’s a great opportunity to do amyloid PET imaging,” posited Dr. Minoshima, a past president and current chair of value initiative at the Society of Nuclear Medicine and Molecular Imaging (SNMMI).

The updated AUC also incorporated the use of tau PET imaging, which could enhance assessment of neuronal injury and possibly assist in differentiating Alzheimer’s disease and other neurodegenerative conditions, according to Dr. Minoshima.

“This clinical distinction between progressive supranuclear palsy (PSP) and Alzheimer’s disease is actually quite difficult, so hopefully the availability of tau pet in the future is going to give us a better differential diagnosis so combining (tau PET) with amyloid PET, we can guide the patient to the right treatment,” noted Dr. Minoshima, the Anne G. Osborn Chair and professor in the Department of Radiology and Imaging Sciences at the University of Utah.

In the podcast, James Williams, the chief executive officer for Siemens Healthcare Molecular Imaging, also noted that the availability of low-cost, easily to perform blood tests in the future may lead to a broader population of patients being tested for neurodegenerative diseases due to family history or genetic predisposition.

“In those cases, I think the imaging gets even more critical because certainly you wouldn't want to … subject someone to the therapy until you're very sure what's going to happen, but they're going to be a different patient population too. (These are) not the images we've seen in the clinical trials or for a large part of the research up to (now),” added Williams.

(Editor’s note: For related content, see “

SNMMI Issues New Appropriate Use Criteria for Amyloid PET and Tau PET Imaging

A Closer Look at the New Appropriate Use Criteria for Brain PET: An Interview with Phillip Kuo, MD, Part 1

A Closer Look at the New Appropriate Use Criteria for Brain PET: An Interview with Phillip Kuo, Part 2

For more insights from Dr. Minoshima and Dr. Williams, listen below or 

In a new podcast, Satoshi Minoshima, M.D., Ph.D., and James Williams, Ph.D., share their insights on the recently updated appropriate use criteria for amyloid PET and tau PET in patients with mild cognitive impairment.

The Reading Room Podcast: Current Perspectives on the Updated Appropriate Use Criteria for Brain PET

For patients at high-risk for biochemical recurrence of prostate cancer, PSMA PET/CT findings revealed that 77 percent had one or more prostate lesions after undergoing local radiation therapy or radical prostatectomy, according to a recent study.

What a New PSMA PET/CT Study Reveals About Local PCa Treatment and High-Risk Recurrence 

For patients with recurrent or metastatic prostate cancer, new research findings showed no significant difference in the sensitivity of 18F-piflufolastat PET/CT between patients on concurrent hormone therapy and those without hormone therapy.

Study Shows No Impact of Hormone Therapy on PET/CT with 18F-Piflufolastat in PCa Imaging

The combination of the Aurora SPECT/CT system with AI-enabled Clarify DL image reconstruction reportedly offers the potential of enhanced image quality and streamlined workflows in nuclear medicine.

FDA Clears Dual-Head SPECT/CT System with Deep Learning Image Reconstruction

While PSMA PET/CT revealed an 87 percent local remission rate after metastasis-directed radiotherapy for oligometastatic prostate cancer in a new study, researchers also found that 80 percent of patients had biochemical progression at a median 32-month follow-up.

PSMA PET/CT Study Shows Mixed Results with Single Metastasis-Directed Radiotherapy for Oligometastatic PCa

In a review of over 1,630,000 office-based non-breast imaging Medicare fee-for-service (FFS) claims from 2022, researchers found that 39.5 percent of nuclear medicine imaging were interpreted by ordering clinicians.

Self-Interpretation of Imaging by Non-Radiologists Accounts for 43.5 Percent of Medicare Imaging Claims

While single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is well validated for the detection of coronary artery disease (CAD) and other cardiovascular abnormalities, there is a degrading effect with attenuation that requires an additional computed tomography (CT) scan to address attenuation compensation.

However, in a recent interview, Abhinav Kumar Jha, Ph.D, noted there are a large number of SPECT scanners that do not have the CT component and this issue is particularly prevalent in community hospitals and rural facilities. Dr. Jha says this problem is compounded as studies have demonstrated a higher prevalence of heart disease in rural health-care settings.

Dr. Jha pointed out that 75 percent of SPECT MPI exams are performed without attenuation compensation and cites a survey of nuclear cardiology providers that found only 5.6 percent provided CT-based attenuation correction.

“Therefore, you can imagine there's a very important need for a large segment of the patient population to have access to this technology of attenuation correction without being able to take a CT scan,” noted Dr. Jha, an associate professor of biomedical engineering and radiology at the Washington University School of Medicine in St. Louis.

