Usefulness of [111In-DTPA0] octreotide scintigraphy in a family with von Hippel-Lindau disease

The identification of patients with von Hippel-Lindau (VHL) disease dictates accurate genetic counseling of family members, whereas screening for early detection of visceral and neurological involvement is usually performed by a combination of radiological and nuclear medicine techniques such as ultrasonography or contrast-enhanced computed tomography of the upper abdomen, magnetic resonance imaging of the central nervous system and 131I-metaiodobenzylguanidine-scintigraphy. The role of 111-indium-diethylenetriaminepentaacetic acid [111In-DTPA0] octreotide scintigraphy in this clinical context has never been investigated. Here, we report imaging findings in a VHL patient and in 3 consecutive family members undergoing clinical and radiological screening that included [111In-DTPA0] octreotide scintigraphy in addition to the above-mentioned procedures. Somatostatin receptor expression was investigated in vitro by immunohistochemistry in pancreatic tumor sections. On the basis of in vivo and in vitro findings, octreotide long-acting release treatment followed by 90Y-1,4,7,10-Tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid (DOTA0)-Tyr3-octreotide led to a lack of progression in this patient although this result is a possibility which needs to be proved by further investigation and longer follow-up. The results of this study suggest that [111In-DTPA0] octreotide scintigraphy may be helpful in the routine work-up of VHL patients for diagnostic and therapeutic purposes.

Efficacy of 90Y ibritumomab-tiuxetan treatment in a case of resistant gastric MALT non-Hodgkin's lymphoma

Treatment modalities for resistant/relapsing gastric mucosa associated lymphoid tissue (MALT) non-Hodgkin's lymphoma (NHL) are not yet well standardized. In the past, most patients were treated surgically with a gastrectomy, while, more recently, radiotherapy and systemic approaches (chemotherapy and immunotherapy) have been used with improving results.Here, we report the case of a patient affected by MALT NHL resistant to antibiotics, chemotherapy and immunotherapy, who achieved a durable complete remission after radio-immunotherapy treatment with Zevalin ((90)Y ibritumomab-tiuxetan), administered in a single-standard dose. This observation must be confirmed on a larger series but suggests that radio-immunotherapy may be a valid approach in treating relapsing MALT NHL patients, or those resistant to conventional therapies, so avoiding more aggressive and toxic approaches.

Institutional guidelines and ongoing studies in management of liver tumours: the experience of the European Institute of Oncology

BACKGROUND

An institutional task force on upper gastrointestinal tumours is active at the European Institute of Oncology (EIO). Members decided to collate the institutional guidelines on management of liver tumours (primary and metastatic) into a document. This article is aimed at presenting the current treatment guidelines as well as ongoing research protocols and trials in this field at the EIO.

METHODS

A steering committee convened to assign tasks to individual members. Contributions from experts in each treatment area were collated in a single document, in order to produce a draft for subsequent review from the aforementioned committee. Six drafts have been discussed and the final version approved.

RESULTS

Surgical, medical oncology, interventional radiology, nuclear medicine and radiation therapy approaches, their roles in management of liver tumours and ongoing research trials are presented and discussed in this article.

CONCLUSIONS

At the EIO a multi-disciplinary integrated approach to liver tumours is standard and several ongoing research projects are currently active in this field.

Role of multidetector CT and FDG-PET/CT in the diagnosis of local and distant recurrence of resected rectal cancer

PURPOSE

The aim of this study was to compare the diagnostic value of multidetector computed tomography (MDCT) and F18-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) for the detection of local and distant recurrence in patients operated on for rectal cancer.

MATERIALS AND METHODS

Sixty-seven patients who underwent radical surgery for rectal cancer and were followed up with FDG-PET/CT and MDCT were included in this retrospective study. The FDG-PET/CT and MDCT findings were independently compared with histological sampling or 2 years' follow-up.

