Somatostatin receptor-positive breast lesions on 68Ga-DOTATATE PET/CT.

OBJECTIVE: This study sets out to evaluate patients with increased uptake in breast lesions on 68Ga-DOTATATE PET/CT (DOTA PET) and determine the clinical significance of somatostatin receptor (SSTR) positive breast lesions. METHODS: We retrospectively evaluated all patients with increased SSTR uptake in breast lesions on DOTA PET. Patients with physiological (e.g., lactation) or normal variant breast uptake (e.g., mild diffuse glandular uptake) were excluded. The maximum standard uptake value (SUVmax) was calculated using a manually drawn region of interest in the most intense uptake of breast lesions. All lesions were correlated with breast imaging, including mammography and ultrasonography. Histopathological correlation was performed if the lesion was suspicious for malignancy. Lesions were followed up radiologically (1-8 years). RESULTS: Out of 1573 retrospectively analyzed DOTA PET scans, the incidence of SSTR + breast lesions was measured as 1.1% (n = 18); however, 4 of 18 patients were excluded due to the lack of final diagnosis of lesions. The median age was 35 (range 14-58 years), and all patients were female. The median SUVmax of SSTR + breast lesions was 5.2 (range 1.5-12.6) for a total of 14 patients. Twelve patients had a single SSTR + breast lesion, while 2 patients had multiple SSTR + lesions on bilateral breasts. In 6 patients, single SSTR + lesions were considered as fibroadenoma; in 2 patients, multiple SSTR + lesions were considered as metastases of NET, based on correlative breast imaging. In 6 patients, histopathological confirmation was needed for the final diagnosis. Histopathologic findings confirmed fibroadenoma in 4 patients by biopsy, in 1 patient with surgical removal of the lesion. The last patient who had a history of IDC was diagnosed with a recurrence of IDC with biopsy. The median SUVmax was 5.1 (range 1.5-9.4) for malignant breast lesions and 5.4 (range 2.2-12.6) for benign breast lesions. CONCLUSION: SSTR + breast lesions on DOTA PET are rarely seen in clinical practice. Uptakes of breast lesions in our cases were variable and not useful for differential diagnosis of lesions. It seems that SSTR + breast lesions should be evaluated with clinical and radiological characteristics, and correlative breast imaging and/or histopathological verification should be performed for suspicious lesions to avoid misdiagnosis.

68Ga-DOTATATE PET-CT imaging in carotid body paragangliomas.

OBJECTIVE: The aim of this study was to present our experience in the baseline evaluation of carotid body paragangliomas (CBP) with 68Ga-DOTATATE PET-CT. METHODS: Five patients (4F, 1M; age 24-73 years) with CBPs who underwent 68Ga-DOTATATE PET-CT scan before the treatment were evaluated retrospectively. PET-CT images were analyzed visually as well as semiquantitatively, with measurement of maximum standardized uptake value (SUVmax). RESULTS: All patients had unilateral CBP lesion, showed intense 68Ga-DOTATATE uptake in PET-CT. Additionally, 68Ga-DOTATATE avid lesions were found in two patients. One of them had focal intense uptake in thyroid gland and frontal cerebrum. The other one had intense uptake in bone and adrenal mass. Four patients were operated for unilateral primary CBP. Last patient was treated with peptide receptor radionuclide therapy (177Lu-DOTATATE) for both metastatic pheochromocytoma and CBP. CONCLUSIONS: 68Ga-DOTATATE PET-CT is a valuable imaging modality for staging of CBPs, detecting unknown lesions and changing the management of patients. It is also useful in demonstrating expression of SSTRs for PRRT opportunity.

Physiological and tumoral uptake of (68)Ga-DOTATATE: standardized uptake values and challenges in interpretation.

