Use of [18F]fluorodeoxyglucose positron emission tomography in patients with primary malignant brain tumors

In patients with malignant gliomas, [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) may discriminate tumor progression from radionecrosis. We evaluated data from 50 patients undergoing FDG-PET for suspicion of tumor progression. Forty-nine were treated with surgery, 48 with radiotherapy, and 37 with chemotherapy. Twenty-one had intensive radiotherapy with either three daily treatments in two 5-day periods and intravenous carboplatin (17) or interstitial brachytherapy or stereotactic radiotherapy. Twenty underwent surgery after magnetic resonance imaging/FDG-PET; 9 demonstrated increased uptake of FDG and evidence of tumor, whereas 6 had decreased uptake and no evidence of tumor. In 5 patients, there was no correlation (all had intensive radiotherapy). In 17 patients who received bromodeoxyuridine intravenously just before surgery, the bromodeoxyuridine labeling index corresponded to the histological appearance in all but 2 patients (both had received intensive radiotherapy). In 30 patients without surgery, decreased uptake of FDG suggested prolonged survival; increased uptake of FDG did not predict survival. Eight of 10 with intensive radiotherapy had decreased label uptake. We conclude FDG-PET for evaluation of patients with possible recurrent tumors requires more study. In patients with intensive radiotherapy, FDG-PET results cannot be correlated accurately with tumor progression.

Imaging of colorectal carcinoma with technetium-99m radiolabeled Fab' fragments

In this phase III study, patients who had previously undergone surgery for colorectal cancer were studied using a technetium-99m (99mTc)-labeled anti CEA antibody (IMMU-4 [Immunomedics, Morris Plains, NJ] 1mg of protein) to evaluate recurrence. Total-body, planar, and single photon emission computed tomography (SPECT) images were performed within 6 hours of injection. Objectives were to evaluate the efficacy of the 99mTc-labeled anti-CEA antibody, to assess sensitivity and specificity of the agent in known lesions, and to detect occult disease. The impact of antibody study on subsequent surgery was also evaluated. The Fab' fragment has a molecular weight of 54,000 and is supplied as a lyophilized kit that can be instantaneously labeled with 20 to 30 mCi of [99mTc]pertechnetate. In 9 patients with known disease, planar spot imaging identified lesions in 7 (78% sensitivity), SPECT imaging detected lesions in 8 (88% sensitivity), and 1 patient did not have SPECT. In the group of 10 patients with occult (or equivocal) disease, planar imaging sensitivity was 50%, and SPECT sensitivity was 100%. Analysis by site showed 14 of 24 lesions detected by planar imaging (58% sensitivity), and SPECT detected 24 of 24 lesions (100% sensitivity). Tumors as small as .5 cm were visualized in the 19 patients studied. The surgeon judged the antibody study to be impact neutral in 73% of the cases and helpful in 27% of the cases when antibody study altered the presurgical plan.

Evolutionary divergence of pobA, the structural gene encoding p-hydroxybenzoate hydroxylase in an Acinetobacter calcoaceticus strain well-suited for genetic analysis

The pobA gene encoding p-hydroxybenzoate hydroxylase (PobA) from Acinetobacter calcoaceticus has been developed as a genetic tool for the analysis of structure-function relationships in this enzyme. By exploiting the favorable genetic system of A. calcoaceticus strain ADP1, it is possible both to select and to map mutations which disturb PobA activity; characterization and sequence determination of mutants derived in this manner may complement site-directed studies with the homologous Pseudomonas aeruginosa gene. We have determined the nucleotide (nt) sequence of A. calcoaceticus pobA and performed a systematic comparison of the deduced amino acid (aa) sequence with that of the PobA enzyme from Pseudomonas fluorescens, for which the three-dimensional structure is known. Despite a 26% difference in the G+C content of the homologous genes, constraints against structural divergence of the proteins were revealed by an overall identity of 62.4% in the aligned aa sequences of PobA. Clusters of identical sequence occur at previously identified sites of ligand binding and at regions associated with subunit-subunit interaction. Based on the conservation of specific residues involved in flavin binding, we have assembled a consensus sequence for nicotinamide-flavoprotein monooxygenases which differs from that of the oxidoreductase class of flavoproteins. In addition to the conserved regions shared by the two PobA homologs, there are isolated pockets of divergence. The nt sequence divergence in one such region within the A. calcoaceticus gene can be attributed to the acquisition of short nt sequence repetitions.

