Repeat injection following sentinel node nonvisualization on lymphoscintigraphy images can decrease axillary dissection rate in breast cancer patients.

AIM: Sentinel node biopsy is considered the standard of care in early-stage breast cancer patients. In the current study, we evaluated the effect of radiotracer reinjection in the case of sentinel node nonvisualization on preoperative lymphoscintigraphy. MATERIALS AND METHODS: Between March 2017 and March 2020, 1850 early-stage breast cancer patients were referred for sentinel node mapping. All patients received a single injected activity of Tc-99m Phytate intradermally in the periareolar area of the index lesion using an insulin syringe. Lymphoscintigraphy images of the patients were done 1-2 h postinjection. Between March 2017 and September 2017, sentinel node nonvisualization was reported to the surgeon, and for the rest of the study period, the patients received another injected activity of the radiotracer, and immediately, other lymphoscintigraphy images were taken (with the same parameters). RESULTS: A total of 255 patients entered our study. Fifty-five patients were in group I without any reinjection. The remainder of the patients were in group II. In 155 out of 200 patients of group II, a sentinel node could be visualized following reinjection of the radiotracer. The detection rate was 15 out of 45 and 15 out of 55 in group I and patients without sentinel node visualization even after reinjection, respectively. Axilla was involved in 5 out of 40 (12.5%) patients in group I with intraoperative sentinel node mapping failure. On the other hand, axilla was involved in 27 out of 30 (90%) group II patients with sentinel node nonvisualization. CONCLUSION: Reinjection of the tracer in cases of no sentinel node visualization in lymphoscintigraphy for breast cancer increases the detection rate of sentinel nodes, and therefore a high number of unnecessary axillary lymph node dissections can be avoided.

Unusual presentation of lumbar chordoma on bone scintigraphy in a young patient.

Chordoma is a rare bone cancer which arises from undifferentiated notochordal remnants in the axial skeleton. It generally has slow-growing and locally aggressive behavior. This tumor is usually diagnosed by CT and MRI modalities and the role of SPECT/CT is still debated. It shows reduced or normal uptake of radioisotope on bone scanning and increased tracer uptake is infrequently reported. Here we present a 33-year-old man with complaint of low back pain and numbness of his right leg. The whole body bone scan showed relatively uniform radiotracer activity throughout the skeleton. A focal increased uptake in the second lumbar vertebra was noted on SPECT/CT images. SPECT/CT also demonstrated multiple lytic lesions in lumbar vertebrae. The lesions were proven to be chordoma on biopsy. Lumbar chordoma could be one of the differential diagnoses for lytic lesions of the vertebrae which show absent or minimal tracer uptake on bone scintigraphy and SPECT/CT imaging. Our case was unusual as the patient was very young for chordoma diagnosis and bone scan showed increased uptake adjacent to the involved vertebral lesion detected by SPECT/CT.

Sentinel ode apping in on-small ell ung ancer sing an ntraoperative adiotracer echnique.

