Abstract: Background: Sentinel Lymph Node Biopsy (SLNB) procedure was found to be an accurate method of staging the axilla in patients with early stage breast cancer. The standard of care for breast cancer patients with positive SLN metastasis includes complete Axillary Lymph Node Dissection (ALND). However, in 40â70% of patients, the SLN is the only involved axillary node. Factors predicting non SLN metastasis should be identified in order to define subgroups of patients with positive SLN in whom the axilla may be staged by SLNB alone.Objectives: To identify the factors predicting metastatic involvement of the non-SLNs in breast cancer patients having SLN metastasis. Patients and Methods: Data were collected and analyzed from 80 patients with early stage invasive breast cancer (T1, T2, N0, M0) who underwent SLNB at the Surgical Oncology Department, Kuwait Cancer Control Center (KCCC) between November 2004 and February 2009. SLNB was performed using a combined technique (radioactive colloid, and blue dye) in the majority of cases. In some cases, only one technique was used. Complete ALND was performed in the case of failure of SLN identification and in patients with positive SLN. Multiple variables (patient, tumor, and SLN characteristics) were tested as possible predictors of nonsentinel lymph node metastasis. Results: The mean age of patients at diagnosis was 46.6years. The median tumor size was 2cm. The SLN identification rate was 96.2% (77 out of 80 patients). The SLN was positive in 24 patients (31%), and half of these showed evidence of capsular invasion. The median number of SLNs removed was two. The median number of positive SLNs was one. The incidence of non-SLN metastasis associated with positive SLN was 50% (12 out of 24 patients). Lymphovascular invasion was found to be the only factor associated with non-SLN metastases. In addition, two trends were observed, though they did not reach the statistical significance: the first is that the majority of patients having capsular invasion of the SLN (8 out of 12 patients, 67%) had positive non-SLN metastasis, and the second is that the patients having more than one SLN metastasis were more likely to have non-SLN metastasis (4 out of 5, 80%). Conclusion: In the current pilot study, only the lymphovascular invasion in the area of the primary tumor was found to be significantly related to the nonsentinel lymph node metastasis. There was a tendency toward higher incidence of nonsentinel lymph node metastasis associated with the number of positive SLN and capsular invasion of SLN, though this did not reach the statistical significance. This could be attributed to the small number of patients recruited. Further evaluation of the predictors of nonsentinel lymph node metastasis on a larger number of patients is required. The validation of these predictors in prospective studies may enable approximately half of early stage breast cancer patients with positive SLN to be staged with SLNB alone while avoiding the morbidity of unnecessary ALND.
Abstract: A 36-years old lady with repeated history of respiratory tract infection, presented with acute shortness of breath and chest pain. Chest X-ray showed the hyperlucent left lung with diminished vascular marking. Lung perfusion and ventilation study was done to rule out pulmonary embolism. Lung perfusion scan with Tc 99m MAA, revealed diminished perfusion in the left lung, while ventilation study with Tc 99m Technigas shows corresponding reduced ventilation with interspersed hot areas most likely representing air trapping. This case report reaffirms the utility of the V/Q scan as a quick and easily noninvasive diagnostic tool that seems to be necessary and complementary with the anatomical imaging modalities in establishing the presence of SwyerâJames Syndrome. This syndrome should be recognized to avoid confusion with asthma and pulmonary embolism, which may result in inappropriate therapy.
Abstract: Sphenoidal sinus carcinoma is a rare cause of hypercalcemia of malignancy. We report on a 37-year-old male with sphenoidal sinus carcinoma with intracranial extension who developed hypercalcemia of malignancy with progressing disease and demonstrated diffuse metastatic visceral calcifications of lungs, myocardium, stomach, kidneys and thyroid on follow-up 99mTc-methylene diphosphonate bone scan. In the absence of extensive skeletal metastases, bone scan help confirm humoral nature of hypercalcaeimia. Keywords: Bone scan, visceral calcification, Humoral hypercalcemia, Sheniodal Sinus carcinoma.
Abstract: Objective: To evaluate the efficacy of somatostatin analog scintigraphy with indium-111-pentetreotide and its overall impact on management in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NET). Subjects and Methods: Twenty-two consecutive patients with a proven or clinically suspected GEP-NET with or without proven metastases were imaged at 24 and 48 h after injection of (111)In-pentetreotide. The scintigraphic findings were compared with results from conventional imaging methods. The final diagnosis was based on histopathological and surgical findings and complementary radiology. Results: Somatostatin receptor-positive lesions were found in 20 of the patients, whereas conventional methods were positive in 18 patients. Additionally, 13 new tumor sites were discovered by somatostatin receptor scintigraphy in 5 patients (liver: 6; chest: 2; bone: 1; abdomen: 4). The surgical therapeutic strategy was changed in 7 patients (32%). Conclusions: Our data reinforced that scintigraphy with (111)In-pentetreotide represents the imaging modality of choice in the initial evaluation of GEP-NET. It is highly accurate and can identify clinically unsuspected lesions and optimize the overall staging. It also guides optimal therapy choice and most importantly identifies patients with inoperable or metastatic disease who might be candidates for high-dose targeted therapy.
Abstract: PURPOSE: Ductal carcinoma in situ (DCIS) currently represents approximately 15-25% of all breast cancers detected. Although inherently a noninvasive disease, occult invasive disease can be found at definitive histology. The role of sentinel lymph node (SLN) biopsy in DCIS is still unclear. The aim of this study was to evaluate the clinical usefulness of SLN biopsy and the incidence of SLN metastases in selected patients with high-risk DCIS, who are at highest risk for being upstaged to invasive carcinoma. MATERIALS AND METHODS: Twenty-three high-risk patients with DCIS proven on core biopsy (mean age, 50 years; median age, 48 years; age range, 37-78 years) were included in the study. SLN scintigraphy was performed 2-4 h before surgery by injecting Tc-99m-labeled nanocolloid intradermally in the periareolar region. The first lymph node to appear on the scan was labeled as SLN and was marked on the skin by using a γ probe. The lymph node was explored in the axilla using a γ probe. RESULTS: The SLN was identified in all patients (100% success rate). Of 23 cases of DCIS on core biopsy, seven patients (30%) were shown to have invasive ductal carcinoma on final histological specimen. Among these seven patients, three had minimal invasive carcinoma (<1 cm) and none of these patients had positive SLN for metastases. Among 23 cases, only one patient with (4%) SLN was positive for metastasis despite histopathological diagnosis of pure DCIS. CONCLUSION: Although the study population is small, our findings suggest that patients with high-risk DCIS have an increased risk of invasive disease, as approximately one-third of these patients had invasive component at the time of definitive operative procedure. Furthermore, the study also suggests that SLNB appears to be reliable in identifying axillary lymph nodes status of these patients.
