The role of PSMA PET/CT in predicting downgrading in patients with Gleason score 4+4 prostate cancer in prostate biopsy

BACKGROUND

To investigate the predictable parameters associated with downgrading in patients with a Gleason score (GS) 8 (4+4) in prostate biopsy after radical prostatectomy.

METHODS

We retrospectively analyzed 62 patients with a GS of 4+4 on prostate biopsy who underwent robotic radical prostatectomy between 2017 and 2022.

RESULTS

38 of 62 (61.2%) were downgraded. In multivariable logistic regression model, Ga-68 prostate-specific membrane antigen (PSMA) positron-emission tomography (PET)/computed tomography (CT) SUV max was independent predictor of downgrading (OR 0.904; p = 0.011) and a Logistic Regression model was constructed using the following formula: Y = 1.465-0.95 (PSMA PET/CT SUV max). The model using this variable correctly predicted the downgrading in 72.6% of patients. The AUC for PSMA PET/CT SUV max was 0.709 the cut off being 8.8. A subgroup analysis was performed in 37 patients who had no other European Association of Urology (EAU) high risk features. 25 out of 37 (67.5%) were downgraded, and 21 of these 25 had organ confined disease. Low PSMA SUV max (<8.1) and percentage of GS 4+4 biopsy cores to cancer bearing cores (45.0%) were independently associated with downgrading to GS 7.

CONCLUSION

PSMA PET/CT can be used to predict downgrading in patients with GS 4+4 PCa. Patients with GS 4+4 disease, but no other EAU high risk features, low percentage of GS 4+4 biopsy cores to cancer bearing cores, and a low PSMA PET/CT SUV max are associated with a high likelihood of the cancer reclassification to intermediate risk group.

Radioligand Therapy With 177 Lu-PSMA-I&T in Patients With Metastatic Prostate Cancer : Oncological Outcomes and Toxicity Profile

INTRODUCTION

This study aimed to investigate the oncological outcomes and toxicity profile of 177 Lu-PSMA-I&T radioligand therapy (RLT) in patients with metastatic castration-resistant prostate cancer (mCRPC), as well as our initial experience in metastatic hormone-sensitive prostate cancer (mHSPC).

PATIENTS AND METHODS

A total of 38 consecutive patients with metastatic prostate cancer (33 mCRPC and 5 mHSPC) received 177 Lu-PSMA-I&T RLT, with a median of 2 cycles per patient (range, 1-7). Response to RLT was evaluated based on prostate-specific antigen (PSA) changes and imaging response. Clinical progression-free survival and overall survival were used to report oncological outcomes. Toxicity was assessed using the Common Toxicity Criteria for Adverse Events criteria.

RESULTS

In mCRPC, 22 (69%), 18 (56%), and 11 (34%) patients achieved any PSA decline, PSA response of ≥30%, and PSA response of ≥50%, respectively. The clinical progression-free survival and overall survival after the first cycle of RLT were 6.3 and 21.4 months, respectively. In mHSPC, 177 Lu-PSMA-I&T RLT resulted in excellent PSA response (93.0%-99.9%) in all cases. Clinical progression and cancer-related mortality occurred in only 1 case. Toxicity profile was favorable in both mHSPC and mCRPC.

CONCLUSIONS

177 Lu-PSMA-I&T RLT demonstrated favorable PSA response (≥30%) in over half of the patients with mCRPC and excellent PSA response in all patients with mHSPC. Toxicity profile was favorable in both mHSPC and mCRPC settings. Further studies are needed to evaluate the role of 177 Lu-PSMA-I&T RLT in the management of metastatic prostate cancer.

Diagnostic Performance of 68Ga-PSMA-11 Positron Emission Tomography/Computed Tomography to Monitor Treatment Response in Patients with Metastatic Prostate Cancer: The Concordance Between Biochemical Response and Prostate-specific Membrane Antigen Results

BACKGROUND

Treatment response is traditionally monitored using prostate-specific antigen (PSA) and conventional imaging in patients with metastatic prostate cancer (mPCa).

OBJECTIVE

To assess the diagnostic performance of prostate-specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT) when monitoring mPCa patients receiving systemic treatment and also to investigate the concordance between PSMA PET response according to the PSMA PET progression (PPP) criteria and biochemical response.

