Molecular Imaging in Neuroendocrine Differentiation of Prostate Cancer: 68Ga-PSMA Versus 68Ga-DOTA NOC PET-CT.

We report on a 62-year-old man with metastatic prostate cancer (cT3b N1) diagnosed in 2011, treated with total androgen blockage with flutamide and goserelin acetate (Zoladex). He presented with left suprascapular swelling and low-back pain after being asymptomatic for 5 years. His prostate-specific antigen was 0.049 ng/mL. F-NaF PET-CT and Ga-PSMA scan were negative, whereas Ga-DOTA NOC scan done after 10 days showed multiple somatostatin-avid hepatic and lymph node metastasis.

The clinical utility of combining pre-operative axillary ultrasonography and fine needle aspiration cytology with radionuclide guided sentinel lymph node biopsy in breast cancer patients with palpable axillary lymph nodes.

PURPOSE: Clinically palpable lymph nodes (CPLN) are usually considered a contraindication to sentinel lymph node biopsy (SLNB) but one third of these patients are node negative. The aim of the present study is to evaluate the clinical usefulness of combining SLNB and preoperative axillary ultrasonography (AUS) with FNAC in patients with clinically palpable but indeterminate axillary lymph nodes. MATERIALS AND METHODS: Fifty three patients with primary breast cancer and CPLN (mean age, 51.6 years; median age 51 years; age range, 28-73 years) were included in the study. All patients underwent AUS and fine needle aspiration (FNAC) followed by SLNB in FNAC negative patients (Group A). Patients with proven metastasis subsequently had axillary lymph node dissection (ALND) (Group B). Standard SLN scintigraphy was performed 2-4h before surgery by injecting Tc-99m labeled nano-colloid intra-dermally in the periareolar region. RESULTS: Nodal metastases were documented at FNAC in 26 (49%) of the 53 patients with subsequent ALND (Group B). All 27 patients (51%) with negative FNAC results (Group A) underwent SLNB, which revealed metastasis in 6 (11%) patients. The remaining 21 (40%) patients were tumor negative and all these patients remain disease free during the follow-up period of 12-36 months with NPV of 100%. SLN was identified in all patients (100% success rate). Preoperative AUS sensitivity was 78%, specificity 76%, PPV 83%, NPV 69% and accuracy 77% (p=0.001). In comparison, ultrasound guided FNAC sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 81%, 100%, 100%, 78%, 89% respectively (p=0.001). CONCLUSIONS: The inaccuracy of clinical assessment allows widening of indication of SLNB. Preoperative ultrasonography and guided FNAC can help in selecting the patients suitable for ALND or SLNB. Patients who are FNAC positive can proceed to ALND whilst FNAC negative samples can undergo SLNB. This combination strategy may be helpful in avoiding unnecessary ALND.

Selective approach to radionuclide-guided sentinel lymph node biopsy in high-risk ductal carcinoma in situ of the breast.

PURPOSE: Ductal carcinoma in situ (DCIS) currently represents approximately 15-25% of all breast cancers detected. Although inherently a noninvasive disease, occult invasive disease can be found at definitive histology. The role of sentinel lymph node (SLN) biopsy in DCIS is still unclear. The aim of this study was to evaluate the clinical usefulness of SLN biopsy and the incidence of SLN metastases in selected patients with high-risk DCIS, who are at highest risk for being upstaged to invasive carcinoma. MATERIALS AND METHODS: Twenty-three high-risk patients with DCIS proven on core biopsy (mean age, 50 years; median age, 48 years; age range, 37-78 years) were included in the study. SLN scintigraphy was performed 2-4 h before surgery by injecting Tc-99m-labeled nanocolloid intradermally in the periareolar region. The first lymph node to appear on the scan was labeled as SLN and was marked on the skin by using a γ probe. The lymph node was explored in the axilla using a γ probe. RESULTS: The SLN was identified in all patients (100% success rate). Of 23 cases of DCIS on core biopsy, seven patients (30%) were shown to have invasive ductal carcinoma on final histological specimen. Among these seven patients, three had minimal invasive carcinoma (<1 cm) and none of these patients had positive SLN for metastases. Among 23 cases, only one patient with (4%) SLN was positive for metastasis despite histopathological diagnosis of pure DCIS. CONCLUSION: Although the study population is small, our findings suggest that patients with high-risk DCIS have an increased risk of invasive disease, as approximately one-third of these patients had invasive component at the time of definitive operative procedure. Furthermore, the study also suggests that SLNB appears to be reliable in identifying axillary lymph nodes status of these patients.

Evaluation of the gamma probe guided sentinel lymph node biopsy and the blue dye technique in the management of breast cancer.