Abstract: The aim of this study was to evaluate the efficacy of lymphoscintigraphy, gamma probe guided sentinel lymph node biopsy (GP-SLNB) in the management of breast cancer and study the follow-up results. Fifty two patients (mean age 47.28+/-9.7; range 23-69yr) with operable breast carcinoma and clinically negative axilla were studied. Scintigraphy for the detection of SLN was performed 2-4h before surgery by injecting technetium-99m labeled nanocolloid intradermally in the peritumoral region. First lymph node (LN) to appear on the scan was labeled as SLN and by using the GP was marked on the skin. Blue dye was also injected in all patients intraoperatively and hot and/or blue LN were studied in the axilla using the GP. The SLN was identified in 50 patients (96% success rate) while in 2 patients SLN was not visualized on imaging. The blue dye successfully localized SLN in 45/52 (87%) of the cases. Of the 52 patients, 16 had axillary lymph node dissection (ALND), including 14 SLNB positive for lymph node metastases cases and the two cases in which no SLN was imaged. In the remaining 36/52 cases SLN were negative for metastases and patients on the follow-up remained disease free (NPV 100% for a follow-up period of 12-36 months). The success rate, sensitivity, negative predictive value, and accuracy were 96%, 93%, 100%, and 98% using the GP-SLNB, 87%, 80%, 100%, and 93% using blue dye, and 98%, 100%, 100%, and 98% using combined methods, respectively. In conclusion, lymphoscintigraphy, GP-SLNB has a higher success rate and sensitivity versus the dye technique and when combined with the blue dye technique its sensitivity increases to 100%. We found a high negative predictive value for SLNB and the recurrence rate in these negative SLNB was comparable to the ALND.
Abstract: OBJECTIVE: Management of differentiated thyroid cancers (DTC) remains controversial with a wide variation in clinical practice. The aim of this audit was to find out strength and weakness of treatment strategy being used at a tertiary care hospital. PATIENTS AND METHOD: Patients with DTC enrolled from January 2006 till May 2009 were reviewed. Histopathology, extent of surgery, measurement of serum markers, I-131 ablation, use of various imaging techniques and follow up rate at 1 year was evaluated. RESULTS: One hundred and six patients (M:F 36:72 with mean age of 40.55 ±16 years) were enrolled and papillary (72%) followed by follicular carcinomas (15%) were the most common tumors. Total or completion thyroidectomies were performed in 78 and 22 patients respectively while 6 had partial thyroidectomies. Serum TSH and thyroglobulin level with antibodies were measured in all patients at baseline and 1 year follow up. Radioiodine-131 (I-131) was given (50-200 mCi) to every patient at a mean TSH level of 55.11 ± 31mU/L. Diagnostic whole body iodine scan (DWBIS) was performed in 36/106 (34%) patients at baseline and 30/48 (63%) at follow up. Therapeutic WBIS (TWBIS) was performed in 103/106 (97%) patients at baseline and 23/25 (92%) at follow up. Neck ultrasound was performed in 25% and 27% patients at baseline and follow up. Follow up failure of 55% was seen at 1 year. CONCLUSIONS: This audit regarding the management of DTC at KIRAN reveals adequacy of extent of surgery, use of I-131 ablation, TWBIS and measurement of clinical markers are in good agreement with recommended guidelines. However, this audit shows over utilization DWBIS, under-utilization of neck ultrasound and dismal follow-up at 1 year and these need to be addressed properly.
Abstract: Th e aim of this study w as to e valuate the prognostic value of a norm al MPI in our population. PATIENTS AND
METH OD: Th is s tudy include d 413 patients with normal MPI (with adequate s tress ) performed with sestaMIBI. Out
of 413 patients , 217 w e re m ale and 19 6 w e re fe m ale with mean age 52.4 ± 9 .8 years (median 52 years ). The study
w as indicate d for ch e s t pain diagnosis in 330 (80% ) and for th e as s e s s m e nt of functional capacity in remaining 83
(20% ) patients . Th e cardiac risk factors were prevalent including hypertension in 9 2 (22.3% ), diabetes in 52 (12.6% )
and dyslipidemia in 52 (12.6% ). Further m ore , 21.5% patients had >2 risk factors. 248 (60% ) individuals underwent
dynamic stress following Bruce or Modified Bruce Protocol and end points were achievement of >85% target heart
rate , ch e s t pain or appearance of significant ECG change s . Remaining 165 (40% ) individuals had dipyridamole
intervention (standard protocol). A stress -rest (one day protocol) SPECT study w as acquired using single head
ECAM (Siemens ) or double h e ad Toshiba GCA-7200A gamma cameras . Th e s e patients w e re follow e d up for 18
month s ± 5 month s and occurrence s of hard cardiac events (MI or cardiac death ) w e re asked on telephone .
RESULTS: Th e observe d cardiac death s w e re 3/413 (0.73% ) and non-fatal MIs w e re s e e n in 4/413 (0.9 7% ) on
18 month s follow up. Th e observe d cardiac mortality rate for patients with normal MPI w as 0.73% . Risk adjusted
(controlling for age , s e x and type of stress ) overall cardiac survival exceeded 9 9 .27% . For women and men, the
ave rage cardiac survival w as 9 9 % and 9 9 .5% respectively (p=0.001). Additionally for patients undergone exercise ,
the annualized survival rate w as 9 9 .6% and 9 8.8% for those w h o had dipyridamole intervention.