DESIGN, SETTING, AND PARTICIPANTS

A total of 96 patients with 68Ga-PSMA-11 PET/CT-detected mPCa at baseline PSMA PET/CT (bPSMA) who underwent at least one follow-up scan after receiving systemic treatment were included in the study. PSA levels at bPSMA and follow-up PSMA PET (fPSMA) scans were recorded. The PPP criteria were used to define PSMA progression. Biochemical progression was defined as ≥25% increase in PSA. PSMA PET and PSA responses were dichotomized into progressive disease (PD) versus non-PD, and the concordance between PSA and PSMA responses was evaluated.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The concordance between PSA and PSMA PET responses was presented using frequencies, percentages, and Cohen's kappa test.

RESULTS AND LIMITATIONS

A total of 345 serial PSMA PET/CT (96 bPSMA and 249 fPSMA) scans were evaluated. The positivity rates of PSMA PET scans for PSA levels of <0.01, 0.01-0.2, 0.2-4, and >4 ng/ml were 55.6%, 75.0%, 100%, and 98.8%, respectively. PSA and PSMA responses showed moderate-to-high concordance (Cohen's κ = 0.623, p < 0.001). PSA-PSMA discordance was detected in 39 scans (17%). The most common cause of discordance was the discordant results between different metastatic lesions (16/28, 57.1%) in patients with PPP without PSA progression and local progression in prostate (n = 7/11, 63.6%) in patients with PSA progression without PPP.

CONCLUSIONS

PSMA PET/CT showed very high detection rates of malignant lesions even at very low PSA values and showed significant concordance with PSA response when monitoring treatment response in patients receiving systemic treatment for mPCa.

PATIENT SUMMARY

This study describes that prostate-specific membrane antigen positron emission tomography (PSMA PET), a new sensitive imaging tool, can detect malignant lesions even at very low prostate-specific antigen values when monitoring metastatic prostate cancer. The PSMA PET response and biochemical response showed significant concordance, and the reason for discordant results seems to be the different responses of metastatic lesions and prostatic lesions to systemic treatment.

SPECT/CT Lymphoscintigraphy Accurately Localizes Clipped and Sentinel Nodes After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer

PURPOSE

The aim of this study was to evaluate the impact of SPECT/CT lymphoscintigraphy on targeted axillary dissection (TAD) in node-positive breast cancer (BC) patients who had undergone neoadjuvant chemotherapy (NAC).

METHODS

Sixty-two female BC patients with biopsy-confirmed axillary nodal metastases underwent NAC, followed by breast surgery with TAD. A metallic clip was placed in the sampled LN before NAC. On the day of surgery, a periareolar intradermal 99m Tc-nanocolloid injection was administered, followed by SPECT/CT lymphoscintigraphy. The clipped nodes were localized on CT images, assessed for 99m Tc uptake before surgery, and confirmed during the procedure.

RESULTS

T1-4, N1-2 patients were enrolled in the study. All patients underwent sentinel lymph node (SLN) biopsy. The clipped node was the SLN in 54 (88.5%) patients. In 3 patients (4.9%), a clip was found in a nonsentinel lymph node. In 4 patients, the clips were not visible on SPECT/CT images, and lymph nodes were not found during the procedure. SPECT/CT correctly localized the clipped lymph node in all patients. The overall false-negative rate for TAD was 3.33%. The mean follow-up duration was 29 months, and there were no axillary recurrences.

CONCLUSIONS

SPECT/CT lymphoscintigraphy can accurately localize clipped nodes and SLNs after NAC in patients with node-positive BC.

68GaPSMA-11 PET/CT to monitor treatment response in patients with metastatic prostate cancer: The concordance between biochemical response and PSMA response

