Value of bone SPECT-CT to predict chronic pain relief after percutaneous vertebroplasty in vertebral fractures

BACKGROUND CONTEXT

Longer life span has resulted in increased risk of vertebral osteoporotic fractures. Among minimally invasive procedures, percutaneous vertebroplasty (PV) has shown excellent results in the treatment of chronic vertebral pain. The role of preintervention bone single photon emission computed tomography-computed tomography (SPECT-CT) has not been clearly established for the management of these patients.

PURPOSE

To determine the value of bone SPECT-CT in patient selection, treatment planning, and prediction of response to PV. A comparison with magnetic resonance imaging (MRI) was also aimed.

STUDY DESIGN

Prospective consecutive series.

PATIENT SAMPLE

We studied the performance of bone SPECT-CT on 33 consecutive patients with chronic pain because of vertebral fracture intended for PV.

OUTCOME MEASURES

Improvement of clinical status was based on comparison of preprocedure and postprocedure outcome measurements of pain, mobility, and analgesic use.

METHODS

Bone SPECT was done using a dual-detector variable-angle gamma camera coupled with a two-slice CT scanner (Symbia T2 System; Siemens, Munich, Germany). Magnetic resonance imaging was done using a magnet of 1.5 T (Giroscan System ACS NT Intera; Philips, Amsterdam, The Netherlands).

RESULTS

Of the 33 patients, 24 finally underwent PV. Positive SPECT-CT images predicted clinical improvement in 91% (21 of 23) of them. Agreement between SPECT-CT and MRI was 80% (20 of 25). Single photon emission computed tomography-computed tomography images showed an alternative cause of pain in some cases, such as new fractures or multiple coexisting fractures, persisting bone remodeling in a previous cemented vertebra, and facet or discal degenerative disease. Single photon emission computed tomography-computed tomography was mandatory in eight patients that could no receive MRI, all of whom improved after PV.

CONCLUSIONS

Positive bone SPECT-CT seems a good predictor of postprocedural response. It also adds valuable information as to the cause of back pain and facilitates complete patient evaluation in patients that can not receive MRI.

[PET/CT-guided salvage surgery protocol. Results with ROLL Technique and PET probe]

OBJECTIVE

To assess the value of intraoperatory radioguided probe detection to guide surgical resection of malignant lesions previously detected by (18)F-FDG PET-CT.

MATERIAL

Twelve consecutive patients with suspected tumor recurrence detected by (18)F-FDG PET-CT considered resectable were enrolled in the study. Ultrasound guided fine needle aspiration (FNA) before surgery was performed in 6 patients and CT guided biopsy was performed in 1 patient. In 5 patients with accessible lesions, a radioguided occult lesion localization (ROLL) technique was performed after injection of (99m)Tc-colloid (1.7-2.4 mCi) inside the lesion under ultrasound or CT guidance, pre-operatively. Radioguided surgical detection was then carried out 19-24 hours afterwards using the gamma probe. In 7 patients with non-accessible needle lesions or multiple lesions, 9.5-10.5 mCi of (18)F-FDG were injected 3-5 hours before radioguided surgery using a PET-dedicated probe (Gamma locator DXI-GF&E).

RESULTS

ROLL technique: All lesions injected with nanocolloid were resected (6 lesions in 5 patients, 1 patient with 2 lesions), and recurrence was histologically confirmed. PET probe: Fourteen out of 16 hypermetabolic lesions detected on the PET-CT were resected. One cervical and one mediastinal lymph node in different patients could not be excised. Histological recurrence was confirmed in 12 out of 14 lesions. In one patient, the 2 lymph nodes excised were inflammatory.

CONCLUSIONS

(18)F-FDG PET-CT can be key in deciding surgical approach and appropriate radioguided protocol. When lesions are solitary and easily accessible, ROLL technique seems the method of choice. PET probe is more adequate for less accessible lesions.