PURPOSE: The objective of this study is to determine the range of SUVmax of 68Ga-DOTATATE in normal organs and tumoral lesions and establish uptake unrelated to NET. MATERIALS AND METHODS: One hundred and twenty patients (57 men, 63 women), who underwent (68)Ga-DOTATATE PET/CT imaging in our institution were analyzed. Patients were indicated for (68)Ga-DOTATATE PET/CT imaging to detect primary tumor or metastasis of suspected or previously known NET, to determine SSTR positivity and to detect occult source of ectopic Cushing syndrome. Normal range of uptake was calculated for the organs that were proven to have no pathology by either conventional radiological imaging or clinical follow-up, using SUVmax as a semiquantitative measure. Uptake and tumor to background (T/B) ratios of tumoral lesions in liver, pancreas, bone, brain and lymph nodes were calculated. Uptakes due to lesions unrelated to NET were also documented. RESULTS: Significant uptake was found in spleen, kidneys, adrenal glands, liver and pituitary gland with mean SUVmax of 24.67, 14.30, 13.73, 9.12 and 9.74 respectively. Uptake was measured separately for the pancreatic head and body separately, however, besides a slightly heterogeneous uptake; the difference was not statistically significant. Uptake in the tumoral lesions had high (T/B) ratios with mean SUVmax of 28.72, 25.21, 18.28, 34.73 and 12.59 for liver, pancreas, bone, brain and lymph nodes, respectively. Incidental benign tumoral lesions were detected in 3 patients (2.5 %) which were meningioma and fibrous dysplasia demonstrating significant and breast fibroadenoma demonstrating mild (68)Ga-DOTATATE uptake. Non-neoplastic processes were detected in 4 patients (14.1 %), including postsurgical inflammation, reactive lymph nodes, arthritis and demonstrated faint to mild (68)Ga-DOTATATE uptake, with the exception of significant uptake in accessory spleen. CONCLUSION: (68)Ga-DOTATATE has high T/B ratio with physiological biodistribution comparable to its counterparts. However, the presence of SSTRs in benign and malignant lesions unrelated to NET may be challenging in interpretation particularly where the physiological uptake is variable.

Hepatic adenomatosis may mimic metastatic lesions of liver with 18F-FDG PET/CT.

Hepatic adenomatosis is an uncommon benign neoplasm, with the presence of multiple adenomas (generally more than 4) within the liver. A 52-year-old woman presented with multiple (>10) solid liver lesions detected with abdominal ultrasonography and verified with magnetic resonance imaging (MRI). Subsequently, F-18 FDG PET/CT demonstrated increased uptake in these lesions. Histology revealed hepatic adenomatosis. F-18 FDG PET/CT cannot reliably differentiate hepatic adenomas from malignant processes on the basis of uptake.

Increased FDG uptake in breast cancer is associated with prognostic factors.

PURPOSE: To evaluate the relationship between FDG uptake and prognostic factors of breast cancer such as hormone receptors (estrogen and progesterone), expression of c-erbB-2, axillary lymph node status, tumor histology, grade and size. MATERIALS AND METHODS: Between May 2009 and February 2011; 79 patients (mean age ± SD: 52.9 ± 13.9 years) with biopsy proven breast cancer underwent F-18 FDG PET/CT scanning for staging. Patients with excisional biopsy or neoadjuvant chemotherapy were excluded from the study. Histological types included were invasive ductal carcinoma (n = 68), invasive lobular carcinoma (n = 2), and invasive ductal plus lobular mixed carcinoma (n = 9). Maximum standardized uptake values (SUVmax) were compared with estrogen (ER) and progesterone receptors (PR), expression of c-erbB-2, as well as tumor grade and tumor size. For the evaluation of relationship between tumor SUVmax values and prognosticators such as hormone receptors, tumor histologic grade, and tumor size, statistical analyses were performed using Student t test, Mann-Whitney U Test and Pearson correlation coefficient and p values of less than 0.05 were considered to indicate statistically significant differences. RESULTS: All primary breast neoplasms were detected by PET/CT scanner. The mean SUVmax values and breast cancer tumor sizes ranged from 2.09 to 39.0 and 0.7 to 10 cm, respectively. Tumors with negative ER [(n = 19); SUVmax median (min-max): 15 (2.09-39.0)] were associated with higher SUVmax values (p = 0.01). Tumors with overexpression of C-erbB-2 [(n = 28); SUVmax median (min-max): 16.0 (5.0-39.0)]; tumor grade 3 [(n = 25); SUVmax median (min-max): 15 (6.43-39)]; axillary lymph node involvement [(n = 60); SUVmax median (min-max): 13.61 (4.0-39.0)]; tumor histopathology and increased tumor size were associated with higher maximum standardized uptake values. However, PR did not show any relationship with SUVmax values. CONCLUSION: In the present report, strong relationships were detected between the negativity of ER, overexpression of c-erbB-2, tumor grade, tumor size, histopathology, axillary lymph node involvement and SUVmax values. Accordingly, we believe that SUVmax values obtained with (18)F-FDG PET/CT may provide some information about tumor biology of breast cancer.