RESULTS

Local recurrence occurred in 15/67 patients. MDCT diagnosed local recurrence in 15/15 cases and FDG-PET/CT in 14/15. Sensitivity and specificity were 100% and 98% for MDCT and 93% and 98% for FDG-PET/CT, respectively. Hepatic lesions were found in 17/67 patients. All hepatic metastases were detected by both techniques. Pulmonary metastases occurred in 8/67 patients: they were correctly identified in all cases by MDCT and in 6/8 by FDG-PET/CT.

CONCLUSIONS

MDCT and FDG-PET/CT showed high sensitivity and specificity for the detection of local recurrence of rectal cancer. Both techniques were equally accurate for the detection of hepatic metastases. MDCT showed slightly higher sensitivity and positive predictive value in detecting pulmonary metastases compared with FDG-PET/CT.

Results of annual screening of lung cancer with low dose computed tomography in 5,000 high-risk individuals

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Background: Screening detected lung cancers are correlated with good prognosis however most of the reported cases were detected at baseline screening and little is known about the evolution of pulmonary nodules at annual screening. We report the results of the first and second year of a single centre screening trial focusing the attention on the evolution of pulmonary nodules. Methods: The Cosmos trial started in October 2004 and enrolled 5,202 asymptomatic persons at high risk for lung cancer in one year. Between October 2005 and October 2006, the participants of the study, have been recalled to undergo the annual low dose CT. New lesions were treated according to the baseline diagnostic work up protocol. Previously detected lesions grown at annual screening were investigated with repeated low dose CT and/or Pet scan. Surgical biopsy was scheduled in case of Pet positive or growing nodules. Stable lesions were sent to one year follow up. Results: 4,745 out of 5,202 underwent the annual screening (compliance 92%). Recall rate was 10.7% at baseline and 4% at annual screening. Rate of malignant disease was 1.03% at baseline and 0.7% at annual screening. Patients with stage I disease were 68% at baseline and 76% at annual screening. Of the 32 lung cancers diagnosed at annual screening 8 were new nodules, 1 nodules was stable and 23 nodules progressed from the previous year. Among these, 9 nodules were lower than 5 mm at baseline (out of 2,190 subjects = 0.4%) and 14 were larger than 5 mm (out of 560 subjects =2.5%). Conclusions: Screening low dose spiral CT is an effective tool for the early detection of lung cancer. At first annual screening malignancy rate decreased from 1% to 0.7% and stage distribution was more favourable. However the high rate of delayed diagnosis (2.5%) in cases of nodules larger than 5 mm at baseline CT may require a revision of our proposed diagnostic work up protocol to further anticipate detection of these cases.

No significant financial relationships to disclose.

[18F] FDG uptake: pay attention to candies

[18F]Fluorodeoxyglucose ([18F]FDG) is a positron emission radiotracer whose biodistribution is similar to glucose. The similar biodistribution of [18F]FDG and glucose in the human body requires a fasting condition for at least six hours prior to performing a [18F]FDG positron emission tomography ([18F]FDG PET) study.

In human studies, FDG PET images, in either the fasting state or the glucose-loaded state, have demonstrated that [18F]FDG uptake is decreased in the tumour, and thus the PET image quality is impaired, when plasma glucose levels are increased. All these results suggest that patients should fast before FDG PET studies, and their plasma glucose concentration needs to be considered when assessing tumour glucose metabolism. However, for lymphomatous disease, the data are contradictory and there are reports that insulin does not induce major changes in glucose uptake of lymphomatous tissue.

Here, we report two cases of lymphoma in which [18F]FDG PET/computed tomography ([18F]FDG PET/CT) was used for chemotherapy response evaluation. In both cases, initial [18F]FDG PET/CT scans were negative for neoplastic lesions but showed increased and diffuse FDG uptake in muscles. This led us to investigate better the importance of a fasting condition. A second [18F]FDG PET/CT performed 3–4 days later revealed pathological uptake in the lymphomatous lesions in both cases.

We demonstrate the importance of a euglycemic state before [18F]FDG administration, and that a fasting period of at least six hours is required prior to administration.

