Metabolic responses in non-small cell lung cancer after hypofractionated stereotactic radiotherapy PET and hypofractionated radiotherapy.

BACKGROUND: The aim of our study was to evaluate the pattern of local failure after stereotactic body radiotherapy (SBRT) of non small cell lung cancer (NSCLC) lesions relating to different type of 18F-FDG positron emission tomography (PET) response. METHODS: Thirteen NSCLC patients for a total of 15 lesions (primary early or locally advanced and metastases) underwent PET before and 6 months after SBRT. Maximum standard uptake value (SUVmax) <2.5 was considered as cut off for complete response (CR) while lesion reduction > or =50% with residual value above 2.5 for partial response (PR). RESULTS: With a median follow up of 30 months pre- and post-SBRT mean SUV max values were 8.2 (range 14.2-3.7) and 2.4 (range 12.9-0), respectively. No "in field recurrence" was observed while 3 cases of "out field recurrence" occurred as regional nodes progression at 7.8 and 14 months after treatment. Three years overall survival, local control and distant metastases free survival were respectively 66.7%, 63.3% and 44.4%. Actuarial 75% and 53.3% 3-year local control, 60% and 40% 3-years distant metastases free survival were observed for complete and partial PET response, respectively, after SBRT. Thereafter, 60% and 50% 3-year overall survival were observed for complete and partial response. CONCLUSIONS: Clinical results were significantly better for "responder" than "non responder" and for "complete" than "partial response" group. Moreover, our data seem to confirm that a significant subset of patients maintain a low metabolic activity without developing local relapse on longer follow up.

The dilemma of diagnosing fever of unknown origin: large arteries vasculitis revealed by 18F-FDG PET/CT imaging. A case report.

Fever of unknown origin (FUO) is an uncommon disease, and its underlying etiology may include a number causes, i.e., infections, malignancies, autoimmune conditions. Diagnosis is often a difficult task, and usually physician spend time and money in order to define the etiology of FUO. We report a case of patient who presented with FUO and headache, and positron emission tomography (PET) with 2-deoxy-2-[fluorine-18] fluoro-D-glucose (18F-FDG) allowed to reveal the presence of a large vessel vasculitis. 18F-FDG PET may represent an useful tool in patients with FUO, since it can early depict an hypermetabolic activity due to inflammation and so help to achieve a final diagnosis in some cases of FUO.

Repeated brain conventional MRI and SPECT evaluation in systemic lupus erythematosus patients with and without neuropsychiatric involvement: a follow up study.

OBJECTIVES: To assess the utility of a combined neuroimaging approach in the follow up of patients affected by systemic lupus erythematosus (SLE) with and without neuropsychiatric (NP) involvement. METHODS: Patients who underwent a first combined brain conventional magnetic resonance imaging (cMRI) and single photon emission computed tomography (SPECT) and later repeated the same examinations between 2001 and 2008 were retrieved from a large database. Clinical and neuroimaging data were analysed and their relationships evaluated at baseline and at follow up. RESULTS: Fifty SLE patients (38 with and 12 without NP involvement, mean age 36.8 yrs and mean disease duration at first instrumental evaluation 5.5 yrs) were enrolled. At baseline, the majority of them had a diffuse pattern of NP involvement. After a mean follow up period of 4 years all patients repeated neuroimaging and clinical evaluation. In 23 patients (22 with and 1 without NP manifestations at baseline) a new NP event occurred. Overall, neuroimaging remained unchanged or improved, but in some cases it worsened. No correlations were found between instrumental findings and clinical picture. CONCLUSIONS: In this study, the clinical features at baseline appeared to be a better predictor of future NP events than morphological and functional neuroimaging. Therefore the utility of repeating a combined instrumental evaluation (cMRI and SPECT) may be debatable especially for patients with diffuse NP involvement where the decision to perform serial combined neuroimaging examinations should be carefully assessed and based mainly on clinical judgement.

A practical method for the estimation of therapeutic activity in the treatment of Graves' hyperthyroidism.