OBJECTIVES: Lymph node metastases are the most significant prognostic factor in localized non-small cell lung cancer (NSCLC). Identification of the first nodal drainage site (sentinel node) may improve detection of metastatic nodes. Extended surgeries, such as lobectomy or pneumonectomy with lymph node dissection, are among the therapeutic options of higher acceptability. Sentinel node biopsy can be an alternative approach to less invasive surgeries. The current study was conducted to evaluate the accuracy of sentinel node mapping in patients with NSCLC using an intraoperative radiotracer techniques. METHODS: This prospective study was conducted on 21 patients with biopsy-proven NSCLC who were candidates for sentinel node mapping during 2012-2014. All patients underwent thoracoabdominal computed tomography, based on which they had no lymph node involvement. Immediately after thoracotomy and before mobilizing the tumor, peritumoral injection of 2mCi/0.4 mL Tc-99m- phytate was performed in 4 corners of tumor. After mobilization of the tumoral tissues, the sentinel nodes were searched for in the hillar and mediastinal areas using hand-held gamma probe . Any lymph node with in vivo count twice the background was considered as sentinel node and removed and sent for frozen section evaluation. All dissected nodes were evaluated by step sectioning and hematoxylin and eosin staining (H&E).The recorded data included age, gender, kind of pathology, site of lesion, number of dissected sentinel nodes, number of sentinel nodes, and site of sentinel nodes. Data analysis was performed in SPSS software (version 22). RESULTS: The mean age of the patients was 58.52±11.46 years with a male to female ratio of 15/6. The left lower lobe was the most commonly affected site (30.09%). Squamous cell carcinoma and adenocarcinoma were detected in 11 and 10 subjects, respectively. A total of 120 lymph nodes were harvested with the mean number of 5.71±2.9 lymph nodes per patient. At least one sentinel node was identified in each patient, resulting in a detection rate of 95.2%. The mean number of sentinel nodes per patient was 3.61±2. Frozen section results showed 100% concordance with the results of hematoxylin and eosin staining. CONCLUSION: Based on the findings, sentinel node mapping can be considered feasible and accurate for lymph node staging and NSCLC treatment.

18FDG PET/CT in pulmonary arcinosarcoma and rain etastasis.

Carcinosarcoma is a rare type of cancer that is composed of a mixture of sarcomatous and carcinomatous elements. Pulmonary carcinosarcoma has a 25% five-year survival rate with a prognosis poorer than other non-small cell lung carcinomas. Herein, we report a case of pulmonary carcinosarcoma and its 18F-FDG PET/CT findings. A 61-year-old male patient presented with brain symptoms, including headache, nausea, right hemiplegia, and few attacks of seizures. He underwent brain computed tomography (CT) scan showing a brain lesion in the left parietal lobe. The patient underwent excisional biopsy, and brain lesion was removed. The results of tissue sampling were indicative of carcinosarcoma. Based on anatomical imaging and evidence of pulmonary lesion, the patient underwent 18FDG PET/CT that revealed a heterogeneous mass on the upper lobe of the left lung. An intense FDG uptake was observed along the rim of the mass; however, no FDG uptake was observed in the center of the mass. There were multiple mediastinal lymph nodes with a high FDG uptake. Pulmonary carcinosarcoma was confirmed by tissue sampling.

Relationship between gated myocardial perfusion SPECT findings and hemodynamic, electrocardiographic, and heart rate changes after Dipyridamole infusion.

After dipyridamole infusion, electrocardiographic (ECG), blood pressure and heart rate (HR) changes were seen. We tried to investigate whether there is a relationship between hemodynamic, ECG and HR changes after dipyridamole infusion and gated myocardial perfusion SPECT findings. We studied 206 consecutive patients which underwent a 2-day protocol Dipyridamole Stress/Rest Tc99m-Sestamibi gated myocardial perfusion SPECT. Systolic blood pressure (SBP), diastolic blood pressure (DBP), HR and ECG were recorded. HR was mildly increased while SBP and DBP were mildly decreased after Dipyridamole infusion. There was only statistically significant difference between ECG changes as well as transient ischemic dilation (TID) ratio between normal scans and scans with ischemia (P = 0.02 and P = 0.01 respectively). There was correlation between these variables and summed stress score (SSS) and summed difference score (SDS). Patients with ischemia in their scans, 44.3% had ST depression after Dipyridamole infusion. Also ST depression most frequently was seen in patients with left anterior descending artery disease. From patients with abnormal scan + ST depression after Dipyridamole infusion (33 patient), 27 patient (81.81%) had ischemia. There was an association between TID ratio as well as ECG changes after Dipyridamole infusion and SSS, SDS and coronary artery territory abnormality. Difference between calculated left ventricular ejection fraction using stress and rest images had significant correlation with SSS and SDS. ST depression after Dipyridamole infusion and TID ratio had association with ischemia, SSS and SDS. So in equivocal Gated SPECT findings, they could be very useful for interpretation.