A comparative study on the value of FDG-PET and sentinel node biopsy to identify occult axillary metastases

BACKGROUND

Sentinel node biopsy (SNB) has become a standard treatment in staging axillary lymph nodes in early breast cancer. SNB, however, is an invasive procedure and is time-consuming when the sentinel node is analysed intra-operatively. Breast cancer is frequently characterised by increased 2-fluoro-2-deoxy-D-glucose uptake and many studies have shown encouraging results in detecting axillary lymph node metastases. The aim of this study was to compare SNB and -positron emission tomography (-PET) imaging, to assess their values in detecting occult axillary metastases.

PATIENTS AND METHODS

In all, 236 patients with breast cancer and clinically negative axilla were enrolled in the study. 18-FDG-PET was carried out before surgery, using a positron emission tomography (PET)/computed tomography scanner. In all patients, SNB was carried out after identification through lymphoscintigraphy. Patients underwent axillary lymph nodes dissection (ALND) in cases of positive FDG-PET or positive SNB. The results of PET scan were compared with histopathology of SNB and ALND.

RESULTS

In all, 103 out of the 236 patients (44%) had metastases in axillary nodes. Sensitivity of FDG-PET scan for detection of axillary lymph node metastases in this series was low (37%); however, specificity and positive predictive values were acceptable (96% and 88%, respectively).

CONCLUSIONS

The high specificity of PET imaging indicates that patients who have a PET-positive axilla should have an ALND rather than an SNB for axillary staging. In contrast, FDG-PET showed poor sensitivity in the detection of axillary metastases, confirming the need for SNB in cases where PET is negative in the axilla.

Vascular tumor targeting

The growth of solid tumors is dependent on their capacity to acquire blood supply. Therefore, much effort has been directed towards the development of anti-angiogenic agents which inhibit the process of neovascularization. More recently, it has become apparent that the targeted destruction of the established tumor vasculature represents a complementary avenue for growing therapeutic opportunities. This review provides evidence that vascular tumor targeting is an effective anti-tumor strategy in animal models. It further describes strategies for the identification of putative tumor vascular targets and discusses future prospects for vascular targeting applications in the clinical setting.

Systemic and locoregional dosimetry in receptor radionuclide therapy with peptides

This paper reviews the methods for calculating dosimetry both after systemic or locoregional injection of radiolabelled peptides. Radiopharmaceutical characteristics, data processing and dosimetric outcomes are reported. The biological effective dose, based on the linear quadratic model, is finally described.

Role of sentinel lymph node biopsy in oral cancer

Squamous cell carcinoma of the oral cavity represents about 2% of all malignant neoplasms and 47% of those developing in the head and neck area. The tongue is the most common site involved, and this incidence is increasing mainly in young people, possibly related to human papilloma virus infections. Prognosis depends on the stage: the 5-year survival rate of tongue squamous cell carcinoma, whatever the T stage, is 73% in pN0 cases, 40% in patients with positive nodes without extracapsular spread (pNl ECS-), and 29% when nodes are metastatic with extracapsular spread (pNl ECS+: p > or = 0.0001). Nodal micrometastases (cN0 pN1) are found in up to 50% of cN0 tongue squamous cell carcinoma patients operated on the neck. At present, no clinical, imaging staging modalities or biological markers are available to diagnose nodal micrometastases. The sentinel node biopsy has been tested since 1996 in order to find a solution to this problem. The sentinel node is the first node reached by the lymphatic stream, assuming an orderly and sequential drainage from the tumour site, and should be predictive of the nodal stage. According to the literature, sentinel node biopsy is a reliable technique in selected cN0 cases, but the procedure is still experimental and should not be performed outside validation trials. Successful application of sentinel node biopsy in the head and neck region requires surgical experience and specific technical devices, including pre-operative lymphoscintigraphy and intra-operative gamma-probe. Moreover, dynamic lymphoscintigraphy seems to be able to show the lymphatic stream from the primary tumour and could allow a selective neck dissection to be tailored thus reducing the related morbidity.

