The Sentinel Node and Occult Lesion Localization (SNOLL) Technique Using a Single Radiopharmaceutical in Non-palpable Breast Lesions.

BACKGROUND: In order to perform a full surgical resection on non-palpable breast lesions, a current method necessitates correct intraoperative localization. Additionally, because it is an important prognostic factor for these patients, the examination of the lymph node status is crucial. OBJECTIVE: The aim of this study was to evaluate the efficiency of the sentinel node and occult lesion localization (SNOLL) technique in localizing nonpalpable breast lesions together with sentinel lymph node (SLN) using a single radiotracer, that is, nanocolloid particles of human serum albumin (NC) labeled with technetium-99m (99mTc). METHODS: 39 patients were included, each having a single non-palpable breast lesion and clinically no evidence of axillary disease. Patients received 99mTc- NC intratumorally on the same day as surgery under the guidance of ultrasound. Planar and single-photon emission computed tomography/computed tomography lymphoscintigraphy were performed to localize the breast lesion and the SLN. The occult breast lesion and SLN were both localized using a hand-held gamma-probe, which was also utilized to determine the optimal access pathway for surgery. In order to ensure a radical treatment in a single surgical session and reduce the amount of normal tissue that would need to be removed, the surgical field was checked with the gamma probe after the specimen was removed to confirm the lack of residual sources of considerable radioactivity. RESULTS: Breast lesions were successfully localized and removed in all patients. Pathological findings revealed breast carcinoma in 11/39 patients (28%) and benign lesions in 28 (72%). Axillary SLNs were detected in 31/39 (79.5%) patients. The metastatic involvement of SLN was only seen in two cases. CONCLUSION: While the identification rate of the SNOLL technique performed with an intratumoral injection of 99mTc-NC as the sole radiotracer in non-palpable breast lesions was great, it was not fully satisfactory in SLNs.

The value of radioembolisation therapy on metastatic liver tumours - a single centre experience.

OBJECTIVE: Local treatments used in metastatic liver tumours efficiently control the disease and survival. Transarterial radioembolisation (TARE) is a safely used locoregional treatment method. We aim to investigate the impact of TARE on different kinds of metastatic liver tumours and the effect of pre-treatment clinical findings. MATERIAL AND METHODS: The patients with metastatic liver tumours referred to our department for radioembolisation were retrospectively evaluated. All patients were given a Y-90 glass microsphere after being selected by the appropriate clinical and imaging criteria, lung shunt fraction levels, vascular investigation, and macro aggregated albumin (MAA) scintigraphy performed in the angiography unit. RESULTS: Thirty-four (17 women, 17 men) patients were suitable for the treatment. Patients were treated with 115.88±47.84 Gy Y-90 glass Microspheres. The mean survival rate was 14.59±12.59 months after treatment. Higher survival rates were detected in patients who had higher pre-treatment serum albumin levels. The optimum cut-off value of albumin to predict response to treatment was 4 g/dl with 88.89% sensitivity, 62.50% specificity, 72.73% PPV and 83.33% NPV. Furthermore, one unit increase in age increased mortality 1.152 times in our patient group. CONCLUSION: Radioembolisation is a safe and efficient method for controlling metastatic liver disease. Albumin levels significantly affect predicting response; higher albumin levels are related to higher survival rates. Furthermore, older age positively correlated with mortality rates in our patient group.

Is there a nonnegligible effect of maximum standardized uptake value in the staging and management of prostate cancer with 68Ga-prostate-specific membrane antigen positron emission tomography/computerized tomography imaging? A single-center experience.