Use of axillary ultrasound, ultrasound-fine needle aspiration biopsy and magnetic resonance imaging in the preoperative triage of breast cancer patients considered for sentinel node biopsy

We assessed the diagnostic yield of axillary ultrasound, alone or in combination with fine-needle aspiration axillary biopsy and magnetic resonance imaging in patients with invasive breast carcinoma compared with final axillary histology by sentinel node biopsy or by axillary lymph node dissection. From January 2003 to March 2009, 520 axillary ultrasound examinations and 105 axillary magnetic resonance imaging studies were included. Compared with final axillary histology, ultrasound fine-needle aspiration showed positive predictive value of 87%, negative predictive value of 82%, sensitivity of 53% and specificity of 100%. In cases of negative ultrasound, the rate of positive nodes was 17% (micro-metastases excluded). Ultrasound examination of the axilla, combined with fine-needle aspiration as appropriate must be included in the preoperative work-up of patients considered for sentinel node biopsy to definitively establish such an indication while minimizing the risk of false-negative sentinel node. Axillary magnetic resonance imaging did not improve the preoperative work-up.

[En garde, sentinel node!]

Injection technique and radiocolloid size are two critical parameters that must be carefully selected according to patient presentation and lesion appearance for accurate sentinel node detection in breast cancer. Scintigraphic detection and intraoperative localization are dependent on these parameters. The present clinical case illustrates how much deep intralesional tracer injection bears on our capacity to detect extra-axillary sentinel nodes and how the use of smaller-size radiocolloids may sometimes facilitate sentinel node detection.

Técnica del ganglio centinela en la cirugía del cáncer de mama en un hospital sin servicio de medicina nuclear

INTRODUCTION

Knowledge of lymph node stage is the most important prognostic factor in breast cancer. The sentinel lymph node biopsy technique (SLNBT), initially developed to avoid unnecessary dissection in melanoma, has been shown to be able to predict the axillary stage of breast cancer. The difficulty of applying the SLNBT in hospitals without a nuclear medicine service has led to the existence of external teams that allow these hospitals to apply the technique.

OBJECTIVE

To test the application of the SLNBT in our hospital which has no nuclear medicine service.

PATIENTS AND METHODS

Coinciding with the validation of the SLNBT in the Germans Trias i Pujol Hospital in Badalona in November 1999, and with their help, the Centre Hospitalari de Manresa began to apply this technique. In 2002, the technique was used in all the hospitals of the ALTHAIA-Xarxa Assistencial de Manresa. From November 1999 to June 2005, the technique was applied in 163 patients.

RESULTS

Of the 163 patients, the technical success rate was 97.55%. In 98% of the patients, the sentinel lymph node was found in the axilla. In 10.7% of the patients, the node was found in the internal mammary basin. Twenty-six percent of the axillas had metastases of over 2 mm, and 16% had micrometastases. One hundred and five patients were spared axillary dissection.

CONCLUSIONS

The SLNBT can be performed in a hospital without a nuclear medicine service. This technique improves and simplifies the surgical technique and reduces length of hospital stay and morbidity.

[Evaluation of splenic function by dynamic gammagraphy, study of pitted erythrocytes and submembranous vacuoles in patients with slight and severe splenic trauma receiving conservative treatment or splenectomy]

BACKGROUND AND OBJECTIVE

The splenic function of patients followed by the Department of General and Digestive Surgery in the Hospital Universitari Germans Trias i Pujol (HUGTiP) from 1985 to 2003 for different degrees of splenic trauma according to the classification of the American Association for the Surgery of Trauma (AAST) 1994 was quantified and related to the treatment received (non surgical, total splenectomy with or without splenosis and splenectomy plus autotransplantation) to detect splenic dysfunction predisposing the development of postsplenectomy sepsis (PSS).

PATIENTS AND METHOD

43 patients underwent an isotopic study with dynamic splenic gammagraphy and pitted erythrocytes (Normarsky optics) and submembranous vacuoles (transmission electron microscopy) were evaluated.

