Relación del ciclo clínico con los parámetros metabólicos de la lesión primaria en el cáncer de pulmón / Relationship between primary lesion metabolic parameters and clinical stage in lung cancer

Objetivo: En pacientes con cáncer de pulmón hemos investigado la relación de los parámetros PET como el valor máximo estandarizado de captación (SUVmax), la glucólisis lesional total (TLG) y el volumen tumoral metabólico (MTV) con el estadio clínico y la correlación del SUVmax del tumor primario con el SUVmax de las metástasis. Material y métodos: El estudio incluyó pacientes con cáncer de pulmón enviados para realizar una estadificación con FDG PET/TC. Resultados: Se estudiaron las imágenes PET/TC y los informes anatomopatológicos de 168 pacientes. De los 168 pacientes, 146 (86,9%) tenían cáncer pulmonar de células no peque˜nas (CPCNP) y 22 (13,1%) cáncer pulmonar de células peque˜nas (CPCP). En todos los estadios de los pacientes con CPCP se detectaron diferencias significativas (p < 0,001) en el SUVmax, la TLG y el MTV. Sin embargo, al excluir los tumores de un tama˜no inferior a 25 mm, no se encontró una diferencia significativa en el SUVmax de los diferentes estadios. No se encontraron diferencias significativas entre estos parámetros metabólicos y la enfermedad limitada o extendida del CPCP. El diámetro del tumor se correlacionó con el SUVmax del tumor primario y se obtuvieron diferencias significativas entre el SUVmax del tumor primario y el SUVmax de las metástasis en todo el conjunto de pacientes. Conclusiones: Aunque se encontraron diferencias en los índices metabólicos entre los distintos estadios del CPCNP, las diferencias de SUVmax en los diferentes estadios parecen ser resultado de una infraestimación del SUVmax en las lesiones peque˜nas. Otros índices del metabolismo de la glucosa, como el MTV y la TLG, muestran resultados prometedores de cara a una estratificación pronóstica y se deberían realizar futuros estudios para alcanzar un mejor conocimiento de su contribución clínica (AU)

Objectives. The relation of PET-derived parameters as maximum standardized uptake value (SUVmax), total lesion glycolysis (TLG), metabolic tumor volume (MTV) with clinical stage in lung cancer and correlation of SUVmax of primary tumor and that of metastatic lesion was studied in lung cancer patients. Materials and methods. Patients with lung cancer who were referred for FDG PET/CT were included in the study. Results. PET/CT scans and pathology reports of 168 patients were assessed. A total of 146 (86.9%) of these patients had a diagnosis of non-small cell lung cancer (NSCLC) and 22 (13.1%) had small cell lung cancer (SCLC). Metabolic parameters such as SUVmax, TLG and MTV showed significant differences in all the stages in NSCLC patients (p < 0.001). However, after tumors sizes <25 mm were excluded, no significant differences in SUVmax between stages were observed. No significant differences were found between these metabolic parameters and limited or extended disease SCLC. Tumor diameter correlated with primary tumor SUVmax and significant correlations between primary lesion SUVmax and metastatic lesion SUVmax were found. Conclusions. Although differences were found regarding indices between stages of NSCLC cases, SUVmax differences between stages seem to be caused by underestimation of SUVmax in small lesions. Other glucose metabolism indexes such as MTV and TLG show promising results in terms of prognostic stratification. Future studies are needed for better understanding of their contribution to clinical cases (AU)

Relationship between primary lesion metabolic parameters and clinical stage in lung cancer.