CONCLUSION: A normal sestaMIBI SPECT study with adequate stress is associated with annualized cardiac death
rate of 0.5% and a negative predictive value of 9 8.33% . Furthermore , these statistics of our population are com parable
with most of the published studies .
Abstract: The aim of this study was to compare the usefulness of (99)Tc(m)-methoxy-isobutyl-isonitrile (MIBI) scintimammography and ultrasonography, alone and in combination, for the detection of chest wall recurrence in the post-mastectomy breast. A total of 41 consecutive post-mastectomy patients (mean age 46.6 years; median age 45 years) with clinical suspicion of breast cancer recurrence were evaluated. For scintimammography all patients received a 740-900 MBq iv injection of (99)Tc(m)-MIBI; planar images were taken 5-10 min post-injection followed by supine single photon emission CT. Breast ultrasonography was performed in each patient using a 7.5 MHz transducer. Both MIBI uptake and ultrasound findings were documented using standard protocols. All patients had fine needle aspiration cytology biopsy (FNAC), core biopsy or excision biopsy for final tissue diagnosis. Of the 41 patients, 24 had true positive signs of local breast cancer recurrence upon ultrasonography, 10 were diagnosed as true negatives, a sensitivity of 86%, specificity 77%, positive predictive value (PPV) 89%, negative predictive value (NPV) 71% and accuracy 83% (p = 0.001). By comparison, scintimammography findings were found to be true positive in 25 patients and true negative in 12 patients - sensitivity 89%, specificity 92%, PPV 96%, NPV 80% and accuracy 90% (p = 0.001). Using a combination of these two modalities, the combined sensitivity was 100%, specificity 77%, PPV 90%, NPV 100% and accuracy 93%. The high NPV of the two studies in combination implies a potential use of this approach to exclude recurrent disease in patients with a low initial index of suspicion and/or when histology is indeterminate.
Abstract: OBJECTIVE: To evaluate the efficacy and usefulness of (99m)Tc-sestamibi scintigraphy and gamma probe localization of parathyroid glands in patients with primary hyperparathyroidism and establish radio-guided minimally invasive parathyroidectomy at Hussain Makki Al Jumma Center for Specialized Surgery, Kuwait. SUBJECTS AND METHODS: Twelve patients with primary hyperparathyroidism (mean age: 48 +/- 14 years; median age: 46 years; age range: 29-68 years) were evaluated. The diagnosis of hyperparathyroidism was established by elevated serum calcium and parathyroid hormone levels. All patients had a well-defined parathyroid lesion on previous standard (99m)Tc-sestamibi scintigraphy with or without ultrasound study. All had a normal thyroid gland, no history of familial hyperparathyroidism or multiple endocrine neoplasia nor any history of previous neck irradiation. On the day of surgery, patients were injected with 740 MBq (20 mCi) of (99m)Tc -sestamibi followed by a half-hour-delayed single standard pinhole view of the neck. A skin marker was placed on the basis of maximum count intensity during gamma probe localization. Patients were then sent for radio-guided minimally invasive parathyroidectomy. RESULTS: The preoperative localization of the affected gland was successful in all cases using a gamma probe and (99m)Tc -sestamibi scintigraphy. The pathological parathyroid tissue was localized and successfully removed with the gamma probe. The histopathological diagnosis was parathyroid adenoma in 11 cases and hyperplasia in the remaining one. All patients remained disease and symptom free at 12-month follow-up. CONCLUSIONS: Our initial experience with intraoperative use of a gamma probe to carry out minimally invasive parathyroidectomy was a useful, easy and safe procedure for treating patients with primary hyperparathyroidism.
Abstract: OBJECTIVE: To determine the prognostic value of myocardial perfusion scintigraphy with dipyridamole stress in patients with preexisting left bundle-branch block (LBBB) with or without chest pain. SUBJECTS AND METHODS: Seventy-six patients, mean age 53 +/- 10 years, with preexisting LBBB underwent technetium-99m-sestamibi perfusion imaging with dipyridamole infusion protocol (0.56 mg/kg). Stress and rest single photon emission computed tomography (SPECT) images were interpreted by consensus of 2 experienced nuclear medicine physicians and classified as low-risk scans (normal myocardial perfusion scan, small reversible/small fixed defect) and high-risk scans (large, severe, fixed or reversible defect and dilated left ventricle cavity). The patients were followed up for 24 +/- 8 months and occurrences of hard cardiac events (infarction or cardiac death) were noted. RESULTS: Of the 76 patients, 52 (68%) had low-risk scans and the remaining 24 (32%) had high-risk scans. In the low-risk group, 1 (1.9%) cardiac death and 2 (3.8%) cases of nonfatal myocardial infarction occurred, while in the high-risk group, 5 (20.8%) suffered cardiac death, and 3 (12.5%) nonfatal myocardial infarction. Overall survival rate was 98.1% in the low-risk group compared with 79.2% in the high-risk group with a significant difference of p = 0.034. Negative predictive value of normal myocardial perfusion scintigraphy for the occurrence of death was 100%. No significant difference in survival rate among patients with or without chest pain (p = 0.31) was observed. CONCLUSIONS: Myocardial perfusion imaging with dipyridamole provided important prognostic information in patients with LBBB; it was useful in stratifying the patients according to cardiovascular morbidity and mortality, and would thus allow the clinician to provide early treatment especially in the high-risk category.