AIM: To test the efficacy of a practical method which allows the calculation of personalized activity in Graves' disease. METHODS: The method is based on International Commission of Radiological Protection (ICRP) 53 data. The model allows the prediction of the activity administered in order to release 300 Gy to the thyroid, once its iodine uptake and mass are known. We applied it to 289 patients investigated by clinical examination, biochemical assessment and neck ultrasonography. The method was applied considering the thyroid 131I uptake and the ultrasound mass. The patients were followed by check of TSH, FT3, FT4 and clinical examination. Finally, we evaluated the difference between our dosimetric method and the hypothetic administration of a fix amount of 131I (185, 370 and 600 Mbq respectively) in term of adsorbed dose. RESULTS: The average activity administered was 403.3+92.5 MBq with an average dose released to thyroid of 304.9+24.8 Gy. From a statistical point of view the administration of standard activities (185 and 600 MBq) would represent respectively a wrong estimate of the optimal dose (meanly 140.8+44.7 Gy and 473.6+142.6 Gy respectively). The administration of a standard activity (370 MBq) would release a dose close to that prescribed (291.2 Gy) with a standard deviation (86.9 Gy), which is considerably higher than the one obtained with the dosimetric model (24.8 Gy). Twenty four months after radioiodine treatment, 57.8% of patients presented hypothyroidism, 23.2% euthyroidism and 19% of hyperthyroidism. The overall therapeutic efficiency was of 81%. CONCLUSION: The dosimetric method based on IRCP 53 data, is effective in controlling Graves' hyperthyroidism. Advantages in adopting this method are: dose optimization to patient, easy implementation in the clinical practice, low budget impact.

[18FDG-PET and large vessel vasculitis: preliminary data on 25 patients]. / 18FDG-PET e vasculiti dei grandi vasi: studio preliminare su 25 pazienti.

OBJECTIVE: To evaluate the predictive value of clinical and biochemical features when compared to 18FDG-PET in the diagnostic work-up of large vessel vasculitis (LVV). METHODS: Twenty-five patients underwent 18FDG-PET for the clinical suspect of LVV. All of them presented history of systemic symptoms lasting >or=6 months and laboratoristic evidence of persistently high markers of inflammation. The patients were stratified according with: i) clinical manifestations, defined as presence of one or more ACR criteria for the classification of LVV; ii) laboratory investigations: Erythrocyte Sedimentation Rate (ESR) higher or lower than 50 mm/h, C-Reactive Protein (CRP) higher or lower than 2 mg/dl; iii) prednisone dose in the 4 weeks preceding PET examination. RESULTS: The total number of positive PET was higher in the group without clinical ACR criteria and in the group with inflammation markers under the established cut-off. The number of scans consistent with LVV was higher in the groups presenting one or more clinical criteria for LVV but in those with very high ESR and CRP. In all the cases differences between groups were not statistically significative. A clear cut negative correlation between steroid dose and number of scans suggestive for LVV has been observed. CONCLUSIONS: Diagnosis of LVV remains challenging, especially in patients presenting with a constellation of non-specific symptoms and laboratory findings. In this study, both clinical and biochemical features show low correlation with a vasculitic pattern of FDG uptake. In our experience 18FDG-PET represents an useful diagnostic tool in early stages of LVV and a powerful instrument to follow the treatment responses.

Single photon emission computed tomography and magnetic resonance imaging evaluation in SLE patients with and without neuropsychiatric involvement.

