Chemotherapy plus radiotherapy vs. radiotherapy alone in high-risk endometrioid endometrial carcinoma

OBJECTIVE

Adding chemotherapy to radiotherapy in patients with high-risk endometrioid endometrial cancer (EEC) remains controversial, particularly in stages I-II. We aimed to investigate the effect of treatment modalities on survival in high-risk EEC patients.

PATIENTS AND METHODS

Patients with high-risk EEC were evaluated retrospectively between 2010 and 2019. Patients who did not receive adjuvant treatment were excluded. We included seventy patients and formed two groups: patients who received radiotherapy (RT) alone and those who received chemotherapy and radiotherapy (CT and RT).

RESULTS

The median follow-up time was 60.3 months (8.0-143.5). 38.5% of the patients had relapsed. Recurrence-free survival (RFS) rates were 97. 1%, 68.3% , and 60.8% at 12-, 36-, and 60-month, respectively. Overall survival rates were 97.1%, 80.6%, and 72.6% at 12-, 36-, and 60-month, respectively. Hematological adverse events and neuropathy were more common in the CT and RT group than in the RT group. Multivariate Cox regression analysis for RFS revealed that the FIGO stage and treatment modalities were statistically independent factors (p=0.031 and p=0.040, respectively). Stage stratified log-rank test revealed that adding chemotherapy improved RFS in patients with stage III (p=0.020) but not in stage I-II disease (p=0.725). The number of chemotherapy cycles administered (≤4 vs. >4) did not affect survival in all patients and stage III disease (p=0.497, and p=0.436, respectively).

CONCLUSIONS

Adding chemotherapy to radiotherapy may be considered in high-risk stage III EEC. Further studies are needed to determine the optimal duration of chemotherapy.

Segmental ATN in a Kidney with a Single Artery Transplanted from Living Related Donor

A sequential 99mTc-MAG3 renogram of a 20-year-old male who received a kidney from a living related donor is presented. Pre-transplant angiography of the donor showed the kidney had a single renal artery with upper and lower branches. The transplantation procedure was uneventful, allowing rapid simultaneous perfusion to the entire kidney. The first scan performed 2 days after the transplantation was normal except for retention of the radiotracer at the upper pole of the kidney. The renal collecting system was normal and no signs of dilatation or obstruction were noticed on ultrasonographic examination. A follow-up scan done on the 5th day of transplantation showed almost complete evacuation of the parenchymal retention previously seen on the upper pole of the kidney. This unusual finding was consistent with segmental acute tubular necrosis (ATN) of the upper pole of the kidney and showed that ATN might involve only a portion of a kidney in spite of the existence of a single artery of the transplant.

Risk factors and complications of intracranial pressure monitoring with a fiberoptic device

We prospectively investigated the complications associated with intraparenchymal intracranial pressure (ICP) monitoring using the Camino intracranial pressure device. A fiberoptic ICP monitoring transducer was implanted in 631 patients. About half of the patients (n=303) also received an external ventricular drainage set (EVDS). The durations (mean+/-SD) of ICP monitoring in patients without and with an EVDS were 6.5+/-4.4 and 7.3+/-5.1 days, respectively. Infection occurred in 6 patients with only an ICP transducer (6/328, 1.8%) and 24 patients with an EVDS also (24/303, 7.9%). The duration of monitoring had no effect on infection, whereas the use of an EVDS for more than 9 days increased infection risk by 5.11 times. Other complications included transducer disconnection (2.37%), epidural hematoma (0.47%), contusion (0.47%), defective probe (0.31%), broken transducer (0.31%), dislocation of the fixation screw (0.15%), and intraparenchymal hematoma (0.15%). In conclusion, intraparenchymal ICP monitoring systems can be safely used in patients who either have, or are at risk of developing, increased ICP.

Dilatation of Virchow-Robin perivascular spaces: report of 3 cases with different localizations

We report on three different cases with Virchow-Robin spaces, including one with extreme widening causing hydrocephalus. In one patient we have performed neuroendoscopic cyst fenestration to resolve the problem.

