Additional value of hybrid SPECT/CT systems in neuroendocrine tumors, adrenal tumors, pheochromocytomas and paragangliomas.

The aim of this review was to evaluate the potential advantages of SPECT/CT hybrid imaging in the management of neuroendocrine tumors, adrenal tumors, pheochromocytomas and paragangliomas. From the collected data, the superiority of fused images was observed as providing both functional/molecular and morphological imaging compared to planar imaging. This provided an improvement in diagnostic imaging, with significant advantages as regards: (1) precise locating of the lesions; (2) an improvement in characterization of the findings, resulting higher specificity, improved sensitivity, and overall greater accuracy, (3) additional anatomical information derived from the CT component; (4) CT-based attenuation correction and potential for volumetric dosimetry calculations, and (5) improvement on the impact on patient management (e.g. in better defining treatment plans, in shortening surgical operating times). It can be concluded that SPECT/CT hybrid imaging provides the nuclear medicine physician with a powerful imaging modality in comparison to planar imaging, providing essential information about the location of lesions, and high quality homogeneous images.

The value of oropharyngoesophageal scintigraphy in the management of aspiration into the tracheobronchial tree in neurological patients.

AIM: Dysphagia and bolus aspiration are two of the most frequent and invalidating symptoms of various neurological diseases. Swallowing disorders often lead to tracheobronchial aspiration with consequent pneumonia episodes. Aspiration pneumonia per se constitutes the most frequent cause of death in these patients, with mortality rate ranging from 20% to 62%. Oropharyngoesophageal scintigraphy (OPES) permits functional quantitative assessment of the different stages of swallowing, together with the detection and quantitative measurement of bolus aspiration. In this work, we analyzed the role of OPES in patients with different neurological conditions to evaluate swallowing and to detect and quantify bolus aspiration. MATERIAL AND METHODS: We enrolled 43 neurological patients (25 women and 18 men, mean age 67.3±12.4 yr) complaining of dysphagia with suspected inhalation. All patients underwent OPES with (99m)Tc-nanocolloid using a liquid bolus first, followed by a semi-solid bolus. We evaluated the following parameters: Oral, Pharyngeal and Esophageal Transit Time, Oro-Pharyngeal Retention Index, Esophageal Emptying Rate, and Aspiration Rate (% AR). RESULTS: OPES detected some airway aspiration in 26/43 patients. 19 patients had tracheal aspiration (with a mean 18.1% AR) and the remaining 7 patients had bilateral broncho-pulmonary aspiration (mean 44.9% AR). CONCLUSIONS: OPES is a feasible, repeatable and noninvasive method that allows quantitative assessment of bolus aspiration into the tracheobronchial tract, thus representing a useful and accurate tool to guide the most appropriate treatment and to monitor response to therapy in neurological patients with dysphagia.

Early prediction of response by ¹8F-FDG PET/CT during preoperative therapy in locally advanced rectal cancer: a systematic review.

AIM: To assess the predictive value of fluorine-18-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) in early assessing response during neo-adjuvant chemoradiotherapy (CRT) in patients with locally advanced rectal cancer. MATERIALS AND METHODS: A systematic review was performed by search of MEDLINE Library for the following terms: "rectal carcinoma OR rectal cancer", "predictive OR prediction OR response assessment OR response OR assessment", "early OR ad interim", "therapy", "FDG OR (18)F-FDG", "PET OR PET/CT". Articles performed by the use of stand-alone PET scanners were excluded. RESULTS: 10 studies met the inclusion criteria, including 302 patients. PET/CT demonstrated a good early predictive value in the global cohort (mean sensitivity = 79%; mean specificity = 78%). SUV and its percentage decrease (response index = RI) were calculated in all studies. A higher accuracy was demonstrated for RI (mean sensitivity = 82%; pooled specificity = 85%) with a mean cut-off of 42%. The mean time point to perform PET scan during CRT resulted to be at 1.85 weeks. Some PET parameters resulted to be both predictive and not statistical predictive of response, maybe due to the small population and few studies bias. CONCLUSION: PET showed high accuracy in early prediction response during preoperative CRT, increased with the use of RI as parameter. In the era of tailored treatment, the precocious assessment of non-responder patients allows modification of the subsequent strategy especially the timing and the type of surgical approach.