PURPOSE: Prostate-specific membrane antigen (PSMA) positron emission tomography/computerized tomography (PET/CT) has been shown to have significant success in detecting local and distant metastases that cannot not be detected by conventional imaging. Initial staging in intermediate- and high-risk patients with prostate cancer is important for management. In addition, PSMA uptake has been shown to have a relation with grade of disease, and thus could be considered a separate noninvasive prognostic factor. In this study, we aimed to investigate the effect of PSMA PET/CT in the staging and management of prostate cancer patients as well as the relation to maximum standardized uptake value (SUVmax). METHODS: The patients referred to our department for staging prostate cancer were evaluated retrospectively (n = 65). Patients were grouped as positive for lymph node or distant metastatic disease. Primary tumor SUVmax data were compared with the prognostic factors of the disease. In addition, decisions about treatment protocol before and after PSMA PET/CT imaging were noted. RESULTS: All the patients except one were accepted as positive for primary tumor. Of the patients, 46.2% were positive for lymph node and 24.6% for distant metastases. After evaluation by PSMA PET/CT, the clinical choice of treatment changed for 43.1% of our patients. Primary tumor SUVmax and tumor-to-background SUVmax ratios were found to have a significant relation with D'Amico risk classification. We found a positive correlation between SUVmax and prostate-specific antigen, Gleason scores, and age. CONCLUSION: PSMA PET/CT images have a nonnegligible effect on staging, clinical decisions, and change in treatment protocol. SUVmax data have a positive correlation with risk classification and could be identified as a potential independent and non-invasive prognostic factor.

Single-photon Emission CT Combined with Spiral CT for Early Detection and Localization of Bone Metastasis: A Review.

BACKGROUND: Bone metastasis is common in cancer. Evaluating the metastatic status in cancer is of utmost importance in order to provide the best patient's management. DISCUSSION: Bone scintigraphy is widely used for evaluation of bone metastasis. It has high sensitivity with limited specificity. Planar bone scintigraphy has been shown to have increased radiotracer uptake without accurate anatomic localization and characterization. Hybrid Single-Photon Emission Computed Tomography/Computerized Tomography (SPECT/CT) system has been developed by combination of SPECT and CT. Accurate lesion localization and discrimination of equivocal bone lesions is an advantage in this hybrid technique. It improves diagnostic accuracy by differentiation of benign bone lesions from malignant ones due to their morphological changes. So, SPECT/CT improves the specificity of bone scintigraphy leading to better outcomes in diagnosis and treatment outcomes of bone metastatic cancer patients. CONCLUSION: In here, we discussed the prognostic value of bone scintigraphy and SPECT/CT in bone metastasis with our clinical experience and review of the literature.

Diagnostic Value of Bone SPECT/CT in Patients with Suspected Osteomyelitis

Objectives: The aim of our retrospective study was to evaluate the contribution of single photon emission computed tomography/computed tomography (SPECT/CT) to three phase bone scintigraphy/SPECT for the assessment of osteomyelitis (OM) and patient's management. Methods: Eighty-five patients who were suspected as having OM were included in this study. Tc-99m MDP three phase bone scintigraphy and SPECT/CT were performed to the region of suspected OM. SPECT/CT findings were compared with the findings of planar images/SPECT. Both planar bone scan/SPECT and SPECT/CT findings were divided into two groups: With OM and without OM. In all patients, scintigraphic diagnosis was confirmed by clinical follow up, laboratory findings, microscopic-bacteriological examinations, radiological, surgical, and pathological findings. Results: SPECT/CT changed the diagnosis and treatment planning in 14/85 (16.5%) patients. SPECT/CT was significantly superior to planar scan/SPECT imaging for determining OM (kappa value was 0.626 for planar scan/SPECT, 0.929 for SPECT/CT). SPECT/CT was statistically more successful in detection of chronic OM, and useful in differentiating chronic OM from acute OM (kappa value was 0.541 for planar scan/SPECT, 0.944 for SPECT/CT). Conclusion: SPECT/CT increases accuracy of the diagnosis in the evaluation of OM when it is compared to three phase bone scintigraphy/SPECT. SPECT/CT can change the diagnosis and management of the patients.

