Is there any improvement in clinical staging with 18F-FDG PET/CT compared to surgical staging in cases of lung cancer?

OBJECTIVE

¹⁸F-Fluorine fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) imaging is considered the standard imaging modality for patients with non-small cell lung carcinoma. The aim of this study was to compare clinical staging (cTNM) performed with ¹⁸F-FDG PET/CT and surgical staging (sTNM) in patients with non-small cell carcinoma treated with surgery.

MATERIAL AND METHODS

We performed a retrospective analysis of 99 surgical patients with non-small cell carcinoma who underwent ¹⁸F-FDG PET/CT examination. Semiquantitative measures were calculated from the primary lesions and mediastinal lymph nodes. Findings of cTNM were compared with final surgical-pathological evaluation. Subjects were divided into two groups as postsurgical cTNM changed and cTNM unchanged. Patients in the cTNM changed group were further classified as postsurgical upstaged (US) and downstaged (DS). Results of the US patients were compared with the results of the remaining patients consisting of cTNM unchanged and DS to evaluate the predictable roles of semiquantitative parameters for postsurgical upstaging. To determine mediastinal tumoral involvement, cut-off values were obtained from calculated semiquantitative results of FDG uptakes in lymph nodes. A p value<0.05 was considered statistically significant.

RESULTS

Subjects were aged 40-82 years with a mean age of 64.78±8.70 years. Classification agreement was observed in 43 patients (43%) and in 57%, postsurgical stage migration was seen. Concurrence of cTNM and sTNM was more pronounced in the T1 and N0 subsets which were 84% and 74%, respectively. The lowest concurrence was observed in N1 classification followed by T4 and N2 (1%, 50% and 58%, respectively). Change in T staging occurred in 20 of 56 (36%), in N staging 22 of 56 (39%) and change in T and N in 14 patients (25%). Distribution of US and DS patients in the cTNM changed group was 43% (24 of 56) and 57% (32 of 56), respectively. Results of semiquantitative measures were significantly higher in US patients than the results of the group consisting of DS patients and cTNM unchanged patients, for all parameters. Cut-off value calculated from mediastinal uptakes was most specific for metastases in MTV (metabolic tumor volume) with an acceptable sensitivity (90% and 67%, respectively).

CONCLUSIONS

The concordance between cTNM and sTNM was better in staging T category compared to N stations. Semiquantitative measures of primary tumor may play a role in predicting postsurgical upstaging. Taking MTV into consideration in the mediastinal region may be more valuable than other parameters in the assessment of nodal involvement.

Relationship between primary tumour 18F-FDG uptake and immunohistochemical and clinical prognostic parameters in breast carcinoma

OBJECTIVE

The objective of this study was to investigate the relationship between level of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) accumulation in primary breast tumour assessed by positron emission tomography/computed tomography (PET/CT) and histopathological and clinical prognostic factors.

MATERIAL AND METHODS

A retrospective analysis was performed using the medical records of 58 female patients (age range: 31-86 years, mean age: 56) with biopsy of proven breast carcinoma, and who had undergone ¹⁸F-FDG PET/CT examination before chemotherapy/surgery. The ¹⁸F-FDG uptake of breast tumours was calculated as tumour to background ratio (TBR), which was compared with histopathological and clinical prognostic parameters.

RESULTS

The histology of the breast tumour in the 58 patients was ductal type in 52 (90%), lobular in 4 (7%), and mucinous in 2 (3%). Tumour size was ≤ 2cm in 31 (53%) patients, and>2cm in 27 (47%). The levels of TBRs were not significantly different between the patients groups with tumours of 2cm or less and greater than 2cm (P=0.131). No significant difference between levels of TBR was observed neither with regards to axillary lymph node involvement (P=0.065) nor in terms of distant metastases (p=0.123). No statistically significant difference was found in levels of TBRs between patients with c-erbB-2 receptor positive and negative ones (P=0.107). Progesterone receptor (PR) expression was observed in 33 patients (57%), and 25 patients (43%) were PR negative. As regards progesterone receptor status, a statistically significant difference was observed in mean TBR levels between patients with and without progesterone receptor expression (P=0.020). Oestrogen receptor expression was positive in 41 (71%) patients, and negative in 17 (29%) patients. The difference in the levels of TBRs between patients with and without oestrogen receptor expression was at the level of significancy (P=0.050).