Diagnostic value of PET/CT is similar to that of conventional MRI and even better for detecting small peritoneal implants in patients with recurrent ovarian cancer.

OBJECTIVE: The aim of this study was to evaluate the diagnostic value of 2-(fluorine-18)-fluoro-2-deoxy-D-glucose ((18)F-FDG) PET/CT in comparison with MRI for the detection of recurrent ovarian cancer. METHODS: Forty-seven patients with suspected ovarian cancer recurrence after total ablative or cytoreductive surgery, as well as neoadjuvant or adjuvant chemotherapy, who had undergone (18)F-FDG PET/CT imaging were recruited for the present study. All patients also underwent MRI within a month of (18)F-FDG PET/CT for the same purpose. Recurrent cancer in the abdomen and pelvis was evaluated in each of the 47 patients and classified as either distant metastasis or local pelvic recurrence involving the vaginal stump, peritoneal implants, supradiaphragmatic region, and/or abdominal and pelvic lymph nodes. Special attention was paid to peritoneal implants. These were divided into five groups according to size of the implants: less than 0.5 cm (group 1), 0.5-1 cm (group 2), 1-2 cm (group 3), 2-3 cm (group 4), and larger than 3 cm (group 5). PET/CT findings were compared with abdominopelvic MR findings. Statistical analysis was carried out using the Wilcoxon signed rank test. RESULTS: Thirty-nine of 47 patients were found to have recurrent ovarian cancer. Both PET/CT and MRI were negative for recurrence in six patients. Overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of PET/CT were 97.5, 100, 100, 87.5, and 97.8%, respectively, whereas those of MRI were 95, 85.7, 97.4, 75, and 93.6%, respectively. For the peritoneal implants in groups 2 and 3, the sensitivity, negative predictive value, and diagnostic accuracy values of PET/CT were significantly better than those of MRI (P<0.05). CONCLUSION: The present study revealed that PET/CT is similar to conventional MRI for the detection of recurrent ovarian cancer. PET/CT has greater accuracy in the detection of small-to-medium-sized (<2 cm) peritoneal implants compared with MRI. This may affect surgical decision making.

Metastasis of malignant melanoma to common biliary duct demonstrated with F-18 FDG PET/CT.

Malignant melanoma is well known for its propensity to spread to unpredictable sites. F-18 FDG PET can highlight metastases at unusual sites that may be missed with conventional imaging modalities. In this study, we present the case of a 57-year-old male patient who was referred to our department for PET/CT imaging because of metabolic characterization of the lesion located in distal common biliary duct and biopsied as malignant melanoma. His PET/CT images revealed a hypermetabolic lesion at the mentioned site. Interestingly, his images also showed mild FDG accumulation on right frontoparietal skin, and the biopsy of this lesion was also reported as malignant melanoma.

Cardiac involvement in melanoma: a case report and review of the literature.

Heart is rarely involved in metastatic cancer. A 44-year-old woman diagnosed with melanoma, with extensive metastases to whole body including interatrial septum demonstrated by PET/CT and echocardiography, was presented and discussed in light of the literature.

Excision efficiency of radioguided occult lesion localization in reoperative thyroid and parathyroid surgery.