OBJECTIVES: The relation of PET-derived parameters as maximum standardized uptake value (SUVmax), total lesion glycolysis (TLG), metabolic tumor volume (MTV) with clinical stage in lung cancer and correlation of SUVmax of primary tumor and that of metastatic lesion was studied in lung cancer patients. MATERIALS AND METHODS: Patients with lung cancer who were referred for FDG PET/CT were included in the study. RESULTS: PET/CT scans and pathology reports of 168 patients were assessed. A total of 146 (86.9%) of these patients had a diagnosis of non-small cell lung cancer (NSCLC) and 22 (13.1%) had small cell lung cancer (SCLC). Metabolic parameters such as SUVmax, TLG and MTV showed significant differences in all the stages in NSCLC patients (p<0.001). However, after tumors sizes <25 mm were excluded, no significant differences in SUVmax between stages were observed. No significant differences were found between these metabolic parameters and limited or extended disease SCLC. Tumor diameter correlated with primary tumor SUVmax and significant correlations between primary lesion SUVmax and metastatic lesion SUVmax were found. CONCLUSIONS: Although differences were found regarding indices between stages of NSCLC cases, SUVmax differences between stages seem to be caused by underestimation of SUVmax in small lesions. Other glucose metabolism indexes such as MTV and TLG show promising results in terms of prognostic stratification. Future studies are needed for better understanding of their contribution to clinical cases.

The association of neurofibromatosis, bilateral pheochromocytoma and primary hyperparathyroidism.

Neurofibromatosis (NF) is a hereditary disease and carries increased risk of both benign and malignant tumor development. Pheochromocytoma or hyperparathyroidism have been reported to be associated with NF type 1 (NF1). However, the coexistance of pheochromocytoma and parathyroid adenoma in a patient with NF1 is very rare. We report a case of a 37-year-old male with NF1, bilateral pheochromocytoma and parathyroid adenoma. This association sould be kept in mind in patients with NF1 in initial evaluation as well as during follow-up.

Decreased osteocalcin levels in patients with chronic obstructive pulmonary disease using long-term inhaled beclomethasone dipropionate.

Inhaled corticosteroids have been used in the treatment of chronic obstructive pulmonary disease (COPD) for many years. However the adverse effects of corticosteroids on bone formation may require special consideration in these patients. This study was undertaken to investigate the effects of long-term inhaled beclomethasone dipropionate treatment on the biochemical markers of bone formation. For this purpose, serum osteocalcin, alkaline phosphatase, free calcium, and inorganic phosphate levels were measured in 65 male COPD patients. Patients in the control group (n = 30) had not taken oral or inhaled corticosteroids for at least 1 year. Only those patients using beclomethasone with metered-dose inhalers were included in the treatment group (n = 35). The mean age of the control group was 61.63 +/- 1.84 (mean +/- SEM). In the treatment group, the mean age was 59.10 +/- 2.29 and patients in this group had taken beclomethasone for an average time of 23.94 +/- 2.72 months (for at least 12 months) at an average concentration of 1,142.0 +/- 79.64 microg/d. The mean serum osteocalcin levels in the control group and treatment group were 7.03 +/- 0.19 ng/mL and 3.74 +/- 0.12 ng/mL, respectively. Comparison of values between groups indicates that serum osteocalcin levels in patients using beclomethasone were significantly lower than that of patients in the control group. Serum alkaline phosphatase levels were 167.96 +/- 1.49 U/L and 168.17 +/- 1.60 U/L for the control and treatment groups, respectively. There was no statistically significant difference among these values (Student's t test; P >.05). The mean values of total serum calcium and inorganic phosphate were not statistically different between the groups (P >.05). These results indicate that long-term inhaled beclomethasone treatment in COPD patients may induce significant changes in osteocalcin levels and require close monitoring for osteoporotic changes.

(51)CrEDTA colonic permeability and therapy response in patients with ulcerative colitis.