RESULTS

The non surgical group presented normal phagocytic and filtration function with the median speed of splenic enhancement being 3.46 Kcts/s2 (interval: 0.8-6.98). The percentage of pitted erythrocytes was 2% (0-8.8), the number of pits per erythrocyte was 0.03 (0-0.12) and the percentage of erythrocytes with 1, 2, 3 and 4 pits was 1.6%, 0.4%, 0% and 0%, respectively. The percentage of red cells with submembranous vacuoles was 2.55% (0-5.6), the number of vacuoles per red cell was 0.03 (0-0.06) and the percentage of red cells with 1, 2, 3 and 4 vacuoles was 2%, 0.2%, 0% and 0%, respectively. In the operated group, the splenic enhancement speed was 0.08 Kcts/s2 (0-1.75) (p < 0.0001). The percentage of pitted erythrocytes was 38% (0.2-64) (p < 0.0001), the number of pits per erythrocyte was 0.86 (0-1.8) (p < 0.0001) and the percentage of erythrocytes with 1,2,3 and 4 pits was 16.39%, 7.2%, 3.59% and 2.52%, respectively (p < 0.0001). The percentage of red cells with submembranous vacuoles was 11.2% (1.8-31.9) (p = 0.0006); the number of vacuoles per cell was 0.16 (p = 0.0022) and the percentage of red cells with 1, 2, 3 and 4 vacuoles was 6.51%, 1.73%, 0.4% and 0.2%, respectively (p = 0.0246, 0.0010, < 0.0001 and 0.0002, respectively).

CONCLUSIONS

Splenic function of patients with a history of splenic trauma receiving conservative treatment is normal, independently of the degree of the lesion, thereby reinforcing the use of this therapeutic approach to avoid the development of postsplenectomy sepsis. In the patients treated with splenectomy, with or without splenosis, splenic function was absent or very altered being partially conserved in cases treated with splenectomy plus autotransplantation.

Is it possible to refine the indication for sentinel node biopsy in high-risk ductal carcinoma in situ?

BACKGROUND

The indication for sentinel node biopsy (SNB) has not been fully established yet for patients with ductal carcinoma in situ (DCIS).

AIM

To relate the conversion rate to invasive carcinoma with sentinel node positivity in high risk DCIS, and to refine the clinical presentation analysis in order to better select patients for SNB. For this purpose, a risk score was devised.

METHODS

From 1998 to 2005, 151 high-risk DCIS patients from six clinical centres were included in a prospective sentinel node database. The conversion rate to invasive carcinoma was 39%. Ten of 142 (7%) successful SNBs showed a positive sentinel node (eight micrometastatic). The sentinel node was positive in 1% of pure DCIS, in 5.5% of DCIS with micro-invasion, and in 19.5% of invasive carcinoma.

RESULTS

Both clinical presentation and corresponding risk score were closely related to conversion to invasive carcinoma. The association of risk score and sentinel node positivity approached but did not reach statistical significance (P=0.06); therefore a subset of further selected higher risk patients could not be defined.

CONCLUSION

The relevance of SNB positivity cannot be overlooked in high-risk DCIS patients, however, because SNB is not free from morbidity and cost, more studies are needed to refine its final indication.

A Comparison of Prediction Equations for Estimating Glomerular Filtration Rate in Adult Patients with Chronic Kidney Disease Stages 4–5

BACKGROUND

The accuracy of prediction equations has not been validated in adult patients with chronic kidney disease (CKD) stages 4-5 in extreme situations of nutritional status and age.

OBJECTIVE AND METHODS

The significance of nutritional status, calculated with the creatinine production (CP) formula, and age (< or =64 years and >64 years) in the application of different prediction equations--modification of diet in renal disease (MDRD), simplified MDRD (sMDRD), Cockcroft-Gault (CG)--and the mean of urea and creatinine clearance (Cr-Ur) compared with the isotopic glomerular filtration rate (GFR) estimation calculated by 51Cr-EDTA was studied in 87 Caucasian adults with CKD stages 4-5 (GFR: 30-8 ml/min/1.73 m2). The Bland-Altman method and Lin's concordance coefficient (Rc) were used to study accuracy (bias) and precision.

RESULTS

The GFR calculated with 51Cr-EDTA in the study group was 22.2 +/- 6.9 ml/min/1.73 m2 (range: 8-30). CG and sMDRD were the best prediction equations with bias of -1.1 and -3.8 ml/min/1.73 m2 and Rc of 0.52-0.50. In this situation, the mean Cr-Ur proved the most inaccurate equation compared with the isotopic technique with bias of -5.4 ml/min/1.73 m2 and Rc of 0.32. In the analysis of patients with higher CP (> 0.90; n = 44), CG and sMDRD obtained the best bias of 1.2 and -2.7 ml/min/1.73 m2 and Rc of 0.54-0.53. In patients aged < or =64 (n = 44), these equations obtained a bias of 1.1 and -3.6 ml/min/1.73 m2 and Rc 0.50-0.49. Both in lower CP (< or =0.90; n = 43) and older age (>64 years; n = 43), all the equations underestimated the value obtained with isotopic GFR. In these situations, the results obtained with CG had a bias of -2.2 and -3.6 ml/min/1.73 m2 (Rc 0.29-0.56) and with sMDRD -4.0 and -4.1 ml/min/1.73 m2 (Rc 0.39-0.51). In these circumstances, Cr-Ur was the most inaccurate equation, obtaining a bias of -10.1 and -13.2 ml/min/1.73 m2 (Rc 0.14-0.16).