BACKGROUND: The purpose of this study was to investigate the efficiency of a radioguided occult lesion localization technique in reoperative thyroid and parathyroid procedures in patients who had undergone previous neck exploration for thyroid or parathyroid disease. METHODS: Twenty-one consecutive patients who were scheduled for reoperative thyroid or parathyroid surgery were studied. The indication for reoperation was recurrent papillary thyroid cancer (PTC) in eight patients, completion thyroidectomy for PTC in eight patients who had previously undergone a bilateral subtotal thyroidectomy, recurrent goiter in two patients, primary hyperparathyroidism in two patients, and recurrent parathyroid cancer in one patient. Ninety minutes before surgery, 0.1 mL of Technetium-99m (0.2 mCi)-labeled macroaggregated albumin was injected directly into the lesion under ultrasonographic guidance. During surgery, a handheld gamma probe was used to localize and excise the lesions. The background and postexcisional site radioactivities were compared to confirm the completeness of each procedure. The radiation dose in the operating room environment, duration of surgery, and postoperative complication rates were evaluated in all patients. In patients with PTC, the change in serum thyroglobulin (Tg) following surgery was noted. RESULTS: Thirty lesions were marked and excised. The postexcisional bed gamma counts (610 ± 141) were markedly decreased compared with the pre-excisional site counts (21,415.8 ± 4993.4; p = 0.0001). The ratio of the postexcisional and background counts (4.6 ± 4.3) was significantly lower than the ratio of the pre-excisional and background counts (173.7 ± 156.4; p = 0.0001). The mean operation duration was 53.3 ± 7.5 minutes. The dose absorbed by the hands of the surgeon was estimated as 0.07 ± 0.02 and 0.15 ± 0.05 millisievert/h when one or three lesions were marked, respectively. One patient developed postoperative transient hypoparathyroidism. After surgery, serum Tg levels dropped to <2 ng/mL in 86% (6/7) of the patients with PTC whose preoperative serum Tg was elevated. CONCLUSIONS: The radioguided occult lesion localization technique was efficient in the perioperative identification of thyroid and parathyroid tumors in patients who were undergoing reoperation for PTC and hyperparathyroidism.

Intracoronary autologous bone marrow-derived mononuclear cell transplantation improves coronary collateral vessel formation and recruitment capacity in patients with ischemic cardiomyopathy: a combined hemodynamic and scintigraphic approach.

This study investigated the effects of intracoronary autologous bone marrow-derived mononuclear cell (BMC) transplantation on coronary microcirculation. Fifteen patients with ischemic cardiomyopathy were treated by intracoronary infusion of BMCs via the patent infarct-related artery. The thermodilution-derived coronary flow reserve, index of microvascular resistance, pressure-derived collateral flow index, and coronary wedge pressure were measured at baseline and at 6 months. Successive balloon inflations during BMC transplantation were performed to observe the recruitment in pressure-derived collateral flow index and coronary wedge pressure, and the percentage changes between baseline and 6 months were calculated. The mean (SD) coronary flow reserve increased from 1.3 (0.4) to 2.1 (0.5), and the mean (SD) index of microvascular resistance decreased from 44.9 (24.4) to 21.2 (14.1) (P = .001 for both). The mean (SD) improvement in pressure-derived collateral flow index (from 0.14 [0.05] to 0.22 [0.08]) was also statistically significant (P = .001). Similarly, the percentage improvements in pressure-derived collateral flow index and coronary wedge pressure were statistically significant (P = .01 for both). The percentage improvement in perfusion assessed by single-photon emission computed tomography strongly correlated with the percentage changes in pressure-derived collateral flow index (r = 0.88, P = .001) and coronary wedge pressure (r = 0.69, P = .01). These results demonstrate for the first time (to our knowledge) that intracoronary autologous BMC transplantation improves coronary collateral vessel formation and recruitment capacity in human subjects.

Does intraoperative radioguided surgery influence the complication rates and completeness of completion thyroidectomy?

BACKGROUND: To investigate whether radioguided surgery (RGS) has any beneficial effects on the complication rates and the completeness of completion thyroidectomy (CT) in a center experienced in endocrine surgery. METHODS: Thirty-three patients scheduled for CT for thyroid carcinoma were randomly selected for 2 types of intervention. CT was performed by RGS following administration of 5 mCi technetium-99m in 15 patients (group 1) and with conventional surgical exploration without RGS in 18 patients (group 2). The duration of the CT, thyroid function tests, iodine-131 uptake at 24 hours at the third postoperative week, and complication rates were compared between groups 1 and 2. RESULTS: In groups 1 and 2, the duration of CT (63.3 +/- 7.5 vs 65 +/- 10.8 minutes, P = .7), postoperative serum thyrotropin-stimulating hormone (TSH) levels (43.9 +/- 17.5 mIU/L vs 36.8 +/- 8.6 mIU/L, P = .2), postoperative (131)I uptake at 24 hours (6.86 +/- 1.7 vs 7.0 +/- 1.3, P = .8), and complication rates (13.3% vs 5.6%, P = .6) showed no significant differences. CONCLUSION: RGS during CT offers no benefit over conventional surgical exploration with respect to operation time, complication rates, or completeness of surgery in a center experienced in endocrine surgery. However, it might be helpful for general surgeons who are less familiar with re-operative thyroid surgery.