However, in recently published research, Dr. Jha and other researchers developed a deep learning technique that provides CT-less (dubbed CTLESS) attenuation compensation. With this research and other studies, Dr. Jha said the CTLESS approach has provided consistent performance across scanner models and patients with different degrees of heart disease.

While acknowledging that more studies are needed to validate the technology, Dr. Jha noted the CTLESS approach has potential to bolster access to SPECT MPI.

“I'm excited about the CTLESS technology (and) making the process of attenuation compensation more accessible, affordable as well as safe,” emphasized Dr. Jha.

Assessing MACE Risk in Women: Can an Emerging Model with SPECT MPI Imaging Have an Impact?

Radiology ‘Game-Changer’: FDA Approves PET Agent for Enhanced Detection of Coronary Artery Disease

Study Shows Merits of CTA-Derived Quantitative Flow Ratio in Predicting MACE

For more insights from Dr. Jha, watch the video below.

Abhinav K. Jha, Ph.D., discusses emerging research for a deep learning CT-less alternative for providing attenuation compensation for SPECT MPI.

Can Deep Learning Provide a CT-Less Alternative for Attenuation Compensation with SPECT MPI?

In a recent interview, Abhinav K. Jha, Ph.D., discussed key challenges with the use of SPECT MRI and how an emerging deep learning model may facilitate attenuation compensation without the need for an additional computed tomography (CT) scan.

“I like to say that amyloid (PET) is necessary for the diagnosis of Alzheimer’s disease but not sufficient,” noted Phillip Kuo, M.D., during a recent interview to discuss the recently released appropriate use criteria for amyloid and tau positron emission tomography (PET) in patients with mild cognitive impairment (MCI).

Dr. Kuo offered insights on the use of amyloid and tau PET in three cases involving a man in his 80s who veered back and forth in testing between early amnestic mild cognitive impairment (MCI) and normal results over the course of a year; a 74-year-old with MCI, suspected vascular contribution and a history of stroke; and a 60-year-old patient who had recent progression from early Alzheimer’s disease to frank dementia.

As Dr. Kuo conveyed with these cases in the interview, these patients had very different stages of disease, yet their amyloid PET scans appeared to be similar.

“The amyloid is the first half, but it doesn't give us the entire second half, like those cases I showed you, (with) that insight into that neuropathology. You can be amyloid PET positive and still not have your symptoms be due to Alzheimer's disease. … The tau PET is more specific that your symptoms are really due to Alzheimer's disease,” explained Dr. Kuo, a professor and division chief of nuclear medicine in the Department of Diagnostic Radiology at the City of Hope Cancer Center in Duarte, Calif.

(Editor’s note: The images and cases discussed in the video are courtesy of Gene Alexander, M.D.,

the Banner Alzheimer’s Institute in Tucson, Az., and the Radiological Society of North America (RSNA).)

While emphasizing that brain PET imaging is among a variety of factors that clinicians use in determining whether anti-amyloid antibody therapy is appropriate for patients, Dr. Kuo emphasized that the combination of amyloid PET and tau PET offers a complementary diagnostic picture in cases of uncertain presentations.

“ … To get that complete picture, we need to know the biomarkers. We can get that non-invasively with both amyloid PET now as well as tau (PET). Hopefully, these 

 will make help clinicians out there to really make sure that we bring value to patient care using these non-invasive, very important and powerful tools for assessing biomarker positivity and also biomarker spatial distribution in the brain,” added Dr. Kuo.

FDA Grants Fast Track Designation to Emerging Tau PET Imaging Agent

For more insights from Dr. Kuo, watch the video below.

Phillip Kuo, MD discusses appropriate use criteria and clinical cases incorporating the use of amyloid and tau PET in patients with mild cognitive impairment.

A Closer Look at the New Appropriate Use Criteria for Brain PET: An Interview with Phillip Kuo, MD, Part 2

In the second part of a two-part interview on the recently published appropriate use criteria for brain positron emission tomography (PET) for patients with mild cognitive impairment (MCI), Phillip Kuo, M.D. discusses clinical cases involving the use of amyloid and tau PET imaging.

Discussing the evolution of updating appropriate use criteria (AUC) for amyloid positron emission tomography (PET) from the originally issued AUC in 2013, Phillip Kuo, M.D., recalls vociferous debates, addressing new clinical scenarios and rescoring of recommendations.