Synthesis of [18F]fluoroalanine and [18F]fluorotamoxifen for imaging breast tumors

To develop ligands for imaging breast tumors, [18F]fluoro analogue of tamoxifen and [18F]fluoroalanine were radiosynthesized. In vivo biodistribution studies were performed in mammary tumor-bearing rats. In studies on the biodistribution of an [18F]fluoro analogue of tamoxifen, tumor uptake decreased when rats were pretreated with diethylstilbestrol (DES), suggesting that tracer uptake in tumors was receptor-mediated. An estrogen receptor assay indicated that tumors have a receptor density of 7.5 fmol/mg protein. Studies of the distribution of [18F]fluoroalanine in tissue showed that the tumor-to-tissue ratio increases as a function of time. Positron emission tomography (PET) images of tumor-bearing rats demonstrated that tumors can be visualized 1 h after rats are injected with an [18F]fluoro analogue of tamoxifen. PET imaging of pigs after injection of 10 mCi of [18F]fluoro analogue of tamoxifen showed uterine uptake that could be blocked by DES (50 mg). The findings suggest that both radiotracers are useful for imaging breast tumors.

Refinement of the crystal structure of ribonuclease S. Comparison with and between the various ribonuclease A structures

Ribonuclease S (RNase-S) is a complex that consists of two proteolytic fragments of bovine pancreatic ribonuclease A (RNase-A): the S-peptide (residues 1-20) and S-protein (residues 21-124). We have refined the crystal structures of three RNase-S complexes. The first two contain the full-length 20-residue S-peptide and were studied at pHs of 4.75 and 5.5. The third one consists of a truncated form of S-peptide (residues 1-15) and was studied at pH 4.75 as the reference structure for a series of mutant peptide complexes to be reported separately. Excluding residues 16-23 which are either missing (in the S15 complex) or disordered (in both S20 complexes), all three structures refined at 1.6-A resolution are identical within the estimated errors in the coordinates (0.048 A for the backbone atoms). The R-values, residual error, range from 17.4% to 18.6%. The final model of S20, pH 4.75, includes 1 sulfate and 84 water molecules. The side chains of 11 residues were modeled in two discrete conformations. The final structures were independent of the particular RNase-A or RNase-S used as a starting model. An extensive comparison with refined crystal structures of RNase-A reveals that the core of the molecule which is held together with extensive hydrogen bonds is in identical pattern in all cases. However, the loop regions vary from one structure to another and are often characterized by high B-factors. The pattern of thermal parameters appears to be dependent on crystal packing and correlates well with the accessibility calculated in the crystal. Gln60 is a conserved residue in all sequences known to date for this class of ribonucleases. However, it is the only residue that is clearly defined in an unfavorable position (phi = -100 degrees, psi = -130 degrees) on the Ramachandran plot. The origin of the substantial differences between RNase-A and RNase-S in stability to both acid and temperature denaturation and in susceptibility to proteolysis at neutral pH is not obvious in our visual comparison of these two structures.

Multiple myeloma: spinal MR imaging in patients with untreated newly diagnosed disease

Spinal magnetic resonance (MR) imaging was performed in 29 patients with newly diagnosed, untreated multiple myeloma. Nineteen (66%) patients were asymptomatic. Sagittal pre- and postcontrast T1-weighted spin-echo images and gradient-recalled-echo images of the thoracic and lumbosacral spine were obtained. Marrow involvement was identified in 20 (69%) patients. There were three MR patterns: focal lesions in nine patients (31%), diffuse involvement in seven (24%), and an inhomogeneous pattern of tiny lesions on a background of normal marrow in four (14%). A statistically significant correlation between MR imaging patterns of marrow involvement and serum hemoglobin values (one-way, P = .0899; Kruskal-Wallis, P = .0620) and between MR imaging patterns and percentage of marrow plasmacytosis (Kruskal-Wallis, P = .0314) was noted, with patterns of diffuse and focal marrow involvement associated with more abnormal values. Spinal MR imaging in patients with early myeloma may reveal marrow involvement in both symptomatic and asymptomatic patients. Some correlation was found between MR imaging patterns and laboratory indexes of disease.

Evaluation of sensitivity and specificity of upper extremity radionuclide venography in cancer patients with indwelling central venous catheters

Two hundred twenty upper extremity radionuclide venograms were performed using upper extremity injection of 5 mCi of Tc-99m DTPA in each arm of patients with indwelling central lines. Evidence of obstruction was found in 123 patients, collateral flow without anatomic obstruction in six patients, and a slow-flow pattern in 12 patients. Twenty-six of these also underwent upper extremity contrast venography within 48 hours of the scan. Contrast venograms and radionuclide venograms agreed in 19 patients (16 correctly identified as obstructed, three correctly identified as unobstructed). Six patients showed the slow-flow pattern without collaterals or obstruction. Subsequently, six follow-up contrast studies showed no evidence of obstruction or collaterals. The authors conclude that obstruction with collateral flow on radionuclide venograms correctly predicts obstruction. However, the slow-flow pattern does not and should not be used as the sole criterion to diagnose partial obstruction.