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Background: The aim of this study was to assess whether PSMA PET is associated with flares, with discordant results in regard to biochemical response, and with positivity rates at low PSA values while monitoring metastatic prostate cancer (mPCa) receiving systemic treatment. Methods: A total of 96 patients with PSMA PET-detected mPCa who underwent at least one follow-up scan after receiving systemic treatment were included in the study. PSA levels at baseline PSMA PET-CT (bPSMA) and follow-up PSMA PET scans (fPSMA) were recorded. Any significant PSMA uptake at prostate and/or metastatic lesions were considered PSMA positivity. PSMA response were decided according to PSMA PET Progression (PPP) criteria . Biochemical progression was defined as ≥25% increase in PSA (1 ng/dL was the minimal starting value). PSMA PET and PSA response were dichotomized into progressive disease (PD) vs non-PD. Discordant responses among different metastases and prostate were defined as the condition when some metastatic lesions (or prostate) are responding (CR or PR) to systemic treatment while others had progressed. Results: A total of 346 serial PSMA PET/CT (96 bPSMA and 249 fPSMA) scans were evaluated. The median time between consecutive PSMA PET scans was 6.3 months (IQR: 4.7 – 10.6) Overall PSMA PET positivity rate of fPSMA scans was 88.4% (220/249). PSMA positivity rates according PSA levels were summarized. PPP was detected in 93 cases (37.8%) and biochemical progression was observed in 73 cases (30.2%). PSA and PSMA responses were highly concordant (Cohen’s K=0.623, p<0.001). PSA-PSMA discordant responses were detected in 39 scans (17%). The possible causes could be identified in 34 of 39 scans (87%) while no obvious reason for discordance could be shown in the remaining 5. Conclusions: PSMA PET/CT showed very high detection rates of malignant lesions even in very low PSA values when monitoring treatment response in patients receiving systemic treatment for mPCa. PSA and PSMA responses were highly concordant. In cases with discordance, the reason seems to be the discordant behaviour of intraprostatic and metastatic lesions and not necessarily PSMA flares. PSMA PET is a promising biomarker to assess treatment response in patients with mPCa. [Table: see text]

Differential treatment response of prostate and metastatic lesions in patients with newly diagnosed metastatic prostate cancer

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Background: We aimed to evaluate the response of primary tumor to systemic treatment in patients with newly diagnosed mPCa with serial PSMA PET/CT scans. Methods: A total of 43 patients with newly diagnosed mPCa who had significant prostatic PSMA uptake at baseline PSMA PET/CT (bPSMA) and underwent at least one follow-up PSMA PET/CT (fPSMA) after receiving systemic treatment were included in the study. Those who received any definitive treatment at localized stage and those who underwent radiotherapy to prostate before fPSMA were excluded. Prostatic and metastatic PSMA response after systemic treatment was categorized as complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD) as recommended by guidelines. Discordant behavior between prostate and metastases was defined as the condition when metastatic lesions are responding (CR or PR) to systemic treatment while prostate had progressed or vice versa. CHAARTED criteria was applied to categorize patients according to the volume of metastatic disease. Results: The mean age of patients at bPSMA was 67.7 ± 8.5 years. The median PSA at bPSMA was 31.7 ng/dL (IQR: 11.3 – 106.0). Patient characteristics and treatments are summarized. The median time interval between bPSMA and the first fPSMA was 5.7 months (IQR: 4.6 – 7.5). Nine patients (20.9%) had CR, 25 (58.1%) had PR, 5 (11.6%) had SD and 4 (9.3%) had PD at prostate following systemic treatment. Patients with low-volume disease had prostatic CR twice more commonly than those with high-volume disease (27.3% vs 14.3%). In 6 (13%) cases, a significant PSMA uptake at prostate was detected despite a complete response of all metastatic sites. Discordant treatment responses at the prostate and metastatic sites were observed in 6 out of 43 (16%) patients. Conclusions: Discordant behavior between prostate and metastases are not rare in mPCa. Almost one-fourth of patients with low-volume mPCa achieved a complete prostatic response with systemic treatment only. Prostatic response on PSMA PET/CT following systemic treatment can be used to select ideal patients for the treatment of the primary tumor in patients with mPCa. [Table: see text]

68Ga-PSMA-11 Positron Emission Tomography/Computed Tomography for Primary Lymph Node Staging Before Radical Prostatectomy: Central Review of Imaging and Comparison with Histopathology of Extended Lymphadenectomy

BACKGROUND

Results from prospective trials have shown higher accuracy of prostate-specific membrane antigen (PSMA)-based positron emission tomography (PET)/computed tomography (CT) in detection of lymph node metastasis (LNM) compared to conventional imaging.

OBJECTIVE

To evaluate the accuracy of ⁶⁸Ga-PSMA-11 PET/CT for LNM detection in patients undergoing radical prostatectomy (RP) and extended pelvic lymph node dissection (PLND).