Solitary rib lesions in bone scans of patients with breast carcinoma

The aetiology of solitary rib lesions detected on bone scans was evaluated retrospectively. Seventy-five patients with breast carcinoma, and each with a solitary hot spot on a bone scan, were included in the study. The aetiology of the solitary rib lesions was determined by using all available clinical, laboratory and radiological data, and was clarified in 65 of the 75 patients, and not clarified in the remaining 10. In 17 of those 65 (26.1%), the aetiology of increased uptake was malignant; while in 48 of the 65 (73.8%) it was benign in origin. Linear lesions were mainly metastatic in origin (seven of nine, 77.7%) whereas focal lesions were mostly benign in origin (46 of 56, 82.19%). In the group of 16 hot spots located at the anterior rib end, 14 (87.5%) were benign, and two (12.5%) were malignant in origin. The relation between mastectomy side and the distribution of anterior and anterior rib end localization of hot spots was also investigated. Twenty-three of 32 rib lesions (71.8%) were on the same side as the surgery. In conclusion, solitary rib lesions on bone scans in patients with breast carcinoma are frequently benign in origin, especially if they are focal and located at the anterior rib end.

Combined use of bone and bone marrow scintigraphies for the diagnosis of active sacroiliitis: a new approach

Diagnosis of sacroiliitis (SI) with bone scintigraphy may involve difficulties even with a quantitative approach. The aim of this study was to evaluate the combined use of bone and bone marrow scintigraphies for the diagnosis of active sacroiliitis. Thirty-one patients who were clinically suspected to have SI were included in the study. Bone and bone marrow scintigraphies were done after injections of 740 MBq of 99mTc-MDP (MDP) and 370 MBq of 99mTc-sulfur colloid (SC) respectively with a 2-day interval. Both visual and quantitative assessment of MDP uptake and visual assessment of SC uptake in sacroiliac joints were performed. Also sacroiliac joint radiographic findings for each patient were evaluated and graded from 0 to 4 according to the New York grading system. Patients were divided into 2 groups according to their x-ray findings (Group A: grade 0-2, Group B: grade 3-4). A total of 14 patients (10 bilateral, 4 unilateral) had increased MDP uptake with decreased/normal SC uptake. Twelve of 14 patients had grade 0-2 radiographic changes while only 2 patients had grade 3-4 radiographic changes. Increased MDP uptake with decreased/normal SC uptake is the most common scintigraphic pattern seen in acute phase SI in which radiographic findings are generally found to be normal or slightly changed. In at least in 8 patients the decreased bone marrow uptake of SC was demonstrated, supporting the diagnosis. Although our results did not reveal any significant superiority of bone marrow scintigraphy to bone scan for the detection of active sacroiliitis, combined use of bone and bone marrow scintigraphies was presented as an alternative method to characterize patients with active sacroiliitis.

Scintigraphic evaluation of impaction grafting for total hip arthroplasty revision

To determine the fate of an impacted allograft after a minimum follow-up of 1 year, we examined 9 of 40 patients who underwent revision arthroplasty with the impaction grafting technique. The allograft used in this study was morselized cancellous freeze-dried allograft. We examined these 9 patients with technetium-99 m methylene diphosphonate bone scintigraphy at an average of 14 (range 12-20) months after surgery. All of them had a good clinical outcome, with an average postoperative Hip Society Score of 89 (range 65-98) and no evidence of radiolucency or subsidence on direct radiography. Scintigraphic examination demonstrated that the area corresponding to the allograft had a remarkable radioactivity accumulation suggesting new bone formation. The allograft in total hip revision using the impaction grafting technique undergoes a significant neovascularization and new bone formation. This study suggests than when vigorous impaction is used, freeze-dried cancellous allograft can be used for impaction grafting.

Superiority of Tc-99m MAG3 to Tc-99m DTPA in treating a patient with mild renal artery stenosis

A 22-year-old female patient with severe hypertension underwent both Technetium-99m diethylenetriaminepentaacetate and Technetium-99m mercaptoacetyltriglycine basal and captopril renal scintigraphy. While no significant change was seen with Tc-99m DTPA, there was left sided parenchymal retention of captopril Tc-99m MAG3 suggesting renal artery stenosis which was confirmed by angiography.

Exercise-induced left bundle branch block during thallium 201 myocardial perfusion scintigraphy--a case report

Exercise-induced left bundle branch block (Ex-LBBB) is a rare entity encountered during exercise testing. The authors present a 53-year-old woman who developed intermittent Ex-LBBB asymptomatically during Tl 201 myocardial perfusion scintigraphy. Scintigraphic findings revealed septal-anteroseptal ischemia while the coronary arteriogram appeared normal. False-positive septal-anteroseptal scintigraphic findings suggesting ischemia in patients with persistent left bundle branch block (LBBB) is well known, but since the LBBB in this case was induced by exercise testing and was spontaneously terminated at rest, scintigraphic findings may be attributed to microcirculatory ischemia, which cannot be detected angiographically, as the cause of Ex-LBBB.

