Early recovery after endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption: A prospective cohort study.

BACKGROUND: Groin pain is a common problem in athletes which results in loss of playing time. Moreover, it can be for the cause of athletic career termination. A common cause of groin pain in athletes is inguinal disruption; pain in the groin area near the pubic tubercle were no obvious other pathology exists to explain the symptoms. Aim of this study was to evaluate the effect of endoscopic totally extraperitoneal (TEP) hernia repair in athletes with inguinal disruption. METHODS: Thirty-one athletes with chronic groin pain due to inguinal disruption, who had undergone conservative therapy without any effect, were included in this prospective cohort study. Prior to surgery patients were assessed by clinical examination, ultrasound of the inguinal region, x-ray and a radionuclide bone scan with single photon-emission computed tomography and CT (SPECT-CT). TEP hernia repair was performed and a lightweight polypropylene mesh was placed pre-peritoneally. Additionally the athletes' perception about their groin disability was assessed preoperatively and 6 weeks postoperatively by means of the Hip and Groin Outcome Score (HAGOS). The HAGOS consists of six subscales: Pain, Symptoms, Physical function in daily living, Physical function in Sport and Recreation, Participation in Physical Activities, and hip and/or groin-related Quality of Life. RESULTS: No complications occurred during and after surgery. After six weeks patients improved in all the separate subscales of the Hip and Groin Outcome Score (HAGOS). Within 6 weeks of surgery, 26 patients (84%) returned to sports activities with no or less groin pain. CONCLUSIONS: This study showed that endoscopic totally extraperitoneal (TEP) hernia repair is an effective surgical treatment of inguinal disruption in athletes with chronic groin pain.

18F-FDG PET/CT Revealing Constrictive Pericarditis as the Only Manifestation of Malignant Mesothelioma.

A 57-year-old man presented with shortness of breath and ankle edema. Constrictive pericarditis with an unexplained mass surrounding the heart was diagnosed by ultrasound. Accordingly, F-FDG PET/CT was performed. Multiple PET-positive noduli and irregular tissue were located in the pericardium, with pleural fluid present, but without additional pulmonic or pleural pathology. A pericardiectomy was successfully performed. Histopathology and immunohistochemical staining revealed epithelioid mesothelioma.

Lactate dehydrogenase levels and 18F-FDG PET/CT metrics differentiate between mediastinal Hodgkin's lymphoma and primary mediastinal B-cell lymphoma.

PURPOSE: This study aims to investigate whether clinical, laboratory, and fluorine-18-fluorodeoxyglucose (F-FDG) PET/CT findings can discriminate between mediastinal Hodgkin's lymphoma and primary mediastinal B-cell lymphoma (PMBCL). PATIENTS AND METHODS: This retrospective study included 56 patients (42 with mediastinal Hodgkin's lymphoma and 14 with PBMCL). Differences in clinical, laboratory, and F-FDG PET/CT metrics were assessed between Hodgkin's lymphoma and PMBCL. RESULTS: Lactate dehydrogenase (LDH) and F-FDG PET/CT-based maximum tumor diameter, lesion-to-liver ratio maximum standardized uptake value (SUVmax), and lesion-to-liver ratio peak standardized uptake value (SUVpeak) were all significantly higher (P<0.001) in PMBCL than in Hodgkin's lymphoma, and PMBCL also significantly more frequently (P=0.001) exhibited necrosis on F-FDG PET/CT than Hodgkin's lymphoma. LDH, maximum tumor diameter, lesion-to-liver ratio SUVmax, and lesion-to-liver ratio SUVpeak yielded areas under the receiver operating characteristic curve of 0.968 [95% confidence interval (CI): 0.923-1.000], 0.866 (95% CI: 0.765-0.968), 0.875 (95% CI: 0.776-0.975), and 0.874 (95% CI: 0.771-0.976), respectively. LDH (with cutoff of 236 U/l) achieved sensitivity and specificity of 81.6 and 100%, respectively; maximum tumor diameter (with cutoff of 9.98 cm) achieved sensitivity and specificity of 87.2 and 78.3%, respectively; lesion-to-liver ratio SUVmax (with cutoff of 7.12) achieved sensitivity and specificity of 94.9 and 64.3%, respectively; lesion-to-liver ratio SUVpeak (with cutoff of 11.45) achieved sensitivity and specificity of 97.4 and 64.3%, respectively; and the presence of necrosis achieved sensitivity and specificity of 78.6 and 74.4%, respectively, in discriminating PMBCL from Hodgkin's lymphoma. CONCLUSION: LDH levels and several F-FDG PET/CT findings (tumor size, presence of necrosis, and degree of F-FDG uptake) are helpful in discriminating mediastinal Hodgkin's lymphoma from PMBCL.