SPECT in the evaluation of cancer patients: not quo vadis; rather, ibi fere summus

In the past 7 years, single photon emission computed tomography (SPECT) has evolved from an interesting nuclear medicine technique rarely performed because of technical difficulties into a valuable clinical tool in the management of cancer cases. The development of stable multidetector instruments with collimators and gantries specifically designed for SPECT and the introduction of new radiopharmaceuticals recently approved by the U.S. Food and Drug Administration have rapidly moved SPECT from the field of clinical investigation to clinical practice. SPECT is a valuable addition to other tomographic modalities capable of displaying the physiology of disease as well as anatomy. In this work the authors describe the role of SPECT in a cancer center and, in particular, how they use it to solve clinical problems. They also review the published literature, when appropriate. The authors have found SPECT of particular value in evaluation of myocardial ischemia, in differentiating tumor recurrence from posttherapy changes in the lymphomas, in tumor diagnosis and surveillance, and in separating hemangioma from malignant lesions in the liver.

MR imaging of extracranial nerve sheath tumors

We retrospectively reviewed MR images of 32 histologically proven extracranial nerve sheath tumors (NSTs). There were 23 benign (10 neurofibromas, 13 schwannomas) and 9 malignant NSTs. On T1-weighted images (T1WIs) tumors were isointense or slightly hyperintense to muscle. On T2-weighted images (T2WIs) (11 lesions) and enhanced T1WIs (1 intraspinal lesion), a target pattern with peripheral hyperintense rim and central low intensity was seen in 12 of 23 (52%) benign NSTs (5 of 10 neurofibromas and 7 of 13 schwannomas). This pattern corresponded histologically to peripheral myxomatous tissue and central fibrocollagenous tissue. The pattern was absent in lesions with cystic, hemorrhagic, or necrotic degeneration. These tumors were hyperintense and variably inhomogenous on T2WIs. Malignant NSTs were hyperintense and variably inhomogenous on T2WIs and mimicked benign variably inhomogeneous lesions unless involvement of contiguous structures was visualized. A target pattern was not visible in malignant lesions. Magnetic resonance imaging cannot distinguish schwannomas from neurofibromas, and benign tumors may mimic malignant NSTs when cystic, hemorrhagic, and necrotic degeneration is present. A target pattern may be visualized in some benign NSTs, and evaluation of this sign with assessment of location and growth along nerves may help to avoid confusion with other lesions.

Differentiation of residual or recurrent tumors from post-treatment changes with F-18 FDG PET

Positron emission tomography (PET) with fluorine-18 fluorodeoxyglucose (FDG) was used to differentiate recurrent or residual malignant disease from the effects of cancer treatment. Transaxial images were obtained after injection of 5-10 mCi (185-370 MBq) of F-18 FDG in 68 patients (including 33 with brain tumors) whose posttreatment computed tomographic (CT) or magnetic resonance (MR) imaging findings had been suggestive of malignant disease. PET findings were correlated with surgical results in 18 patients and with the outcomes of CT, MR imaging, clinical, and laboratory 9-month follow-up studies in 50 patients. There was good agreement between F-18 FDG uptake and presence or absence of malignant disease except in four cases of brain tumors in which histologic findings could not be correlated with biologic behavior. The putative sensitivity and specificity in the 33 cases of brain tumors were 80% and 94%, respectively. The authors conclude that PET with F-18 FDG is useful in detection of previously treated metabolically active tumors but is limited in diagnosis of recurrent microscopic or metabolically inactive tumors.

Mutation of a single amino acid converts germ cell alkaline phosphatase to placental alkaline phosphatase