Scintigraphic evaluation of synovial inflammation in rheumatoid arthritis with (99m)technetium-labelled human polyclonal immunoglobulin G

The aim of this study was to investigate whether (99m)technetium-labelled polyclonal human immunoglobulin G (99mTc-IgG) scintigraphy reflects synovial inflammation in patients with rheumatoid arthritis (RA). We evaluated 29 patients with RA for this reason and found a highly significant correlation between total scintigraphic scores and total tenderness scores (r = 0.781, P < 0.001). A significant correlation was also found between 99mTc-IgG scintigraphic scores and tenderness in all joints other than the shoulders. The 99mTc-IgG scintigraphy had a sensitivity of 69% and specificity of 88% in cases with tenderness and 72% and 81%, respectively, in cases with swelling. Total scintigraphic scores were correlated with serum levels of C-reactive protein (r = 0.401, P < 0.05) but not with erythrocyte sedimentation rate (r = 0.149, P > 0.05). The correlation between disease activity scores and total scintigraphic scores was also found to be significant (r = 0.812, P < 0.001). We suggest that 99mTc-IgG scintigraphy is a reliable and objective method in detecting synovial activity and can be appropriate for observing disease prognosis in clinical trials with RA.

Dobutamine combined with low-level exercise for myocardial perfusion scintigraphy

Increased abdominal background activity is one of the limitations of dobutamine myocardial perfusion scintigraphy which may interfere with interpretation of the images. In this study, we evaluated the value of low-level exercise supplementation to dobutamine infusion in improving image quality. The control group (n = 32, Group A) received dobutamine alone, while the study group received dobutamine plus low-level exercise for the last 2 min of dobutamine administration (n = 26, Group B). One hundred and eleven MBq of 201Tl was injected 1 min before cessation of peak dose. The ratios of cardiac/hepatic (C/HEP), cardiac/subdiaphragmatic (C/INF) and cardiac/pulmonary (C/PUL) were calculated from anterior planar images taken immediately following the test. Cardiac/non-cardiac activity was also visually graded on a three-point scale. Visual evaluation showed improved cardiac/non-cardiac ratios as confirmed by significantly higher C/HEP and C/INF ratios for Group B (1.5+/-0.3 and 1.7+/-0.2, respectively) compared to corresponding values in Group A (1.2+/-0.4 and 1.4+/-0.4, respectively) (P<0.05). The cardiac/pulmonary (C/PUL) ratio was also higher for Group B (2.3+/-0.5) as compared to corresponding value in Group A (2.0+/-0.6, respectively), but this difference did not reach statistical significance (P > 0.05). No difference in the frequency of side effects and ECG changes were detected between the two groups (P > 0.05). Low-level exercise supplementation to dobutamine infusion for myocardial perfusion scintigraphy is a safe method and leads to a significant decrease in uptake by the areas adjacent to the heart, improving image quality.

Comparison of 99mTc-methoxyisobutyl isonitrile and 201T1 scintigraphy in visualization of suppressed thyroid tissue

Both (201)TI and (99m)Tc-methoxyisobutyl isonitrile (MIBI) have been used in the visualization of suppressed thyroid tissue in patients with autonomously functioning thyroid nodules (AFTNs). It has been suggested that thyroid-stimulating hormone (TSH) control is not a major determinant of both tracers. However, the mechanism of thyroid uptake of these agents is controversial. In this study, we compared (201)TI and MIBI in the visualization of suppressed thyroid tissue in patients with a solitary toxic AFTN.

METHODS

Thirty-two patients (13 triiodothyronine [T3] and 19 T3 + levorotatory thyroxine [T4] hyperthyroid patients) with toxic AFTNs visualized on (99m)Tc-pertechnetate scanning were included in the study. All patients underwent MIBI and (201)TI thyroid scintigraphy within a 3-d interval. The scintigrams were analyzed both visually and semiquantitatively. For the semiquantitative analysis, regions of interest (ROIs) were generated over the nodule (N) and contralateral normal lobe (E), and the mean counts in each ROI were calculated.

RESULTS

The N/E uptakes (mean +/- SD) for pertechnetate, MIBI, and (201)TI were 11.37 +/- 4.53, 4.76 +/- 1.38, and 1.63 +/- 0.15, respectively, in T3 + T4 hyperthyroid patients and 9.46 +/- 3.64, 2.73 +/- 0.63, and 1.57 +/- 0.23, respectively, in T3 hyperthyroid patients. Our results showed that (201)TI uptake of suppressed thyroid tissue compared with AFTN was more prominent and significantly higher than that of MIBI for both groups of patients (P = 1.08E-05 for T3 and 6.15E-09 for T3 + T4 hyperthyroidism). There was no significant difference for either pertechnetate or (201)TI (P > 0.05) when the N/E uptakes of both groups of patients were compared. However, the N/E uptake of MIBI in T3 + T4 hyperthyroid patients was significantly higher than that in T3 hyperthyroid patients (P = 6.69E-06).