Comparison of different injection sites of radionuclide for sentinel lymph node detection in breast cancer: single institution experience.

BACKGROUND: There are still ongoing controversies about several aspects of lymphatic mapping and sentinel lymph node biopsy for breast cancer, including injection site of radioisotope and blue dye. This study aims to evaluate the success rate of different radiocolloid injection techniques in the detection of sentinel lymph nodes (SLN) in early breast cancer. STUDY DESIGN: One hundred ninety-two women with early breast cancer were included. For SLN mapping with lymphoscintigraphy (LSG), 5 different injections were used. Group A (36 patients) had 4 peritumoral (PT), group B (n = 36) had 1 subdermal (SD) injection of Tc-99m rhenium sulfide colloid over the tumor quadrant. Group C (59 patients) had 1 PT and 1 SD combined injections. In group D (56 patients), lymphatic mapping was performed with 2 intradermal periareolar (ID-PA) injections. In group E (n = 41), 2 ID-PA and 1 PT combined injections were performed. Early dynamic and delayed images were obtained. A surgical gamma probe was used to explore the SLNs. Surgical specimens were evaluated histopathologically. The SLN identification rate, false negative rate, and comparison of groups were evaluated by statistical methods. RESULTS: The SLN identification rate by LSG in groups A, B, C, D, and E were 72%; 92%, 93.2%, 98%, and 95%, respectively. The highest detection rates for the axilla (98%) and mammary internal (MI) drainage (22%) were obtained with ID-PA injections and a peritumoral injection, respectively. Seventy of 192 patients (36.4%) had positive axillary lymph nodes. The only statistically significant difference was between the PT and SD injection groups in axillary SLN identification rate by LSG (P = 0.016). CONCLUSION: The success rate was superior with intradermal periareolar injection compared with PT and SD injection to visualize the axillary SLN. However, PT deep injection combined with ID-PA injections may be more favorable to demonstrate the primary internal mammary (IM) lymphatic drainage.

[Intracoronary autologous bone marrow-derived stem cell transplantation in patients with ischemic cardiomyopathy: results of 18-month follow-up]. / Iskemik kardiyomiyopatili hastalarda intrakoroner otolog kemik iligi kaynakli mononükleer kök hücre nakli: 18 aylik takip sonuçlari.

OBJECTIVES: It has been demonstrated that intracoronary stem cell transplantation may have beneficial effects on left ventricular function and perfusion both in patients with acute and chronic ischemic cardiomyopathy (ICMP). We evaluated the safety and feasibility of intracoronary autologous bone marrow-derived mononuclear stem cell (MSC) implantation in patients with ICMP. STUDY DESIGN: The study included 15 patients (14 males, 1 female; mean age 49+/-11 years) with ICMP. All the patients received MSC transplantation via a balloon catheter to the target vessel which had been revascularized by percutaneous coronary intervention and was patent before the procedure. Evaluations were made at baseline and 6, 12, and 18 months after the procedure with complete clinical and laboratory examinations, and by treadmill exercise test, conventional echocardiography, and SPECT imaging. RESULTS: At six months, left ventricular ejection fraction increased significantly (p=0.001), hypoperfused areas on SPECT images reduced (p=0.002), and both myocardial oxygen consumption (p=0.001) and metabolic equivalents (p=0.001) increased. These beneficial effects of stem cell therapy were also observed at 12 and 18 months. No complications or in-hospital events occurred related with the procedure. CONCLUSION: Due to its beneficial effects on heart failure symptoms, left ventricular function, and perfusion, intracoronary stem cell transplantation can be used as an alternative, adjunctive treatment option in patients with ICMP.

The additional value of FDG PET imaging for distinguishing N0 or N1 from N2 stage in preoperative staging of non-small cell lung cancer in region where the prevalence of inflammatory lung disease is high.