CONCLUSIONS

In the group with higher CP and age < or =64 years, results of the presented data yielded no evidence for superiority of the MDRD equation over CG formula in patients with advanced renal failure. On the basis of our results, we do not recommend the use of the Cr-Ur adjusted to 1.73 m(2) of body surface area, which was the most imprecise equation. Application of all the equations proved inaccurate in lower CP patients with or without advanced age, implying the premature start of substitution renal treatment. In these circumstances, ambulatory GFR determination by isotopic techniques would be indicated.

Monitorization of primary therapy (PT) by additional imaging methods in locally advanced breast cancer (LABC)

10580

Introduction: The response of locally advanced breast cancer (LABC) to Primary therapy (PT) may be monitored clinically and by mammography (MG). Magnetic resonance (MR) and 99mTc-sestamibi scintimammography (SMM) are increasingly being used. The aim of this study was to determine whether MG, MR and SMM are accurate indicators of tumour response to PT and whether they are predictors of histological response. Patients and Methods: A prospective observational study was approved at our institution and 52 patients( p) with core biopsy diagnostic of LABC and written consent were enrolled (mean age 52 years, SD 13) All p had clinical, MG, MR, SM assessment pre- and post- PT. Primary chemotherapy based on anthracyclines was administered as follows: 19 p FEC, 17 p AC-Docetaxel, 8 p Gemcitabine- Doxorubicine- Paclitaxel, 1 p FEC- Docetaxel and 1 p Carboplatin- VP16. 6 p were treated with hormone-therapy. RECIST criteria were considered for clinical response assessment and the same criteria was adapted for imaging and pathologic response. Results: After PT 33 tumours were considered not suitable for breast-conserving surgery. Based on histopathological findings, 10 (19%) lesions showed complete pathologic response, 30 (58%) partial response, 12 (23%) stabilization. No progression was detected. Clinical assessment of tumour complete response agreed with pathology in 40 of 52 tumours (78%), and with MG in 39 (78%). Correlation between MG and pathological findings was observed in 42 p (84%). Correlation between MR and pathological findings was observed in 42 p (82%). Correlation between SMM and pathological findings was observed in 31 p (66%). Among patients with complete pathologic remission, 9 of ten patients achieve a complete response by MR and SMM. Conclusion: In conclusion, our results don’t show that MR and SMM add any benefit to the diagnostic arsenal for predicting histopathological complete response to PT. However these new diagnostic methods should be considered in selected cases.

No significant financial relationships to disclose.

Prognostic significance of molecular staging study of sentinel lymph nodes by reverse transcriptase-polymerase chain reaction for tyrosinase in melanoma patients

BACKGROUND

We performed this study to evaluate the clinical effect of microscopic and submicroscopic metastases in sentinel lymph nodes (SLNs) from patients with early-stage melanoma.

METHODS

Patients with confirmed cutaneous melanoma (American Joint Committee on Cancer stages I and II) underwent standard lymphoscintigraphy and SLN biopsy. Serial sections were divided between routine histopathology with hematoxylin and eosin plus immunohistochemistry for HMB-45 and molecular analysis by nested reverse transcriptase-polymerase chain reaction (RT-PCR) assay for tyrosinase (using beta-actin as a control).

RESULTS

Of 180 patients analyzed (318 SLNs), 38 (21%) patients had positive SLN(s) by routine hematoxylin and eosin and immunohistochemistry (microscopic disease; group 1), and 142 (79%) had negative histological results. Analysis by RT-PCR detected tyrosinase in at least 1 SLN from 124 (69%) patients. Among patients with histologically negative SLN(s), tyrosinase was detected in 86 (48%) patients (submicroscopic disease; group 2), whereas 40 (22%) patients had negative results by both histology and RT-PCR (group 3). Sixteen (9%) patients had histologically negative SLNs and ambiguous RT-PCR results (group 4). Among 138 patients in the analysis of recurrence (mean follow-up, 45 months), only 18 patients had a recurrence: 11 (31%) of 35 in group 1, 5 (10%) of 51 in group 2, and 2 (5%) of 37 in group 3. No recurrences were seen in group 4. Only group 1 had a significantly shorter disease-free survival and overall survival compared with the other groups.