Abstract: Breast cancer is the most common cancer among women and the second leading cause of death in women after lung cancer. Local recurrence rate is about 1-2% per year. It is important to find a sensitive and accurate diagnostic method for early detection of recurrent tumor for planning subsequent management. The principal aim of the present study was to assess the utility of Tc-99m MIBI scintimammography in the detection of loco-regional recurrence of breast cancer in comparison with the conventionally used methods like x-ray mammography and ultrasonography. A total number of 42 patients (Age: mean= 45.55 yrs; median = 43.5; range, 22-77 yrs) suspected to have loco-regional recurrence of breast cancer on the basis of clinical examination and/or conventional imaging procedures were included in this study. All patients were subjected to planar scintimammography (SMM), SPECT imaging of the breast, x-ray mammography and Ultrasound scanning. The results were correlated with the final diagnosis arrived at by fine needle aspiration cytology (FNAC), core biopsy or definite wide local excision. Sensitivity (SEN), specificity (SPE), positive predictive value (PPV), negative predictive value (NPV) and accuracy (ACC) of scintimammography in the diagnosis of recurrent disease were found to be 82.75, 92.3, 96.0, 70.58 and 85.71% respectively; compared to 45.83, 66.6, 78.57, 31.57, 51.51 for x-ray mammography and 65.51, 69.23, 82.6, 47.36, 66.66 for Ultrasonography. Scintimammography results were correlated with x-ray mammography and ultrasonography by applying Pearson correlation. No significant correlation was found between SMM and XMM (r=0.27) or SMM and US (r=0.23). Based on the results of this study it is concluded that SMM has better diagnostic accuracy than mammography and ultrasonography in the detection of loco-regional recurrence of breast cancer
Abstract: OBJECTIVES: The interpretation of mammogram in a postsurgical breast can be extremely complex and difficult because masses, calcifications, and architectural distortion can mimic cancer. Scintimammography has been proposed because it is not affected by these morphological changes and can potentially be used in patients after excision biopsy to assess any residual tumor, other foci of disease (multifocal disease). MATERIALS AND METHODS: The population comprised of 21 patients (mean age: 47.80 years, median age: 50 years, and age range: 26-77 years) evaluated for suspected residual breast cancer after excision biopsy. All patients received a 740-1000 MBq bolus IV injection of Tc-99m-methoxy isobutyl isonitrile (MIBI) preferably in pedal vein. At 5-10 min after injection, planar images were obtained in prone lateral and supine anterior positions using dual head gamma camera. MIBI uptake was scored as follows: 1 - as normal uptake (compared with contralateral side), 2 - focal low-intense uptake (equivocal), and 3 - focal high-intense uptake (positive). All patients had histopathology for tissue diagnosis. RESULTS: Of the 21 patients evaluated, scintimammography planar was found true positive in 13 and true negative in six. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 92.85, 85.71, 92.85, 85.71, and 90.47%, respectively (P<0.001). Scintimammography detected 2/2 multifocal disease. CONCLUSION: In patients after excision biopsy, scintimammography with Tc-99m-MIBI is valuable in assessing residual or multifocal disease. Scintimammography has high positive predictive value and may influence planning further management.
Abstract: Breast cancer is the most common cancer among women and the second leading cause of death in women after lung cancer. The principle aim is to study the utility of Tc- MIBI scintimammography in evaluation of breast cancer and lymph node metastases. MATERIALS AND METHODS: A total of 36 patients both with breast lumps or/and axillary masses suspected breast cancer on clinical examination and/or at conventional imaging procedures (CIP's) were included in this study. The mean age was 47.13 years, median age 47 and age range 22-77 years. All patients received a 740-1000 MBq bolus IV injection of 99mTc-MIBI preferably in a pedal vein. At 5-10 min post injection planar images were obtained in prone lateral and supine anterior position using dual head gamma camera. MIBI uptake was scored as follows: 1 for normal uptake (compared with contralateral side), 2 for focal low intense uptake (equivocal), 3 for focal high intense uptake (positive). All patients had histopathology for tissue diagnosis. RESULTS: There were 36 patients who presented with breast lesions (30 palpable, 6 non-palpable) and 8 patients with axillary lump. Scan was found true positive in 24 patients and was true negative in 7 patients with breast lesion. In case of axillary lump, it was true positive in 4 and true negative in 2 patients. Planar scintimammography showed sensitivity of 86%, specificity 88%, PPV 96%, NPV 64% and accuracy of 86% (p<0.01). However sensitivity, specificity, PPV, NPV and accuracy for axially metastasis were 86%, 67%, 80%, 67% and 75% respectively. (P-value <0.01). CONCLUSION: It is concluded from the study that SMM has good diagnostic accuracy in the detection of breast cancer specially in palpable lesion and lymph node metastases.
Abstract: PURPOSE: To evaluate in serial gallium-67 scans (GS) the role of semiquantitative tumor-to-background (Tm/Bg) and tumor-to-liver ratios in assessing response rates to chemotherapy, in Hodgkin's disease and non-Hodgkin's lymphoma. MATERIALS AND METHODS: Twenty-seven consecutive patients (15 Hodgkin's disease and 12 non-Hodgkin's lymphoma patients) with an average age of 30 (range, 5-60) years underwent GS at prechemotherapy, early chemotherapy (after first cycle), and postchemotherapy. Average tumor, background, and liver region of interest counts obtained and Tm/Bg, tumor-to-liver, and liver region to background ratios were derived for each patient on serial GS. All patients were assessed by visual and quantitative GS and followed up clinically for more than 7 years. RESULTS: At early visual GS, 70% (19 of 27) of the patients showed rapid response, 15% (four of 27) showed delayed response (negative at post-GS), and 15% showed no response. Mean early-GS Tm/Bg ratio of disease-free patients (1+/-0.04) was significantly different from relapsed (1.4+/-0.2) (P<0.025) and progressive disease (1.8+/-0.7) patients. A significant difference was noted (P<0.01) in serial paired comparisons of Tm/Bg ratios between pretherapy and early-therapy scans in relapsed patients, whereas progressive disease patients showed no significant change during the same time. At early-GS, 15 patients showed quantitative rapid response (Tm/Bg ratio 1.04), nine patients showed quantitative delayed response (Tm/Bg ratio >1.04 with significant serial change between pretherapy and early-therapy GS), and three patients showed quantitative no response (Tm/Bg ratio >1.04 with nonsignificant serial change between pretherapy and posttherapy GS). CONCLUSION: Quantitative GS is an effective tool in the detection of early response to chemotherapy. Quantitative response rates after the first cycle can more reliably identify patients who are most likely to be disease-free or relapse after first-line therapy or those that will show no response to therapy as compared with visual analysis alone.