The predictive value of C-reactive protein and erythrocyte sedimentation rate for 18F-FDG PET/CT outcome in patients with fever and inflammation of unknown origin.

OBJECTIVES: The objective of this study was to determine the predictive value of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to a positive fluorine-18 fluorodeoxyglucose ((18)F-FDG) PET/computed tomography (CT) result in patients with inflammation of unknown origin and fever of unknown origin. PATIENTS AND METHODS: Individual data of 498 patients were retrieved from three retrospective studies. Receiver operating characteristic derived areas under the curve were used to assess (18)F-FDG PET/CT versus age, CRP, and ESR. The discriminative value of age, CRP, and ESR related to (18)F-FDG PET/CT was examined using the net reclassification improvement (NRI). RESULTS: A diagnosis was established in 331 patients; (18)F-FDG PET/CT had a diagnostic accuracy of 89%. (18)F-FDG PET/CT had the highest area under the curve (0.89, P<0.001). The addition of (18)F-FDG PET/CT to a diagnosis prediction model including age, CRP, and ESR resulted in an NRI of 42% (P<0.001). In the same model with CRP values below 20 mg/l or ESR values below 20 mm/h, the NRI was 64% (P<0.001) and 29% (P=0.059), respectively. In 30 of 91 patients with CRP less than 10 mg/l, a diagnosis could be established; (18)F-FDG PET/CT was 100% true negative only in patients with CRP levels less than 5 mg/l. CONCLUSION: In patients with fever of unknown origin or inflammation of unknown origin, compared with elevated ESR levels, elevated CRP levels more often indicate a true positive (18)F-FDG PET/CT outcome.In addition, (18)F-FDG PET/CT, compared with CRP and ESR, shows the highest discrimination of patients with possible disabling disease.

Primary Epstein-Barr virus infection diffusing F18-fluorodeoxyglucose-positron emission tomography/computed tomography response monitoring of Hodgkin's disease: a case report.

INTRODUCTION: Hodgkin's disease is highly curable by radiotherapy and/or chemotherapy, but refractory disease or early relapses are rarely cured by conventional salvage therapy. CASE PRESENTATION: We report a case of a 20-year-old Caucasian man, with a biopsy-proven intrapulmonary relapse of Hodgkin's disease, for whom salvage chemotherapy was administered. During salvage chemotherapy intense increased F18-fluorodeoxyglucose uptake was noticed in multiple lymph nodes and diffuse increased splenic uptake, suggesting chemotherapy-refractory disease. However, additional information obtained from the patient revealed he recently had met his first girlfriend. An asymptomatic primary Epstein-Barr virus infection was considered proven. CONCLUSIONS: Interim F18-fluorodeoxyglucose-positron emission tomography/computed tomography is a strong prognostic factor for advanced Hodgkin's and may better identify those patients needing intensified chemotherapy. Related to the nonspecificity of F18-fluorodeoxyglucose, clinical awareness of the potential interference of intercurrent asymptomatic viral infections with treatment and remission status monitoring continues to be important in the interpretation of equivocal medical imaging results.

Diagnostic utility of (18)F-FDG PET/CT in inflammation of unknown origin.