Low dose spiral computed tomography for early diagnosis of lung cancer. Results of baseline screening in 5,000 high-risk volunteers

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Background: The high lethality of lung cancer is related to the advanced stage at diagnosis. Early studies have demonstrated that screening with CT is effective to diagnose lung cancer at earlier stage but the optimal clinical approach for the management of patients identified with nodules during screening has yet to be defined. We report the first-year results of our CT screening trial. Method: Between October 2004 and October 2005, 5,189 asymptomatic current or former smokers of more than 20 packs/year, older than 50 years, were enrolled in a single-institution screening trial using annual low-dose multidetector CT for 5 years. A protocol for the diagnostic work-up of nodules identified by CT was LD-CT at 1 year for nodules with maximum diameter less than 5 mm, LD-CT at 3 months for lesions between 5.1 and 8 mm and FDG-PET for lesions larger than 8.1 mm. Trans cutaneous biopsy was not routine part of this protocol. End-points were: prevalence and incidence rates of lung cancer, stage distribution, resectability, recall rate and invasive procedure for benign disease. Results: Median age of volunteers was 57 years, 66% were males and 80% current smokers. The prevalence of lung cancer diagnosed at first CT was 1.0% (54 cases; 65% stage I; 9% stage II; 22% stage III and 4% Stage IV). Forty-seven tumors (87%) were radically resected (45 lobectomies, 1 pneumonectomy, 1 atypical segmentectomy). Major surgical morbidity and mortality were 4% and 2% respectively. Recall rate was 10%. Seven patients (1.3% of all recalled subjects) underwent surgical diagnostic procedures for non-malignant disease representing 12% of all screening surgical procedures versus 16% in a non-screening control group treated in the same unit and period. Conclusions: Our results confirmed that screening with low-dose CT allows the detection of early stage lung cancer in a high proportion of cases increasing the probability of cure. Although follow-up is necessary to confirm the efficacy of the proposed work-up protocol, the initial results are promising, with a very low number of invasive procedures performed for benign lesions.

No significant financial relationships to disclose.

High dose 90Yttrium ibritumomab tiuxetan with PBSC support in refractory-resistant NHL patients: Preliminary results of a phase I/II study

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Background: Therapeutic options are limited in the treatment of relapsing NHL pts not suitable to HDCT. 90Yttrium ibritumomab tiuxetan (Zevalin) is active in DLBCL at 0.4 mCi/kg, but duration of response is usually short. We present feasibility and toxicity results of a phase I/II study of HD-Zevalin with PBSC support in resistant-refractory NHL pts. From 04/04 to 11/05, 14 pts were enrolled. Median age was 68ys. 13/14 pts had advanced stage disease (III/IV) at diagnosis. 8 DLBCL, 4 MCL, 1 FL G3, 1 transformed MZL. Median number of prior therapies were 3, including rituximab, RT and HD-CT. Methods: 3 dose levels were fixed: 0.8, 1.2, 1.5 mCi/kg. 4 pts received 0.8, 4 pts 1.2 and 6 pts 1.5 mCi/kg. 1wk prior to Zevalin all pts underwent dosimetry: if no abnormal uptake was observed they received the planned dose. On d13 pts received PBSC previously harvested. On d28 from reinfusion (+41 from Zevalin) engraftment was considered to be delayed if ANC <1.0×109/L or PLT<20.0×109/L. Results: Dosimetry showed acceptable radiation-absorbed doses to uninvolved organs, reaching max 20Gy. Only 1pt received 30Gy to the liver without developing toxicity. The median radiation-activity delivered was 90 mCi (range 57–150): 8 pts received a dose within 80 and 100 and 6 pts >100 mCi. Mean dose to red marrow: 0.8±0.2 mGy/MBq. All pts but 1 engrafted promptly. PLT/ANC count nadirs were observed 21/17 days after Zevalin (median values: 11×109/L and 0.01×109/L). No statistically significant difference in terms of hematological toxicity exists in PLT-recovering for pts receiving 1.5 mCi/kg and it is probably influenced by PLT count at baseline and by the several treatment previously received. Non-haematologic toxicity: 1 febrile neutropenia and 1HZV at 2nd level; 1 febrile neutropenia, 1 G3 liver toxicity, 1 bacterial pneumonia, 1HZV, 1HCV reactivation (pt died 4 months after treatment) at the 3rd level. 13/14pts are evaluable for response: 6CR, 2PR, 5PD. Conclusions: Zevalin at myeloablative activity with PBSC is feasible. It could be safely delivered in elderly and heavily pretreated pts, including those who previously received HDCT. Efficacy and mild toxicities suggest further investigation. We are continuing enrollment, including pts who previously received no more than 2 lines of CT.

