Familial diagnostic experiences in paediatric oncology.

BACKGROUND: Diagnostic delays may not have significant prognostic implications in paediatric oncology, but psychological impacts remain understudied. METHODS: Interviews exploring diagnostic experiences were conducted with childhood cancer survivors (n=19), parents (n=78) and siblings (n=15). RESULTS: Median diagnostic time was 3 weeks. Participants described a mixture of rapid diagnoses (28.9%), plus delayed appraisal intervals (that is, parent- or patient-associated diagnostic delays; 40.0%) and diagnostic intervals (that is, healthcare-associated delays; 46.7%). Families experiencing delays described guilt and anger and deleterious impacts on the family-clinician relationship. Some believed delays impacted on treatment and prognosis. CONCLUSIONS: The effect of the diagnostic experience can be considerable.

Superimposition of PET images using 18F-fluorodeoxyglucose with magnetic resonance images in patients with pancreatic carcinoma.

Six patients with histologically proven adenocarcinoma of the pancreas were studied using 2-deoxy-2-[18F]-fluoro-D-glucose (18F-FDG) using positron emission tomography (PET), and magnetic resonance imaging (MRI). In all six cases there was avid accumulation of 18F-FDG within the pancreatic tumour and clear visualization of the tumour on the MRI images. Delineation of the tumours was aided by superimposition of the images from the two imaging methods, which was achieved by using a system of surface markers.

Positron emission tomography: 2-deoxy-2-[18F]-fluoro-D-glucose uptake in locally advanced breast cancers.

Fifteen patients with locally advanced breast cancers were studied using the radiopharmaceutical 2-deoxy-2-[18F]-fluoro-D-glucose (FDG) with positron emission tomography (PET). Five patients were sequentially imaged before and after two pulses of chemotherapy. In 14 of 15 tumours increased uptake of FDG was observed which correlated with the clinical site of the tumour. The PET images were compared with the mammographic and ultrasonomammographic appearances of the tumours in selected patients. In two patients with normal mammograms PET imaging detected the tumour and in a further four patients, with suspicious but not conclusively malignant mammographic changes, a well-defined area of increased FDG uptake was demonstrated by PET. In all five sequentially imaged tumours, following chemotherapy, there was a decrease of the FDG tumour: normal breast uptake ratio. In four patients who completed a full chemotherapeutic course this change preceded a pathological response of their tumours. These findings suggest that this technique may be of benefit in imaging carcinomas in the breasts of pre-menopausal women which may appear dense on mammography and moreover, that sequential imaging may have a role in the prediction, at an early stage, of the response of locally advanced carcinomas to chemotherapy.

Measurement of lower limb blood flow in patients with neurogenic claudication using positron emission tomography.

STUDY DESIGN: Ten subjects (seven with neurogenic claudication and three control subjects) underwent examination of lower limb muscle blood flow before and after exercise using positron emission tomography. OBJECTIVES: To investigate the hypothesis that lower limb muscle ischemia was the origin of symptoms in neurogenic claudication. BACKGROUND: Patients with neurogenic claudication secondary to spinal stenosis experience lower limb discomfort after exercise similar to that of ischemic claudication. However, they do not have clinical evidence of peripheral vascular disease. The authors postulated that the lower limb discomfort in patients with neurogenic claudication may arise from muscle ischemia due to inadequate dilatation of arterioles in response to exercise, this itself arising secondary to sympathetic dysfunction due to spinal stenosis. METHOD: Using O15-labeled water and positron emission tomography measured thigh and leg muscle blood flow response to exercise bilaterally in seven patients with unilateral neurogenic claudication and three control subjects were measured. RESULTS: The average values obtained for mid-thigh and mid-calf muscle perfusion at rest were 2.57 ml/min/100 g tissue (2.23-3.90) and 2.39 ml/min/100 g tissue (2.03-3.46), respectively. The average values obtained from mid-thigh and mid-calf perfusion after exercise were 4.41 ml/min/100 g tissue (2.8-6.0) and 4.87 ml/min/100 g (2.2-11.7). We found no difference in muscle perfusion between symptomatic and asymptomatic limbs in this group of patients. CONCLUSION: These studies suggest that muscle ischemia is not the origin of symptoms in most patients with neurogenic claudication.

Assessment of left ventricular regional wall motion with blood pool tomography: comparison of 11CO PET with 99Tcm SPECT.