OBJECTIVE: To assess the relationship between clinical picture and neuroimaging in patients affected by SLE with and without neuropsychiatric (NP) involvement. METHODS: One hundred and seven SLE patients including 66 with NP involvement (NPSLE) with focal or diffuse presentation and 41 without underwent single photon emission computed tomography (SPECT) and MRI. RESULTS: After stratification for diffuse or focal NP involvement, in the 52 patients with diffuse presentation, abnormalities detected with MRI or SPECT did not differ from patients without NP; however, after combining the two techniques, a normal result was more frequently observed in patients without NP involvement (P = 0.010). In the 14 patients with focal presentation, MRI alone and concordant abnormal MRI plus SPECT were more frequently detected in the NPSLE group; again normal findings by both techniques simultaneously applied were more frequently found in SLE patients without NP involvement. White matter hyperintense T2-weighted lesions were the most frequent MRI abnormal findings in both groups, but the presence of multiple lesions (>5) involving both the hemispheres at subtentorial level was limited to NPSLE patients. Multifocal hypoperfused SPECT areas were more frequently observed in frontal and parietal lobes of NPSLE. CONCLUSIONS: Combining SPECT and MRI appears more useful than the two techniques alone and may help the clinician in the assessment of patients with NP involvement since normal findings contemporarily detected by these two techniques have been rarely observed in patients with NP involvement especially in those with focal manifestations where MRI and SPECT were never simultaneously normal.

Radiolabelled somatostatin analogs for diagnosis and radio-guided surgery of neuroendocrine breast cancer undetectable with conventional imaging procedures.

Some neoplasms are classified as primary neuroendocrine tumours (NETs) because of their positivity for neuroendocrine markers [chromogranins A and B (CgA, CgB) and neuron-specific enolase (NSE)]. Neuroendocrine differentiation has been reported, for example, in both "in situ" and infiltrating breast cancer. Diagnosis of NET is bio-humoral (CgA, NSE, synaptophysin) and instrumental. Even if the final diagnosis is made by open biopsy, radionuclide imaging using radiolabelled somatostatin analogs, such as In-111 pentetreotide, may detect neuroendocrine primary tumours and metastases before they become detectable using traditional and advanced imaging modalities [mammography (MX), ultrasound (US) and magnetic resonance imaging (MRI)]. When neuroendocrine breast lesions are not detectable, radio-guided surgery (RGS) is able to localise cancer. We report a case of a woman with a palpable lymph node in the left axilla. She underwent a US-guided lymph node biopsy, which was positive for massive metastases, probably of neuroendocrine breast origin. Mammary plus axillary US showed only lymphadenopathy in the left axilla. MX and breast MRI were negative. Neoplastic markers (CEA, CA 15.3, CA 125 and CA 19.9) were negative too. On the other hand, neuroendocrine markers (NSE and CgA) were positive. A whole body scintigraphic scan plus thorax and abdomen single photon emission computed tomography (SPECT) with In-111 pentetreotide (222 MBq; 6 mCi) showed an uptake in the left mammary gland. No other pathological localisations were observed. The day after the intravenous injection of In-111 pentetreotide, the patient underwent RGS breast tumour resection and left axillary lymphadenectomy. In conclusion, we would like to emphasise: (1) the role of radionuclide imaging for the detection of breast NETs in relation to conventional diagnostic procedures; (2) the role of RGS in localising and removing a non-palpable breast NET that was undetectable with the use of conventional imaging techniques.

Use of preoperative lymphoscintigraphy and intraoperative gamma-probe detection for identification of the sentinel lymph node in patients with papillary thyroid carcinoma.

AIMS: Lymph node metastases for papillary thyroid carcinoma are associated with an increased incidence of locoregional recurrence. The use of preoperative lymphoscintigraphy and intraoperative gamma probe detection to localize the sentinel lymph node in papillary thyroid carcinoma was investigated. METHODS: From February 2004 to December 2005 the sentinel lymph node technique was studied in 64 consecutive patients with cytological evidence of papillary thyroid carcinoma. The day before surgery, patients were submitted to US-guided peri-tumoural injection of the radiotracer and a lymphoscintigraphy was performed. In the operating room a total thyroidectomy was done, and thanks to a hand-held gamma probe the sentinel lymph node and all lymph nodes, belonging to the sentinel node compartment, were removed. RESULTS: The gamma probe identified the sentinel lymph node in 62 patients (96.8%). We found 48 (77.5%) sentinel lymph node without metastases; 12 (19.3%) with metastases and 2 (3.2%) with micrometastases. In 7 cases (11.3%), with a negative sentinel lymph node, metastases in other nodes of the same region were recorded. In 22 cases (34.3%) the ultrasound give an erroneous indication (P=0.004). Five patients (8.0%), 4 with multifocal cancer, had a positive postoperative lymphoscintigraphy. CONCLUSION: This study shows that the sentinel lymph node technique for papillary thyroid carcinoma is feasible, repeatable, and more accurate than preoperative ultrasound. In cases of multifocal thyroid lesions more patients should be enrolled to establish the utility of the radio-guided technique.