Human placental and germ cell alkaline phosphatases (PLAP and GCAP, respectively), are characterized by their differential sensitivities to inhibition by L-leucine, EDTA, and heat. Yet, they differ by only 7 amino acids at positions 15, 67, 68, 84, 241, 254, and 429 within their respective 484 residues. To determine the structural basis and the amino acid(s) involved in these physicochemical differences, we constructed three GCAP mutants by site-directed mutagenesis and six GCAP/PLAP chimeras and then expressed these alkaline phosphatase mutants in COS-1 cells. We report that the differential reactivity of PLAP and GCAP depends critically on a single amino acid at position 429. GCAP with Gly-429 is strongly inhibited by L-leucine, EDTA, and heat, whereas PLAP with Glu-429 is resistant. By substituting Gly-429 of GCAP with a series of amino acids, we demonstrate that the relative sensitivities of these mutants to L-leucine, EDTA, and heat inhibition are, in general, parallel. Mutants in the order of resistance to these treatments are: Glu (most resistant), Asp/Ile/Leu, Gln/Val/Lys, Ser/His, and Arg/Thr/Met/Cys/Phe/Trp/Tyr/Pro/Asn/Ala/Gly (least resistant). However, the Ser-429 and His-429 mutants were more resistant to EDTA and heat inhibition than the wild-type GCAP, but were equally sensitive to L-leucine inhibition. Structural analysis of mammalian alkaline phosphatase modeled on the refined crystal structure of Escherichia coli alkaline phosphatase indicates that the negative charge of Glu-429 of PLAP, which simultaneously stabilizes the protein as a whole and the metal binding specifically, probably acts through interactions with the metal ligand His-320 (His-331 in E. coli alkaline phosphatase). Replacement of codon 429 with Gly in GCAP leads to destabilization and loosening of the metal binding. The data suggest that the natural binding site for L-leucine may be near position 429, with the amino and carboxyl groups of L-leucine interacting with bound phosphate and His-432 (His-412 in E. coli alkaline phosphatase), respectively.

Soft-tissue sarcoma: MR imaging vs sonography for detection of local recurrence after surgery

To determine the value of MR and sonography in detecting local recurrences of soft-tissue sarcomas after surgery, 26 MR and sonographic studies performed in 21 patients were reviewed retrospectively. Recurrences were confirmed histologically in 12 (46%) of 26 studies. The MR images and sonograms were obtained within 1 month of each other. The findings were classified as recurrence, no recurrence, or indeterminate. Sonography was instrumental in guiding fine-needle aspiration biopsy of impalpable lesions. In two cases, the findings on sonography were indeterminate. In both of these cases, the sonograms had been obtained soon after surgery (at 2 and 4 months). The sensitivity and specificity in the detection of local recurrences were 83% and 93%, respectively, for MR and 100% and 79%, respectively, for sonography. These differences were not statistically significant. We conclude that MR and sonography appear to be equally useful in the detection of local recurrences of soft-tissue sarcomas, sonography can be used for routine follow-up and in guiding needle biopsies, sonography may be more difficult to interpret than MR during the early postoperative period, and MR should be used if sonography is inconclusive.

Case report 682. Neuroepithelioma of soft tissues of the knee

Peripheral neuroepitheliomas should be included in the differential diagnosis of a soft-tissue tumor in the extremities or chest wall, especially in young adolescents. MRI provides useful information as to the extent of the tumor and relationship with adjacent structures, although it may not differentiate neuroepitheliomas from other, more common, soft-tissue sarcomas. Together with clinical and histological findings, MRI can assist in the diagnosis and treatment planning of this tumor.

MR appearance of the distended iliopsoas bursa

The purpose of this essay is to illustrate the MR appearance of the distended iliopsoas bursa. The bursa must be recognized on MR scans to avoid confusing it with malignant neoplasms and other lesions.

Reaction mechanism of alkaline phosphatase based on crystal structures. Two-metal ion catalysis

Alkaline phosphatase (AP) is a widely distributed non-specific phosphomonoesterase that functions through formation of a covalent phosphoseryl intermediate (E-P). The enzyme also catalyzes phosphoryl transfer reaction to various alcohols. Escherichia coli AP is a homodimer with 449 residues per monomer. It is a metalloenzyme with two Zn2+ and one Mg2+ at each active site. The crystal structure of native E. coli AP complexed with inorganic phosphate (Pi), which is a strong competitive inhibitor as well as a substrate for the reverse reaction, has been refined at 2.0 A resolution. Some parts of the molecular have been retraced, starting from the previous 2.8 A study. The active site has been modified substantially and is described in this paper. The changes in the active site region suggest the need to reinterpret earlier spectral data, and suggestions are made. Also presented are the structures of the Cd-substituted enzyme complexed with inorganic phosphate at 2.5 A resolution, and the phosphate-free native enzyme at 2.8 A resolution. At pH 7.5, where the X-ray data were collected, the Cd-substituted enzyme is predominantly the covalent phosphoenzyme (E-P) while the native Zn/Mg enzyme exists in predominantly noncovalent (E.P) form. Implication of these results for the catalytic mechanism of the enzyme is discussed. APs from other sources are believed to function in a similar manner.

