Primary non-Hodgkin's lymphoma presenting as a uterine cervical mass.

We report a 43-year-old woman who presented with post-coital bleeding. Pelvic examination revealed a uterine cervical mass, which confirmed to be large B cell lymphoma on histopathological examination. Computed tomography showed a primary lesion in the uterine cervix with no lymph node or other extranodal involvement. The patient responded to CHOP (cyclophosphamide, adriamycin, vincristine and prednisolone) chemotherapy regime with no major side effects.

Lady Windermere syndrome: an inappropriate eponym for an increasingly important condition.

Non-tuberculous mycobacterial infection (NMI) occurs in elderly women with no pre-existing lung disease, and this has been termed the Lady Windermere syndrome. NMIs are increasing in prevalence and an increasing number of pulmonary mycobacterial infections is due to non-tuberculous mycobacteria. The diagnosis is often difficult because the organism is not readily isolated or cultured, and the condition may not be considered by the radiologist. We report NMI in a 64-year-old woman, based on clinical and radiological findings. Although termed the Lady Windermere syndrome, the name does not correspond to the character in Oscar Wilde's play; hence the eponym is not widely used.

Radiation-induced osteosarcoma of the maxilla.

Radiation-induced sarcomas are well-known though uncommon potential late sequelae of radiation therapy. We report irradiation-induced osteosarcoma involving the maxilla following treatment of nasopharyngeal carcinoma in a 44-year-old man who presented with painful cheek swelling. Radiographs and computed tomography showed a large destructive lesion of the left maxilla. Diagnosis of osteosarcoma was confirmed by excision biopsy.

Computed tomography of focal splenic lesions in patients presenting with fever.

INTRODUCTION: There is an awareness of the increased incidence of splenic abscess in Southeast Asia giving rise to unexplained fever. This study looks at the role of computed tomography (CT) in evaluating focal splenic lesions in patients presenting with fever. METHODS: 37 patients presenting with fever of unknown origin underwent CT and this study retrospectively analyses the findings in these patients. 13 patients also had associated abdominal pain. Patients with conditions at high risk for splenic infection include: diabetes mellitus in ten patients, leukaemia in seven patients, human immunodeficiency virus infection in five patients, intravenous drug abuse in six patients, and steroid therapy in two patients. No risk factors could be identified in seven patients. RESULTS: Splenic abscess was diagnosed in 28 patients. A range of infecting organisms was isolated but the most frequent were Staphylococcus aureus (eight), tuberculosis (four), Streptococcus (four), fungal (four) and melioidosis (four). No infecting organism could be identified in ten cases though in patients with leukaemia with multiple low attenuation areas, the cause was presumed to be fungal. Six patients were diagnosed to have splenic infarcts though differentiation from splenic abscess could be difficult; these patients were treated for an abscess and all had endocarditis. Three patients were subsequently diagnosed with lymphoma. Percutaneous abscess drainage was performed in five patients and splenectomy was carried out in six patients. CONCLUSION: CT proved to be very useful as it not only revealed the size and extent of any splenic abnormality but it assisted with guidance for percutaneous drainage, determined the site for biopsy, and provided follow-up after treatment.

Kostmann's syndrome.

Kostmann's syndrome is a rare congenital disorder of neutrophil production due to impairment of myeloid differentiation in the bone marrow, with the neutrophil count being characteristically less than 500 x 10(3) cells/l (normal: 2-7 x 10(9)/l). Severe persistent neutropenia results in an increased susceptibility to frequent bacterial infections. The condition can be treated with recombinant human granulocyte colony-stimulating factor (G-CSF). Although several articles have addressed the clinicopathological and haematological aspects of this disorder, little or no information has been available concerning the radiological findings in this disorder. This report summarizes the clinical features, radiological findings and management of a patient with Kostmann's syndrome.

Does simple estimation of 131I-metaiodobenzylguanidine uptake in patients with neural crest tumours correlate with clinical outcome?

A retrospective study was undertaken in six patients (three male and three female) with neural crest tumours who received therapeutic doses of 131I-meta-iodobenzylguanidine (131I-MIBG) (6.7-10.5 GBq). The age range of the patients was 13-65 years (mean 36 years). Quantification of tumour uptake was obtained from images acquired with a large-field-of-view gamma camera on a single occasion between 2 and 10 days post-treatment. Tumour uptake was calculated to be 0.1% and 3.2% of the administered dose, corresponding to uptakes of 6.7-142.8 MBq. Tumour volume was assessed from computed tomography (CT) or magnetic resonance (MR) images and estimates of tumour dose made from the Medical Internal Radiation Dosimetry scheme (MIRD) tables. Estimated doses were between 7 and 113 Gy. Most significantly, our findings indicate that high tumour uptake did not always correlate with good clinical response.