Abstract: OBJECTIVE: To evaluate the utility of Tc- MIBI scintimammography in the loco-regional recurrence of breast cancer and its comparison with mammography. METHODS: The study population comprised of 33 subjects (mean age, 44.9 +/- 14.1 years); evaluated for suspected loco-regional recurrence of breast cancer on clinical examination. All subjects received a 740-1000 MBq bolus IV injection of 99mTc-MIBI preferably in pedal vein. At 5-10 min and 60-90 min post injection planar images were obtained in prone lateral and supine anterior position using double head gamma camera. MIBI uptake was scored as follows: 1: as normal uptake (compared with contralateral side); 2: focal low intense uptake (equivocal); 3: focal high intense uptake (positive). Mammography was performed by two standard views of cranio-caudal and mediolateral oblique in 26 patients. All patients had either excision biopsy or fine needle aspiration cytology (FNAC) for tissue diagnosis. RESULTS: Out of 33 patients, 21 had confirmed as recurrence on hiostopathology/cytology. Scintimammography was found true positive in 18 and true negative in 11 patients. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 85.7%, 91.7%, 94.7%, 78.6% and 87.8% respectively. In comparison, mammography was true positive in 9 and true negative in 6 patients with sensitivity of 52.9%, specificity, 66.7%, PPV 75%, NPV 42.9% and accuracy 57.7%. CONCLUSION: Scintimammography has better diagnostic accuracy than mammography in the detection of loco-regional recurrence of breast cancer.
Abstract: OBJECTIVE: To determine the efficacy of 99mTcMIBI with nitrate administration for the detection of viable myocardium in patients with MI. METHODS: Thirty-five patients (31 men, 4 women; mean age 51.91 +/- 8.86 years, median = 50) with previous history of myocardial infarction (with mean duration of 11.50 +/- 11.4, median =4 months after MI) were included in the study. All patients underwent baseline rest and Nitroglycerine 99mTcMIBI myocardial perfusion imaging (2 day protocol). Fifteen out of 34 patients were also submitted for rest and redistribution TI-201 imaging (3 day protocol). The data were reconstructed in transaxial slices and then reoriented into short, vertical long and horizontal long axis slices. The images were divided into seven different segments for qualitative as well as semi quantitative analysis. The images were interpreted by two independent observers. The segments with tracer activity of more than 55% as compared to maximum, were considered as viable. RESULTS: In the baseline study with 99mTcMIBI, 168/245 (68.57%) were viable segments and these were increased to 197 (80.40%) in the Nitrate MIBI study (p = 0.001 vs. baseline). Total 21 (60%) out of 35 patients demonstrated viable myocardium. The concordance for viable segments detection between Nitroglycerine MIBI and redistribution TI-201 imaging was found in 100 out of 105 segments (95.24%) for 15 patients, with significant kappa = 0.746 +/- 0.079 SE. CONCLUSION: The data suggest that use of nitrate augmented 99mTcMIBI protocol in Cardiac SPECT imaging results in improved detection of viable but hypoperfused segments and achieves results similar to those from standard TI-201 rest and redistribution protocol.
Abstract: BACKGROUND: The mastectomy site is usually assessed by clinical examination and ultrasonography for recurrence of breast cancer, although post-surgical and radiotherapy changes limit the accuracy of these methods. MRI has been used successfully but it remains an expensive modality and may not be readily available. Scintimammography is an alternative method which has the advantage of not being affected by post-operative morphological changes. AIM: To evaluate the usefulness of planar Tc-MIBI scintimammography and supine Tc-MIBI SPECT in the detection of chest wall recurrence post-mastectomy. METHODS: The study population comprised of 26 patients (mean age, 47.15 years; median age 47 years; age range, 22-77 years) with suspected chest wall recurrence of breast cancer on clinical examination. All patients received a 740-1000 MBq bolus i.v. injection of Tc-MIBI preferably in the pedal vein. At 5-10 min post-injection planar images were obtained in the prone lateral and supine anterior positions using a double-head gamma camera. After planar imaging supine SPECT was performed (64 projections, 64x64 matrix, 30 s.frame). MIBI uptake was scored as follows: 1 = normal uptake (compared with contralateral side); 2 = focal low uptake (equivocal); and 3 = focal high uptake (positive). All patients underwent excision biopsy or FNAC for tissue diagnosis. FNAC was considered sufficient if unequivocally positive. RESULTS: For the 26 patients, planar scintimammography was found true positive in 14 and true negative in seven. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 78%, 87.5%, 93%, 64% and 81%, respectively (P<0.001). SPECT showed a significantly higher overall sensitivity than planar imaging (89% vs. 78%; P<0.001). SPECT and planar imaging showed the same specificity (87.5%). SPECT showed a significantly higher negative predictive value and accuracy than planar imaging (78% vs. 64% and 88% vs. 81%, respectively; P<0.05). CONCLUSION: Scintimammography is a reliable diagnostic tool and appears accurate in the detection of chest wall recurrence. SPECT shows high positive predictive value and aids in the diagnosis of the chest wall recurrence with greater confidence.
Abstract: PURPOSE: To evaluate the effectiveness of 99mTc-MIBI Scintimamography (SMM) for the detection of residual disease after post excision biopsy (PE) and local recurrence of breast cancer in modified radical mastectomy (MRM) post lumpectomy (PL) patients. MATERIALS AND METHODS: 156 consecutive patients (mean age 47yrs; median age 47.5yrs) from September 2003 to December 2010 with clinical suspicion of residual and loco-regional recurrence of breast cancer were divided into three groups. Group I comprised of 26 PE patients, group II of 49 MRM patients and Group III of 81 PL patients. All patients received a 740-1000 MBq bolus IV injection of 99mTc-MIBI, followed by Planar and SPECT imaging. All patients had either excision biopsy or FNAC for tissue diagnosis. RESULTS: 98/156 (63%) patients were found disease positive on histopathology In group I, SMM had sensitivity, specificity and accuracy of (94%, 90% and 92% p = 0.001). In group II, observed sensitivity, specificity and accuracy of SMM are (89%, 78% and 86% respectively p = 0.001), while in Group III sensitivity, specificity and accuracy are 87%, 90% and 90%. The overall sensitivity, specificity and accuracy of SMM was 89%, 90% and 89%. No significant statistical difference was observed between sensitivity, specificity and accuracy of SMM among the groups. CONCLUSIONS: SMM can be used with confidence to discriminate tumor recurrence, from benign changes resulting from surgery and irradiation. SMM can be used as first line test for the detection of residual disease and local recurrence of breast cancer.