CONCLUSION

Clear visualization of suppressed thyroid tissue with both (201)TI and MIBI in patients with low serum concentrations of TSH suggests that TSH is not a major factor in the thyroid uptake of either agent. (201)TI is superior to MIBI in the visualization of suppressed thyroid tissue in patients with a toxic thyroid nodule. An increased rate of metabolism in the follicular cells of AFTNs in T3 + T4 hyperthyroid patients compared with that in T3 hyperthyroid patients might be responsible for the higher N/E for MIBI compared with that for (201)TI.

Tc-99m pertechnetate scintigraphy before and after potassium perchlorate administration for the diagnosis of retrosternal goiter

A 52-year-old woman was hospitalized because of dyspnea and dysphagia. Thoracic computed tomography revealed a retrotracheal mass. Tc-99m pertechnetate scintigraphy showed intense accumulation of radioactivity corresponding to the mediastinal mass detected by computed tomography. Repeated Tc-99m pertechnetate scintigraphy performed after oral administration of potassium perchlorate (KCLO4) revealed complete disappearance of the radioactive accumulation in the mediastinum, suggesting that the retrotracheal mass was a retrosternal goiter. Subsequent surgical removal and analysis of the mass showed it was indeed a retrosternal goiter. This case highlights the importance of Tc-99m pertechnetate thyroid scintigraphy with and without KCLO4 administration as a simple, accurate, and cost-effective imaging method to diagnose retrosternal goiter.

Immediate thallium re-injection after stress imaging for the detection of myocardial viability

Myocardial perfusion imaging with thallium is an established method to assess the presence of ischaemic and viable myocardium. Using planar imaging, images acquired 1 h after immediate thallium re-injection have been shown to be comparable to those of 3 h redistribution. The aim of this study was to clarify this using SPET. Twenty patients with chronic coronary artery disease with at least two perfusion defects on post-exercise images participated in this study. All patients received thallium re-injection after post-stress SPET and all had 1 h, 3 h and 24 h redistribution imaging. The thallium myocardial tomograms were divided into 14 segments for each patient. A total of 78 segments were studied. When the frequency of reversibility on 1 h, 3 h and 24 h redistribution images is compared, of the 78 SPET defects 18 (23.1%) showed reversibility by 1 h, 34 (43.6%) by combined 1 h and 3 h imaging (P < 0.05) and 50 (64.1%) by combined 1 h, 3 h and 24 h imaging (P < 0.05). Our results show that, compared to 3 h images, images acquired 1 h after immediate thallium re-injection underestimate the extent of viable myocardial segments and the incidence of late reversibility was not reduced by the immediate re-injection of thallium.

Effect of silicone breast implants on myocardial imaging

The authors investigated the effect of silicone breast implants (SBIs) on thallium-201 myocardial perfusion scintigraphy. Twenty-nine patients with SBIs and 14 control subjects were included in the study. All of the participants underwent a resting thallium-201 myocardial perfusion study. Comparison of the thallium images between patients with SBI and control subjects was done both visually and semiquantitatively. On visual analysis, neither image distortion nor image artifact attributable to the SBIs was noted. Semiquantitative analysis revealed that in patients with SBIs, the uptake values of the anteroseptal, anterolateral, lateroanterior, and lateroinferior myocardial walls was slightly, but significantly, lower than those of control subjects: anteroseptal, 87.7+/-6.0% vs. 92.8+/-5.1%; anterolateral, 88.0+/-5% vs. 92.6+/-4.5%; lateroanterior, 87.4+/-5% vs. 91.4+/-4.7%; and lateroinferior, 86.0+/-6.0% vs. 91.7+/-7.0%. The uptake value of the remaining walls in patients with SBIs were not significantly different than the control subjects. In conclusion, SBIs did cause a significant decrease in uptake values of the myocardial walls, which should be considered during interpretation of the images.