Left ventricular contraction is routinely assessed by radionuclide ventriculography. Although a planar image is conventionally used, tomography has been to improve the detection of wall motion abnormalities. A blood pool image is often used in positron emission tomography on which to superimpose metabolic tracers. Can this image also be used to assess left ventricular contraction? Nine healthy controls, mean (S.D.) age 55 (5) years, and 12 patients, mean (S.D.) age 61 (8) years, with normal, proven or suspected left ventricular damage underwent blood pool tomography with 11CO positron emission tomography (PET) and 99Tcm single photon emission computed tomography (SPECT). A normal value of ejection fraction and range of phase were defined. The normal left ventricular ejection fraction was > or = 37% for PET and > or = 40% for SPECT. The ejection fractions obtained by the two methods in the patient group were positively correlated (r = 0.89, P < 0.001). Abnormalities of left ventricular contraction were detected in nine patients by PET and 10 patients by SPECT imaging. The discrepancy was in a patient with a previous inferior myocardial infarction. Blood pool imaging with 11CO PET can be used to assess left ventricular ejection fraction and regional wall motion.

Study of left and right ventricular function in Romano-Ward syndrome.

OBJECTIVE: To examine left and right ventricular contraction in Romano-Ward syndrome: does abnormal myocardium affect the predisposition to arrhythmia? DESIGN: Tomographic radionuclide ventriculography was performed after the red blood cells were labelled conventionally with stannous pyrophosphate and technetium-99m. SETTING: Department of Nuclear Medicine, Aberdeen Royal Infirmary. PATIENTS: Eight subjects from two families known to have Romano-Ward syndrome, four of whom (two from each family) had had symptoms. RESULTS: The five subjects from family 1 had normal left ventricular contraction; two had subtle abnormalities of right ventricular phase. in family 2 all three subjects had abnormal left ventricular contraction (reduced amplitude in three, abnormal phase in two). All had subtle abnormalities of right ventricular phase. CONCLUSION: Abnormal right or left ventricular myocardium may be partly or wholly responsible for the repolarisation changes seen on the electrocardiogram of these families or may act as an ectopic focus to start ventricular tachycardias in a susceptible heart.

Measurement of blood flow in tibial fracture patients using positron emission tomography.

The quantification of local bone blood flow in man has not previously been possible, despite its importance in the study of normal and pathological bone. We report the use of positron emission tomography, using 15O-labelled water, to measure bone blood flow in patients with closed unilateral fractures of the tibia. We compared fractured and unfractured limbs; alterations in blood flow paralleled those found in animal models. There was increased tibial blood flow at the fracture site as early as 24 hours after fracture, reaching up to 14 times that in the normal limb at two weeks. Blood flow increase was less in displaced than in undisplaced fractures. The muscle to bone ratios of blood flow were similar to those in previous animal work using other techniques. Positron emission tomography will allow study of human bone blood flow in vivo in a wide variety of pathological conditions.

Pattern of 2-deoxy-2-[18F]-fluro-D-glucose accumulation in liver tumours: primary, metastatic and after chemotherapy.

Eight patients with liver metastases from adenocarcinoma of the colon or rectum, two with suspected hepatic metastases and one with primary hepatoma were studied with 2-deoxy-2-[18F]-fluro-D-glucose (18F-FDG) using positron emission tomography (PET). In five of the patients with metastatic tumour a second examination was performed four weeks after treatment with recombinant interleukin-2 (rIL2) and fluorouracil (5FU). In all tumours (one primary and eight metastatic) the radioactivity was seen to accumulate in a rim around each tumour with a large central area showing no uptake. In the five cases imaged after treatment with rIL2, the appearance of the tumour uptake was the same as before treatment. In the two cases of suspected but not proven metastases, no abnormal accumulation of 18F-FDG was seen.

Regional cerebral blood flow imaging: a quantitative comparison of technetium-99m-HMPAO SPECT with C15O2 PET.

The aim of this study was to compare technetium-99m-hexamethylpropyleneamineoxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) with regional cerebral blood flow (rCBF) imaging using positron emission tomography (PET). As investigation of dementia is likely to be one of the main uses of routine rCBF imaging, 18 demented patients were imaged with both techniques. The PET data were compared quantitatively with three versions of the SPECT data. These were, first, data normalized to the SPECT cerebellar uptake, second, data linearly corrected using the PET cerebellar value and, finally, data Lassen corrected for washout from the high flow areas. Both the linearly-corrected (r = 0.81) and the Lassen-corrected (r = 0.79) HMPAO SPECT data showed good correlation with the PET rCBF data. The relationship between the normalized HMPAO SPECT data and the PET data was nonlinear. It is not yet possible to obtain rCBF values in absolute units from HMPAO SPECT without knowledge of the true rCBF in one reference region for each patient.