No significant financial relationships to disclose.

Sentinel lymph node biopsy in multicentric breast cancer. The experience of the European Institute of Oncology

AIM

To present our experience with sentinel lymph node biopsy (SLNB) performed in patients with multicentric breast cancer.

METHODS

Between May 2001 and May 2004, 42 patients with multicentric breast cancer and a clinically negative axilla underwent lymphatic mapping either by a single subareolar (n = 25) or a double peritumoral/subdermal injection (n = 17) of 99Tc-HSA nanocolloids. The sentinel lymph node (SLN) was evaluated by intraoperative frozen section and axillary dissection was performed only in case of positive SLN.

RESULTS

Mean age was 49 years (range 25-78). Mean number of SLNs identified by lymphoscintigraphy was 1.36 (range 1-5) and mean number of SLNs removed at surgery was 1.55 (range 1-5), with an identification rate of 100%. The mean number of hot spots identified by lymphoscintigraphy was similar in patients who underwent single or double injections (1.36 and 1.35, respectively). In 21 of 42 patients the SLN was positive, and in seven of these 21 patients the SLN was the only positive node. After a median follow-up of 24 months no overt axillary metastases occurred in patients with negative SLN.

CONCLUSIONS

The number of SLNs is not dependent on the number and site of injections. SLNB is our standard procedure for nodal staging in patients with multicentric breast cancer and a clinically negative axilla.

Carcinoid crisis induced by receptor radionuclide therapy with 90Y-DOTATOC in a case of liver metastases from bronchial neuroendocrine tumor (atypical carcinoid)

SS receptors are overexpressed in many tumors, mainly of neuroendocrine origin, thus enabling the treatment with SS analogs. The clinical experience of receptor radionuclide therapy with the new analog [90Y-DOTA0-Tyr3 ]-octreotide [90Y-DOTATOC] has been developed over the last decade and is gaining a pivotal role in the therapeutic workout of these tumors. It is well known that some procedures performed in diagnostic and therapeutic management of endocrine tumors, such as agobiopsy and hepatic chemoembolization, can be associated with the occurrence of symptoms related to the release of vasoactive amines and/or hormonal peptides from tumor cell lysis. This is the first report of a severe carcinoid crisis developed after receptor radionuclide therapy with 90Y-DOTATOC administered in a patient affected by liver metastases from bronchial neuroendocrine tumor (atypical carcinoid). Despite protection with H1 receptor antagonists, octreotide and corticosteroids, few days after the therapy the patient complained of persistent flushing of the face and upper trunk, severe labial and periocular oedema, diarrhoea and loss of appetite. These symptoms increased and required new hospitalisation. The patient received iv infusion of octreotide associated with H1 and H2 receptor antagonists and corticosteroid therapy, which induced symptom remission within few days. The case here reported confirms that radionuclide therapy is highly effective in determining early rupture of metastatic tissue and also suggests that pre-medication should be implemented before the radiopeptide administration associated with a close monitoring of the patient in the following days.