OBJECTIVES: The goal of this multicenter retrospective study was to evaluate the contribution of F-FDG PET/CT in the diagnosis of patients with inflammation of unknown origin (IUO). In addition, C-reactive protein (CRP) level and erythrocyte sedimentation rate were assessed as possible predictors for the outcome of F-FDG PET/CT. METHODS: Inflammation of unknown origin was defined as prolonged and perplexing inflammation, with repeated CRP levels more than 20 mg/L or erythrocyte sedimentation rate more than 20 mm/h, body temperature of less than 38.3°C, and without a diagnosis after a variety of conventional diagnostic procedures.A total of 140 patients with IUO (67 men, 73 women; mean age, 64.2 years; age range, 18-87 years) underwent F-FDG PET/CT. F-FDG PET/CT was considered helpful when the imaging findings led to a diagnosis, either confirmed by histopathology, microbiological assays, clinical and imaging follow-up, or response to treatment. RESULTS: In 104 patients (73%), a final diagnosis could be established as follows: infection in 35 patients, malignancy in 18 patients, noninfectious inflammatory disease in 44 patients, and a variety of uncommon conditions in 7 patients. F-FDG PET/CT was true positive in 95 patients, true negative in 30 patients (ie, self-limiting conditions), false positive in 6 patients, and false negative in 9 patients (predominantly systemic diseases). In this population, the positive predictive value, negative predictive value, and diagnostic accuracy of F-FDG PET/CT were 94%, 77%, and 89%, respectively. In a multivariate analysis, CRP was the only independent predictor for the outcome of F-FDG PET/CT. CONCLUSIONS: F-FDG PET/CT correctly identified or excluded a causal explanation in approximately 90% of patients with IUO. However, a negative F-FDG PET/CT is indicative for a self-limiting condition only after systemic diseases are excluded by other diagnostic tests.

Diffuse renal parenchyma uptake with bone scintigraphy in a patient with paroxysmal nocturnal hemoglobinuria and normal kidney function.

A 41-year-old woman with a Harrington spondylodesis presented with lower back pain. Bone scintigraphy showed diffusely increased parenchymal uptake in both kidneys. She reported 2 previous periods of dark, almost black, urine. Additional flow cytometric analysis confirmed the diagnosis of paroxysmal nocturnal hemoglobinuria. The increased renal parenchyma uptake is very probably due to paroxysmal nocturnal hemoglobinuria-related renal hemosiderosis. Remarkably, the patient did not develop any abnormality of renal function.

Unilateral hyperlucent lung in a child caused by a foreign body identified with v/q scintigraphy.

A 5-year-old girl presented with episodes of coughing, inspiratory stridor, and occasionally squeaking breath sounds. There was no history of a foreign body aspiration. Initially, she was diagnosed with allergic asthma. However, signs and symptoms continued despite a trial of inhaled corticosteroids. A chest radiograph showed a hyperlucent right lung, mainly in the upper lobe, with decreased vascular markings compatible with Swyer-James-MacLeod syndrome, or foreign body aspiration. V/Q imaging showed markedly diminished right lung ventilation and perfusion, especially in the upper lobe, with a hot spot in the area of the right bronchus. At bronchoscopy, a pistachio nutshell was removed from the right main bronchus.

Assessment of ovarian teratoma and lymphadenopathy by 18F-FDG PET/CT.

Two women presented with abdominal complaints; after clinical investigation and ultrasonography, both were suspected of having (ovarian) teratoma. The CT scan showed enlarged para-aortic lymph nodes, which increased the suspicion of a malignant process. Total-body 18F-FDG PET/CT studies helped to differentiate benign from malignant ovarian teratoma, as well as abdominal lymphadenopathy, subsequently confirmed by histopathology. When there is suspicion of a malignant teratoma, 18F-FDG PET/CT may help in accurate diagnosis and staging; as for malignant disease (either malignant transformation of mature cystic teratoma or malignant immature teratoma), a more aggressive, multimodality approach may be indicated.