In a recent interview, Dr. Kuo said the normally arduous undertaking of updating an AUC with a multidisciplinary panel was a dynamic four-year process marked by the challenges of incorporating tau PET into the 

 and reflecting the emergence of the newly FDA-approved anti-amyloid antibody therapies lecanemab (Leqembi, Eisai/Biogen) and donanemab (Kisunla, Eli Lilly) upon updates for amyloid PET.

“Even within this short period of time, relatively speaking, (there were a lot) of changes in the therapeutic landscape that obviously would affect the AUC criteria,” explained Dr. Kuo, a professor and division chief of nuclear medicine in the Department of Diagnostic Radiology at the City of Hope Cancer Center in Duarte, Calif.

“Those scenarios were added and then had to be rescored to reflect the fact that we now know that these anti-amyloid antibodies can have a statistically significant slowing of cognitive decline in patients who are amyloid positive and have (mild cognitive impairment) or early dementia due to Alzheimer's disease.”

While the multidisciplinary panel was originally charged with updates to the AUC for amyloid PET, Dr. Kuo said there was fairly strong consensus that tau PET recommendations needed to be included in the new AUC as well.

“ … While (amyloid PET) is a very sensitive and accurate marker for amyloid deposition in your brain, it doesn’t necessarily track very well with the clinical symptoms or the functional decline. That is where tau (PET) really has its strength,” emphasized Dr. Kuo. “It is a much more dynamic biomarker and is far more reflective, generally speaking, … of clinical symptoms.”

New PET and MRI Research Suggests that Visceral Fat Reduction May Prevent or Delay Alzheimer’s Disease

FDA Clears New Centiloid Scoring and Tau PET Quantification Tools

Phillip Kuo, MD discusses the new appropriate use criteria for amyloid positron emission tomography (PET) and tau PET for patients with mild cognitive impairment (MCI).

In a recent interview, Phillip Kuo, M.D., discussed the impact of newer anti-amyloid antibody therapies for Alzheimer’s disease upon recently issued appropriate use criteria (AUC) for amyloid positron emission tomography (PET) imaging as well as the incorporation of tau PET into the AUC for patients with mild cognitive impairment.

New research shows that non-physician practitioner (NPP) image interpretation in office settings grew by more than nine percent annually over the course of a decade for ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) and increased by more than seven percent annually for nuclear medicine interpretation.

In a recent interview, study co-author Richard Duszak, MD, shared his perspective on the increases in NPP image interpretation reported in the study, which was recently published in the 

Journal of the American College of Radiology

“The compound growth rate here is pretty staggering: 9 percent per year for X-ray, ultrasound, CT, and MR with (nuclear medicine) not far behind at 7 percent. They’re all growing at a relatively similar rate,” noted Dr. Duszak, a professor and chair of the Department of Radiology, at the University of Mississippi Medical Center.

“It's only about 5.5 percent of all the nurse practitioners and (physician assistants) that we were able to identify (via) Medicare claims (data) that are doing this, but they are empowered, perhaps emboldened, to say, ‘I can look at an ankle X ray, therefore, I'm going to look at a brain CT scan.’ From somebody who spent an extensive amount of time in medical school, in residency, going through board certification, to have folks come out of nurse practitioner school with essentially no training in imaging — which is what the data from nurse practitioner training program literature says — (and attempt to interpret images) is a bit scary.”

The Rise of NPP Image Interpretation: What New Radiology Research Reveals

Current Perspectives on Radiology Workforce Issues and Potential Solutions

Emergency Department Radiology: Study Shows Higher Imaging Orders by NPPs

Dr. Duszak said there was considerable state by state variation with the NPP image interpretation rates. For example, Dr. Duszak explained that the probability of having an office-based NPP interpret imaging in Alaska is approximately 20 percent and noted this would have been closer to zero percent when he was in residency training. He noted the importance of identifying causes behind these trends in outlier states and emphasizing targeted advocacy and education.

“This is an exponential curve. It really is a potential game changer with regard to what's happening in the workforce and in the marketplace. I think (this) really requires a lot more attention, not just from researchers, but from policy makers as well,” emphasizes Dr. Duszak, a member of the Board of Chancellors for the American College of Radiology.

For more insights from Dr. Duszak, watch the video below.

Richard Duszak, MD discusses new study findings that show significant annual increases in CT, MRI and ultrasound interpretation by office-based non-physician practitioners.

Radiology Study Finds Increasing Rates of Non-Physician Practitioner Image Interpretation in Office Settings

In a recent interview, Richard Duszak, MD, discussed new study findings that showed over nine percent annual increases in ultrasound, CT and MRI interpretation by office-based non-physician practitioners (NPPs) between 2013 and 2022.