PURPOSE: The aim of this study was to evaluate the efficacy of PET imaging and compare it with the performance of CT in mediastinal and hilar lymph node staging in potentially operable non-small cell lung cancer (NSCLC). METHODS: Fifty-nine patients with potentially resectable NSCLC who underwent preoperative PET and CT imaging were enrolled into this prospective study. All patients underwent surgical evaluation by means of mediastinoscopy with mediastinal lymph node sampling (14 patients) or thoracotomy (45 patients). RESULTS: The prevalence of lymph node metastases was 53%. Overall, the sensitivity, specificity, accuracy, PPV, and NPV of PET were 79%, 76%, 78%, 86%, and 76% for N0 and N1 lymph nodes and 76%, 79%, 80%, 67%, and 83% for N2 lymph nodes, while those values for CT were 66%, 43%, 58%, 68%, and 43% for N0 and N1 stations and 43%, 66%, 54%, 41%, and 66% for N2 lymph nodes, respectively. PET correctly differentiated cases with mediastinal lymph node involvement (N2) from those without such involvement (N0 or N1) in 76% of cases. Statistical analysis of the diagnostic accuracy of nodal involvement showed that PET improves diagnostic accuracy significantly in the detection of both N0 or N1 and N2 status in the individual patient based on analysis, compared with CT (P < 0.01 and P < 0.01, respectively). When preoperative nodal staging was compared with postoperative histopathological staging, 38 (65%) patients were correctly staged, 9 (15%) were overstaged, and 12 (20%) were understaged by PET, while 29 patients (49%) were correctly staged, 13 (22%) were overstaged, and 17 (29%) were understaged by CT. CONCLUSION: It has been clearly shown that PET is more accurate than CT for the differentiation of N0 or N1 from N2 disease in patients with NSCLC. However, PET imaging alone does not appear to be sufficient to replace mediastinoscopy for mediastinal staging in patients with lung cancer, especially in geographic regions with high granulomatous or inflammatory mediastinal disease prevalence.

Radio-guided nonpalpable metastatic lymph node localization in patients with recurrent thyroid cancer.

The detection of nonpalpable recurrent thyroid carcinoma has increased due to the use of imaging techniques in time. This report is to investigate whether preoperative injection of a radiotracer under ultrasound guidance is useful in nonpalpable recurrent thyroid carcinoma. The neck of two patients with recurrent thyroid carcinoma was scanned with the probe to localize the area of maximal radioactivity allowing appropriate location of the incision over the lesion. After the lymph nodes were removed, radioactivity was measured in the lesion bed to confirm the success of the dissection. In conclusion, the radio-guided nonpalpable lesion localization technique can be performed safely for the detection and excision of metastatic foci.

The role of peritoneal scintigraphy in the detection of continuous ambulatory peritoneal dialysis complications.

While continuous ambulatory peritoneal dialysis (CAPD) offers several advantages over hemodialysis in patients with end-stage renal disease, several complications have been recognized. The intraperitoneal instillation of dialysate increases intra-abdominal pressure and consequently predisposes the patient to leaks and herniations through defects in the abdominal wall. The use of an intraperitoneal radiolabeled colloid has been previously described to image entities such as hernias, patent processus vaginalis, abdominal wall, and diaphragmatic leakage. This study shows a simple, non-invasive method of determining the site of dialysate leak and its importance to assist further patient management. There has been a continuing increase in the number of end stage renal disease patients maintained on chronic peritoneal dialysis (CPD). Many patients choose CPD as their preferred chronic dialysis treatment, though approximately 20% of patients who drop out transfer to hemodialysis annually.[1] Although peritonitis remains the major reason for transfer to hemodialysis, other factors such as exit site infections, catheter-related problems, abdominal wall and inguinal hernias, loss of ultrafiltrations, and poor clearance contribute to CPD technique failure.[2] In order to permit the continuation of long-term therapy with CPD, these complications should be resolved. Routine laboratory evaluation or physical examination can detect some CPD-related problems; however, some patients require more complicated investigations to evaluate their problems properly.

The value of combined peritumoral and subdermal injection techniques for lymphoscintigraphy in detection of sentinel lymph node in breast cancer.