Orally administered (51)Cr-labelled ethylenediaminetetraacetic acid ((51)CrEDTA) has been used to evaluate intestinal permeability in inflammatory bowel disease, especially Crohn's disease. However, information about colonic permeability in ulcerative colitis (UC) is relatively scarce. The aim of this study was to investigate the urinary excretion of orally administered (51)CrEDTA, its relation to disease activity and its response to medical therapy in patients with UC. Forty-three patients with UC and 19 controls were examined. Disease activity was evaluated by endoscopy. In 19 patients with active UC, the (51)CrEDTA permeability test was repeated after medical therapy. (51)CrEDTA (95 microCi; 26 MBq) was given orally after an overnight fast and urine was collected over a 24 h period. The first urine samples were taken 5 h and the second 24 h after the oral administration of (51)CrEDTA. Urine samples were counted in a gamma counter. In controls, the median 5 h and 24 h excretions were 0.10% and 0.93%, respectively. Patients with UC showed significantly increased urine (51)CrEDTA excretion at both time intervals (5 h: 2.41%, P<0.0002; 24 h: 6.72%, P<0.0001). There was also a significant correlation between intestinal permeability and disease activity (5 h: r=0.45, P=0.0025; 24 h: r=0.51 P=0.0006). After medical therapy, (51)CrEDTA urinary excretion was significantly decreased (pre-treatment UC: 7.87%; post-treatment UC: 2.50%; P<0.0002). Briefly, the (51)CrEDTA test reflected colonic permeability in UC and might be useful as an indicator of disease severity. Moreover, this study suggested that, in patients with UC, medical therapy not only leads to the recovery of acute inflammation but also restores mucosal barrier integrity and function.

Tc-99m HMPAO brain perfusion imaging in young Down's syndrome patients.

Down's syndrome (DS) is characterized by moderate mental retardation and a variety of abnormalities involving multiple organ systems. There is a high incidence of Alzheimer's disease (AD) type dementia beyond the age of 35. In this study, single photon emission computed tomography (SPECT) brain perfusion imaging of young Down's syndrome patients was performed to define the perfusion pattern. Tc-99m HMPAO brain perfusion SPECT was performed on 17 young DS patients, aged 3-24 years (mean: 10.9+/-5.9 years). None of the patients had dementia symptoms. Brain perfusion scans were acquired 15 min after i.v. injection of 12 MBq/kg of Tc-99m HMPAO using a single head rotating gamma camera. Images were analyzed visually and semiquantitatively by defining side-to-side asymmetry index. Nine DS cases showed normal brain perfusion. Eight of the 17 cases revealed mostly unilateral parieto-temporal, parieto-occipital and frontal hypoperfusions. The side-to-side asymmetry indices for these visually interpreted regional brain perfusion abnormalities ranged from 6 to 15%. These findings revealing mostly unilateral parieto-temporal and frontal hypoperfusions may not be considered as predictive patterns of dementia related Alzheimer type perfusion deficits in DS. However, such findings may connect to other functional imaging studies related to the higher cortical dysfunction in mental retardation.

Tc-99m MDP scintimammography in palpable and nonpalpable breast lesions: comparison with mammographic probability of malignancy.

We evaluated the contribution of Tc-99m methylene diphosphonate (MDP) scintimammography (MDP-SMM) to the diagnosis of breast cancer in 96 patients with 109 (52 palpable, 57 nonpalpable) breast lesions and compared them with mammography. Mammographic classification of the lesions were done as probably malignant (29), indeterminate (29) and probably benign (51). There were 23 malignant and 86 benign lesions. MDP-SMM successfully detected 16 of 23 (70%) breast cancers. Twelve of the 13 palpable and 4 of the 10 nonpalpable cancers showed Tc-99m MDP accumulation. Eight of the 86 (9%) benign breast lesions showed Tc-99m MDP accumulation (false positives). In the mammographically indeterminate group, MDP-SMM changed 22 of the 24 false positives into true negatives and showed 2 false negatives. In the 35 lesions detected in dense breasts, 10 of the 13 false positives were changed into true negatives and showed 1 false negative. As a conclusion, combined use of MDP-SMM with mammography seems to be useful in cases with mammographically indeterminate breast lesions and dense breasts and may help to preclude unnecessary breast biopsies.

Technetium-99m-HMPAO brain SPECT in anorexia nervosa.