Abstract: OBJECTIVE: To evaluate the efficacy of somatostatin analog scintigraphy with indium-111-pentetreotide, and its overall impact on management in patients with gastroenteropancreatic neuroendocrine tumours (GEP-NET). Subjects and Methods: Twenty two (22) consecutive patients with a proven or clinically suspected GEP-NET with or without proven metastases were imaged at 24 and 48 hr after injection of 111In-pentetreotide. The scintigraphic findings were compared with results from conventional imaging methods. Final diagnosis was based on histopathological and surgical findings and complimentary radiology. RESULTS: Somatostatin receptor-positive lesions were found in 20 of the patients, whereas conventional methods were positive in 18 patients. Additional 13 new tumor sites were discovered by somatostatin receptor scintigraphy (SRS) in 5 patients (liver : 6; chest : 2 ; bone : 1 ; abdomen : 4). Surgical therapeutic strategy was changed in 7 (32%) patients. CONCLUSIONS: Our data reinforced that scintigraphy with 111In- pentetreotide represents the imaging modality of choice in the initial evaluation of GEP-NET. It is highly accurate and can identify clinically unsuspected lesions and optimize the overall staging. It also guides optimal therapy choice and most importantly identifies patients with inoperable or metastatic disease who might be candidates for high dose targeted therapy
Abstract: PURPOSE: Malignant external otitis (MEO) is an invasive, potentially life-threatening infection that affects the external auditory canal and temporal bone. Disease recurrence is reported in 9-27% of patients. It usually is related to inadequate length of therapy. The aim of this study was to present the initial experience with 18F-FDG PET/CT for the assessment of infection and moreover the monitoring of therapeutic effect in patients of Malignant Otitis Externa. MATERIALS AND METHODS: Seven patients (four males, three females, mean age, 63±2 yrs; median age 63yrs;). 18F-FDG PET/CT was performed initial diagnosis and during follow-up. Max SUV at initial diagnosis and during follow-up were assessed in correlation with clinical and biochemical data (ESR) and with the results of CT scans. RESULTS: All patients showed increased FDG uptake on the affected side and combined with CT allowed better anatomical localization of the infectious focus with clear distinction between soft tissue and osseous infection. Initial maximum SUV of the lesion ranged from 3.4 to 8.6 at the time of diagnosis. Five patients were treated with IV antibiotics alone. Two patients underwent surgical intervention with drainage of pus and tympano-mastdectomy on basis of PET/CT findings. Follow up scan was performed in five patients. Three patients shows complete metabolic response and show clinically unremarkable follow-up. In two patients antibiotic treatment was prolonged for several weeks because of persistent increased FDG uptake in the affected area on the first follow-up scan. CONCLUSIONS: Although patient population is small, our initial experience suggests that PET/CT imaging with its much higher spatial resolution allows better detection and characterization of the lesion and FDG PET/CT imaging may have a role in the management of patients with MOE and prove valuable in evaluating response to therapy
Abstract: PURPOSE: Ductal carcinoma in situ (DCIS) currently represents about 15-25% of all breast cancers detected. Although inherently a non-invasive disease, occult invasive disease could be found at definitive histology. The role Sentinel Lymph Node (SLN) biopsy in DCIS is still unclear. The aim of the present study is to evaluate the clinical usefulness of sentinel lymph node biopsy and the incidence of sentinel lymph node metastases in a selected high-risk ductal carcinoma in situ who are at highest risk for being upstaged to invasive carcinoma. MATERIALS AND METHODS: Twenty three high risk patients with DCIS proven on core biopsy (mean age, 50yrs; median age 48yrs; age range, 37-78 yrs) were included in the study. SLN scintigraphy was performed 2-4 hour before surgery by injecting Tc-99m labeled nanocolloid intra-dermally in the periareolar region. First lymph node (LN) to appear on the scan was labeled as SLN and marked on the skin by using gamma probe. LN was explored in the axilla using a gamma probe. RESULTS: The SLN was identified in all patients (100% success rate). One out of 23 cases, SLN was positive for metastasis. Seven patients (30%) were came out to be ductal carcinoma on final histological specimen despite of DCIS on core biopsy. Among these seven patient, three has only minimal invasive carcinoma (<1cm). CONCLUSIONS: Our study suggests that high risk DCIS patients and have an increased risk of invasive disease and approximately one-third of patients with DCIS population has invasive disease at the time of definitive operative procedure. SLNB is a reliable and minimally invasive procedure providing axillary information and avoiding a second operation in this particular group of patients.
Abstract: PURPOSE: To compare the effectiveness of 99mTc-MIBI Scintimamography (SMM) and Ultrasonography (US) for the detection of local recurrence of breast cancer in modified radical mastectomy (MRM) patients and post lumpectomy (PL) patients.
MATERIALS/METHODS: 62 consecutive patients (mean age 47yrs; median age 47.5yrs) with clinical suspicion of loco-regional recurrence of breast cancer were divided into two groups. Group I comprised of 26 PL patients and Group II of 36 MRM patients. All patients received a 740-1000 MBq bolus IV injection of 99mTc-MIBI, followed by Planar and SPECT imaging. Ultrasonography of breast was performed by experienced radiologists using a 7.5MHz transducer. All patients had either excision biopsy or FNAC for tissue diagnosis. RESULTS: 43/62 (69%) patients were found disease positive on histopathology. In group I, SMM had better sensitivity, specificity and accuracy then US (93% vs 67%, 81% vs 73% and 88% vs 69%, p = 0.001). In group II, no significant statistical difference was observed between the sensitivity, specificity and accuracy of SMM and US (89% vs 86, 87.5 vs 75 and 89 vs 83 % respectively, p=0.30). The overall sensitivity, specificity and accuracy of SMM and US was 91% vs 79%, 84% vs 73% and 89% vs 77% (p =0.04) respectively CONCLUSION: SMM can be used with confidence to discriminate tumor recurrence, from benign changes resulting from surgery and irradiation. SMM was as accurate as US in MRM patients but was more accurate in PL patients. SMM can be used as first line test in PL patients.