DESIGN, SETTING, AND PARTICIPANTS

Between June 2014 and November 2020, 96 patients with ⁶⁸Ga-PSMA PET/CT for primary staging underwent RP and extended PLND.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The results from ⁶⁸Ga-PSMA PET/CT were compared with histologic data from primary PLND in 96 patients. All ⁶⁸Ga-PSMA PET/CT scans were centrally reviewed.

RESULTS AND LIMITATIONS

Of 96 patients, 15.6% (n = 15) harbored LNMs. The median prostate-specific antigen at ⁶⁸Ga-PSMA PET/CT was 8.0 ng/ml (interquartile range 5.5-11.7). The majority of patients had intermediate- (52.1%) or high-risk disease (41.7%). Biopsy grade group 4 and 5 was present in 22.9% and 15.6%, respectively. The ⁶⁸Ga-PSMA PET/CT scans identified eight of 15 patients (53.3%) as LN-positive (true positive). The calculated per-patient sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of ⁶⁸Ga-PSMA PET/CT in the detection of LNM were 53.3%, 98.8%, 88.9%, 92.0%, and 91.7%, respectively. The per-patient sensitivity and specificity in the detection of LNMs larger than 2 mm were 61.5% and 98.8%, respectively. The main limitation is the retrospective design of the study.

CONCLUSIONS

⁶⁸Ga-PSMA PET/CT is accurate in lymph node staging and the results support its use for primary staging of prostate cancer.

PATIENT SUMMARY

We compared prostate-specific membrane antigen (PSMA)-based positron emission tomography (PET)/computed tomography (CT) findings with histopathology results after extended lymph node dissection and showed that it is accurate in detecting lymph node metastases. Our results support the use of PSMA PET/CT for primary staging of prostate cancer.

Diagnostic ability of Ga-68 PSMA PET to detect dominant and non-dominant tumors, upgrading and adverse pathology in patients with PIRADS 4-5 index lesions undergoing radical prostatectomy

BACKGROUND

To evaluate the additive role of Ga-68 PSMA PET as a primary staging tool in patients bearing prostate cancer in single PIRADS 4 or 5 index lesions.

METHODS

Eighty-one biopsy-naive patients with preoperative mpMRI and Ga-68 PSMA PET who underwent radical prostatectomy (RP) were evaluated retrospectively. Forty-nine patients had PIRADS 4 and 32 had PIRADS 5 index lesions. The localization, grade, and volumetric properties of dominant (DT) and non-dominant tumors (NDT) in RP were compared to the index lesions of mpMRI and Ga-68 PSMA PET.

RESULTS

The median age and PSA level were 62 (IQR; 59-69) years and 7 (IQR; 2-8) ng/ml, respectively. Ga-68 PSMA PET detected DTs in 100% of the patients including 13 patients in whom mpMR failed. In 45 patients an NDT was reported in RP. Ga-68 PSMA PET accurately detected NDT in 24 of 45 (53.3%) patients. Six patients (12.2%) in PIRADS 4 and 8 (25%) in PIRADS 5 group showed upgrading. In PIRADS 4, Ga-68 PSMA PET localized DT in all patients with upgraded tumors whereas mpMRI missed exact location in 2 of 6 (33.3%). In PIRADS 5 both mpMRI and Ga-68 PSMA PET accurately located all DTs. Overall detection rates of extracapsular extension (ECE) and seminal vesicle invasion (SVI) by mpMRI were 51.1% and 53.8%, respectively. Ga-68 PSMA PET detected ECE and SVI in 27.9% and 30.7%, respectively. When mpMRI and Ga-68 PSMA PET were used in combination detection rates of ECE and SVI increased to 65.1 and 61.5%. Ga-68 PSMA PET-detected six of ten patients with positive lymph nodes whereas mpMRI could not identify any.

CONCLUSIONS

Ga-68 PSMA PET has a better diagnostic accuracy in detecting DT, NDT, upgrading, adverse pathology in patients with PIRADS 4 index lesions. However, mpMRI better predicted ECE and SVI than Ga-68 PSMA PET.

Virtual reality tumor navigated robotic radical prostatectomy by using three‐dimensional reconstructed multiparametric prostate MRI and 68 Ga‐PSMA PET/CT images: A useful tool to guide the robotic surgery?

Objectives

To evaluate the use and benefits of tumor navigation during performing robotic assisted radical prostatectomy (RARP).