The relation between the degree of gastro-oesophageal reflux and the rate of gastric emptying

In this study, we evaluated the relationship between the degree of gastro-oesophageal reflux and the rate of gastric emptying and determined the variability of gastric emptying in children. The reproducibility of radionuclide imaging for the presence and grading of gastro-oesophageal reflux was also examined. Twenty-eight children less than 2 years of age participated in the study. For assessment of variability, all subjects underwent two scintigraphic studies. For each study, the number of reflux episodes and gastric emptying half-times were recorded. The amount of reflux was graded according to the classification suggested by Blumhagen. Patients with grade 1 reflux were considered low-grade refluxers, while patients with grade 2 or 3 reflux were considered high-grade refluxers. The level of reflux for each patient was based on the highest reflux grade recorded in either study. Of the 28 patients, 19 had reflux in at least one study. Ten patients had high-grade and nine patients low-grade reflux. All patients but one with high-grade reflux had the same grade of reflux in both studies (90%). Of nine patients with low-grade reflux, three had the same grade in both studies. The mean half-time was significantly higher for high-grade than for low-grade refluxers (P < 0.05). For subjects with low-grade reflux, this value did not differ significantly from that of non-refluxers (P > 0.05). Our results show that patients with high-grade gastro-oesophageal reflux had prolonged gastric emptying. The inter- and intra-subject variability of gastric emptying in children appeared to be low. Reproducibility for the presence and grading of gastro-oesophageal reflux by the radionuclide method was good, with the highest value being for the diagnosis of high-grade gastro-oesophageal reflux.

The effect of trimebutine maleate on gastric emptying in patients with non-ulcer dyspepsia

The study was designed to investigate the effect of trimebutine maleate, a drug used in both hyperkinetic and hypokinetic motility disorders, on gastric emptying in patients with non-ulcer dyspepsia having prolonged gastric emptying rates and to compare the parameters used for the determination of the lag period observed during the emptying of solid foods from the stomach. Gastric emptying was measured by the radionuclide technique. Twenty normal volunteers and 43 patients with non-ulcer dyspepsia participated in the study. Radionuclide imaging was performed by using a solid meal labeled with 99mTc-tin colloid. Of the patients with non-ulcer dyspepsia, 20 had prolonged gastric emptying. They were given three weeks of oral treatment with trimebutine maleate and had their radionuclide gastric emptying study repeated. Treatment with trimebutine maleate resulted in reduction in duration of the lag period and less retention of food at 100 minutes (p < 0.0005). After treatment with trimebutine maleate, no significant difference has been observed in the mean symptom score of patients with prolonged gastric emptying. Among the parameters used for the determination of the lag period, lag period determined by a mathematical equation (TLAG) has been found to be longer than the lag period determined by visual inspection of the images (VLAG) and there was correlation between the two parameters when the lag time was short.

Comparison of Tc-99m EC and Tc-99m DTPA captopril scintigraphy to diagnose renal artery stenosis

PURPOSE

Although, captopril scintigraphy is a well established method to detect renovascular hypertension, the optimal radiopharmaceutical for this test remains to be determined. Recently, Tc-99m ethylenedicysteine (Tc-99m EC) appeared as an alternative agent for captopril scintigraphy. The aim of this study was to compare the diagnostic accuracy of Tc-99m EC with Tc-99m DTPA, which is a well-established renal radiopharmaceutical for the captopril test.

METHODS

Nineteen hypertensive patients who had various degrees of renal artery stenosis on angiography were included in the study. All patients had baseline and captopril Tc-99m EC and Tc-99m DTPA scintigraphy within a 1-week period. The results were compared with angiography and in eight patients with changes in blood pressure after revascularization. The images were interpreted without knowledge of the angiography and revascularization data as low, intermediate, or high probability for hemodynamically significant renal artery stenosis, which was defined as an area of stenosis exceeding 50%.

RESULTS

Tc-99m EC and Tc-99m DTPA study results were in agreement in 16 of the 19 patients. In two patients with branch artery stenosis, Tc-99m EC was definitely superior to Tc-99m DTPA and correctly identified the probability of stenosis on scintigraphy. On kidney analysis, Tc-99m EC had a slightly greater diagnostic sensitivity compared with Tc-99m DTPA (79% vs. 68%; P > 0.05 by the chi-squared test) but equal specificity (93% for both agents). Both Tc-99m EC and Tc-99m DTPA showed the same accuracy in predicting the outcome after revascularization in all but one patient with branch artery stenosis, in whom Tc-99m EC accurately predicted a successful outcome of the intervention but Tc-99m DTPA did not. Tc-99m EC had better renal uptake in patients with decreased renal function and provided more dramatic evidence of renogram changes after captopril intervention, which resulted in more confident interpretation.

CONCLUSIONS

There is no significant difference between Tc-99m EC and Tc-99m DTPA captopril scintigraphy for detecting renal artery stenosis. However, because of the better imaging characteristics and more confident interpretation provided by the dramatic changes in the degree of renogram abnormality after captopril intervention, Tc-99m EC captopril scintigraphy should be used, particularly in patients with decreased renal function or branch artery stenosis.