99mTc-Labeled Ubiquicidin Accumulation in a Retained Surgical Gauze.

A 31-year-old woman underwent Tc-labeled UBI scanning for diagnosis of possible prosthesis infection evaluation in our department. The scan showed an area of increased tracer uptake in the mid-lateral portion of the left thigh. This was proven to be due to a retained surgical gauze in her left thigh.

Nano Liposomes Labeled with (99m)Tc-HMPAO, a Novel Agent for Blood Pool Imaging.

In-vitro labeling of RBC with (99m)Tc is an intricate procedure and there is always a need for an alternate blood pool imaging agent. The aim of this study was to prepare an effective nano sized liposome (NLs) similar to human RBC for blood pool scintigraphy. This study formulates PEG-NLs and non-PEG-NLs using film method plus high pressure homogenization technique. Biodistribution studies were performed on BALB/C mice 1, 4 and 24 h after tail vein injection of labeled NLs with (99m)Tc hexamethylpropylene-amine-oxime ((99m)Tc-HMPAO). Planar images were acquired using a 256 × 256 matrix following(99m) Tc-HMPAO-NLs injection into ear vein of rabbits 1, 2 and 24 h later. SPECT images were obtained 15 minutes after the injection (64 slices, 30 second/projection). The mean diameter, zeta potential and polydispersity index (PDI) of the PEG-NLs and the NLs were (80.88 ± 0.594 nm, -12.5 ± 0.56 mv, 0.158 ± 0.025) and (94.14 ± 0.114 nm, -35.5 ± 0.67 mv and 0.198 ± 0.007), respectively. (99m)Tc-HMPAO-PEG-NLs showed a significant circulation tracer activity (7.74 ± 1.63%ID/g at 1 h and 4.9 ± 0.77 %ID/g at 4 h), with low liver accumulation (12.07 ± 3.66 %ID/g at 1 h and 14.85 ± 1.3 %ID/g at 4 h). Heart to liver, spleen and background ROIs (region of interests) for (99m) Tc-HMPAO-PEG-NLs were 1.25, 4 and 4.28 respectively at 2 h which changed to 1.06, 1.75 and 2.51 respectively at 24 h. The (99m)Tc-HMPAO-PEG-NLs with a prolonged blood circulation time could be an excellent RBC alternative for scintigraphy and gastrointestinal bleeding.

Comparison between fragmented QRS and Q waves in myocardial scar detection using myocardial perfusion single photon emission computed tomography.

BACKGROUND: Accurate diagnosis of myocardial infarction (MI) is of paramount importance in patient management, which necessitates the development of efficient and accurate diagnostic methods. Q wave is not present in all patients with MI, and its prevalence is declining. Recently, fragmented QRS (fQRS) complex has been introduced as a marker of prior MI. AIM: To investigate diagnostic value of fQRS compared to Q wave. METHODS: We included 500 consecutive patients with known or suspected coronary artery disease who underwent two days of gated myocardial perfusion imaging using dipyridamole pharmacologic stress. Electrocardiogram (ECG) was evaluated to detect fQRS as well as Q-wave. Finally, subjects were compared in terms of ventricular perfusion and function indices. RESULTS: A total of 207 men and 269 women with mean age of 57.06 ± 12 years were studied. ECG analysis showed that 14.3% of the patients had both fQRS and Q waves, 30.7% had fQRS, and 3.8% had Q waves. Fixed myocardial perfusion defect was noted in 22.3% of patients according to MPIs. Sensitivity, specificity, and positive and negative predictive values for myocardial scar detection were 78%, 65%, 39%, and 91%, respectively, for fQRS and 61%, 94%, 76%, and 89%, respectively, for Q wave. CONCLUSIONS: Although fQRS had lower specificity compared to Q wave in the detection of myocardial scar, due to higher sensitivity and negative predictive value can be an invaluable diagnostic index. There is also an incremental value for fQRS in association with Q-wave in myocardial scar assessment.