Radionuclide bone scintigraphy in the detection of significant complications after total knee joint replacement.

AIM: Post-arthroplasty knee pain is common and clinically it can be difficult to identify those patients with complications requiring active treatment. The aim of this study was to determine the usefulness of(99)Tc(m)-MDP bone scintigraphy. METHOD: A retrospective study of all patients having a(99)Tc(m)-MDP bone scintigram for a painful knee arthroplasty between 1993 and 1999 was performed. Bone scintigrams were classified as normal or abnormal by a single observer. The results of these investigations were correlated with clinical outcome. RESULTS: Seventy-five patients with painful knee arthroplasties were referred for investigation. A total of 80 bone scintigrams were performed. The average patient age was 66.2 years (42 female and 33 male). The mean time period between surgery and onset of knee pain was 3 years. A final clinical diagnosis based on arthroscopy, open surgery, and extended clinical follow-up was available for all patients. Forty-three (53.8%) of the scintigrams were normal and 37 (46.3%) abnormal. Two patients with a normal bone scintigram has loose prostheses. Thirteen patients with an abnormal study had normal prostheses on follow-up and these tended to be patients scanned less than a year after surgery. The sensitivity, specificity, positive predictive value and negative predictive value of an unequivocally normal or abnormal bone scintigram was 92.3, 75.9, 64.9 and 95.0%, respectively. The pattern of isotope uptake in the abnormal studies was not specific enough to reliably differentiate aseptic from septic loosening. CONCLUSION: Radionuclide bone scintigraphy is useful in the assessment of the painful knee arthroplasty. A negative bone scintigram is reassuring and makes loosening or infection unlikely.

Imaging for staging bladder cancer: a clinical study of intravenous 111indium-labelled anti-MUC1 mucin monoclonal antibody C595.

OBJECTIVE: To investigate the clinical application of an 111In-labelled anti-MUC1 mucin monoclonal antibody (mAb) imaging for staging invasive bladder cancer. PATIENTS AND METHODS: Indirect immunohistochemistry was used to confirm the expression of the MUC1 target antigen by metastatic tumours. Twelve patients with bladder cancer (two with superficial and 10 with locally invasive/metastatic disease) underwent planar gamma-scintigraphy 48 h after an intravenous injection with 111In-labelled anti-MUC1 mucin mAb C595. RESULTS: No bladder uptake was detected in the two patients with superficial disease, but scintigraphy showed primary and recurrent bladder tumours and metastases in nine of the remaining 10 patients with invasive disease. In three patients additional staging information was obtained from the mAb imaging which would have altered patient management. There were no reported side-effects. CONCLUSION: This study confirmed the ability of the mAb technique to detect both primary and recurrent invasive bladder tumours and distant metastases. Some lesions shown by mAb imaging were not detected by other methods. The use of mAb imaging has the potential to improve clinical staging and assist in selecting those patients most likely to benefit from radical therapy.

Targeting superficial bladder cancer by the intravesical administration of copper-67-labeled anti-MUC1 mucin monoclonal antibody C595.

PURPOSE: More effective intravesical agents are required to limit the recurrence and progression of superficial bladder cancer. This study assessed the ability of copper-67 ((67)Cu)-C595 murine antimucin monoclonal antibody to bind selectively to superficial bladder tumors when administered intravesically, with a view to its development for therapy. PATIENTS AND METHODS: Approximately 20 MBq of (67)Cu-C595 monoclonal antibody was administered intravesically to 16 patients with a clinical indication of superficial bladder cancer. After 1 hour, the bladder was drained and irrigated. Tissue uptake was assessed by imaging and by the assay of tumor and normal tissues obtained by endoscopic resection. RESULTS: Tumor was correctly identified in the images of 12 of 15 patients who were subsequently found to have tumors. Assay of biopsy samples at 2 hours showed a mean tumor uptake of 59.4% of the injected dose per kilogram (SD = 48.0), with a tumor-to-normal tissue ratio of 14.6:1 (SD = 20). After 24 hours (n = 5), this decreased to 4.3% of the injected dose per kilogram (SD = 2.9), with a tumor-to-normal tissue ratio of 1.8:1 (SD = 0.8). CONCLUSION: This study indicates a promising method for the treatment of superficial bladder cancer. Although the mean initial tumor uptake was high, effective therapy of bladder tumors will require an increased retention of the cytotoxic radionuclide in tumor tissue.

Human biodistribution of an ultrasound contrast agent (Quantison) by radiolabelling and gamma scintigraphy.