Eating disorders have been redefined in recent years. Brain imaging techniques are useful in demonstrating the association between the morphologic and the functional cerebral changes in these cases. We report 99mTc-HMPAO brain SPECT findings in two patients with anorexia nervosa, before and after the treatment. While the detailed neurologic and laboratory examinations, including EEG and cranial CT, were within normal limits before therapy, SPECT study revealed diffuse bilateral hypoperfusion in frontal, parietal and frontotemporal areas which was more prominent in the left hemisphere. Post-treatment SPECT studies obtained after a clinical remission period of 3 mo showed normal brain perfusion in both patients. The pre- and post-treatment SPECT studies accurately reflect the functional state of the patients, and this technique may be used to follow-up the effect of treatment and predict the clinical response to therapy in patients with eating disorders.

Evaluation of pentavalent Tc-99m DMSA scintigraphy in small cell and nonsmall cell lung cancers.

AIM: The purpose of this study was to evaluate the clinical usefulness of Tc-99m (V) DMSA in patients suspected of lung cancer and determine whether this agent may have value in differentiation between small cell (SCLC) and non-small cell (NSCLC) lung carcinoma. METHODS: Thirty-six patients with clinical and radiological suspicion of primary lung carcinoma were injected 450-600 MBq of Tc-99m (V) DMSA intravenously. Whole body and planar anterior, posterior thorax images were obtained 4-5 h after injection of the radioactive complex. RESULTS: Histopathological results confirmed 23 NSCLC, 10 SCLC and 1 metastatic lung carcinoma and 2 lung abscess. Nineteen of the 23 (82%) NSCLC and all of the 10 (100%) SCLC cases showed Tc-99m (V) DMSA uptake. Single metastatic lung cancer also accumulated radiotracer. Lung abscess did not show uptake. Lesion/Nonlesion (L/N) ratio of SCLC (1.59 +/- 0.32) and NSCLC (1.43 +/- 0.19) tumour types did not show statistical difference (p > 0.05). Tc-99m (V) DMSA whole body imaging also showed bone metastases. CONCLUSION: Tc-99m (V) DMSA is a noninvasive and cheap imaging method to detect malignant lung cancers and their bone metastases but, differentiation of SCLC and NSCLC is not possible.

Comparison of indium-111 octreotide and thallium-201 scintigraphy in patients mammographically suspected of having breast cancer: preliminary results.

Indium-111 octreotide and thallium-201 scintigraphic studies were compared in 21 patients (16 with palpable and five with non-palpable lesions) suspected of having breast malignancies on the basis of mammography. Early (15 min) and late (3 h) 201Tl (111 MBq) and 4-h and 24-h 111In-octreotide (111-148 MBq) static planar anterior images (matrix 256 x 256) were obtained on separate days. Images were evaluated both visually and quantitatively. Biopsy was performed following the imaging studies. Histopathology revealed 17 breast carcinomas (15 cases of invasive ductal carcinoma, one mucinous adenocarcinoma and one intraductal carcinoma) and four benign breast lesions (two fibroadenomas, one abscess and one case of fat necrosis). The means histopathological tumour size (mean largest diameter) was 3.38 +/- 1.9 cm. 111In-octreotide detected 16 of the 17 breast cancers (94%) while 201Tl detected 13 of them (76%). Both 111In-octreotide and 201Tl missed one non-palpable carcinoma showing only an isolated cluster of microcalcifications on mammography. The smallest tumour size detected by both agents 1.5 x 1.5 cm. Of the four benign lesions, only the breast abscess revealed both 201Tl and 111In-octreotide uptake. 111In-octreotide scan also showed tracer uptake in five of the six patients with histologically proven axillary metastases, while four of these six patients showed 201Tl uptake. The tumour/background (T/B) ratios of late 111In-octreotide and 201Tl images were 1.71 +/- 0.38 and 1.46 +/- 0.30 respectively (P = 0.039). In this preliminary study, 111In-octreotide yielded more favourable results than 201Tl in the detection of breast carcinomas. However, the diagnostic efficacy of 111In-octreotide imaging needs to be investigated in larger patient series.