Suppression of 18F-FDG Myocardial Uptake Using a Fat-Allowed, Carbohydrate-Restricted Diet.

UNLABELLED: Patients prepared by the generally used fasting protocol show variable myocardial (18)F-FDG uptake, which may result in difficult interpretation of mediastinal (18)F-FDG uptake. This retrospective study described the effect of a 1-d fat-allowed, carbohydrate-restricted diet on myocardial (18)F-FDG uptake. METHODS: The study included 100 patients on a carbohydrate-restricted diet from the Medical Center Leeuwarden and 100 patients on an unrestricted diet from the University Medical Center of Utrecht. A visual uptake scale was used, with category 0 indicating myocardial uptake less than liver uptake, category 1 indicating myocardial uptake comparable to liver uptake, and category 2 indicating myocardial uptake considerably higher than liver uptake. RESULTS: After a carbohydrate-restricted diet, 68% of patients had a homogeneously low myocardial uptake of (18)F-FDG (category 0), 14% had moderate myocardial uptake (category 1), and 18% had homogeneously intense myocardial uptake (category 2). Without a carbohydrate-restricted diet, 69% of patients showed a homogeneously intense myocardial uptake (category 2), 16% a moderate myocardial uptake (category 1), and 15% a homogeneously low myocardial uptake (category 0). CONCLUSION: A fat-allowed, carbohydrate-restricted diet starting the day before (18)F-FDG administration suppresses myocardial (18)F-FDG uptake satisfactorily.

18F-FDG PET as a routine posttreatment surveillance tool in oral and oropharyngeal squamous cell carcinoma: a prospective study.

UNLABELLED: The purpose of this study was to evaluate the role and timing of serial (18)F-FDG PET scans as routine surveillance for detecting early locoregional recurrence, distant metastases, and second primary tumors in patients treated for advanced squamous cell carcinoma (SCC) in the oral cavity or oropharynx during the first year after completion of their curative treatment. METHODS: Forty-eight consecutive patients with SCC in the oral cavity or oropharynx were included after completing their initial therapy with curative intent. Prospective follow-up of the participants was 2-fold: regular follow-up (history and physical examination) and serial (18)F-FDG PET scans. Patients underwent standard follow-up and (18)F-FDG PET at 3, 6, 9, and 12 mo after initial treatment. Findings were validated by histopathology or 18 mo of clinical follow-up and imaging after initial treatment. RESULTS: Incidence of recurrences and second primary tumors was 27% and 10%, respectively. (18)F-FDG PET was significantly (P = 0.035) more often in agreement with the gold standard than was regular follow-up. (18)F-FDG PET showed a sensitivity, specificity, positive predictive value, and negative predictive value of 100%, 43%, 51%, and 100%, respectively. For regular follow-up, these values were 0%, 60%, 0%, and 50%, respectively. (18)F-FDG PET accounted for a change in diagnostics or treatment in 63% of the patients and regular follow-up in 25% of the patients. Sensitivity and specificity of (18)F-FDG PET were both irrespective of timing of (18)F-FDG PET. For the 3- and 6-mo posttherapy results combined, (18)F-FDG PET detected malignancy in 16 of the 18 patients. CONCLUSION: (18)F-FDG PET is a suitable routine posttreatment surveillance tool in oral and oropharyngeal SCC patients and detects malignancy before clinical suggestion by the regular follow-up arises. The best timing of a systematic (18)F-FDG PET scan is between 3 and 6 mo after treatment.

High F-18 FDG uptake in bone marrow by cytokines secreting ectopic mucoepidermoid carcinoma.