Acute spinal cord injury: magnetic resonance imaging correlated with myelopathy

Thirty-one patients (29 males and two females, 13-87 years of age (mean, 46.7 years] with acute spinal cord injury were studied by MR (magnetic resonance) imaging and the results were correlated with neurological findings. Magnetic resonance images were obtained with a 0.5 T superconductive MR scanner (Phillips Gyroscan S5). Initial imaging was performed within 24 hours after trauma in 13 patients, 1-7 days in 13 patients and 7-14 days in five patients. Twenty-six patients underwent follow-up examinations with MR imaging. Cord abnormalities including cord compression (23 patients), cord swelling (seven patients), and abnormal signal intensities on either T1 or T2-weighted images (26 patients) were observed on initial examination. Multivariate analysis showed that cord compression and abnormal intensities on T1-weighted images were important prognostic indicators. Hyperintensity on T2-weighted images was non-specific but correlated well with clinical recovery. Magnetic resonance imaging is useful in predicting the prognosis and for planning treatment following spinal cord injuries.

Synthesis and in vitro receptor binding studies of fluorotamoxifen analogues

We describe the synthesis of new fluorotamoxifen analogues with the fluorine atom positioned on the end of the aliphatic chain of tamoxifen. The binding of fluorotamoxifens to cytosol estrogen receptors of rat uteri was determined with [3H]estradiol (5 nM). The fluorotamoxifens had similar or superior binding affinities compared with tamoxifen. The IC50 value was as follows: tamoxifen, 5 x 10(-7) M; fluorotamoxifen (VII), 5 x 10(-7) M; N,N-diethylfluorotamoxifen (IV)-cis, 1 x 10(-6) M, and trans, 2 x 10(-7) M; and (cis) fluoromethyl-N,N-diethyltamoxifen (VI) 1 x 10(-7) M. Therefore, the fluorinated tamoxifens have potential use in imaging estrogen receptors by PET.

Bacillus subtilis alkaline phosphatases III and IV. Cloning, sequencing, and comparisons of deduced amino acid sequence with Escherichia coli alkaline phosphatase three-dimensional structure

Bacillus subtilis has an alkaline phosphatase multigene family. Two members of this gene family, phoAIII and phoAIV, were cloned, taking advantage of in vitro constructed strains containing a plasmid insertion within one or the other of the structural genes. The DNA sequences of the two genes showed approximately 64% identity at the DNA level and 63% identity in the deduced primary amino acid sequences. The phoAIII and phoAIV genes code for predicted proteins of 47,149 and 45,935 Da, respectively. Comparison of the deduced primary amino acid sequence of the mature proteins with other sequenced alkaline phosphatases from Escherichia coli, yeast, and humans shows 25-30% identity. Based on the refined crystal structure of E. coli alkaline phosphatase, it appears that the active site and the core of the structure are retained in both Bacillus alkaline phosphatases. However, both proteins are truncated at the amino terminus compared with other mature alkaline phosphatases, three sizable surface loops of E. coli are deleted, and a minidomain is replaced with a larger domain in the model. Neither Bacillus alkaline phosphatase sequenced contains any cysteine residues, an amino acid implicated in intrachain disulfide bond formation in other alkaline phosphatases.

Reusable gels for germanium-68 sources

Two water-soluble gels, gelatin and Carbowax, were mixed with radioactive 68Ge solutions and evaluated for their use as long-lived (half-life, 280 days) radioactive sources. These gels melt at 40-50 degrees C and solidify at room temperature. The amount of 68Ge mixed with them can be increased or decreased as needed, eliminating waste of 68Ge. These gel sources also may replace short-lived 68Ga (half-life 68 min) as attenuation correction sources in positron emission tomography (PET) and reduce frequency of source preparation, thus reducing exposure of PET operators to radiation.

Quality assurance in a nuclear medicine department

This article reviews the general principles of quality assurance (QA) in an imaging department, with emphasis on nuclear medicine. The various steps taken during the development of the QA program reflect the response of the QA committee as it came to a better understanding of the components of QA. Accrediting and regulatory bodies have had important roles in providing guidance. Quality control of instrumentation and radiopharmaceuticals opened the gateway to monitoring in high-volume, high-risk areas; however, QA expanded this concept into better generic and clinical monitoring. Encouragement of the use of quality of care referral forms resulted in greater participation by all members of the department. Examples of physicians' QA activities include double reading of images and sending of code cards. Experience with other forms of physician QA activities is also included. The QA committee provides a forum for five steps of QA: identify problems, assess the causes, implement action to prevent them, monitor effects of the actions, and document these activities. These steps should lead to improvement in the standards of patient care.

Mandibular chloroma demonstrated by magnetic resonance imaging

A case of chloroma or granulocytic sarcoma in the mandible of a young child is presented with magnetic resonance imaging (MRI) features.