(99m)Tc-DTPA scintigraphy assesses the absence of glomerular filtration rate impairment of Aliskiren in high-risk hypertensive subjects. A 12-month follow-up study.

AIM: Glomerular filtration rate (GFR) is commonly calculated using the modification of diet in renal disease (MDRD) and Cockroft-Gault (CG) formulas and recently by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) algorithm and not directly measured, so that the real impact of antihypertensive therapy on GFR could not be well defined. In this study, the effect of Aliskiren on the GFR measured by radionuclide clearance of 99mTc-diethylene triamine penta-acetic acid (DTPA) was investigated. METHODS: In 106 hypertensive subjects (53% men) aged 61.9±12.7 years with uncontrolled blood pressure (BP) receiving at least 2 antihypertensive medications, Aliskiren was added once-daily at a dose of 150-300 mg for 12 months. Clinic BP measurements were taken at every follow-up visit (1st, 6th and 12th month), while 24-hours ambulatory BP and GFR (in mL/min/1.73 m2) were evaluated at baseline and at the end of the follow-up. Analysis of variance for repeated measures of BP, GFR and microalbuminuria was provided. RESULTS: With the use of Aliskiren a significant reduction of BP and microalbuminuria was found (P<0.0001). Only in male population, a significant reduction in GFR calculated with CKD-EPI (82.4±15 vs. 78.6±18.2, P<0.01) and CG (81.6±29.5 vs. 74.2±28.4, P<0.0001) formulas was observed. This impairment of GFR was not found either with MDRD formula (70.5±19.6 vs. 68.3±23.4) or by radionuclide clearance (62.4±18.6 vs. 61.4±20.5). CONCLUSION: This study seems to demonstrate that the efficacy on BP control of Aliskiren is not accompanied by an impairment of GFR. In order to evaluate the effect of Aliskiren on GFR scintigraphy technique or MDRD formula resulted to be the most accurate methods.

Does the ultrasound dissector improve parathyroid gland preservation during surgery?

BACKGROUND: The most common complication of thyroid surgery is hypoparathyroidism, usually temporary. Ischemic injury or parathyroid avulsion are the causes of surgical hypoparathyroidism. We assessed the value of an ultrasound scalpel, the Harmonic Focus(®) (HF), could prevent surgical-related hypoparathyroidism. METHODS: Patients consecutively undergoing total thyroidectomy using the HF from November 2009 to February 2011 were recruited and their clinical characteristics, type of operation, histology, and postoperative calcium levels (normal range: 2.10-2.55 mMol/l) were recorded. The prevalence of transient and permanent hypocalcemia was calculated for benign vs. malignant diseases and compared with a control group of 147 patients treated surgically in 2005 using manual technique. RESULTS: 139 patients treated by the same surgeon with a total thyroidectomy (41.7% for a malignant disease) were considered. Prevalence of transient hypoparathyroidism (THP) was 45.2% and of definitive hypoparathyroidism (DHP) 1.4%. None of the patients with malignancies were hypocalcemic at 1-year follow-up. In the control group THP was found in 51.7% of cases and DHP in 5.4% (p < 0.001). CONCLUSIONS: Use of the ultrasound scalpel improved the likelihood of the parathyroid glands preservation during thyroid surgery. Paradoxically, the HF appears to be more effective in treating malignant disease, i.e. when central node dissection is required.

Role of FDG PET/CT in investigating the mechanisms underlying atherosclerotic plaque formation and evolution

Este artículo se centra en el papel de la FDG PET/TC en la identificación de la aterosclerosis y en la relevancia de las células inflamatorias como los macrófagos y los linfocitos T en la formación de la placa aterosclerótica. Se discute también sobre la vulnerabilidad de la placa inflamatoria y el riesgo asociado a determinar incidentes cardio y cerebro-vasculares independientemente de la presencia de vasos estenóticos, así como sobre la evolución hacia la placa calcificada. El importante papel de la FDG PET/TC en el diagnóstico precoz de la placa inflamatoria se discute tanto en estudios con animales como a nivel clínico. Se discute, finalmente, la posibilidad de curar la placa inflamatoria, el tipo de fármacos utilizados y la posibilidad de controlar el tratamiento anti-inflamatorio a través de FDG PET/TC(AU)