Patients and Methods

Borders of the visible tumor(s) was/were and surrounding structures marked on multiparametric prostate magnetic resonance imaging (mpMRI) and ⁶⁸Ga‐labeled prostate‐specific membrane antigen ligand using positron emission computed tomography (Ga68 PSMA‐PET/CT). Three dimensional (3D) reconstruction of the images were done that were transferred to virtual reality (VR) headsets and Da Vinci surgical robot via TilePro. Images were used as a guide during RARP procedures in five cases. Indocyanine green (ICG) guided pelvic lymph node dissection (n = 2) and Martini Klinik Neurosafe technique (n = 2) were also applied.

Results

Mean patient age was 60.6 ± 3.7 years (range, 56‐66). All VR models were finalized with the agreement of radiologist, urologist, nuclear physician, and engineer. Surgeon examined images before the surgery. All VR models were found very useful particularly in pT3 diseases. Pathological stages included pT2N0 (n = 1), pT3aN0 (n = 1), pT3aN1 (n = 2), and pT3bN1 (n = 1). Positive surgical margins (SMs) occurred in two patients with extensive disease (pT3aN1 and pT3bN1) and tumor occupied 30% and 50% of the prostate volumes. Mean estimated blood loss was 150 ± 86.6 cc (range, 100‐300). Mean follow‐up was 3.4 ± 1.7 months (range, 2‐6). No complication occurred during perioperative (0‐30 days) and postoperative (30‐90 days) periods in any patient.

Conclusions

3D reconstructed VR models by using mpMRI and Ga68 PSMA‐PET/CT images can be accurately prepared and effectively applied during RARP that might be a useful tool for tumor navigation. Images show prostate tumors and anatomy and might be a guide for the console surgeon. This is promising new technology that needs further study and validation.

Dealing with the gray zones in the management of gastric cancer: The consensus statement of the İstanbul Group

The geographical location and differences in tumor biology significantly change the management of gastric cancer. The prevalence of gastric cancer ranks fifth and sixth among men and women, respectively, in Turkey. The international guidelines from the Eastern and Western countries fail to manage a considerable amount of inconclusive issues in the management of gastric cancer. The uncertainties lead to significant heterogeneities in clinical practice, lack of homogeneous data collection, and subsequently, diverse outcomes. The physicians who are professionally involved in the management of gastric cancer at two institutions in Istanbul, Turkey, organized a consensus meeting to address current problems and plan feasible, logical, measurable, and collective solutions in their clinical practice for this challenging disease. The evidence-based data and current guidelines were reviewed. The gray zones in the management of gastric cancer were determined in the first session of this consensus meeting. The second session was constructed to discuss, vote, and ratify the ultimate decisions. The identification of the T stage, the esophagogastric area, imaging algorithm for proper staging and follow-up, timing and patient selection for neoadjuvant treatment, and management of advanced and metastatic disease have been accepted as the major issues in the management of gastric cancer. The recommendations are presented with the percentage of supporting votes in the results section with related data.

Isolated omental metastasis of renal cell carcinoma after extraperitoneal open partial nephrectomy: A case report

INTRODUCTION

Metachronous metastatic spread of clinically localized renal cell carcinoma (RCC) affects almost 1/3 of the patients. They occur most frequently in lung, liver, bone and brain. Isolated omental metastasis of RCC has not been reported so far.

CASE PRESENTATION

A 62-year-old patient previously diagnosed and treated due to pulmonary sarcoidosis has developed an omental metastatic lesion 13 years after having undergone open extraperitoneal partial nephrectomy for T1 clear-cell RCC. Constitutional symptoms and imaging findings that were attributed to the presence of a sarcomatoid paraneoplastic syndrome triggered by the development this metastatic focus complicated the diagnostic work-up. Biopsy of the [18F]-fluorodeoxyglucose (+) lesions confirmed the diagnosis of metastatic RCC and the patient was managed by the resection of the omental mass via near-total omentectomy followed by targeted therapy with a tyrosine kinase inhibitor.

DISCUSSION

Late recurrence of RCC has been reported to occur in 10-20% of the patients within 20 years. Therefore lifelong follow up of RCC has been advocated by some authors. Diffuse peritoneal metastases have been reported in certain RCC subtypes with adverse histopathological features. However, isolated omental metastasis without any sign of peritoneal involvement is an extremely rare condition.