CONCLUSIONS

After a long follow-up period, molecular upstaging by tyrosinase RT-PCR failed to detect a subgroup of patients with an increased probability of recurrence.

Single-Institution Experience in the Management of Patients with Clinical Stage I and II Cutaneous Melanoma: Results of Sentinel Lymph Node Biopsy in 240 Cases

BACKGROUND

Lymphatic mapping and sentinel lymph node biopsy (SLNB) has been developed as a minimally invasive technique to determine the pathologic status of regional lymph nodes in patients without clinically palpable disease and incorporated in the latest version of the American Joint Committee on Cancer (AJCC) staging system for cutaneous melanoma.

OBJECTIVE

To analyze the results of SLNB and the prognostic value of the micrometastases and the pattern of early recurrences in patients according to sentinel lymph node (SLN) status.

METHOD

Patients with cutaneous melanoma in stages I and II (AJCC 2002) who underwent lymphatic mapping and SLNB from 1997 to 2003 were included in a prospective database for analysis.

RESULTS

The rate of identification of the SLN was 100%. Micrometastases to SLN were found in 20.8% of patients. The rate of SLN micrometastases increased according to Breslow thickness and clinical stage. Breslow thickness of 0.99 mm was the optimal cutpoint for predicting the SLNB result. Twenty-four patients (12.3%) developed a locoregional or distant recurrence at a median follow-up of 31 months. Recurrences were more frequent in patients with a positive SLN. Among patients who had a recurrence, those with a positive SLN were more likely to have distant metastases than those with negative SLN. Nodal recurrences were more frequent in patients with a negative SLN compared with those with a positive SLN.

CONCLUSIONS

The status of the SLN provides accurate staging for identifying patients who may benefit from further therapy and is the most important prognostic factor of relapse-free survival.

Hepatic vein reconstruction in living donor liver transplantation

INTRODUCTION

Living donor liver transplantation has emerged as a response to the cadaveric graft shortage, especially for adult recipients. Both right and left liver grafts are widely used, although some technical problems remain unresolved. Herein we describe our technique for reconstruction of the venous outflow in living donor liver transplantation.

METHODS

From April 1986 to September 2004, 1012 liver transplantations were performed including 30 living donor liver transplantations between April 1995 and September 2004. We have selected the first 28 cases to ensure a mean follow-up of 21.07 +/- 13.11 months. We transplanted 18 right lobe grafts, 7 left lobe grafts, and 3 left lateral segment grafts. A surgical technique is described herein.

RESULTS

No venous outflow obstruction developed among living donor liver transplantation recipients.

CONCLUSION

We recommend reconstruction of the hepatic veins in living donor liver transplantation including joining together the three hepatic veins in the recipient to avoid venous outflow obstruction.

Liver transplantation and transjugular intrahepatic portosystemic shunt

OBJECTIVE

Describe the results of liver transplantation after installing Transjugular Intrahepatic Portosystemic Shunt (TIPS) and compare them with those of a control group in a comparative, longitudinal, retrospective study.

MATERIALS AND METHODS

Between April 1986 and October 2002, we performed 875 liver transplantations. Between January 1996 and October 2002, 26 transplantations were performed on TIPS carriers. This group was compared with a control cohort of 50 randomly selected patients who underwent transplantation in this period (non-TIPS carriers). Both groups were homogeneous with no significant differences between age, sex United Network for Organ Sharing (UNOS) score, Child stage, or etiology.

RESULTS

Actuarial survival rates at 1 and 3 years: TIPS group 96.15% and 89.29% versus control cohort 87.8% and 81%, respectively. In 73.9%, the TIPS was clearly effective; in 88.9%, a postoperative Doppler revealed normal flow. There were no statistically significant differences compared with time on the waiting list for transplant, duration of the operation, ischemia times, intraoperative consumption of hemoderivates, vascular or nonvascular postoperative complications, duration of stay in the intensive care unit, hospital stay, or retransplantation rate.