Lymphatic mapping to tailor selective lymphadenectomy in cN0 tongue carcinoma: beyond the sentinel node concept

PURPOSE

Cervical lymph node status is the most important pathological determinant of prognosis and decision making in head and neck squamous cell carcinoma (SCC). The aim of this study was to demonstrate that lymphoscintigraphy (LS) can supply a complete map of the lymphatic drainage before surgery, allowing planning of the type of intervention and serving to guide lymphadenectomy.

METHODS

The study population comprised 14 patients with T2-4 SCCs of the tongue and clinically negative lymph nodes in the neck (cN0) who were scheduled to undergo tumour resection and selective level I-IV neck dissection extended to level V. LS was performed in all patients following the injection of (99m)Tc-colloidal sulphide in three aliquots around the primary lesion. Dynamic, static and tomographic images of the head and neck were acquired. The operative specimens were subjected to lymphoscintigraphic evaluation. Preoperative and postoperative imaging results were compared with the pathological findings. All nodes were examined using haematoxylin-eosin staining.

RESULTS

Preoperative LS was successful in all patients. Preferential pathways of lymphatic drainage were identified: level II of the neck was the most common lymphatic drainage pattern, followed by levels IV and III. Contralateral drainage occurred in 11 patients and in two of them metastatic nodes were found on the contralateral side. Metastases were observed only in radioactive lymph nodes.

CONCLUSION

LS is able to supply a complete map of the lymphatic drainage before surgery, making it possible to tailor selective neck dissection to each individual patient based on the results of preoperative mapping, thereby sparing healthy lymphatic tissue and reducing surgery-related morbidity.

Sentinel lymph node biopsy for localised ductal carcinoma in situ?

Intraductal carcinoma of the breast (DCIS), by definition, cannot give axillary metastases. Axillary dissection is therefore not indicated. The role of the sentinel lymph node (SLN) biopsy in the management of DCIS has not yet been established. A 6-13% risk of SLN involvement is reported in Literature. The aim of the present study is to assess the role of SLN biopsy in patients with pure DCIS and attempt to identify guidelines for routine practice in managing such patients. From March 1996 to December 2003, 508 consecutive patients with pure DCIS of the breast underwent SLN biopsy at the European Institute of Oncology in Milan. Clinical and pathological data were prospectively collected. In all cases of previous surgery or stereotactic biopsy performed elsewhere all pathological slides were reviewed. Cases with microinvasion were excluded from this investigation. Lymphatic mapping was performed using a radiocolloid technique. Most of the patients underwent conservative surgery and removal of the SLN which was sent for conclusive histology. SLN metastases were detected in 9 out of 508 (1.8%) patients. In five patients only micrometastasis (<2 mm) was detected. Eight patients underwent complete axillary dissection. In none of these patients did we find additional positive axillary lymph nodes. In conclusion, due to the low prevalence of metastatic involvement (1.8%), SLNB should not be considered a standard procedure in the treatment of all patients with DCIS. In pure non-comedo DCIS completely excised by radical surgery with free margins of resection SLNB should be avoided since not only it is unnecessary but could also jeopardize a successive re-SLNB in case of invasive recurrence. A very extensive and accurate histological examination of the tumour in DCIS is compulsory to exclude micro-invasive foci and, finally, to decrease the prevalence of unexpected SLN metastases. SLNB should be considered in case of DCIS where there exists a strong doubt of invasion at the definitive histology, such as large solid tumours or diffuse or pluricentric microcalcifications undergoing mastectomy. Moreover, if the trend is statistically confirmed with a wider population, large comedo-DCIS, presenting superior risk of SLNs metastasis, could be scheduled for SLNB. If the SLN is micrometastatic complete axillary dissection is not unavoidable.

Development of axillary surgery in breast cancer

Axillary surgery is a critical part of the treatment of breast carcinoma: its importance is related to the staging of disease, prescription of adjuvant therapy and prognosis. For years, complete axillary dissection has remained the standard approach to breast cancer lymphatic staging; its value is still high, but the development of sentinel-node biopsy has significantly changed the indication of the procedure. We discuss the evolution of axillary surgery in breast cancer.