The aim of this study was to evaluate the efficacy of lymphoscintigraphy, gamma probe guided sentinel lymph node biopsy (GP-SLNB) in the management of breast cancer and study the follow-up results. Fifty two patients (mean age 47.28+/-9.7; range 23-69yr) with operable breast carcinoma and clinically negative axilla were studied. Scintigraphy for the detection of SLN was performed 2-4h before surgery by injecting technetium-99m labeled nanocolloid intradermally in the peritumoral region. First lymph node (LN) to appear on the scan was labeled as SLN and by using the GP was marked on the skin. Blue dye was also injected in all patients intraoperatively and hot and/or blue LN were studied in the axilla using the GP. The SLN was identified in 50 patients (96% success rate) while in 2 patients SLN was not visualized on imaging. The blue dye successfully localized SLN in 45/52 (87%) of the cases. Of the 52 patients, 16 had axillary lymph node dissection (ALND), including 14 SLNB positive for lymph node metastases cases and the two cases in which no SLN was imaged. In the remaining 36/52 cases SLN were negative for metastases and patients on the follow-up remained disease free (NPV 100% for a follow-up period of 12-36 months). The success rate, sensitivity, negative predictive value, and accuracy were 96%, 93%, 100%, and 98% using the GP-SLNB, 87%, 80%, 100%, and 93% using blue dye, and 98%, 100%, 100%, and 98% using combined methods, respectively. In conclusion, lymphoscintigraphy, GP-SLNB has a higher success rate and sensitivity versus the dye technique and when combined with the blue dye technique its sensitivity increases to 100%. We found a high negative predictive value for SLNB and the recurrence rate in these negative SLNB was comparable to the ALND.

Minimally invasive radionuclide-guided parathyroidectomy using 99mTc-sestamibi in patients with primary hyperparathyroidism: a single-institution experience.

OBJECTIVE: To evaluate the efficacy and usefulness of (99m)Tc-sestamibi scintigraphy and gamma probe localization of parathyroid glands in patients with primary hyperparathyroidism and establish radio-guided minimally invasive parathyroidectomy at Hussain Makki Al Jumma Center for Specialized Surgery, Kuwait. SUBJECTS AND METHODS: Twelve patients with primary hyperparathyroidism (mean age: 48 +/- 14 years; median age: 46 years; age range: 29-68 years) were evaluated. The diagnosis of hyperparathyroidism was established by elevated serum calcium and parathyroid hormone levels. All patients had a well-defined parathyroid lesion on previous standard (99m)Tc-sestamibi scintigraphy with or without ultrasound study. All had a normal thyroid gland, no history of familial hyperparathyroidism or multiple endocrine neoplasia nor any history of previous neck irradiation. On the day of surgery, patients were injected with 740 MBq (20 mCi) of (99m)Tc -sestamibi followed by a half-hour-delayed single standard pinhole view of the neck. A skin marker was placed on the basis of maximum count intensity during gamma probe localization. Patients were then sent for radio-guided minimally invasive parathyroidectomy. RESULTS: The preoperative localization of the affected gland was successful in all cases using a gamma probe and (99m)Tc -sestamibi scintigraphy. The pathological parathyroid tissue was localized and successfully removed with the gamma probe. The histopathological diagnosis was parathyroid adenoma in 11 cases and hyperplasia in the remaining one. All patients remained disease and symptom free at 12-month follow-up. CONCLUSIONS: Our initial experience with intraoperative use of a gamma probe to carry out minimally invasive parathyroidectomy was a useful, easy and safe procedure for treating patients with primary hyperparathyroidism.

Fine needle aspiration cytology of Hodgkin's lymphoma: A cytohistologic correlation study from a cancer center in Kuwait.

OBJECTIVE: To assess the diagnostic accuracy offine needle aspiration cytology (FNAC) in the diagnosis of Hodgkin's lymphoma (HL). STUDY DESIGN: We selected all the cases in which a cytologic diagnosis of HL, suggestive of or suspicious for HL, or HL as the prime differential diagnosis was offered on FNAC. These cases were correlated with histopathologic follow-up. Cases of primary HL diagnosed on cytology but without histopathology were excluded from the study. RESULTS: Histopathologic follow-up was available in 46 cases. Of these, 42 were correctly diagnosed as HL, and there was a discorrelation in 4 cases, comprising 3 cases of non-HL (T-cell-rich B-cell lymphoma [TCRBCL]-2, anaplastic large cell lymphoma-1) and 1 case of metastatic carcinoma. Overall accuracy was 91.3%. In 14 cases, the cytologic features were diagnostic ofrecurrence; hence, no histopathologic examination was done. No follow-up was available for the remaining 19 cases, which were excluded from the study. CONCLUSION: FNAC is very useful for rapid and accurate approach to the diagnosis of recurrent and most cases of primary HL. Because of morphologic similarities, it is difficult to differentiate HL from anaplastic large cell lymphoma and TCRBCL on FNAC. It is advisable to request a histopathologic examination in all cases of primary HL.