Abstract: Objective: To determine the incremental value of Tc 99m Sestamibi Myocardial Perfusion Scintigraphy (MPS) findings in cardiac risk stratification of patients having Left Bundle-Branch Block (LBBB) Methodology: 76 patients (mean age=53±10 years) with preexisting LBBB underwent MPS (dipyridamole infusion protocol 0.56 mg/kg). Single Photon Emission Computed Tomography (SPECT) images were assessed by consensus between two experienced nuclear medicine physicians. Patients were classified into a low-risk group (normal MPS or small reversible/fixed defect only) and high-risk group (large fixed or reversible defect or dilated left ventricular cavity). The patients were followed up for 24±8 months and occurrences of hard cardiac events (infarction or cardiac death) were noted. Results: In the low-risk group (52/76, 68%),1 (1.9%) patient died due to cardiac causes, and 2 (3.8%) suffered non-fatal myocardial infarction. In the high-risk group (24/76, 32%), 5 (20.8%) patients died of cardiac causes, and 3 (12.5%) suffered non-fatal myocardial infarction. Overall survival rate was 98.1% in the low-risk group compared with 79.2% in the high-risk group(p = 0.034). Conclusions: MPS with dipyridamole stress provides important prognostic information in patients with LBBB. It is useful in stratifying patients for cardiovascular morbidity and mortality allowing clinicians to plan management in high risk patients.
Abstract: Introduction: To evaluate the efficacy and usefulness of Tc 99m MIBI scintigraphy and gamma probe localization of parathyroid glands in patients with primary hyperparathyroidism. Methods: Thirteen patients with primary hyperparathyroidism (mean age, 49±14yrs; median age 46yrs; age range, 29-68 yrs) were evaluated. The diagnosis of hyperparathyroidism was established by elevated serum calcium and parathormone levels. All patients had a well defined parathyroid lesion on a previous standard Tc 99m MIBI scintigraphy ± US study. They had normal thyroid glands, no history of familial hyperparathyroidism or MEN nor any history of previous neck irradiation. On the day of surgery, patients were injected 20 mCi of Tc99m MIBI followed by half hour delayed single standard pin hole view of the neck. A skin marker was placed on the basis of maximum count intensity during gamma probe localization. The patients were then sent for radioguided minimally invasive parathyroidectomy. Results: The preoperative localization of the affected gland was successful in all cases, using gamma probe and Tc 99m MIBI scintigraphy. The pathological parathyroid tissue was localized and successfully removed with the aid of gamma probe. The histopathological diagnosis was parathyroid adenoma in 12 cases and hyperplasia in one. Conclusions: Our initial experience intraoperative use of gamma probe is useful to determine the side of the parathyroid lesion. The intraoperative use of gamma probe helps the surgeon to detect parathyroid lesion more easily. Radioguided minimally invasive parathyroidectomy is an attractive, easy, safe surgical approach to treat patient with primary hyperparathyroidism.
Abstract: PURPOSE: Various diagnostic radiology (DR) modalities are used in the diagnosis of lower back pain (LBP). European guidelines indicate bone scintigraphy (BS) has a limited role in diagnosing LBP. We assessed the concordance between BS and other DR findings and how these findings influence clinical management. METHODS: Clinical details of 140 patients with LBP were reviewed and 60 patients (Mean age=55 years) with non-metastatic LBP were included. BS, other DR investigations (plain radiographs, CT and MRI) and the concordance in findings were assessed from clinical records. BS results were compared with other contemporary DR investigations. RESULTS: BS furnished information additional to DR in 11/60 (18%) patients, influencing Clinical Management (CM) in all cases (p-0.032). Of the 15/60 patients who had contemporaneous BS and DR investigations, BS furnished additional information in only 4 patients. BS influenced final management decisions in 10/15 of these patients. This included intervention [3], conservative management [3], further investigation [2], discharge [1] and further referral [1]. Of 6 patients with contemporaneous BS and MRI, there was 83% concordance. Overall, BS findings influenced management in 41/60 (68%) patients. Of these, normal BS (30/60) and those showing facet joint disease (5/60) had the greatest influence on CM (23/30 and 5/5, respectively). CONCLUSION: BS findings affected CM in the majority of patients. The contemporaneous use of DR in combination with BS may not always deliver additional clinically relevant information. BS in addition to other DR is most likely to influence CM when it is normal, show facet joint involvement or when it provides information above and beyond other DR.
Abstract: Purpose: The aim of this study was to evaluate the diagnostic accuracy of Tc-99m labeled anti-granulocyte monoclonal antibody fragment Fabâ(Leukoscan) for the detection of bone and soft tissue infection in pediatric population. Methods:
This is a retrospective study of 18 patients (10males, 8 females) with the mean age of 5.1years (range 3 to 14 years). These patients were referred to Nuclear Medicine Departments of Hussain Makki Al Jumma and Farwania hospitals, from July 2005 to November 2007, for hip pain (n=3), PUO (n=1), orthopedic implant infection (n=1) and osteomyelitis (n=13). Three phases bone scan and Leukoscan were carried out with maximum interval of 10 days. Imaging for Leukoscan was done at 3-4 hours and in 8 cases at 24 hours. The dose was age adjusted with a minimum dose of-3.5mCi. The scintigraphic diagnosis was compared with clinical diagnosis and informations collected from routine blood test (erythrocytes sedimentation rate, full blood count & C-reactive protein), plain radiograph & microbiology. The final diagnosis was determined by above mentioned informations and complementary investigations like computed tomography/ magnetic resonance imaging and long term clinical follow-up. No adverse reactions were observed till 24 hours after Leukoscan injection. Results:
The sensitivity, specificity, positive and negative predictive value for Leukoscan are 100%, 82%, 78% & 100% respectively. Accuracy of the scan is 89%. By adding delayed 24 hours imaging, in suspicious cases, the specificity and accuracy can be increased to 91% and 94% respectively. Conclusion: Leukoscan has high sensitivity and negative predictive values, so it can be used with confidence to rule out infection of bones and soft tissue in pediatric population. In case of positive study with faint radiotracer uptake, imaging after 24 hours can improve specificity.