A 57-year-old woman, just returned from a bicycling holiday in the mountains, presented with discomfort, hoarseness and chronic cough complaints. After chest x-ray, bronchoscopy and fluoro-deoxy-glucose positron emission tomography/computed tomography (F-18 FDG PET/CT), a diagnosis of a tumor in the bronchus of the right upper lobe with obstruction pneumonia was made. After lobectomy of the right upper lobe, pathology revealed an ectopic bronchial low-grade mucoepidermoid carcinoma.The diffuse high FDG uptake in the bone marrow standardized uptake value (SUV mean 3.6 and max 5.2) is unlikely to be related to bone marrow stimulation due to pneumonia, but correlates with a high serum level of correlated with transforming growth factor-beta (TGF-beta1) secreted by the low-grade bronchial mucoepidermoid carcinoma.

F-18 FDG PET/CT in the diagnosis of fever of unknown origin.

METHODS: The utility of Fluorine-18 fluorodeoxyglucose positron emission tomography/CT in identifying the causal source was assessed in this retrospective study. A total of 68 patients (33 men, 35 women; age range, 23-91 years) with fever of unknown origin (FUO) underwent a positron emission tomography/computed tomography (PET/CT) scan. PET/CT was considered helpful when abnormal results allowed an accurate diagnosis, based on histopathology, microbiologic assays, or clinical and imaging follow-up. RESULTS: PET/CT demonstrated suspected pathologic foci of Fluorine-18 fluorodeoxyglucose (F-18 FDG) uptake in 41 patients (60%), in 38 of these 41 patients (93%) F-18 FDG PET/CT helped in identifying the causal source, including infection in 25 patients, inflammation in 11 patients, a benign neoplasm in 1 patient, and in 1 patient rejection of a pancreas transplant. In 27 negative F-18 FDG PET/CT studies, no focal pathologic disease was diagnosed in the follow-up. In 6 of these 27 patients, a systemic disease without a focal manifestation was the cause for FUO. In the remaining 21 patients, fever and other signs subsided during follow-up. CONCLUSION: Overall 56% of the F-18 FDG PET/CT studies contributed in the identification of the source in patients with FUO, and elevated erythrocyte sedimentation rate and C-reactive protein (positive predictive value 93%). When systemic diseases are excluded F18-FDG PET/CT has a high negative predictive value for focal etiologies of FUO (negative predictive value 100%).

Diagnosis of abdominal aortic prosthesis infection with FDG-PET/CT.

A 79-year-old man was referred with recurrent periods of fever and chills. Six years earlier an aortic bifurcation graft had been implanted. Blood examination showed elevated infection parameters. A regular computed tomographic (CT) scan in the previous hospital showed no signs of graft infection. When blood cultures revealed multiple enteric bacteria, a 2-deoxy-2-[F18]fluoro- d-glucose-positron emission tomographic/CT (FDG- PET/CT) scan was performed that demonstrated ring-shaped pathological uptake at the proximal anastomosis. The patient was operated on and an infected graft was found, with a 1-cm defect in the distal part of the duodenum. Bacterial cultures of the explanted graft were positive. The patient recovered well from surgery and is on a regimen of prolonged antibiotic and antimycotic treatment.

Repetitive phosphorus-32 peritoneal instillations in a patient with malignant ascites.

During the last decade, intraperitoneal injection of phosphorus-32 chromic phosphate (P-32 CP) has been used principally for its initial intended purpose, the palliative management of malignant ascites. The authors describe a patient with a stage IIIB well-differentiated extraovarian peritoneal serous papillary adenocarcinoma. As a palliative treatment for malignant ascites, P-32 CP was instilled intraabdominally eight times. Adverse effects were limited to the third instillation, when abdominal pain occurred as a result of leakage of the P-32 CP in the subcutaneous tissue. The P-32 CP instillations reduced the frequency of paracentesis for almost 1 year, until disease progression prevented palliation. Considering the few palliative options, there could be more widespread use of P-32 CP as a palliative treatment for patients with malignant ascites caused by ovarian cancer or extraovarian peritoneal adenocarcinoma. However, intraperitoneal P-32 CP is not without potential intestinal complications, which must be considered before it is recommended.