Evaluation of therapy response in children with untreated malignant lymphomas using technetium-99m-sestamibi.

UNLABELLED: The aim of this study was to investigate the relationship between 99mTc-sestamibi accumulation in tumors and response to chemotherapy in children with untreated malignant lymphomas. METHODS: Twenty-four children with malignant lymphoma (16 with Hodgkin's disease and 8 with non-Hodgkin's lymphoma) were studied with 201Tl and then with 99mTc-sestamibi scintigraphy before any therapeutic intervention. Visual and quantitative interpretation of 201Tl and 99mTc-sestamibi scans were performed. Visual uptake scores > or = 2+ were considered positive studies for 201Tl and 99mTc-sestamibi scintigraphy. Remission rates were evaluated at the end of induction therapy; patients were then followed clinically for 1-2 yr. RESULTS: All 17 patients who had positive 99mTc-sestamibi scans subsequently had a complete response to chemotherapy; all seven patients who had negative 99mTc-sestamibi scans subsequently had partial or no response to chemotherapy, irrespective of the lymphoma type. The mean tumor-to-background ratios of patients with complete response and with partial or no response were 1.395 +/- 0.2 and 1.031 +/- 0.05 (p = 0.0002), respectively. Thallium-201 scintigraphy results were not related to the response to chemotherapy. CONCLUSION: Technetium-99m-sestamibi scintigraphy can provide information predicting the response to chemotherapy in patients with malignant lymphoma.

Tl-201 scintigraphy, mammography and ultrasonography in the evaluation of palpable and nonpalpable breast lesions: a correlative study.

PURPOSE: To determine the feasibility of Tl-201 as a tumor localizing agent in palpable and nonpalpable breast lesions, in comparison with mammography and ultrasonography (US), and to evaluate the contribution of these modalities to each other in obviating biopsy. MATERIALS AND METHODS: Seventy-two palpable and nonpalpable breast lesions were prospectively classified as benign, indeterminate, or malignant according to the sonographic and mammographic criteria and were further analyzed with Tl-201 scanning. These classifications were compared with biopsy results. The sensitivity, specificity, accuracy, false positive and false negative rates (FPR, FNR), negative and positive predictive values (npv, ppv) were calculated for each individual modality and combination of modalities to evaluate the contribution of these three techniques to each other. RESULTS: Of 72 lesions 52 were histologically malignant and 20 were benign. Overall, mammography was the most sensitive (92%) and Tl-201 was the most specific (75%) of the three modalities. Mammography + Tl combination was the most specific (90%) and accurate (97%) of dual combinations. In mammographically or sonographically indeterminate cases, Tl-201 was much more specific (75% versus 37% for mammography and US) and more accurate (82% versus 36% for mammography and 54% for US) than the other two modalities, and mammography + Tl combination was significantly superior to other dual combinations (87% specific and 91% accurate). Use of Tl-201 scanning as an adjunct to mammography + US combination increased the specificity, ppv, and accuracy rates overall, particularly in mammographically or sonographically indeterminate cases. CONCLUSIONS: In mammographically and sonographically indeterminate breast lesions thallium scanning may be offered as a third step of investigation to obviate biopsy.

Ictal and interictal SPECT in a newborn infant with intractable seizure.

Neonatal seizures can be difficult to classify according to partial vs generalized onset based on clinical appearance, electroencephalogram (EEG) or other adjunctive imaging techniques. Single-photon emission computed tomography (SPECT) has proven to be useful in adults; however, its use is limited in the paediatric age group, particularly in neonates. A case of a 12-d-old infant with intractable seizures is reported, on whom an interictal Tc-99m HMPAO SPECT showed an area of hypoperfusion in the left temporal cortex, whereas the ictal SPECT revealed prominent hyperperfusion in the same area. The EEG of the infant demonstrated generalized epileptiform activity, while computed tomography and magnetic resonance (MR) imaging findings were normal. This case indicates that the use of SPECT may provide valuable data in evaluation of neonatal seizures, particularly with poorly localized EEG changes and normal MRI scans.