Intra-Operative Lymphatic Mapping and Sentinel Node Biopsy in Laryngeal Carcinoma: Preliminary Results.

INTRODUCTION: Sentinel node mapping has been used for laryngeal carcinoma in several studies, with excellent results thus far. In the current study, we report our preliminary results on sentinel node mapping in laryngeal carcinoma using intra-operative peri-tumoral injection of a radiotracer. MATERIALS AND METHODS: Patients with biopsy-proven squamous cell carcinoma of the larynx were included in the study. Two mCi/0.4 cc Tc-99m-phytate in four aliquots was injected on the day of surgery, after induction of anesthesia, in the sub-mucosal peri-tumoral location using a suspension laryngoscopy. After waiting for 10 minutes, a portable gamma probe was used to search for sentinel nodes. All patients underwent laryngectomy and modified radical bilateral neck dissection. All sentinel nodes and removed non-sentinel nodes were examined by hematoxylin and eosin (H&E) staining. RESULTS: Ten patients with laryngeal carcinoma were included. At least one sentinel node could be detected in five patients (bilateral nodes in four patients). One patient had pathologically involved sentinel and non-sentinel nodes (no false-negative cases). CONCLUSION: Sentinel node mapping in laryngeal carcinoma is technically feasible using an intra-operative radiotracer injection. In order to evaluate the relationship of T-stage and the laterality of the tumor with accuracy, larger studies are needed.

Accuracy of sentinel node biopsy in esophageal carcinoma: a systematic review and meta-analysis of the pertinent literature.

The use of sentinel node surgery for esophageal carcinoma is still under investigation. We evaluated the data available in the literature on this topic, and herein present the results in a systematic review format. PUBMED, SCOPUS, the ISI web of knowledge and the information from the annual meetings of the Japan Esophageal Society were searched using the search terms: "(esophagus OR esophageal) AND sentinel". The outcomes of interest were the detection rate and sensitivity. Overall, 18 studies were included. The pooled detection rate was 89.2% [82.6-93.5]. Patients with T1 and two tumors had a 17% higher detection rate compared to those with T3 and four tumors. The pooled sensitivity was 84% [78-88%]. The sensitivity was higher for adenocarcinoma compared to squamous cell carcinoma (SCC) (91 vs. 81%). In the SCC patients, there was a trend toward decreased sensitivity associated with an increasing tumor depth (T1:88%, T2:76%, T3:50%). Our analysis indicated that sentinel node biopsy is useful in adenocarcinoma patients. For SCC patients, including only cN0 patients (preferably T1 and 2) would increase the detection rate and sensitivity. Due to the limited number of high-quality studies, drawing any more definite conclusions is impossible. Large cohort studies with a standardized and consistent design will be needed in the future.

Sentinel node mapping in anal canal cancer: systematic review and meta-analysis.

BACKGROUND & AIMS: The pathological condition of inguinal lymph nodes is an independent prognostic factor in predicting tumor recurrence and overall survival in anal canal cancer. Sentinel node mapping is a non-invasive method for the detection of inguinal lymph node involvement in anal cancer. In the current study, we conducted a comprehensive search of literature in this regard and then interpreted the final results in a systematic review and meta-analysis format. METHODS: Medline, SCOPUS, and ISI Web of Knowledge were searched with the following search terms: (anal OR anus) AND sentinel. Outcomes of interest were inguinal detection rate and inguinal recurrence in patients receiving inguinal sparing radiotherapy due to pathologically negative inguinal sentinel nodes (false negative cases). RESULTS: Overall 16 studies (323 patients) were included in the meta-analysis. Pooled inguinal detection rate was 86.2%: 73.4-93.4%: for studies using both blue dye and radiotracer it was 90.1% [78.7-95.8] and for studies using radiotracer alone it was 72.4% [46.3-88.9]. Pooled sensitivity was 90% [79-97%]. CONCLUSIONS: Sentinel node biopsy is a promising method for inguinal lymph node staging in anal cancer. Combined blue dye and radiotracer technique can maximize the inguinal detection rate. Location of the tumor is highly associated with the detection of inguinal sentinel nodes. Despite fairly high pooled sensitivity, no definite conclusion can be made regarding false negative rate of this technique due to low sample size and sub-optimal quality of the included studies. Large multicenter studies with long and consistent follow up are needed to definitely validate this technique in the future.