CONCLUSIONS

It is concluded that ¹⁸F-FDG uptake correlates with progesterone negativity of the tumour. However, a significant association with clinical prognostic parameters and level of ¹⁸F-FDG uptake levels could not be demonstrated.

A case of hypercalcaemic crisis secondary to coexistence of primary hyperparathyroidism and Graves' disease

A 46 year-old female patient presented to the hospital with ongoing and progressively increasing fatigue, severe nausea and vomiting, loss of appetite, constipation, palpitations and somnolence. Laboratory evaluation revealed a severe hypercalcaemia and overt hyperthyroidism. She was diagnosed with primary hyperparathyroidism accompanied by Graves' disease. The patient underwent total thyroidectomy and right inferior parathyroid gland adenoma excision on the 24th day of her admission to the hospital after calcium levels and free thyroid hormone levels were brought to normal ranges. We suggest that a possibility of simultaneous thyrotoxicosis and primary hyperparathyroidism in cases presenting with a hypercalcaemic crisis should be considered.

Incidental pheochromocytoma in a patient with nasopharyngeal carcinoma

Because the adrenal glands are common locations for metastases, pheochromocytoma is frequently misdiagnosed as adrenal metastasis in patients with a history of cancer. An incidental adrenal mass was detected during an abdominal computed tomography (CT) scan performed to stage the nasopharyngeal carcinoma in a 35-year-old male patient. The features of an adrenal mass on the CT, magnetic resonance imaging (MRI), and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) were thought to show adrenal metastasis. However, the patient did not complain about flushing, palpitation, headache or excessive sweating. His blood pressure was 132/74 mmHg, and his pulse rate was 82 bpm. A pheochromocytoma was found during a biochemical diagnosis that evaluated the catecholamine in urine collected over a 24-hour period. The urine had elevated urinary adrenaline, metanephrine, and vanillylmandelic. An I123 MIBG scan showed avid tracer uptake in the right adrenal mass with no evidence of abnormal uptake elsewhere. A right adrenalectomy operation was performed and a diagnosis of pheochromocytoma was confirmed histopathologically. Incidental adrenal masses detected in the presence history of cancer should always be subjected to hormonal evaluation. Although patients may be asymptomatic, the probability of incidental pheochromocytoma should not be ignored.

The value of FDG-PET/CT in the post-treatment evaluation of endometrial carcinoma: a comparison of PET/CT findings with conventional imaging and CA 125 as a tumour marker

OBJECTIVES

This retrospective study was designed to assess the value of positron emission tomography/computed tomography imaging (PET/CT) in the post-treatment evaluation of the patients with endometrial carcinoma and to compare PET/CT scan with conventional imaging (CI) including computed tomography (CT), ultrasonography (US) and magnetic resonance imaging (MRI) and CA 125 with both 20U/ml and 35U/ml cut-off values.

MATERIALS AND METHODS

A total of 31 patients who were treated for histopathologically proven endometrial adenocarcinoma, underwent PET/CT examination for restaging and suspected recurrence. Thirty five PET/CT studies were performed in 31 patients. Lesion status was determined on the basis of clinical follow-up including radiological imaging (follow-up CT scan) at least 6 months and response to therapy.

