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• W2039634557 abstract "Twenty-five years ago, Michal Gorbachev became the leader of the Soviet Union, postage stamps were 22 cents, a gallon of gas was $1.09, the Federal Drug Administration approved a blood test for acquired immunodeficiency syndrome, Microsoft introduced its first version of Windows, and the first issue of the Journal of Thoracic Imaging (JTI) was published. The December 1985 inaugural issue was initiated as a “specialty” journal dedicated to thoracic imaging and, as stated by the first editor, Dr Eric Milne, “provides a forum that will bring together critical articles dealing with all aspects of the diagnosis of chest diseases using imaging techniques.” Over the past 25 years, there have been many advances in thoracic imaging, and JTI has become a primary source for reporting these findings. We now reflect on the original articles and the vision of the contributors in that first issue. Of particular interest is the manuscript, Positron Emission Tomography in the Lung, written by Hughes et al, based on the prevailing research in positron emission tomography (PET) and their experience acquired through the Hammersmith Medical Research Council Cyclotron Unit PET lung program.1 It is remarkable that this topic was included in JTI's inaugural issue as most PET investigations at this time revolved around brain imaging. The authors and Editorial Board must have recognized that while this technology was in its infancy, it had potential clinical applications in the thorax. However, no one seems to have predicted the impact that PET would have on oncology, and especially its role in promoting the field of molecular imaging. The study by Hughes et al, a general commentary on PET in the chest, described a spectrum of indications and “stressed its quantitative aspects.” PET provided objective data using the physics of positrons and a variety of radiotracers, and the authors stated that this was “unique in the field of whole-body imaging.” The authors discussed the ability of PET to evaluate regional blood volume with carbon monoxide C11 (11CO), image lung structure and measure regional lung function including ventilation and perfusion with 19Ne, 11CO, H15O2, and 13N. The authors then described the relatively new and uncommon radiotracer, 18F-2-deoxy-D-glucose (FDG), to measure glucose metabolism. Potential clinical applications, including asthma, chronic obstructive lung disease, pulmonary vascular disease, interstitial lung disease, and lung carcinoma, were briefly outlined, but the true direction of this technology was not defined. Hughes's study went on to suggest that although quantitative assessment of lung physiology was possible, limitations to clinical use included the poor resolution of the scanners, the high cost, the short half-life of the radionuclides, and the long time required to image patients. Although these factors may have initially contributed to the failure of PET to disseminate in routine practice, it is more likely that the appropriate clinical indications showing how PET was to be integrated into conventional imaging departments were not obvious. This reflected a common trend in radiology, a discipline that has often been driven by technology in search of an application, and not by a clinical problem looking for a diagnostic solution. The study by Hughes et al was in many ways farsighted, but it was not until the first clinical studies in lung cancer were performed in the early 1990s that FDG-PET began to be viewed as an imaging modality with clinical potential. However, acceptance of the results of those early studies was cautionary, and it seemed as if FDG-PET imaging would remain under the purview of research institutions. Again the high cost, lack of reimbursement, limited availability of radiotracers, and premature clinical acceptance were all given as limitations in adopting the technology. That perspective has proved incorrect, and PET has become an essential, clinically relevant diagnostic tool. The perspective of 25 years allows one to now understand how innovation and persistence established PET using the radiopharmaceutical FDG as a stalwart of current oncologic imaging. The current status of PET in clinical medicine validates some of the research and assumptions made in 1985, but supersedes many of the expectations. In this regard, there were only 42 PET scanners worldwide in 1985 compared with the more than 2000 PET-computed tomography scanners currently in use. Astoundingly, it is estimated that over 1.5 million clinical PET studies were carried out in the United States in 2008 (www.imvinfo.com). This increase in utilization is not only due to a better understanding among physicians as to the role of FDG-PET imaging in patient management, but also due to the widespread availability of FDG as a result of regional commercial distribution centers and technological developments in PET scanners. In fact, the considerable technological developments in PET, including better resolution (which were anticipated by the Hughes et al), and new, faster scintillators such as gadolinium oxyorthosilicate and lutetium oxyorthosilicate, together with significant improvements in image reconstruction algorithms and the use of computed tomography for attenuation correction, have not only improved image quality and interpretation, but have reduced the time to acquire whole-body PET studies from 45 to 60 minutes to 10 to 20 minutes.2 These developments, combined with the more recent benefits of the National Oncologic PET Registry that further expands indications for PET imaging and increases eligibility for reimbursement, have established the primary role of FDG-PET imaging in managing oncologic patients. Currently, numerous studies have shown FDG-PET to be a clinically useful imaging modality that complements conventional radiologic studies in the evaluation of malignant tumors throughout the body. In the thorax, FDG-PET has several well-defined roles in the evaluation of focal pulmonary opacities, staging of lung and esophageal cancers, and in detecting tumor recurrence and radiotherapy planning.3–6 Although the clinical utility in determining treatment response and prognosis is not defined clearly, FDG-PET imaging is currently being evaluated and has the potential to allow more appropriate selection of patients for surgical resection and neoadjuvant and adjuvant therapy, and an earlier assessment of the response to chemotherapy.7–14 However, it remains unclear as to how to optimally incorporate FDG-PET imaging into clinical decisions regarding therapy. Although prospective multi-institutional trials and standardization of PET imaging protocols are required before the true utility is determined, the evolving experience with FDG-PET imaging indicates a potentially important role in treatment decisions. FDG-PET represents a true paradigm shift from conventional anatomic imaging and has become an essential tool in evaluating cancer patients. However, the next 25 years will undoubtedly bring additional advances and novel applications. Molecular imaging initiatives have been focused on improving instrumentation and designing better imaging probes. In this regard, novel radiotracers are being developed to evaluate specific biologic properties including DNA synthesis [thymidine analogs, 18F-fluoro-deoxythymidine, amino acid alterations (L-[methyl-11C] methionine)], hypoxia [Cu-labeled diacetyl-bis(N4-methylthiosemicarbazone)], and tumor receptors such as EGFR in lung cancer.15,16 Although the dominant focus of future PET imaging has been in oncology, cardiac applications are increasing, including rubidium PET imaging for myocardial perfusion and the development of new cardiac PET perfusion agents. Hughes et al concluded their study with the sentence, “This is only the beginning.” Twenty-five years later, it is clear that no one could have imagined the impact that this technology would have in the thorax. One can now envision that with novel imaging probes, new molecular targets, and improved technology, PET will play an ever increasing role in clinical diagnostics. However, advances in PET and molecular imaging need to be focused and clinically pragmatic if this modality is to further improve patient care. The next generation of thoracic imagers will be able to evaluate the true success of this technology when they are writing the 50th anniversary edition of JTI." @default.
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• W2039634557 title "Commentary on “Positron Emission Tomography in the Lung” 25 Years After Publication in the Inaugural Issue of the Journal of Thoracic Imaging" @default.
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