The biodistribution and kinetics of an air filled human serum albumin microcapsule formulation (Quantison) intended for use as an intravenous ultrasound contrast agent have been examined. 12 healthy subjects were administered with approximately 50 million microcapsules per kilogram body weight, radiolabelled with 50 MBq 123I. Imaging was performed over a period of 58 h using a large field-of-view gamma camera and the amount of labelled material present in the blood, urine and faeces measured. Imaging demonstrated that the liver was the organ with the highest uptake, with a mean uptake of 41.8% (SD 10.4%) of the administered dose 1 h following administration. The maximum uptake of the agent in the lungs was low, mean 4.0% (SD 3.4%). A small amount of uptake was visible in the bone marrow; however, this was not quantifiable. There was also evidence of minimal myocardial activity within 5 min of administration. No adverse events were observed and there were no changes in any of the individual post-study indices. The present study demonstrates the safety of Quantison. Gamma scintigraphy played a useful role in confirming the biodistribution of the agent with little lung uptake, high liver uptake and evidence of myocardial uptake.

Bedside nuclear medicine investigations in the intensive care unit.

The functional nature of nuclear medicine procedures makes them especially valuable in the management of patients undergoing intensive care. However, the severe nature of the patient's condition invariably prevents him or her from attending the nuclear medicine department for diagnostic investigations. We have piloted a bedside nuclear medicine service using a four-probe detector system linked to an IBM computer with curve processing software. Protocols for a range of radionuclide probe investigations, including renal, hepatobiliary, gastric outflow and lung vascular permeability, using 99Tcm and 111In radiopharmaceuticals have been established. The measurement of lung vascular permeability in patients with clinical symptoms of adult respiratory distress syndrome was considered to be a valuable procedure on the intensive care unit. Due to the poor availability of 113Inm, which had previously been used for the measurement of lung permeability, we used a technique based on in vivo labelling of serum transferrin with 111In-chloride together with 99Tcm-red blood cells for the calculation of the plasma protein accumulation index. Other procedures include the measurement of gastric outflow in patients previously on parenteral feeding, and the assessment of hepatobiliary and renal function. The equipment proved to be reliable and convenient for use at the bedside, although ultrasound imaging was essential for the correct positioning of the probe detectors over smaller organs such as the kidneys and the gallbladder. The high sensitivity of the probe detectors required only low administered amounts of activity, minimizing radiation protection measures for patients and staff. The administration of radiopharmaceuticals via indwelling lines and tubes presented particular problems and we recommend that parenteral injections should not be given through manifold giving set, or via Teflon cannulae.

Magnetic resonance imaging in the management of fistula in ano.

Fistula-in-ano is a common condition in which accurate diagnosis of the fistula track is essential as inadequate assessment and surgical treatment may lead to multiple unnecessary operations and may also render the patient incontinent. Several studies have suggested that Magnetic Resonance Imaging (MRI) can accurately identify the fistula track in relation to the sphincter complex. The aim of this study was to investigate the value of the routine use of completely non-invasive pre-operative MRI in patients with suspected fistula-in-ano. Each scan was reported by a consultant radiologist on two occasions to determine whether the radiologist's opinion had changed and/or become more accurate with further experience. Surgical assessment of the fistula was performed under general anaesthesia by one surgeon without knowledge of the result of the MRI scan. The results of the surgical assessment and the MRI scan were compared and the surgical procedure completed. Thirty three patients with a clinical diagnosis of fistula-in-ano were treated and 27 subsequently confirmed to have a fistula. MRI detected 42% of tracks, identified correctly on initial assessment which increased to 50% at the end of the study, 63% and 74% of internal openings, 33% and 46% of external openings and 50% and 33% of abscesses. These data suggest that there is a learning curve for radiologists undertaking MRI scanning for fistula in ano, this is probably because the pathology of fistula in ano and anatomy of the anal sphincter complex are relatively new to radiologists. Routine MRI scanning of patients with fistula-in-ano is not necessary but there may be a role for MRI in assessing complex or difficult fistulae.

Lymphoscintigraphy and colour Doppler sonography in the assessment of leg oedema of unknown cause.

Oedema of the lower limbs may be associated with a number of factors, most commonly a lymphatic or venous abnormality. Generally effective treatment options are only available with venous disorders. The aim of this study is to show that a combination of duplex Doppler sonography and lymphoscintigraphy in patients with limb oedema will help to determine the aetiology and thus identify patients for whom treatment is appropriate. 32 patients presenting with unexplained oedema involving the lower limb have been studied. Each patient underwent Doppler sonography followed by lymphoscintigraphy. In 16 patients the lymphoscintigraphy was abnormal, showing absent or poorly visualized lymphatics. The Doppler study was abnormal in 17 patients, nine of whom went on to receive definitive surgical treatment. In five patients both studies were abnormal and there were six cases where both investigations were normal. It is concluded that in the great majority of referrals (82%), the combination of lymphoscintigraphy and Doppler ultrasound is a satisfactory means of assessment of patients with unexplained limb oedema.