This review article is focused on the role of FDG-PET/CT in visualizing atherosclerosis and on the relevance of inflammatory cells such as macrophages and T-lymphocytes in the formation of the atherosclerotic plaque. The vulnerability of the inflammatory plaque and the risk derived from the provocation of cardio- and cerebrovascular incidents independently from the presence of stenotic vessels are discussed as well as the evolution toward calcified plaque. The important role of FDG-PET/CT in early diagnosis of inflammatory plaque is discussed in both animal studies and in clinical setting. The possibility of curing inflammatory plaques, type of drugs, and the possibility of monitoring the anti-inflammatory treatment by FDG-PET/CT are also discussed(AU)

Role of FDG PET/CT in investigating the mechanisms underlying atherosclerotic plaque formation and evolution.

This review article is focused on the role of FDG-PET/CT in visualizing atherosclerosis and on the relevance of inflammatory cells such as macrophages and T-lymphocytes in the formation of the atherosclerotic plaque. The vulnerability of the inflammatory plaque and the risk derived from the provocation of cardio- and cerebrovascular incidents independently from the presence of stenotic vessels are discussed as well as the evolution toward calcified plaque. The important role of FDG-PET/CT in early diagnosis of inflammatory plaque is discussed in both animal studies and in clinical setting. The possibility of curing inflammatory plaques, type of drugs, and the possibility of monitoring the anti-inflammatory treatment by FDG-PET/CT are also discussed.

Diagnóstico de sarcoidosis desconocida asociada a eritema nodoso, mediante 18F-FDG PET/TAC / Diagnosis of unknown sarcoidosis associated to erythema nodosum with 18F-FDG PET/CT

Una mujer de 76 años fue remitida a nuestro Centro de Medicina Nuclear para someterse a 18F-FDG PET/TAC con sospecha clínica de vasculitis. La PET de cuerpo entero resultó negativa para vasculitis pero mostró hipermetabolismo moderado en varios ganglios linfáticos del mediastino y una captación intensa en las glándulas parótidas. Dado que la paciente refirió en anamnesis lesiones eritematosas de la piel en ambas piernas, realizamos una adquisición de PET de las extremidades inferiores que mostró una captación difusa en la región perimaleolar en ambas piernas. Sobre la base de los hallazgos de la PET/TAC que sugirieron sarcoidosis la paciente fue sometida a un lavado broncoalveolar (BAL) y a una biopsia de un ganglio linfático mediastínico que confirmó la sospecha de sarcoidosis(AU)

A 76-year-old woman was referred to our centre to perform 18F-FDG PET/CT with the clinical suspicion of vasculitis. Whole body PET was negative for vasculitis but it depicted moderate hypermetabolism in several lymph nodes of the mediastinum and intense uptake of the tracer in the parotid glands. Since the patient referred skin lesion on both legs a particular acquisition of the lower extremities was performed which showed diffuse uptake on the perimalleolar region of both legs. On the basis of the PET/CT findings that were suggestive for sarcoidosis the patient performed bronchoalveolar lavage (BAL) and biopsy of a mediastinal lymph node which confirmed the suspicion of sarcoidosis(AU)

Diagnosis of unknown sarcoidosis associated to erythema nodosum with 18F-FDG PET/CT.

A 76-year-old woman was referred to our centre to perform (18)F-FDG PET/CT with the clinical suspicion of vasculitis. Whole body PET was negative for vasculitis but it depicted moderate hypermetabolism in several lymph nodes of the mediastinum and intense uptake of the tracer in the parotid glands. Since the patient referred skin lesion on both legs a particular acquisition of the lower extremities was performed which showed diffuse uptake on the perimalleolar region of both legs. On the basis of the PET/CT findings that were suggestive for sarcoidosis the patient performed bronchoalveolar lavage (BAL) and biopsy of a mediastinal lymph node which confirmed the suspicion of sarcoidosis.

Contemporary nuclear medicine imaging of neuroendocrine tumours.