Primary breast cancer features can predict additional lymph node involvement in patients with sentinel node micrometastases.

OBJECTIVE: The aim of this retrospective study was to identify biological features of primary breast cancer from which to predict the presence of further axillary involvement in patients bearing micrometastases in the sentinel lymph node (SLN). METHODS: From a starting group of 690 patients, we isolated patients with micrometastases in the SLN. Those patients were classified according to the presence/absence of further metastases in nonsentinel lymph nodes (NSLNs). We examined primary tumor features to identify any relevant difference. Analysis of primary tumors evaluated histology, tumor size, lymphovascular invasion, mitotic index (Mib-1), estrogen and progesterone receptor status (ER/PR status), C-erb B-2 (HER-2/neu) expression and amplification, and p53 expression. Chi square analysis for statistical significance was applied. RESULTS: Of the original 690 patients, 296 showed some kind of metastases in the SLN; 238 patients had gross metastases in the SLN. After axillary lymph node dissection (ALND), 102 patients (43%) had NSLNs with metastases, and 136 (57%) had negative axillary non-sentinel nodes. Another 58 patients harbored solitary micrometastases in the SLN. After ALND, 8 (14%) patients had further NSLN involvement, and 50 (86%) had negative axillary nodes. CONCLUSIONS: Analysis of the primary breast lesion in patients with micrometastatic SLN and metastatic NSLNs revealed the presence of lymphovascular invasion, Mib-1 index > 10%, and tumor size > 2 cm. Patients without lymphovascular invasion, Mib-1 < 10% and T size < 2 cm could avoid further ALND.

Accuracy and reliability of sentinel node biopsy in patients with breast cancer. Single centre study with long term follow-up.

The aim of our study is to evaluate the frequency of false-negative (FN) sentinel node procedures in patients with breast cancer. A total of 791 breast cancer patients underwent sentinel lymph node (SLN) biopsy at our institution between July 1997 and February 2005. A 2-day protocol was used to localise the sentinel node with the injection of 99mTc-nanocolloid. There were two phases in the study: the learning phase (50 patients) and the application phase (741 patients). In the learning phase, a complete lymphadenectomy was always performed. In the application phase, sentinel nodes were studied postoperatively with breast cancer and lymphadenectomy was performed when considered warranted by the pathological postoperative results. The median follow-up duration in the 741 patients studied during the application phase was 32.3 months (range 6-72 months). In this phase a total of 787 sentinel nodes (719 axillary and 68 intramammary chain) were obtained (range 0-5 per patient, mean 1.01), with 153 (41 with micrometastasis) positive sentinel nodes. We observed a total of three FN SLN results (0.5%). All three presented as an axillary recurrence into 24 months from operation. After a median follow-up of 32.3 months we observed only three clinical recurrences among 741 patients. Our results indicate that the sentinel node protocol can give an adequate local control.

Reliability and accuracy of sentinel node biopsy in cutaneous malignant melanoma.