While it took over a decade of advocacy to lead to the recent decision by the Centers for Medicare and Medicaid Services (CMS) to unbundle reimbursement for diagnostic radiopharmaceuticals exceeding $630 in per-day costs, the new policy significantly expands access to these modalities, according to Cathy Cutler, Ph.D., the president of the Society for Nuclear Medicine and Molecular Imaging (SNMMI).

“By CMS agreeing to walk away from bundling and to provide appropriate reimbursement (for diagnostic radiopharmaceuticals), this means that these important tools that physicians use to help ensure patients are getting optimal treatment will now be widely available,” noted Dr. Cutler in a recent interview.

Dr. Cutler said the shift away from bundling diagnostic radiopharmaceuticals as supplies and providing separate reimbursement for these modalities that exceed the daily cost threshold of $630 is a significant advance.

The policy, which goes into effect on January 1, 2025, will likely spur the development of new radiopharmaceuticals, according to Dr. Cutler, the Director of the Medical Isotope Research Production and Development Group in Brookhaven National Laboratory in New York.

While the new CMS policy was preceded by years of advocacy efforts from SNMMI, Dr. Cutler said the broader access to diagnostic radiopharmaceuticals is rewarding as it can lead to improved decision-making in the treatment of patients.

New SNMMI President Cathy Cutler, PhD, Discusses Current Challenges and Goals for Nuclear Medicine

What SPECT/CT May Reveal About Early Treatment Response for Pluvicto in Patients with mCRPC

FDA Clears Automated Dosimetry with the Monte Carlo Method for Radionuclide Therapy

“I'm very happy for patients. I do think that these are very valuable tools that physicians get to use to help (patients) have optimal treatment and improves their quality of life. It can lead to extension of life, and it can ensure that they're not taking drugs that are not benefiting them, so I think this is a real win for patients,” emphasized Dr. Cutler.

For more insights from Dr. Cutler, watch the video below.

SNMMI president Cathy Cutler, PhD discusses a recent CMS decision to unbundle reimbursement for diagnostic radiopharmaceuticals costing over $630 a day. 

Assessing a Landmark Change in CMS Reimbursement for Diagnostic Radiopharmaceuticals

In an interview, SNMMI president Cathy Cutler, PhD, discussed the impact of the recent CMS decision to unbundle reimbursement for diagnostic radiopharmaceuticals costing above $630 a day, calling it a “game changer” decision that will benefit patients, physicians, and the development of new radiopharmaceutical agents.



In separate studies presented at the recent 

, the positron emission tomography (PET) radiotracer 

F-flotufolastat demonstrated no urinary retention in patients with primary prostate cancer (PCa) and facilitated a 15 percent higher percentage of biochemical failure-free survival in comparison to conventional imaging for guided salvage radiotherapy in patients with recurrent PCa.

In one study comparing 18F-flotufolastat (Posluma, Blue Earth Diagnostics) and 

, researchers found that 18 percent of primary tumors located near the bladder in the 

Ga-PSMA-11-PET group (3/17) were obscured by radioactivity in the bladder in comparison no obscured tumors with 

F-flotufolastat (0/24). The study authors also reported a 27.4 percent rate of halo artifacts with the 

Ga-PSMA-11-PET cohort (17/62) in contrast to 4.8 percent (3/62) for those in the 

The researchers also emphasized that there was no ureter retention with 

F-flotufolastat in comparison to 21 percent (13/62) for men in the 

David Gauden, D.Phil, discussed these study results during an interview at the SNMMI conference.

“Their findings were clinically impactful in their opinion in that they had a much lower background radioactivity in the bladder (with 

F-flotufolastat) when they were evaluating the scans. (This) gave them more confidence in their diagnostic findings when they evaluated it on a multi-point scale of background (radiopharmaceutical) activity, leading them to believe that when you’re looking for local recurrences, using an agent with this lower bladder excretion could be clinically valuable in helping with the management of these patients,” noted Gauden, the chief executive officer for Blue Earth Diagnostics.

Study: 18F-Flotufolastat PET Imaging Changes Treatment in 89 Percent of Patients with Prostate Cancer Recurrence

Could Pluvicto Have a Role in Taxane-Naïve mCRPC?: an Interview with Oliver Sartor, MD

SNMMI: PSMA-18F DCFPyL Changes Treatment for PCa Recurrence in Significant Number of Patients with Low PSAs

In a separate study of 110 patients with biochemical recurrence of PCa after radical prostatectomy, researchers compared 

F-flotufolastat PET-guided salvage radiotherapy (SRT) to conventional SRT. Although the researchers conceded a lack of statistical significance, they found that the 

F-flotufolastat PET-guided group had 8 percent, 15 percent, and 21 percent higher rates of biochemical failure-free survival at one, two and three years, respectively, than those who had conventional SRT.