RESULTS

Of the 35 PET/CT studies, 13 (37%) studies were positive, whereas 22 (63%) of them were negative. On study-based analysis the overall sensitivity, specificity, accuracy for PET/CT imaging were 100%, 96% and 97%, respectively. The corresponding information for CI were 46%, 87% and 74%, for CA 125 (cut off=20U/ml) measurement were 45%, 88% and 74%, and for CA 125 (cut off=35U/ml) measurement were 27%, 100% and 78%, respectively. On lesion-based analysis, PET/CT revealed only one false positive case. In none of 21 patients with negative 22 PET/CT studies, no subsequent clinical or radiological recurrences were observed with a follow-up of at least 6 months.

CONCLUSION

FDG-PET/CT is found more useful modality than CI and CA 125 in the evaluation of post-treatment endometrial carcinoma patients, for suspected recurrence.

Splenic and multiple abdominal metastases of endometrial carcinoma detected with FDG-PET/CT

A 58 year old female was referred for FDG-PET/CT for restaging of endometrial adenocarcinoma. For evaluation of treatment, no metastases were detected on FDG-PET/CT which was performed 18 months later after the surgery. During follow-up, FDG-PET/CT was performed 6 months later than the previous FDG-PET/CT for restaging. A lesion with increased metabolic activity (SUV max: 10.21) was detected at spleen which was not seen on previous FDG-PET/CT scan. The lesion was consistent with metastasis of endometrial carcinoma. Splenic metastasis of endometrial carcinoma is extremely rare. There are only 13 cases of splenic metastasis from endometrial carcinoma that reported in the literature before. There is only one splenic metastasis of endometrial carcinoma case reported in the literature which is imaged with FDG-PET. To best of our knowledge this is the first report of solitary splenic metastasis of endometrial carcinoma that is imaged with FDG-PET/CT.

The role of FDG-PET/CT in ovarian cancer patients with high tumor markers or suspicious lesion on contrast-enhanced CT in evaluation of recurrence and/or in determination of intraabdominal metastases

OBJECTIVES

This retrospective study was designed to investigate the role of fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in determination of recurrence and/or intraabdominal metastasis in patients with ovarian cancer having increased tumor markers or suspicious lesion detected by a contrast-enhanced abdominal CT (ceCT).

MATERIALS AND METHODS

A total of 34 female patients who were treated for histopathologically proven ovarian cancer, underwent PET/CT examination for restaging and suspected recurrence. Patients with pathology report, tumor marker levels, ceCT and PET/CT performed within one month were included in the study.

RESULTS

A total of 34 patients were included in the study. 25 of 34 patients had high tumor marker (CA 125) level. The remaining 9 patients had suspected recurrence on ceCT imaging with normal tumor marker levels. Recurrence was confirmed by re-operation and biopsy (n=4), clinical and imaging follow-up (n=21) in 25 patients with elevated tumor markers. Recurrent disease was not shown in 5 of 25 patients on ceCT imaging and 1 of 25 patients on PET/CT imaging with high CA125 values. Both ceCT and PET/CT revealed recurrent disease in 19 of 25 patients. PET/CT showed more lesions in 11 of 19 patients. Sensitivity, specificity and accuracy of the PET/CT were 96.1%, 100% and 97%, respectively.

CONCLUSION

PET/CT is found as a beneficial method for detection of the recurrence, in patients with increased serum CA 125 level and negative CT findings or with normal CA 125 level and recurrence detected by CT which was performed due to clinical symptoms.

Primary epithelioid trophoblastic tumor with a synchronous breast carcinoma detected only with FDG-PET/CT Scan

Epithelioid trophoblastic tumor is a recently described, rare and distinctive type of gestational trophoblastic tumor. We report the case of a 31-year old patient who had a full-term pregnancy 18 months before presentation. She had a right axillary lymph node metastasis and was referred for FDG-PET/CT scan for evaluation of distant metastasis and to detect primary malignancy. The axillary lymph node biopsy revealed metastatic breast carcinoma. FDG-PET/CT revealed increased uptake of right axillary lymph node, soft tissue density lesion with a diameter of 24 mm on left cervical region with increased FDG uptake, increased uptake on cervical region and left inguinal lymph node with increased uptake. Pelvic MRI imaging and ultrasonography were negative for malignancy in cervical region. Biopsy of the lesion was consistent with epithelioid trophoblastic tumor in cervical region. Gestational trophoblastic tumor was not suspected because she had no signs such as abnormal vaginal bleeding. FDG-PET/CT demonstrated the primary lesion in cervical region. We report a rare case of primary epithelioid trophoblastic tumor detected only with FDG-PET/CT scan which synchronized with breast carcinoma.