AIMS AND BACKGROUND: The aims of this study were 1) to investigate whether sentinel lymph node (SLN) biopsy could become the method of choice for the early detection of metastatic disease in patients with malignant melanoma and 2) to identify those patients with lymph node metastases who could benefit from regional lymphadenectomy. METHODS AND STUDY DESIGN: Our study started in March 1998 and involved 110 patients with primary cutaneous malignant melanoma stage I or II (AJCC) in whom the primary lesion had been surgically removed no more than 90 days previously. On the day of lymph node dissection patients were given an intradermal injection of colloid particles of human serum albumin labeled with technetium-99m and an injection of isosulfan blue. The surgical procedure was usually performed with local anesthesia but in some cases locoregional or general anesthesia was preferred. Contralateral and ipsilateral lymphatic areas were scanned with a hand-held gamma camera (Scintiprobe MR 100) to measure the background and identify the hot point indicating the location of the sentinel node to direct the incision. RESULTS: The combined use of lymphoscintigraphy, isosulfan blue and gamma probe allowed us to identify sentinel nodes in 108 of 110 patients (98.18%) while the SLN was blue in only 90 cases (81.81%). The SLN was positive for metastases in 13 of the 108 patients (12.03%) and regional and distal lymphadenectomy was performed in all of them. The distribution of positive SLNs by primary lesion thickness was as follows: 0.76-1.5 mm: one positive SLN/44 patients (2.27%); 1.51-4 mm: six positive SLNs/51 patients (11.7%); > 4 mm: six positive SLNs/15 patients (40%). Only four of 12 patients with ulcerated cutaneous melanoma had positive SLNs. The patients in our study underwent follow-up visits every four months. The median follow-up was 481 days (range, 97-1271 days). CONCLUSIONS: In patients with primary cutaneous melanoma the histological status of the SLN accurately reflects the presence or absence of metastatic disease in the relevant regional lymph node basin. Complete lymph node dissection should only be performed in patients with positive SLNs. Patients with lesions > 4 mm are likely to develop recurrences and to die of systemic disease, so in these patients the usefulness of SLN biopsy is questionable. In conclusion, sentinel node mapping is a rational approach for the selection of patients who might benefit from early lymph node dissection of the affected basin.

Prognostic and therapeutic impact of sentinel node micrometastasis in patients with invasive breast cancer.

AIMS AND BACKGROUND: Locoregional lymph node status is one of the most important prognostic factors determining the need for adjuvant chemotherapy in patients with breast cancer. Many authors have reported that micrometastases were not detected by routine sectioning of lymph nodes but were identified by multiple sectioning and additional staining. Among lymph node-negative patients 15-20% had an unfavorable outcome at five years from primary surgery. Sentinel lymph node (SLN) biopsy is an accurate technique for identifying axillary metastases because the pathologist utilizes hematoxylin-eosin (H-E) staining together with immunohistochemistry (IH) to examine all lymph node sections. Sentinel node micrometastasis has therefore become an important tumor-related prognostic factor. METHODS AND STUDY DESIGN: From November 1997 to October 2001 we examined in 210 patients the pathological features of primary breast lesions and SLN metastases and we correlated these with the tumor status of non-SLNs in the same axillary basin. We applied IH examination to both SLNs and non-SLNs of patients who were negative for metastasis by standard H-E examination. RESULTS: In this study lymph node staging was based on SLN findings, primary tumor size and the presence of peritumoral lymphovascular invasion (LVI). We found 18 SLN micrometastases (9%) in 210 patients and one of these (5.5%) of patients with SLN micrometastasis) also had one non-SLN metastasis: this patient had LVI and a larger primary tumor than patients with SLN micrometastasis without non-SLN metastasis. We also found 24 SLN macrometastases (11.5%) in 210 patients and 13 of these (54.2% of patients with SLN macrometastases) had one or more non-SLN metastases. CONCLUSIONS: According to the results reported in the literature, tumor cells are unlikely to be found in non SLNs when the primary lesion is small and SLN involvement micrometastatic (5.5% in our experience, 7% in Giuliano's). Our findings suggest that axillary lymph node dissection may not be necessary in patients with SLN micrometastasis from T1 lesions.

Sentinel node biopsy in the evaluation of the internal mammary node chain in patients with breast cancer.