Effect of radiotracer injection volume on the success of sentinel node biopsy in early-stage breast cancer patients.

OBJECTIVE: The volume of radiotracer to be injected for sentinel node mapping is a controversial issue in breast cancer patients. In the current study, we evaluated the effect of radiotracer injection volume on the success rate of sentinel node mapping in early-stage breast cancer patients. MATERIALS AND METHODS: A total of 383 patients with early-stage breast cancer (cN0) were included in the study. The patients received an intradermal injection of Tc-antimony sulfide colloid for sentinel node mapping. The volume of injection was 0.1 ml for 102 patients, 0.2 ml for 221 patients, 0.5 ml for 30 patients, and 1 ml for 30 patients. The detection rate of the sentinel nodes during surgery was compared between the different injection volume groups. RESULTS: The overall detection rate was 93.9%. Detection rates were 95.1, 95, 90, and 86.7% for 0.1, 0.2, 0.5, and 1 ml volumes, respectively, which did not show a statistically significant difference despite minimal decrease in detection at higher volumes (P=0.214). The time of sentinel node visualization was not statistically different between the studied groups either (P=0.65). CONCLUSION: Increasing the volume of radiotracer in intradermal injections does not have a statistically significant effect on the sentinel node detection rate (despite minimal decrease in detection at higher volumes), nor on the time of sentinel node visualization. A low volume (0.1 ml) of radiotracer for intradermal injections can be as successful as higher volumes for sentinel node mapping with the added benefit of reduced pain from injections.

Is (99m)Tc-MIBI scintigraphy a predictor of response to pre-operative neoadjuvant chemotherapy in Osteosarcoma?

OBJECTIVES: Multidrug resistance (MDR), which may be due to the over expression of P-glycoprotein (Pgp) and/or MRP, is a major problem in neoadjuvant chemotherapy of osteosarcoma. The aim of this study was to investigate the role of Tc-99m MIBI scan for predicting the response to pre-operative chemotherapy. METHODS: Twenty-five patients (12 males and 13 females, aged between 8 and 52y) with osteosarcoma were studied. Before the chemotherapy, planar (99m)Tc-MIBI anterior and posterior images were obtained 10-min [tumor-to-background ratio: (T1/B1)10min] and 3-hr after tracer injection. After completion of chemotherapy, again (99m)Tc-MIBI scan was performed at 10-min after tracer injection. In addition to calculation of decay corrected tumor to background (T/B) ratios, using the 10-min and 3-hr images of the pre-chemotherapy scintigraphy, percent wash-out rate (WR%) of (99m)Tc-MIBI was calculated. Using the 10-min images of the pre- and post-chemotherapy scans, the percent reduction in uptake at the tumor site after treatment (Red%) was also calculated. Then after surgical resection, tumor response was assessed by percentage of necrosis. RESULTS: All patients showed significant (99m)Tc-MIBI uptake in early images. Only 9 patients showed good response to chemotherapy (necrosis≥90%) while 16 patients were considered as non-responder (necrosis<90%). There was no statistical significant difference between non-responders and responders in (T1/B1)10min.There was a significant negative correlation between WR% and percentage of necrosis (P=0.001). On the other hand, there was a significant correlation between Red% and percentage of necrosis (P<0.001).There was also statistical significant difference in WR% and Red% between non-responders and responders (both P< 0.001). CONCLUSION: Washout rate of (99m)Tc-MIBI in pre-chemotherapy scintigraphy as well as Red% using pre- and post-chemotherapy MIBI scintigraphy are useful methods for predicting response to neoadjuvant chemotherapy.