“Although it was a small study without a statistically significant finding, there were trends toward longer biochemical progression-free survival for the group where the radiotherapy was guided by PET imaging in addition to the standard field … ,” added Gauden.

For more insights from Mr. Gauden, watch the video below.

David Gsuden, D.Phil, discusses new research, presented at the SNMMI meeting, that examines use of 18F-flotufolastat in patients with prostate cancer.

Emerging Research at SNMMI Examines 18F-flotufolastat in Managing Primary and Recurrent Prostate Cancer

1. Rauscher I, Langbein T, Fuetterer CS, Weber W, Eiber M. Evaluation of qualitative and quantitative PET parameters in primary prostate cancer patients: double-match comparison of 18F-flotufolastat and 68Ga-PSMA-11-PET. Presented at the 2024 Society of Nuclear Medicine and Molecular Imaging Annual Meeting, June 8-11, Toronto, Canada. Available at: 

https://www.xcdsystem.com/snmmi/program/10OD8Tq/index.cfm

2. Rauscher I, Vogel MME, Gschwend J, Peeken JC, Eiber M. 18F-rhPSMA-7 and 18F-flotufolastat PET-guided salvage radiotherapy in recurrent prostate cancer. Presented at the 2024 Society of Nuclear Medicine and Molecular Imaging Annual Meeting, June 8-11, Toronto, Canada. Available at: 

In a recent interview at the SNMMI conference, David Gauden, D.Phil, discussed key findings from new research evaluating the use of the PET radiotracer 18F-flotufolastat in patients with primary prostate cancer (PCa) and men with biochemical recurrence of PCa. 

Emerging Research at SNMMI Examines 18F-Flotufolastat in Managing Primary and Recurrent Prostate Cancer

The radiopharmaceutical agent (177Lu)Lu-PSMA-617 (Pluvicto, Novartis) may be a viable option in the treatment of patients with taxane-naïve metastatic castration-resistant prostate cancer (mCRPC), according to emerging research findings presented at the 2024 Society of Nuclear Medicine and Molecular Imaging (SNMMI) Annual Meeting.

, Oliver Sartor, MD, said there are reimbursement challenges as well as mixed results with current androgen receptor pathway inhibitor (ARPI) treatment in this patient population.

“We know (ARPI therapy) is a viable alternative, but we also know these patients will progress and go on to need additional therapy,” noted Dr. Sartor, the director of radiopharmaceutical trials at the Mayo Clinic in Rochester, Minnesota.

In new research, which garnered Abstract of the Year honors at the SNMMI conference, researchers compared the use of Pluvicto versus a change in ARPI therapy (abiraterone or enzalutamide) in 468 taxane-naïve patients with mCRPC.

In the primary study analysis, the researchers found that patients in the Pluvicto group had a significantly higher median radiographic progression-free survival in comparison to those in the ARPI change group (9.3 months vs. 5.55 months). A second interim analysis revealed that patients in the Pluvicto group had over a 35 percent higher objective response rate (50.7 percent vs. 14.9 percent) and a significantly longer median time to PSA progression (10.55 months vs. 4.24 months) in contrast to patients in the ARPI change cohort.

Dr. Sartor, a co-author of the study, also noted that the second interim analysis showed a lower incidence of grade > 3 adverse events in patients receiving Pluvicto.

Emerging Perspectives on PSMA PET Radiotracers: An Interview with Kenneth J. Pienta, MD

Study: PSMA PET/CT Agent May Rule Out csPCa in 93 Percent of PI-RADS 3 Lesions

While Pluvicto was approved by the FDA for patients with PSMA-positive mRCPC who previously had ARPI therapy and taxane-based chemotherapy, Dr. Sartor suggested there is “reasonable hope” for an expanded indication for Pluvicto in the management of patients with taxane-naïve mRCPC.

“If the FDA does give an approval, it will truly be practice-changing, Insurances will cover it and patients can be treated,” added Dr. Sartor.

For more insights from Dr. Sartor, watch the video below.

In an interview at the SNMMI 2024 conference, Oliver Sartor, M.D. discussed key findings from new award-winning research evaluating the potential of Pluvicto in treating patients with taxane-naïve metastatic castration-resistant prostate cancer (mCRPC).

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