AIMS AND BACKGROUND: In patients with breast cancer the presence of internal mammary chain (IMC) metastases changes tumor staging, and the occurrence of IMC drainage is quite common in breast cancer. Nevertheless, IMC dissection is not a routine procedure in modern surgical approaches towards breast cancer. We therefore need minimally invasive techniques for accurate assessment of the IMC nodal basin. The aim of this study was to investigate whether sentinel node biopsy (SLNB) could offer a solution. METHODS AND STUDY DESIGN: From November 1997 to June 2001 143 female patients who were eligible for breast cancer surgery were included in the study. All patients had T1 breast cancer and clinically negative axillae. Patients were submitted to preoperative lymphoscintigraphy with subsequent SLNB. We used a 99m-technitium nanocolloid tracer (Nanocoll) that was injected peritumorally so as to have about 10 MBq of radioactivity at the time of surgery. Scintigraphy was performed about 17 hours after tracer administration. During surgery, lymphoscintigraphic imaging and a gamma ray detection probe were used to locate the sentinel node. Histological examination after embedding in paraffin was usually requested and multilevel sectioning of the sentinel node (SLN) was performed, with hematoxylin and eosin staining and immunohistochemistry. RESULTS: Preoperative lymphoscintigraphy localized SLNs in the IMC basin in 27 of 143 patients (18.9%). Harvesting of IMC-SLNs based on lymphoscintigraphy results was successful in 20 of 27 patients (74.1%). Histological examination revealed micrometastases in four of the 20 harvested nodes. One of these patients showed no axillary drainage and no axillary lymph node dissection was therefore performed. In the remaining three patients also axillary SLNs were harvested, which turned out to be free from metastatic involvement. CONCLUSIONS: In our experience lymphoscintigraphy with SLNB was an accurate method to detect IMC metastases in patients with breast cancer. We recommend peritumoral tracer injection and a reasonable interval between injection and scintigraphy. IMC-SLN biopsy did not result in any serious additional complications or morbidity. In our study this approach led to improved cancer staging: four of 20 harvested IMC-SLNs proved to be micrometastatic. None of these four patients had metastatic axillary SLNs. Exclusive drainage to the IMC is present in only a small number of breast cancer patients, and our results suggest that it is possible to avoid unnecessary axillary node dissection in such cases.

Sentinel lymph node analysis in squamous carcinoma of the oral cavity and oropharynx.

AIMS: The aim of our study was to evaluate the usefulness and applicability of sentinel lymph node (SLN) identification in N0 carcinomas of the oral cavity and oropharynx. STUDY DESIGN: We carried out a prospective evaluation of SLN identification in 20 patients with oral cavity or oropharynx carcinomas with no clinical evidence of lymph node metastases. METHODS: Peritumoral infiltration with technetium-99-labeled nanocolloid followed by lymphoscintigraphy was carried out approximately 18 hours prior to surgery. A vital dye was injected intraoperatively and the SLN was identified with the aid of a gamma probe. All patients underwent routine neck dissection. RESULTS: While multiple radioactive nodes were generally identified on lymphoscintigraphy, the number of nodes ranging from one to five with variable degrees of uptake, intraoperative gamma probe scanning allowed the identification of a single more radioactive lymph node in 19 of the 20 patients. In only one patient did this method lead to the identification of two equally highly radioactive SLNs, with no uptake in the remaining nodes. All SLNs were ipsilateral to the neoplastic lesion. In 15 cases the SLN was tumor negative and so were the remaining nodes obtained by comprehensive neck dissection. In five cases the SLN was the only lymph node containing micrometastasis among those obtained by dissection. There were no instances of node positivity not involving the SLN. CONCLUSIONS: Sentinel lymph node identification in ENT surgery may indicate intraoperatively if node metastasis are present, thereby avoiding overtreatment in a substantial proportion of patients with N0 carcinomas of the oral cavity or oropharynx.

An original approach in the diagnosis of early breast cancer: use of the same radiopharmaceutical for both non-palpable lesions and sentinel node localisation.