PURPOSE: The aim of this study was to evaluate the success rate of combined peritumoral and subdermal injection techniques based on our previous experience on different injection techniques for lymphoscintigraphy. PATIENTS AND METHODS: Fifty-nine women with early breast cancer (mean tumor size, 20.5 mm) were prospectively studied. On the morning of the operation, each patient had 2 injections, one peritumoral (PT) medial to the lesion and one subdermal (SD) into the skin over the tumor quadrant. Each injection consisted of 20 MBq (540 mCi) Tc-99m rhenium sulfide colloid. Early dynamic and delayed static images were obtained up to 4 hours after injections. An intraoperative gamma probe was used to explore the axillary sentinel lymph nodes (SLN). All surgical specimens were evaluated histopathologically. RESULTS: Forty patients had breast-preserving surgery and 19 had modified radical mastectomy. Thirty-eight patients had axillary dissection. All but 4 patients showed axillary lymphatic drainage. Twelve of 59 patients (20%) showed extraaxillary drainage with lymphoscintigraphy. Combined injection technique yielded a 93.2% success rate in detecting axillary SLN. In 2 of 4 patients with no drainage on lymphoscintigraphy, intraoperative gamma probe revealed SLN during the surgery. Twenty patients (33%) had positive axillary lymph nodes. In 14 of them, the SLN was the only positive node. A false-negative rate was found 1.6% (one of 59 patients). CONCLUSION: This results suggest that a combination of both PT and SD techniques increases the success rate of visualization SLN and enhances the visualization of extraaxillary nodes for further treatment planning.

Sentinel lymph node biopsy for the staging of anal melanoma: report of two cases.

Primary melanoma of the anal region is a rare pathological entity and its prognosis is generally poor. The aim of this report is to demonstrate the feasibility of the sentinel lymph node (SLN) procedure with combined technique in patients with anal melanoma. We report of two cases with anal melanoma that had wide local excision of the primary lesion and was referred for further evaluation. After diagnostic metastatic work-up, SLN procedure consisted of a combination of preoperative lymphoscintigraphy with technetium-99m nanocolloid injected around the tumor, and intraoperative detection of SLN with gamma probe (combined technique) was performed. In addition, patent blue dye was injected at the periphery of the tumor to facilitate direct identification of the blue-stained lymph node. In the first case, SLN identified both inguinal and iliac lymph node basins, both of which were histologically negative on both frozen and paraffin sections. In the other case, SLN removed from the inguinal lymph node basin showed micrometastasis by paraffin section. In both cases SLN procedure with combined technique was performed sufficiently without significant complications. Consequently, we suggest that SLN procedure with combined technique is also a useful technique in malignant melanomas similar to other anal canal cancers.

Radiosynovectomy in hemophilic synovitis: correlation of therapeutic response and blood-pool changes.

AIM: The aim of this study was to evaluate the efficacy of 90Y and 186Re radiosynovectomy in patients with hemophilic synovitis. METHODS: Radiosynovectomy was performed in 32 joints of 20 patients with hemophilic synovitis by using 90Y citrate colloid in the knee and 186Re sulfide colloid in the elbow, shoulder, and ankle. The indication for radiosynovectomy was the continuous presence of intra-articular blood or effusion and three or more hemorrhages into the same joint within the last 6 months. Response to therapy was first assessed at the 4th month with blood-pool imaging. Patients were followed up by clinical evaluation based on assessments of joint-bleeding frequency, using range of motion measurements at 6-month intervals for an average of 1 year (range, 9-15 months). RESULTS: A marked decrease (an 80%-100% decrease) in bleeding episodes was seen in 24 of 32 (75%) joints, a moderate decrease (51%-79% decrease) in 1 (9%) joint, and a mild decrease (30%-50%) in 3 (13%) joints. Frequency of intra-articular bleeding after treatment was unchanged in only 13% of the joints. The number of hemarthroses significantly decreased after therapy (p < 0.05). The mean bleeding frequency of the joints were 1.7 +/- 0.9 and 0.3 +/- 0.7 per month before and after therapy, respectively. The ratios of joints which had marked improvement after therapy were 86% in the ankle, 73% in the elbow, and 58% in the knee. There was no significant difference between percent joint range of motion limitations measured before and after therapy (p > 0.05). The correlation between therapeutic outcome (in terms of joint bleeding) and the difference of pre- and posttherapeutic blood-pool indices were significant (r = 0.594; p < 0.05), while the correlation between therapeutic outcome and pretherapeutic radiologic scale and pretherapeutic blood-pool indices were not significant (r = 0.095; p > 0.05; r = -0.089; p > 0.05, respectively). CONCLUSION: Radiosynovectomy is a simple but quite effective and efficient procedure in limiting the frequency of joint hemorrhage in patients with hemophilia. Blood-pool imaging may be an objective means for monitoring therapy response in these patients.