CONCLUSIONS

In our experience, TIPS insertion does not affect either the intraoperative or postoperative evolution and is not associated with an increased time on the liver transplant waiting list.

Internal mammary sentinel node metastases in an otherwise lymph-node negative breast cancer patient

A 35 year old woman with biopsy proved breast cancer was submitted for sentinel node (SN) biopsy. Preoperative lymphoscintigraphy displayed both axillary and internal mammary (IM) uptake foci consistent with SNs. Full axillary dissection was completed because of a greater-than 2 cm primary lesion. Two axillary SNs were excised. An IM SN was also excised through the second intercostal space, with the aid of the gamma probe. Fourteen axillary nodes, including SNs, were negative, whereas the IM SN harbored several metastatic implants. Implications for staging, prognosis and further therapy of such IM-only positive sentinel nodes are discussed.

Use of 201Tl SPECT imaging to assess the response to therapy in patients with high grade gliomas

PURPOSE

To assess the potential role of 201Tl single photon emission tomography (201-Thallium SPECT) when compared to other imaging modalities in the evaluation of the response to therapy in high grade gliomas.

MATERIALS AND METHODS

Twenty patients with histologically proved high grade glioma have been included: 15 with glioblastoma (GBM), 3 with anaplastic astrocytoma (AA) and 2 with anaplastic oligoastrocytoma (AOA). Patients were assessed by 201Tl SPECT, computed tomography (CT) and magnetic resonance imaging (MRI) at (a) either at the moment of maximum response to first line chemotherapy, or after the completion of radiotherapy and chemotherapy if post-surgical residual disease was present, and (b) after the completion of second line chemotherapy if disease persisted, or either a relapse or disease progression was confirmed. Final response was evaluated according to the McDonald criteria, and by comparing SPECT, CT and MRI results.

RESULTS

According to the McDonald criteria, clinical response after first line chemotherapy was 5 partial response, 7 stable disease and 8 progressive disease. Evaluation by 201Tl SPECT was in agreement with such criteria in nearly all patients (90%). MRI findings closely agreed with the clinical follow-up. CT findings clearly differed from those observed by SPECT and MRI. After second line therapy, 10 patients progressed, 3 had stable disease and 7 had partial response. 201Tl SPECT agreed with the clinical status in 89% cases, whereas MRI and, specially CT, fared significantly lower.

CONCLUSION

Compared to conventional neuroimaging, 201Tl SPECT added valuable information in the assessment of the response to therapy in our patient population; whenever findings were not conclusive and in the case of disagreement between CT and MRI findings.

Intraoperative assessment of sentinel lymph nodes in patients with breast carcinoma: accuracy of rapid imprint cytology compared with definitive histologic workup

BACKGROUND

As sentinel lymph node biopsy (SNB) becomes a new surgical standard in the treatment of patients with breast carcinoma, there is an emergent need for a fast and accurate method with which to assess the SN intraoperatively, so a decision can be made regarding whether to perform axillary lymph node dissection during primary surgery. In the current study, the authors performed a prospective investigation of the relative merits of imprint cytology for that purpose.

METHODS

Seventy-six patients with T1-T2 breast carcinoma were included after undergoing successful SNB. SNs were freshly sectioned at 2-mm intervals and imprint smears were obtained from all cut surfaces. The smears were examined using a rapid May-Grünwald-Giemsa stain variation, and the SNs were judged to be positive or negative for metastases. SNs later were submitted for paraffin embedding and serial sectioning. Both hematoxylin and eosin stained and cytokeratin (CK) immunostained sections were examined. The postoperative evaluation of the SNs was taken as the gold standard.

RESULTS

Intraoperative cytology showed a sensitivity of 67.7%, a specificity of 100%, an accuracy of 86.8%, and a negative predictive value of 81.8%. The majority of false-negative cases (8 of 10 cases) were due to micrometastasis in the SNs that were discovered only after exhaustive examination with serial sectioning and CK immunostaining.

CONCLUSIONS

The results of the current study demonstrate that the accuracy of imprint cytology is high enough to warrant its use for intraoperative SN assessment. If the findings are negative, axillary lymph node dissection can be omitted. Only a few patients with SN micrometastasis may require reoperation.