A modern approach to the surgical treatment of early breast carcinoma requires intraoperative localisation of non-palpable lesions and assessment of the lymph node status. Localisation of breast lesions can be achieved by intratumoural injection of a small amount of radiotracer and intraoperative use of a gamma probe (i.e. radioguided occult lesion localisation, or ROLL). Assessment of the lymph node status is possible by means of the sentinel node approach. To date, two different radiopharmaceuticals have been used for localisation of tumour and sentinel node. We now propose the use of a single nanocolloidal tracer (Nanocoll, with a particle size of less than 80 nm) which is labelled with technetium-99m for simultaneous performance of ROLL and sentinel node identification. The aim of this study was to evaluate the feasibility of this approach, which should be easier and more practical than the dual-tracer injection method. We have employed this new technique in 73 patients with non-palpable, cytologically diagnosed breast cancer and non-palpable axillary lymph nodes. In all patients the radiocolloid, in a total volume of 0.3-0.4 cc, was injected under sonographic or stereotactic guidance. Half of the dose was injected intratumourally and half superficially, but very close to the tumour. Because of the slow lymphatic flow in the breast, Nanocoll must be injected some time before surgery in order to enable adequate migration to the axilla. We injected colloid in the afternoon before surgery (16-23 h before the start of the operation, with an average interval of 18 h). An average dose of 130 MBq (range 110-150) was injected in order to have about 10 MBq of radioactivity when surgery commenced. Lymphoscintigraphy was performed after 15-19 h, with an average interval of 17 h. The procedure was always successful in permitting the localisation of occult breast lesions. Lesions were always localised at the first attempt, and were always contained within the surgical margins. Histological examination revealed all 73 resected lesions to be malignant: there were 64 cases of infiltrating carcinoma and nine of intraductal carcinoma. All breast lesions were therefore confirmed to be early breast cancer. We achieved sentinel node localisation in 71 out of 73, either at scintigraphy or with the intraoperative probe; in two patients, radiopharmaceutical migration was absent. Lymphoscintigraphy showed only axillary drainage in 52 cases, only internal mammary chain (IMC) drainage in nine cases, and combined axillary and IMC drainage in eight cases. In two cases, lymphoscintigraphy suggested the sentinel node was located inside the same breast (intramammary lymph node). All the visualised sentinel nodes were biopsied except for four that were localised in the IMC. Histological examination of the nodes showed metastases in 20 cases: in 15 cases there were micrometastases, and in five, macrometastases. In conclusion, this study has demonstrated the feasibility of the proposed procedure. Simultaneous performance of ROLL and sentinel node localisation using a single tracer represents a useful and practicable choice in the management of early breast cancer.

Role of radio-guided surgery in recurrent secondary hyperparathyroidism.

BACKGROUND: The aim of this paper is to state the role of radio-guided surgery (RGS) in case of recurrent secondary hyperparathyroidism. METHODS: Two cases of recurrent secondary hyperparathyroidism were treated using RGS. After a preoperative assessment, which included ultrasonography (US), MRI and (99m)Tc-radiolabelled sestamibi scan, a radio-guided neck re-exploration was planned. On the day of surgery the patients underwent a radionuclide injection. After 90 min, surgery began. RESULTS: Dissection was guided by placing the probe in the wound to localize any increased concentration of radioactivity. In the first case the probe identified the gland located deeply in the right tracheo-esophageal groove; in the other case the probe detected a site of increased uptake in the upper mediastinum. Both lesions were dissected and excised; a frozen section confirmed they were parathyroid glands with diffuse hyperplasia. The operative time was less than 60 min in both cases. The patients were discharged on the first postoperative day. A decrease in serum calcium and PTH was observed subsequently. A minimum follow-up of 6 months did not show any recurrence. CONCLUSION: RGS can help in detecting the parathyroid tissue in selected cases of renal hyperparathyroidism and makes operation much easier and more predictable.

[Malignancy: treatment and prognosis of gastrointestinal and pancreatic endocrine neoplasia: retrospective study of a series of 16 cases]. / Malignità: trattamento e prognosi delle Neoplasie Endocrine Gastrointestinali e del Pancreas: studio retrospettivo su una serie di 16 casi.