Scatterogram: a method for outlining the body during lymphoscintigraphy without using external flood source.

BACKGROUND: We evaluated the feasibility of outlining the body with scattered photons using a low dose intradermal injection of the radiotracer. PATIENTS AND METHODS.: Sixty breast cancer patients were included into the study. 30 minutes post radiotracer injection static lymphoscintigraphy images were acquired using low energy high resolution collimator in anterior and lateral views. For patients with 2-day protocol another set of images was taken 20 hours post-injection. Two photopeaks were used during imaging: 1-Tc-99m (130-150 keV) and 2- Scatter photons (60-120). The fusion image of these two images was constructed by NM-NM fusion workflow of the workstation. The usual body outline of the patients was also acquired in 20 cases using the external flood source without moving the patients from their positions. RESULTS: The early (30 minute image) scatterograms of the patients clearly showed the contour of the body. The 20 hour scatterograms were not as high quality as the corresponding early images. The constructed overlaid images showed the location of the axillary sentinel nodes and the body contours clearly for early scatterograms but not the delayed (20 hour) ones. The processing of the images for the reconstruction of overlaid scatterograms took the mean time of 10±5 seconds. CONCLUSIONS: Imaging the scattered photons is feasible for the intradermal low dose injection of the radiotracers in order to outline the body contour. This imaging method does not increase the radiation exposure of the patients or operators and does not extend the time of imaging either.

Systemic absorption of Tc-99m-pertechnetate during dacryoscintigraphy: a note of caution.

We report a 37-year-old patient with the history of bilateral epiphora, who was referred to our department for dacryoscintigraphy imaging. The patient had bilateral obstruction of the lacrimal apparatus at the sac-duct level on the scintigraphy images. Delayed imaging showed Tc-99m pertechnetate uptake in the thyroid due to systemic absorption of the tracer from the conjunctiva. We recommend using tracers with large particle size and lower possibility of mucosal absorption for dacryoscintigraphy in order to decrease unnecessary thyroid radiation.

How long the lymphoscintigraphy imaging should be continued for sentinel lymph node mapping?

OBJECTIVE: We assessed the need for delayed lymphoscintigraphy imaging for sentinel lymph node (SLN) biopsy in stage I and II breast cancer patients using intradermal injection of (99m)Tc-antimony sulfide colloid. METHOD: Seventy-five patients with early-stage breast cancer were included in our study. Periareolar intradermal injections of 0.5 mCi/0.2 mL (99m)Tc-antimony sulfide colloid was used for the patients without previous excisional biopsy (45 patients). Two intradermal injection of 0.5 mCi/0.2 mL (99m)Tc-antimony sulfide colloid was used on each side of the dermal incision in patients with the history of excisional biopsy (30 patients). Anterior and lateral static images were taken at 2 min. If SLN was not visualized, delayed imaging at 5, 10, 30, 60, 90, 150, and 180 min was done (till the visualization of the SLN or 180 min). SLN was performed by the combination of gamma probe and blue dye during surgery. RESULTS: Sentinel lymph node detection rate was 96% (72/75). SLNs were detected on the immediate (2 min) images in 55 (73.33%) patients. In the remaining patients, the SLNs were detected first on the 5-, 10-, and 30-min images in 10 (13/33%), 5 (6.66%), and 2 (2.66%) patients, respectively. In three patients (4%), SLN was not detected by lymphoscintigraphy even on 180-min images. During surgery, SLN was not detected in these three patients either. CONCLUSION: Considering the rapid flow of (99m)Tc-antimony sulfide colloid in our study, lymphoscintigraphy imaging can be completed in the nuclear medicine department without any delay in sending the patient back to the surgery department. Thirty minutes after radiotracer injection seems to be the optimal time for lymphoscintigraphy and delayed imaging beyond 30 min would not be necessary.