Neuroendocrine tumours (NETs) are rare, heterogeneous, and often hormonally active neoplasms. Nuclear medicine (NM) imaging using single photon- and positron-emitting radiopharmaceuticals allows sensitive and highly specific molecular imaging of NETs, complementary to anatomy-based techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI). Somatostatin-receptor scintigraphy is a whole-body imaging technique widely used for diagnosis, staging and restaging of NETs. The increasing availability of hybrid single-photon emission CT (SPECT)/CT cameras now offers superior accuracy for localization and functional characterization of NETs compared to traditional planar and SPECT imaging. The potential role of positron-emission tomography (PET) tracers in the functional imaging of NETs is also being increasingly recognized. In addition to 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG), newer positron-emitting radiopharmaceuticals such as (18)F-dihydroxyphenylalanine (DOPA) and (68)Ga-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) peptides, show promise for the future. This article will summarize the role of current and emerging radiopharmaceuticals in NM imaging of this rare but important group of tumours.

Molecular imaging in the management of thyroid cancer.

Thyroid cancer is the most common endocrine malignancy in adults. The disease is classified into papillary, follicular, medullary and anaplastic types, each with characteristic histology and patterns of biological behavior. Diagnosis of thyroid cancer is usually made by needle aspiration of suspicious thyroid nodules. Disease management of well-differentiated thyroid cancer relies upon characteristic accumulation of radioisotopes of iodine that continues to play a central role in detection and treatment of disease. Recombinant human thyrotropin (rhTSH) is used as an alternative to thyroid hormone withdrawal to provide TSH stimulation necessary for diagnostic radioiodine scintigraphy and preparation for thyroid remnant ablation and cancer therapy. Hybrid SPECT/CT cameras combining functional scintigraphic information with CT anatomy are replacing stand-alone gamma cameras and these devices have been shown to outperform traditional planar and SPECT imaging techniques. Similarly, clinical application of novel radioisotopes like [124I]iodine with PET/CT for thyroid cancer imaging provides improved lesion resolution and direct tumor dosimetry. Alternative tracers such as [18F]fluorodeoxyglucose (FDG) can be used to evaluate well-differentiated thyroid cancers that no longer express the Na+/I- symporter, with a role in staging Hürthle cell, poorly differentiated, and anaplastic thyroid cancers. Medullary thyroid cancer recurrences are often difficult to detect using conventional imaging and traditional radionuclide studies, whereas [18F]FDG and [18F]fluorodihydroxyphenylalanine (DOPA) PET and PET/CT show promise for localizing the often elusive source (s) of elevated calcitonin in these patients.

Arterial hypertension and thyroid disorders: what is important to know in clinical practice?

This review describes the pathogenic mechanisms of blood pressure (BP) regulation and long-term control in thyroid disorders. Variations from the euthyroid status affect virtually all physiological systems but the effects on the cardiovascular system are particularly pronounced. Thyroid disorders induce several hemodynamic changes leading to elevated BP as a consequence of their interaction with endothelial function, vascular reactivity, renal hemodynamic and renin-angiotensin system. However, in thyroid disorders, the regulation of BP and the development and maintenance of variable forms of arterial hypertension (HT) are different. Hyperthyroidism results in an increased endothelium-dependent responsiveness secondary to the shear stress induced by the hyperdynamic circulation, and contributes to reduce vascular resistance. Conversely, hypothyroidism is accompanied by a marked decrease in sensitivity to sympathetic agonists with an increase of peripheral vascular resistance and arterial stiffness. Furthermore in animal models, hypothyroidism reduces the endothelium-dependent and nitric oxide-dependent vasodilatation. HT due to thyroid disorders is usually reversible with achievement of euthyroidism, but in some cases pharmacological treatment for BP control is required. In hyperthyroidism, ß-blockers are the first-choice treatment to control BP but when they are contraindicated or not tolerated, ACE-inhibitors or calcium-channel blockers (CCB) are recommended. Hypothyroidism is a typical low rennin HT form showing a better antihypertensive response to CCB and diuretics; indeed in hypothyroidism a low-sodium diet seems further to improve BP control. Randomized clinical trials to compare the efficacy on BP control of the antihypertensive treatment in thyroid disorders are needed.

Modern PET imaging for paragangliomas: relation to genetic mutations.