PET/CT Findings of a Patient with Cardiac Metastasis of Subungual Malign Melanoma

A 58-year old patient with a history of subungual malign melanoma was referred to our department for a 18F-FDG positron emission tomography (PET)/computed tomography (CT) whole body scan. An unexpected 18F-FDG uptake in left ventricule which mimicked either trombus or physiological papillary muscle was detected. Filling defect of intravenous contrast in CT images was also demonstrated in left ventricule cavity. Magnetic resonance imaging scan confirmed cardiac mass with metastatic features of malign melanoma in left ventricule

A Case of Hypertrophic Pulmonary Osteoarthropathy in Both Upper and Lower Extremities: A Rare Involvement.

Hypertrophic pulmonary osteoarthropathy (HPOA) is a paraneoplastic manifestation of gastric and, more frequently, lung carcinomas. It is characterized by extremity pain, clubbing, arthritis and periostitis of the long bones. Periostitis is the hallmark of HPOA and can be revealed with bone scintigraphy. Whole-body bone scintigraphy (WBBS) is very sensitive during the active lesion period and WBBS findings usually precede that of plain radiography. WBBS can also show improvement in the first 6 months following treatment, thus making it an important technique in the management and follow-up of these patients. While HPOA findings are usually seen in the lower extremities, involvement of both upper and lower extremities is a rare condition. In this case report, it is aimed to present findings of a 67-year-old male patient with lung cancer and complaint of extremity pain. We report on this patient to draw attention to HPOA of both upper and lower extremities.

The Contribution of SPECT/CT in the Diagnosis of Stress Fracture of the Proximal Tibia.

Stress fractures are injuries most commonly seen in the lower limbs and are usually caused by repetitive stress. While the distal and middle third of the tibia is the most frequent site for stress fractures (almost 50%), stress fractures of the proximal tibia is relatively rare and could be confused with other types of tibial fractures, thus altering management plans for the clinician. Early diagnosis of stress fractures is also important to avoid complications. Imaging plays an important role in the diagnosis of stress fractures, especially bone scan. Combined with single-photon emission computed tomography/computed tomography (SPECT/CT) it is an important imaging technique for stress fractures in both upper and lower extremities, and is widely preferred over other imaging techniques. In this case, we present the case of a 39-year-old male patient diagnosed with stress fracture of the proximal tibia and demonstrate the contribution of CT scan fused with SPECT imaging in the early diagnosis of stress fracture prior to other imaging modalities.

A Family with Von Hippel-Lindau Syndrome: The Findings of Indium-111 Somatostatin Receptor Scintigraphy, Iodine-123 Metaiodobenzylguanidine Scintigraphy and Single Photon Emission Computerized Tomography.

Von Hippel-Lindau syndrome (VHLS) is an autosomal dominant hereditary familial disorder characterized by development of malignant and benign neoplasms. Differential diagnosis of the adrenal and pancreatic masses are difficult in patients with VHLS. Iodine-123 metaiodobenzylguanidine (I-123 MIBG) and indium-111 somatostatin receptor scintigraphies (In-111 SRS) have important roles in the differential diagnosis of adrenal and pancreatic masses in those patients. In this case report, we present the findings of I-123 MIBG single-photon emission computerized tomography (SPECT/CT) and In-111 SRS SPECT/CT in three members of a family with VHLS. In case 1, a residual neuroendocrine tumor (NET) was detected in the head of pancreas on In-111 SRS SPECT/CT images. In case 2 and 3, I-123 MIBG SPECT/CT confirmed the adrenal masses as pheochromocytoma, and the extra-adrenal mass as NET, before surgery. We thought that In-111 SRS and I-123 MIBG scan might be helpful in the routine work up of VHLS patients for diagnostic and therapeutic purposes. Hybrid SPECT/CT system may improve diagnostic accuracy of planar images since it assesses morphologic and functional information together.

The role of bone SPECT/CT in the evaluation of painful joint prostheses.