Epitrochlear and axillary lymph node visualization on FDG-PET/CT imaging in a patient with rheumatoid arthritis

An 38 year-old female with oral tongue cancer was referred for FDG-PET/CT scan for evaluating axillary lymph nodes and restaging malignancy. Bilateral uptake of axillary and epitrochlear lymph nodes were observed on PET/CT imaging. The uptake pattern was unexpected for the patient with this malignancy and she had a history of rheumatoid arthritis. Additionally, the wrists were included in the field of view and showed elevated FDG uptake. In this case report, we report benign axillary and epitrochlear tracer uptake on FDG-PET/CT scan in a patient with a history of rheumatoid arthritis.

Evaluation of cardiovascular complications with 99mTc tetrofosmin gated myocardial perfusion scintigraphy in patients with thalassemia major

OBJECTIVE

Iron overload limits the life expectancy of thalassaemic patients by causing cardiac toxicity. Iron also plays a catalytic role in the pathogenesis of atherosclerosis. The aim of this study was to evaluate the role of (99m)Tc Tetrofosmin gated myocardial perfusion scintigraphy (GMPS) in the detection of cardiac dysfunction in patients with thalassemia major.

MATERIALS AND METHODS

Forty two patients with homozygous beta-thalassemia were enrolled in the study. Myocardial perfusion and wall motion were analysed in all patients (mean age 17 +/- 5.28) and 34 age-matched controls using GMPS. Clinical data, liver function tests, hemoglobin, ferritin, low density lipoprotein (LDL) and cholesterol levels, and the total number and frequency of transfusions were collected from patient records.

RESULTS

97.6 % and 78.5 % of patients had normal myocardial perfusion and wall motion respectively. Nine out of 42 thalassaemic patients had abnormal left ventricular wall motion; half of these had septal hypokinesia. No significant correlation was found between the total number of transfusions, serum ferritin levels and left ventricular ejection fraction (p = 0.442 and p = 1.00, respectively). Echocardiography revealed systolic dysfunction in 5 out of 9 patients with wall motion abnormality. LDL was normal in 38 out of 42 patients and cholesterol levels were normal in 37 out of 42 patients.

CONCLUSIONS

Regional wall motion abnormalities can be seen in patients with thalassemia major. This early damage is frequently located in the septum and can be detected by GMPS. Serum ferritin levels and the number of blood transfusions are inadequate as predictors of myocardial dysfunction.

The additional diagnostic value of a single-session combined scintigraphic and ultrasonographic examination in patients with thyroid and parathyroid diseases

AIM

The aim of this study was to investigate the diagnostic efficacy and the clinical impact of scintigraphy combined with ultrasonography (USG) in the management of thyroid and parathyroid disorders in a large series of patients.