AIM AND METHODS: Paragangliomas (PGL) are neural crest-derived tumours that are found along the autonomic neural network throughout the body and can be multiple and/or metastatic. Nuclear medicine imaging in combination with conventional imaging is required to fully delineate the extent of the disease. The performance of molecular imaging modalities is widely dependent on tumour biology. RESULTS: In the present paper we discuss the recent publications focused on the role of positron emission tomography (PET) imaging and the relationship between tracer uptake patterns and genetic mutations associated with the disease. CONCLUSION: Recent advances in genetic and molecular pathogenesis of PGL have allowed for the identification of new molecular diagnostic and therapeutic radiopharmaceuticals tailored to genetic abnormalities. However, the optimal diagnostic imaging algorithm remains to be determined.

Surgical therapeutic planning options in nodular goiter.

Nodular goiter encompasses a spectrum of diseases from the incidental asyntomatic small solitary nodule to the large intrathoracic goiter causing pressure symptoms as well as functional complaints. The mainstay in the diagnostic evaluation is related to functional and morphological characterization with serum thyroid-stimulating hormone (TSH), ultrasound (US) and other imaging procedures and cytology by fine needle aspiration (FNA) on the basis of the different diseases. A clinical classification considering solitary cyst, adenomatous functioning nodule, follicular lesion and multinodular goiter may be proposed to consider the alternative therapies other than surgery as TSH suppressive or thyrostatic treatment, 131I therapy, percutaneous ethanol injection therapy (PEIT) or the only clinical exam in benignant lesions. Surgery should be advocated for the treatment of thyroid nodules whenever a patient presents with either pressure symptoms, hyperthyroidism or follicular/indeterminate cytology. Surgical approach, intraoperatory strategy and the extension of surgical treatment are correlated to the different clinical categories. At surgery the frozen section analysis in case of hemithyroidectomy is of aid to rule out malignancy and to prevent the reoperation. The surgical treatment of choice in case of uninodular goiter is lobectomy, total thyroidectomy or near total thyroidectomy is the correct treatment of multinodular bilateral goiter. The choice of the treatment must be condivided with the patient.

Dual PET/CT with (18)F-DOPA and (18)F-FDG in metastatic medullary thyroid carcinoma and rapidly increasing calcitonin levels: Comparison with conventional imaging.

BACKGROUND: To evaluate the role of a multi-imaging PET with (18)F-DOPA and (18)F-FDG in comparison with conventional imaging (CI) in recurrent medullary thyroid carcinoma (MTC). METHODS: 18 MTC patients who had thyroidectomy were included; they presented with elevated and rapidly increasing calcitonin levels during follow up. CI had revealed metastatic deposits in 9 patients. Patients were referred to us for a PET/CT with (18)F-DOPA and (18)F-FDG. Histologic/cytologic confirmation of recurrent MTC was obtained in at least one PET-positive lesion in all patients. RESULTS: Foci of abnormal uptake were observed in 15 patients at (18)F-DOPA and in 11 at (18)F-FDG; 8 patients showed the same number of positive lesions with both tracers, 2 showed more lesions on (18)F-FDG, 1 was positive at (18)F-FDG alone and 5 at (18)F-DOPA alone. In 3 patients with a DOPA-positive loco-regional relapse a re-operation with curative intent was offered. SUV(max) values were higher for (18)F-FDG compared to (18)F-DOPA (mean 12.7+/-4.1 vs. 5.5+/-2.1, p<0.05). Calcitonin was higher in PET-positive patients compared to PET negative ones, while no significant differences were observed between (18)F-DOPA and (18)F-FDG positive patients. CONCLUSIONS: In MTC patients with rapidly increasing calcitonin levels during follow up, (18)F-DOPA has a good sensitivity and a complementary role with (18)F-FDG PET/CT in detecting metastatic deposits. In our experience, the sensitivity of a multi-imaging (18)F-DOPA &(18)F-FDG PET/CT approach is greater than that obtained with CI. The higher SUV(max) values found with (18)F-FDG in some patients may reflect more aggressive tumors.

Endocrine tumors: the evolving role of positron emission tomography in diagnosis and management.

Endocrine tumors comprise a range of benign and malignant conditions that produce a spectrum of clinical symptoms and signs depending on the specific hormones they produce. The symptoms and presentations of these tumors are often independent of their size and location. Because of their expression of cell membrane receptors or production of specific types of hormones or peptides, endocrine tumors can be identified with functional radionuclide imaging much more readily compared to standard cross-sectional imaging. In recent years, 18F-fluoro-deoxy- D-glucose positron emission tomography (18F-FDG-PET) has emerged as a useful tool for diagnosing and assessing many tumors. In this review we describe how PET, using 18F-FDG and other radiopharmaceuticals can be useful in the diagnosis and management of a wide range of endocrine tumors.