OBJECTIVE: In this study, we aimed to evaluate the contribution of single-photon emission computerized tomography/computed tomography (SPECT/CT) to three-phase planar bone scintigraphy/SPECT in the assessment of aseptic and septic prosthesis loosening in patients with painful hip and knee prostheses. METHODS: Fifty patients who had undergone arthroplasties (20 hips and 30 knees) and were suspected to have complications and had undergone revision surgery were included in this study. Technetium-99m methylene diphosphonate three-phase bone scintigraphy and SPECT/CT were performed at the region of prostheses in all patients. Planar bone/SPECT and SPECT/CT images were separately assessed by two nuclear medicine physicians. SPECT/CT findings were compared with the findings of planar images/SPECT. Both planar bone scan/SPECT and SPECT/CT findings were divided into three groups: aseptic loosening, septic loosening, and miscellaneous. In all patients, scintigraphic diagnosis was confirmed by surgical findings. RESULTS: SPECT/CT changed the diagnosis and treatment plan in 8/50 (16%) patients. SPECT/CT was significantly better than planar scan/SPECT imaging for the diagnosis of aseptic and septic loosening in both joints (κ value: 0.477 for planar scan/SPECT; κ value: 0.717 for SPECT/CT). Moreover, both planar scan/SPECT and SPECT/CT were statistically successful in knee prostheses than in hip prostheses (κ value: 0.271 vs. 0.579 for planar/SPECT; κ value: 0.579 vs. 0.80 for SPECT/CT). For the hip, SPECT/CT was successful on the acetabular component than on the femoral component. For the knee, the results of SPECT/CT were similar for the femoral and tibial components. CONCLUSION: SPECT/CT increases diagnostic accuracy in the evaluation of aseptic and septic loosening in hip and knee prostheses compared with three-phase bone scintigraphy/SPECT.

The effect of the excisional biopsy in the detection of the sentinel lymph node by lymphoscintigraphy and intraoperative gamma probe in breast cancer.

OBJECTIVE: Sentinel lymph node (SLN) scintigraphy is used widespread in breast cancer, but the effect of the radionuclide agent, injection technique, the method of biopsy, tumor localization, breast size remain controversial. We examined the effects of the excisional biopsy in the rate of the SLN identification with lymphoscintigraphy (LS) and intraoperative gamma probe (IGP). MATERIAL AND METHODS: One hundred patients (age range: 28-79 yr) with breast cancer were included in the study. They consisted of two groups: Group 1; there were 58 patients without excisional biopsy Group 2; there were 42 patients with excisional biopsy LS: 2 hours before the operation, 37 MBq/ ml Tc 99m colloidal rhenium sulphide was injected at the periaerolar region intradermally Anterior and lateral static images were acquired. IGP: The hot spot of greatest radioactivity were marked on the skin during the surgery with IGP and removed. Excised SLNs were examined with frozen section. After that histopathological and immunohistochemical examinations were performed. RESULTS: SLNs were found in all patients in group 1 (100%), in 39 patients of group 2 (93%) with LS. SLNs were excised in 57 of the 58 patients of group 1 (98%), in 38 of the 42 patients of group 2 (90%) with IGF. Metastases were found in SLNs in 27 patients (28%). Axillary dissection was performed in these patients. CONCLUSION: According to results of our study the excisional biopsy was not the only factor but also other factors such as breast mass, calcified or metastatic lymph node may be affected the success rate of the SLN. CONFLICT OF INTEREST: None declared.

Parapharyngeal lymph node involvement in papillary thyroid carcinoma.

Papillary thyroid cancer extends to lymphatic nodes in approximately 40% of cases. Node involvement often occurs in the internal jugular and recurrent laryngeal chain on the side of the lesion. To the authors' knowledge, only 4 cases with I-131 uptake in pharyngeal metastatic nodes have been reported previously in the literature. The authors report parapharyngeal node involvement demonstrated by I-131 scintigraphy in a patient with papillary thyroid cancer.