METHODS

A total of 387 consecutive patients referred to the Nuclear Medicine Department of Hacettepe University in the period from January to September 2007 for investigating a thyroid (N. 339 patients: 232 females and 107 males, mean age+/-SD=48.9+/-13.6 years) or a parathyroid disease (N. 48 patients: 34 females and 14 males, mean age+/-SD=47.4+/-9.6 years) were prospectively evaluated, systematically performing both scintigraphy and USG in a single-day session. All the examinations were independently reviewed by two nuclear medicine physicians; in cases of discrepancy (3%) a final diagnosis was reached by consensus. For thyroid pathologies, USG results were considered to provide additional diagnostic information over scintigraphy: 1) if more nodules were identified; 2) if an irregular hyperactive area at scintigraphy suspicious for the presence of a nodule was clearly characterized at USG; 3) if a nodule missed at scintigraphy because of small size (<1 cm) was well depicted at USG, thus allowing an USG-guided fine needle aspiration cytology (FNAC) to reach a final diagnosis. For parathyroid pathologies, USG was considered to provide additional diagnostic information over scintigraphy if a low intensity radiotracer retention from the parathyroid suspected of being a parathyroid enlargement was clearly depicted at USG. In thyroid diseases, scintigraphy was considered to provide additional diagnostic information over USG, if the functional status of a diffuse or uni- or multi-nodular goiter were clearly defined at scintigraphy. In parathyroid diseases, scintigraphy was considered to provide additional diagnostic information over USG, if the differential diagnosis between a lymph node or a muscle or a vessel depicted at USG was clearly defined as a parathyroid enlargement at scintigraphy. Lastly, the clinical impact of the single-day combined scintigraphic/USG protocol was evaluated.

RESULTS

USG. In the thyroid diseases group, USG was particularly useful: 1) to detect additional nodules in glands with suppressed thyroid tissue; 2) to disclose small thyroid nodules (<1 cm) in which it was possible to perform a USG-FNAC. In the parathyroid diseases group, USG was particularly useful for the detection of parathyroid enlargements not visualized at scintigraphy because characterized by a rapid wash-out of the radiotracer and thus by a low radioactivity intensity in the delayed scintigraphic images. Scintigraphy. In the thyroid diseases group, scintigraphy was particularly useful: 1) to diagnose a diffuse hyperfunctioning thyroid gland, and to differentiate in multinodular goiters the hyper- from the hypo-functioning nodules. In the hyperparathyroid diseases group, scintigraphy was particular useful in making a differential diagnosis between a true parathyroid enlargement vs. a lymph node or a muscle or a vessel as depicted at USG, and in cases with deeply or ectopically-positioned parathyroid glands. Combined imaging approach. Combined interpretation provided additional benefit in 225 of 339 patients (64.4%). Overall, using the combined scintigraphic/USG single-day protocol, in the thyroid diseases group the therapeutic strategy (drug therapy vs radioiodine therapy vs surgery) was changed in 176/225 patients (78.2%, P<0.001 by chi(2) of Pearson), and in the parathyroid disease group the therapeutic strategy (medical therapy vs surgery) was changed in 18/48 patients (37.5%, P<0.01 by chi2 test of Pearson).

CONCLUSION

In agreement with some previous published experiences, the combined single-day scintigraphic/USG protocol systematically adopted in a large series of consecutive patients with thyroid and parathyroid diseases, enrolled in a limited period of time, proved to significantly increase the global diagnostic accuracy and to change the therapeutic strategy in more than two third of patients with a thyroid disease and in more than one third of patients with a parathyroid disease.

The role of 99mTc DMSA renal scintigraphy in Joubert syndrome

Joubert syndrome is a severe autosomal recessive disorder, which is characterized by hypotonia, impaired psychomotor development, retinal dystrophy with abnormal ocular movements and cerebellar vermis agenesis with dilatation of the fourth ventricle. Joubert syndrome type B is a developmental disorder of the nephronophtisis complex with multiple organ involvement. Although this syndrome is rare, since first described by Joubert et al in 1969, there have been several cases about the components and the chromosomal abnormalities related with it. Here we report 2 patients with Joubert syndrome in whom renal involvement was demonstrated by ultrasonography as renal cystic disorders which represented nephronophtisis. For each patient we performed renal cortical scintigraphy with 99mTc-DMSA ( 99mtechnetium-dimercaptosuccinic acid) which showed bilaterally decreased radiopharmaceutical uptake in kidneys due to tubulointerstitial nephropathy. Scintigraphy may have a great value in the diagnosis and evaluation of the presence and severity of renal involvement in Joubert syndrome since it can evaluate kidney parenchyma and functioning renal tissue.