Comparison between 99mTc-sestamibi scintimammography and X-ray mammography in the characterization of clusters of microcalcifications: a prospective long-term study.

BACKGROUND: The early diagnosis of non-palpable breast cancer is the object of recent developments in the imaging procedures employed for screening purposes. In some patients, the presence of microcalcifications (MC) is the only indication of tumor. Although X-ray mammography (MRx) has high sensitivity in detecting MC, its specificity is however too low for diagnostic purposes. The aim of this study was to compare (99m)Tc-sestamibi scintimammography (SMM) and MRx in the differential diagnosis between benign and malignant clusters of MC and to assess the possible incremental value of SMM on specificity. PATIENTS AND METHODS: A total of 283 consecutive women (mean age 53+/-8 years) with MC identified on X-ray mammograms underwent SMM. Scintigraphic images were acquired 10 minutes after the i.v. injection of (99m)Tc-sestamibi (740 MBq). Planar images of both breasts were simultaneously obtained in the lateral prone position and in the anterior and oblique projections using a dual head camera. Sixty-nine women underwent surgery, whereas the remaining 214 patients had completely negative follow-up for 5 years (a 5-year follow-up period is considered the "gold standard" for diagnosing benign lesions). RESULTS: Histology demonstrated 32/69 primary breast carcinomas (prevalence of disease: 11% of all the 283 patients) and 37/69 benign lesions. The receiver operating characteristic (ROC) statistical technique was employed to compare the diagnostic value of Mrx alone to that of combined MRx and SMM. The detected difference between the areas under the MRx ROC curve (area=0.72, standard error 0.052) and the MRX and SMM ROC curve (area=0.86, standard error 0.039) was statistically significant (p<0.01). Moreover, the combination of MRx and SMM provided a significant improvement of the negative predictive value (NPV=98%) for MC with low-suspicion of malignancy at MRx. CONCLUSION: SMM can be considered as a complementary tool in the pre-operative work-up of patients with breast lesions. Furthermore, the high negative predictive value of this technique, makes it especially valuable in the perspective of reducing the number of negative breast biopsies or unnecessary surgical interventions.

Accuracy of ultrasonography and 99mTc-sestamibi scintimammography for assessing axillary lymph node status in breast cancer patients. A prospective study.

AIMS: The aim of this study was to evaluate the sensitivity, specificity and accuracy of axillary ultrasonography (US) and (99m)Tc-sestamibi scintimammography (SSM) in patients with breast cancer (BC) undergoing curative surgery. METHODS: A series of 77 consecutive women (median age 54 years, range 36-70) with primary BC underwent both US and SSM from 2 to 15 (median 4) days prior to curative surgery. The results of imaging studies were compared against the final pathology. Breast-conserving surgery with axillary node (AN) dissection was performed in 49 (63.6%) patients, and modified radical mastectomy in 28 (36.4%) patients, according to the tumour staging. RESULTS: Final pathology showed 5 pT1bN0, 1 pT1bN1, 28 pT1cN0, 19 pT1cN1, 7 pT2N0, and 17 pT2N1 BC. Overall, 719 AN were removed of which 106 (14.7%) were metastatized nodes (median 3, range 1-5 per patient). The sensitivity, specificity and accuracy were 67.6%, 80.0%, and 74.0% for US, 78.4%, 85.0%, and 81.8% for SSM, and 91.9%, 92.5%, and 92.2% for US and SSM together, respectively. There was a significant difference (p<0.05) in the number of metastatized AN between patients with metastases correctly detected and undetected by both US (3.1+/-1.3 vs. 2.0+/-0.7) and SSM (3.2+/-1.3 vs. 1.7+/-0.7). CONCLUSIONS: Although the results of each diagnostic tests are strictly dependent on the number of the metastatized AN, the combination of axillary US and SSM is a sensitive low-cost procedure that should be suggested in all patients with BC, when a preoperative evaluation of the AN status is required.