The aim of this study was to review our experience with endocrine tumours of the gastrointestinal tract and pancreas (ETGIP). Between February 1991 and March 2000, sixteen patients with ETGIP were operated on at our institution. Of these patients we reviewed preoperative symptoms, diagnostic techniques (ultrasound, CT, MRI, radiolabelled octreotide scintigraphy, angiography, immunohistochemical study), treatment (surgical operation, neoadjuvant and adjuvant chemotherapy, and radiometabolic therapy) and survival. Nine patients (56%) had a carcinoid tumour, three (19%) an unspecified endocrine tumour, and four (25%) an endocrine tumour associated with a non-endocrine neoplasm. Only five patients (31%) had a preoperative diagnosis of endocrine tumour. Eight patients (50%) had metastatic disease at the time of the operation. All patients without preoperative metastasis (eight patients, 50%) are still alive without recurrent disease, with a mean postoperative survival of 36 months (12-60 months). Of eight patients with metastatic disease, six (75%) died after a mean of 20.5 months (3-60 months) and two (25%) are still alive with the disease after 3 and 6 months, respectively. These data show that presence of metastasis strongly influence survival. Furthermore, survival of patients with metastatic disease seems to be longer as compared to other gastrointestinal tract malignancies. ETGIP are more common and aggressive than previously believed and, therefore, early diagnosis is crucial for cure. Nowadays, however, new diagnostic tools such as radiolabelled octreotide scintigraphy are available for diagnosis and postoperative follow-up. The optimal treatment for ETGIP is a multimodal approach with surgical operation, chemoradiation, radiometabolic, and genetic therapies.

Sentinel node study in early breast cancer.

Since October 1997 60 patients with early breast cancer (T <3 cm) were studied. All patients underwent lymphoscintigraphy with two types of colloid: the first (17 pts) with a particle size <1,000 nm; the second (43 pts) with a particle size <80 nm. The standard procedure consists of injection, on the day before surgery, of 70 MBq of the smaller nanocolloid in 0.4 cc saline divided over four sites, around the lesion or subdermally around the surgical scar. We utilize a low-energy, high-resolution LFOV camera for scintigraphy and a probe specific for the sentinel node during surgery. In 56/60 patients (93.3%) lymphoscintigraphy showed the sentinel node (SN). In two cases the SN was not detected presumably because of lymphatic interruption by an old surgical scar; in the other two cases the sites of injection were too close to the SN, thus masking it. In five cases (9%) the SN was not visualized with the surgical probe but in two of these drainage to the internal mammary chain was observed. The apparently lower sensitivity of intraoperative localization was due to the extra-axillary lymphatic drainage or to the vicinity of the SN to the primary lesion. The SN proved to be metastatic in 12 cases. No false-negative SNs were found. In five cases (10%) the radiolabeled lymph node was the only node containing tumor cells (micrometastases): this result depends on the combined use of hematoxylin-eosin and rapid cytokeratin staining. The application of blue dye was useful for easier identification of the SN but did not allow detection of more SNs. Our preliminary results are extremely encouraging. Considering that at the early stages of breast cancer the likelihood of lymph node metastases is low (20% in our series) and no false negative were reported in this study, we conclude that with SN biopsy axillary lymph node dissection can be avoided, making surgery less aggressive but maintaining accuracy.

Massive bleeding in an adult patient suffering from Meckel's diverticulum.

The case of a 22-year-old male who bled from a Meckel's diverticulum is described. The diagnosis was achieved after 99mTechnetium pertechnetate scintigraphy. With the administration of somatostatin very clear images were obtained. The histological examination confirmed the presence of ectopic gastric mucosa. The literature, over the last 10 years, has been reviewed to identify factors associated with bleeding in adults. Ectopic gastric mucosa is the most important factor predicting bleeding. The diagnostic approach to bleeding Meckel's diverticulum and the improvement in the quality of 99mTechnetium pertechnetate scintigraphy, following administration of somatostatin, is discussed.