Assessment of completeness of thyroid ablation by estimation of neck uptake of 131I on whole-body scans: comparison of quantification and visual assessment of thyroid bed uptake.

Thyroid cancer is treated by thyroidectomy followed by radioiodine ablation of the residual active tissue in the thyroid bed. Completeness of ablation can be assessed from neck images of whole-body 131I scans by visual estimation or quantitative analysis By visual assessment, ablation can be considered complete if there is no uptake in the neck or the uptake is empirically considered too small. By quantification, ablation is considered complete if neck uptake is < 1%. Further radioiodine therapy is considered necessary only if neck uptake exceeds 1% of the administered dose. Both visual assessment and quantification of thyroid bed uptake were applied to 46 scans after diagnostic or therapeutic doses of 131I had been administered to 25 patients who were being followed up for follicular or papillary carcinoma of the thyroid. The results were compared to assess the effect of either method on determining the need for a further ablative dose of 131I. Visual assessment overestimated thyroid bed uptake in 10 of 46 (22%) of the scans. Bearing in mind the unpleasantness of radioiodine ablation and the potential for bone marrow toxicity, it is recommended that quantification of neck uptake should be routinely performed as a guide to completeness of ablation and to determine the need for a therapeutic dose of the isotope. This should help to avoid unnecessary radioiodine treatment in patients with thyroid cancer.

A reproducibility study of technetium-99m macroaggregated albumin foot perfusion imaging in patients with diabetes mellitus.

The reproducibility of Technetium-99m macroaggregated albumin (99mTc-MAA) foot perfusion imaging was assessed in 14 diabetic patients with foot ulcers. Bilateral femoral intra-arterial injections of 99mTc-MAA were administered and the feet imaged with a gamma camera. Patients returned 1 week later for a repeat study. The scans of 10 patients including one unilateral amputee were evaluated. Of these 19 limbs there were 4 failed injections (21%). The remaining 15 completed repeat studies were analysed both subjectively and semiquantitatively by 2 different observers who were blind to the patient's name and scan date. Subjectively the images of each individual were similar with reports highlighting the same abnormalities. Semiquantitatively areas of increased uptake on both images were significantly correlated for each individual (Pearson's Rho correlation coefficient = 0.96, r2 = 0.92, p < 0.0001) as were areas of poor uptake reported, reflecting decreased tissue perfusion (Pearson's Rho = 0.93, r2 = 0.86, p < 0.0001). There were no side-effects. 99mTc-MAA has proven to be a safe, generally acceptable, and reproducible technique for assessing tissue perfusion in the extremities which provides an accurate means of differentiating viable from non-viable tissue in patients with foot ulcers.

Planar, SPET and three-dimensional immunoscintigraphy of suspected recurrent colorectal cancer using 111In-B72.3 (Oncoscint CR-OV): effect of administered activity.

The monoclonal antibody conjugate 111In-B72.3 was the first such antibody-based radiopharmaceutical for tumour detection to be granted a propriety product licence in Europe. However, the optimum activity of 111In for planar and SPET imaging is yet to be established. A baseline study of 20 patients with suspected recurrent colorectal cancer has been carried out to assess any effect of administered activity of radionuclide on image quality and tumour detection. Ten patients were administered 80 MBq 111In-Oncoscint and 10 patients a larger amount of activity, 150 MBq (resulting in effective dose equivalents of 25 and 47 mSv, respectively). Planar, orthogonal SPET and 3D volume-rendered SPET images were obtained and the image quality was assessed. The clinical results were compared with computed tomography (CT) and in selected patients magnetic resonance imaging (MRI). No difference in the overall tumour detection was apparent between the two groups and the use of 150 MBq 111In for planar imaging alone cannot be justified. Orthogonal and 3D SPET imaging was helpful in confirming sites of uptake and may justify the use of the higher administered amount of activity; however, false-positive results raise the need for caution in the interpretation of these images. Volume-rendered 3D images offer an attractive method of displaying antibody data and require further evaluation.

Clinical signs in scaphoid fractures.

In a prospective study we investigated 12 clinical features for scaphoid fractures in 52 patients: 23 in whom a fracture of the scaphoid was diagnosed radiologically and 29 patients in whom a fracture was clinically suspected but could not be confirmed by radiography or scintigraphy. The signs were tested within a few days of injury and again 2 weeks later. None was reliable in diagnosing a scaphoid fracture.