CONCLUSION

To our knowledge, this is the first reported case of metachronously developed, isolated omental metastasis of an initially T1 clear-cell RCC. Constitutional symptoms, despite a long interval since nephrectomy, should raise the possibility of a paraneoplastic syndrome being associated with metastatic RCC. Morphological and molecular imaging studies together with histopathological documentation will be diagnostic.

The role of positron emission tomography/computed tomography in the diagnosis of pleural diseases

BACKGROUND

The aim of the study was to assess the role of F-18 fluoro-2-D-deoxyglucose positron emission tomography ( (18)FDG-PET)/computed tomography (CT) in patients with undiagnosed pleural diseases and to compare the findings with those of invasive diagnostic procedures.

METHODS

The study included 83 patients with pleural lesions (63 with pleural effusion; 20 with pleural thickening) on CT scan performed between November 2005 and December 2007. The study group consisted of 63 males and 20 females; their median age was 47 years. PET-CT scan was performed for all patients before surgery. A maximum standard uptake value greater than 3.0 was accepted as positive for malignancy. For histopathological diagnosis, video-assisted thoracoscopic surgery was performed in 76 patients and a mini-thoracotomy was performed for the remaining 7 patients.

RESULTS

Postoperative histopathological examination revealed malignancy in 44 cases, 25 of which were malignant mesothelioma; the remaining 39 cases were benign. There were no false negative results, but two false positive results (tuberculosis). PET-CT scanning had 100 % sensitivity, 94.8 % specificity and 97.5 % accuracy.

CONCLUSION

Our study suggests that PET-CT may be an effective tool for the differentiation of benign and malignant pleural diseases. We believe that PET/CT may prevent redundant surgical procedures in young patients who are SUVmax negative.

Can Exercise Renography Be an Alternative to ACE Inhibitor Renography in Hypertensive Patients Who Are Suspicious for Renal Artery Stenosis?

The aim of this study was to evaluate the value of Tc-99m ethylenedicysteine exercise renography in patients with hypertension who were suspicious for renal artery stenosis and compare the results with captopril renography.

METHODS

Twenty-nine patients with hypertension who were highly suspect for having renal artery stenosis were included in the study. Basal captopril exercise renograms were performed within 1 week in all patients with Tc-99m EC. Exercise was performed with a bicycle ergometer as described in the literature. Interpretations of renograms were made according to the consensus report on angiotensin converting enzyme (ACE) inhibitor renography as high, low, or intermediate probability. The sensitivity, specificity, and positive and negative predictive values were also obtained on both the kidneys and a patient basis. The results were compared with renal angiography in 19 patients.

RESULTS

Twenty of 29 patients had concordant results with both captopril and exercise studies. All discordant tests were normal with captopril but positive with exercise renograms. Nineteen patients with 38 kidneys were included for statistical data analysis. Nine kidneys, which were either atrophic or abnormal during the basal study, were excluded from the kidney-based analysis. With contrast angiography, 8 patients had renal artery stenosis. When evaluated on a kidney basis, the sensitivity, specificity, and positive and negative predictive values for captopril scans were 87%, 100%, 100%, and 95%, and for the exercise scans were 100%, 90%, 80%, and 100% respectively. When calculated on a patient basis with regard to the captopril scans, the sensitivity, specificity, and positive and negative predictive values were 87%, 81%, 77%, and 88%, and for exercise scans were 100%, 54%, 61%, and 100% respectively. There were 2 false-positive exercise scans that were found to be the result of dilated minor collecting systems and changes in kidney contours as a result of motion during exercise.

CONCLUSIONS

These results indicate that exercise renography has a similar sensitivity but lower specificity compared with captopril scintigraphy in the diagnosis of renal artery stenosis. Because of the lower specificity, its use in the screening of renovascular hypertension may be limited. Exercise renography may be more useful as an investigative tool for essential hypertension.

A case of Noonan syndrome with pulmonary and abdominal lymphangiectasia

Noonan syndrome is characterised by a Turner-like phenotype and a normal karyotype. Although it is reported to be associated with abnormalities of the lymphatic system, involvement of the pulmonary lymphatics is rare. We present a case of Noonan syndrome where a whole body scintigraphy revealed lymphangiectasia of the lower extremities, abdomen and lungs.