201Tl scintigraphy in the evaluation of palpable and nonpalpable breast lesions: correlation with mammography and ultrasonography.

AIM: Our goal was to determine the clinical usefulness of Tl-201 to identify breast cancer in patients with suspicious breast lesions on clinical examination, and/or abnormal radiologic (mammography and/or ultrasonography) findings. METHODS: Tl-201 scintigraphy were performed in sixty-eight patients with 70 breast abnormalities (51 palpable, 19 nonpalpable) and compared with mammography and ultrasonography (US). Early (15 min) and late (3 h) images of the breasts were obtained following the injection of 111 MBq (3 mCi) of Tl-201. Visual and semiquantitative interpretation was performed. RESULTS: Final diagnosis confirmed 52 malignant breast lesions and 18 benign conditions. Tl-201 visualized 47 of 52 (90%) overall malignant lesions. Thirty-eight of 40 (95%) palpable and 9 of 12 (75%) nonpalpable breast cancers were detected by Tl-201 scintigraphy. The smallest mass lesion detected by Tl-201 measured 1.5 x 1.0 cm. Eleven breast lesions were interpreted as indeterminate by mammography and/or sonography. Tl-201 scintigraphy excluded malignancy in 7 of 8 (88%) patients with benign breast lesions interpreted as indeterminate. Five of the 18 (28%) benign breast lesions showed Tl-201 uptake. None of the fibroadenoma and fibrocystic changes accumulated Tl-201. Tl-201 scintigraphy, mammography and ultrasonography showed 90%, 92%, 85% overall sensitivity and 72%, 56%, 61% overall specificity respectively. Twenty-one of the 28 (75%) axillary nodal metastatic sites were also detected by Tl-201. In malignant and benign lesions, early and late lesion/contralateral normal side (L/N) ratios were 1.58 +/- 0.38 (mean +/- SD) and 1.48 +/- 0.32 (p > 0.05), 1.87 +/- 0.65 and 1.34 +/- 0.20 (p < 0.05) respectively. The mean early and late L/N ratios of malignant and benign groups did not show statistical difference (p > 0.05). CONCLUSION: Overall, Tl-201 scintigraphy was the most specific of the three methods and yielded favourable results in palpable breast cancers, while it showed lower sensitivity in nonpalpable cancers and axillary metastases. Combined use of Tl-201 scintigraphy with mammography and US seems to be useful in difficult cases, such as dense breasts and indeterminate breast lesions.

Evaluation of malignant and benign lung lesions with 99Tcm-tetrofosmin.

99Tcm-tetrofosmin planar imaging was performed in 30 patients with malignant and benign lung lesions. There were 21 cases of primary lung cancer (10 squamous cell, 5 small cell, 4 adenocarcinoma and 2 large cell) and 9 benign lung lesions (4 pneumonia, 3 tuberculosis, 1 infected bronchiectasis and 1 bronchiectasis obliterans). Anterior and posterior planar thorax images were obtained 30 min after the intravenous injection of 740 MBq (20 mCi) of 99Tcm-tetrofosmin. Visual and quantitative evaluations were performed. For the quantitative evaluation, regions of interest were drawn over the lesioned area (L) and over the contralateral non-lesioned area (N). Of 21 malignant primary lesions; 19 (90%) showed 99Tcm-tetrofosmin accumulation. Four (44%) of the nine benign lung lesions (3 cases of pneumonia and the one case of active tuberculosis) showed uptake. The mean L/N ratios for the malignant and benign lesions were 1.63 +/- 0.29 and 1.64 +/- 0.19, respectively. There were no significant differences (P > 0.05) in the L/N ratios of the malignant and benign lesions or the various histological types of cancer. In conclusion, 99Tcm-tetrofosmin was highly sensitive (90%) in detecting malignant lung lesions, but it had poor specificity (55%).