Combining imaging techniques.

There are many potential advantages in being able to compare corresponding images produced by different modalities. For example, the fine anatomical detail produced by MRI can be combined with the functional data from SPET. Using brain imaging as an example, techniques for selecting the image plane, displaying the images and quantifying the data are discussed.

Gated cardiac tomography.

An ECG gated tomographic system is described and its application to routine diagnosis of cardiac wall dyskinesis discussed. The tomographic sections are gathered by a single section scanning system (Aberdeen Section Scanner). Technetium labelled red blood cells are used as the imaging agent. The time of the occurrence of the ECG R-wave is superimposed on the tomographic projection data stream and the gated images produced subsequently. The average patient study requires 15 min. Images at 8 phases of the cardiac cycle are generated at each of 5 levels, 16 mm apart, covering the length of the left ventricle. The images are stored as a three dimensional matrix and may be analysed in sections at any orientation. Fourier analysis of computer generated short axis sections are used to generate a set of coefficients describing the contraction of the left ventricle. The coefficients for each patient study are displayed as a series of two dimensional polar images, schematically displaying the spatial distribution of the coefficient over the left ventricle. These polar images are further analysed by comparison with distributions obtained from normal patient studies. The calculated deviations from the normal are then used to diagnose the magnitude and position of any dyskinesis. Initial results show that the tomographic system is capable of routinely detecting inferior cardiac wall dyskinesis, showing an advantage over non tomographic techniques.

Technetium-99m HM-PAO stereoisomers as potential agents for imaging regional cerebral blood flow: human volunteer studies.

A total of nine normal volunteer subjects were studied with three forms of [99mTc] hexamethylpropyleneamineoxime (HM-PAO), a potential cerebral blood flow imaging agent. One, the d,l isomer, showed 4.1% uptake in the brain which remained constant over 8 hr. There was good differentiation between uptake in gray and white matter on tomographic slices. We propose that this agent may allow regional cerebral blood flow imaging to be performed on a routine basis.

The Aberdeen Mark II single-photon-emission tomographic scanner: specification and some clinical applications.

The construction, operation and physical characteristics of a single-section multi-detector single-photon-emission scanner are described. The machine has 24 detectors arranged along the sides of a square. Movements and data collection are under the control of a series of distributed microprocessors. Both head and trunk tomograms can be produced. The spatial resolution at the collimator focus is 9 mm in the transverse plane, and the effective slice thickness is 14 mm. The volume sensitivity is 300 counts/s kBq ml with a 20 cm diameter cylindrical phantom filled with 99Tcm solution. The application of this machine to the examination of the brain, liver and heart has been found to be clinically useful.

Considerations of radiofrequency induction heating for localised hyperthermia.

A finite difference technique for studying both spatial and temporal variations in temperature in tissues subjected to local hyperthermia is described. The calculation offers speed and simplicity whilst remaining stable. Its form is discussed in both 3-dimensional Cartesian coordinates and cylindrical coordinates. The technique is used to predict RF induction heating of a plane skin-fat-muscle model. Physical and physiological parameters are incorporated. These include the contributions to heating from both E and H fields associated with a plane coil, heat transfer across the skin surface for various environmental conditions, and an appropriate dependence of blood flow on temperature for each tissue layer. The effects on tissue temperature of varying each of a number of parameters in the model are considered.

Diffusion of oxygen through the mouse ear.

Oxygen tension differences across the mouse ear have been measured polarographically under conditions of no blood flow. For some experiments the ear was split into two by cleavage along the central cartilage plate, and the diffusion of oxygen measured in both directions across these asymmetrical preparations. Measurements were also made on ears from which the stratum corneum had been removed by stripping with Sellotape. It was possible to relate these results to a simple multi-layer diffusion model. The main barrier to diffusion of oxygen resides in the stratum corneum, whose permeability is estimated to be 1 . 2 X 10(-8) ml O2 atm-1 cm-1 S-1. The permeability of the rest of the ear is 4 . 7 X 10(-7) ml O2 atm-1 cm-1 S-1. The inhibition of tissue respiration by the local injection of solutions of sodium amytal, potassium cyanide and other substances reduced the oxygen gradients by factors of between 3 and 7. Cooling the ear from room temperature to 0 degree C reduced the gradients by a factor of about 4.