Abstract: OBJECTIVES: Trastuzumab is a monoclonal antibody used for the treatment of breast carcinoma in women whose tumors overexpress the HER2 protein. Cardiotoxicity has been reported to occur with trastuzumab when administered alone and in combination with anthracyclines. Aim of study was to carefully monitor and identify patients who are at risk of developing unpredictable and sometimes irreversible cardiac dysfunction with trastuzumab therapy. METHODS: 65 patients had a HER2 3+overexpressing primary tumor (immunohistochemistry) treated sequentially with trastuzumab (mean age was 48.6 yrs), with 8mg/kg loading dose and 6mg/kg maintenance dose given at 3 weekly intervals over 1 year. All patients had a baseline LVEF>50%. Standard ERNA was carried out at baseline and then at three monthly intervals (i.e. 3, 6, 9 and 12 months), and after 4 weeks after withholding Trastuzumab. Results: The incidence of cardiotoxicity was 21% (n=12), mostly manifest as a decline in LVEF >10% from baseline, eight of these had received prior anthracycline and cyclophosphamide. Trastuzumab was discontinued for symptomatic CHF (n=2). 9 patients who improved (EF=>50%) on removal of the trastuzumab were retreated. Mean time to recovery of LVEF was 1.5 months. Inadequate recovery was seen in 3 patients. CONCLUSIONS: Serial ERNA picked up early evidence of cardiac dysfunction that necessitated withdrawal of trastuzumab. Further ERNA studies separated patients who could be retreated from those with irreversible cardiac damage. Serial measurement of left ventricular ejection fraction by radionuclide angiocardiography reliably identified patient at risk of irreversible cardiac dysfunction.
Abstract: Objectives: To evaluate usefulness of 99mTc-MIBI Scintimammography (SMM) and ultrasonography (US) and in combination for the detection of loco-regional recurrence in post mastectomy breast. Methods: 26 patients (mean age 47.15yr) evaluated for suspected local recurrence of breast cancer on clinical examination in post mastectomy breast. All patients received IV 740-1000 MBq of 99mTc-MIBI preferably in pedal vein. 5-10 min post injection planar images were obtained in prone lateral and supine anterior position followed by supine SPECT (64 projection, 64x 64 matrix, 30 sec/frame). MIBI uptake was scored as: 1: normal uptake; 2: focal low intense uptake (equivocal); 3: focal high intense uptake (positive). US of breast performed using 7.5MHz transducer. All patients underwent excision biopsy or FNAC for tissue diagnosis. Results: Out of twenty-six patients, SMM was found true positive in 16 and true negative in 7. The sensitivity, specificity, PPV, NPV and accuracy were 88.8%, 87.5%, 94.11%, 77.77%, 88.46% respectively (p<0.001). In comparison US had Sens. 77.77%, Spec. 62.5%, PPV 82.35% NPV 55.55% and accuracy 73.07% (p<0.05). Significant correlation was found between SMM and US. (r=0.85). Using a combination of two test the combined Sens. was 100%, spec. 75%, PPV 90% NPV 100% and accuracy 92.3%. ROC curve analysis demonstrates that combination of SMM and US should be the test of choice for the investigation was significantly more accurate than either of the test alone. Conclusions: For the diagnosis of loco-regional recurrence of breast cancer, the addition of SMM to US gives as significant increase in accuracy of breast imaging with acceptable degree of confidence.
Abstract: Objectives: Trastuzumab is a monoclonal antibody used for the treatment of metastatic breast carcinoma in women whose tumors overexpress the HER2 protein. Cardiotoxicity has been reported with trastuzumab when administered alone or in combination with anthracyclines. Aim of study was serial cardiac monitoring by equilibrium radionuclide angiocardiography (ERNA) to identify patients at risk of developing unpredictable and sometimes-irreversible cardiac dysfunction on trastuzmab treatement. Methods: 57 patients had a HER2 3+overexpressing primary tumor (immunohistochemistry) treated sequentially with trastuzumab (mean age was 48.6 yrs), with 8mg/kg loading dose and 6mg/kg maintenance dose given at 3 weekly intervals over 1 year. All patients had a baseline LVEF>50%. Standard ERNA was carried out at baseline and then at three monthly intervals (i.e. 3, 6, 9 and 12 months), and after 4 weeks after withholding Trastuzumab. Results: The incidence of cardiotoxicity was 21% (n=12), mostly manifest as a decline in LVEF >10% from baseline, eight of these had received prior anthracycline and cyclophosphamide. Trastuzumab was discontinued for symptomatic CHF (n=2). 9 patients who improved (EF=>50%) on removal of the trastuzumab were retreated. Mean time to recovery of LVEF was 1.5 months. Inadequate recovery was seen in 3 patients. Conclusions: Serial ERNA picked up early evidence of cardiac dysfunction that necessitated withdrawal of trastuzumab. Further ERNA studies separated patients who could be retreated from those with irreversible cardiac damage. Therefore we recommend that serial assessment of LVEF at rest by ERNA proved an effective method of monitoring patients during the course of trastuzumab.
Abstract: Aim of the study was to assess the response and tolerability of Rituximab and 90Yibritumomab tiuxetan (Zevalin) treatment in mature B Cell (CD 20 positive) non- Hodgkinâs lymphoma (NHL). Material and Methods: We have treated 12 NHL patients, 8 had low grade follicular Lymphoma (FL) and 4 had Diffuse Large B Cell Lymphoma (DLBL), with mean age 59.13 ± 5.7 years (6 males, 6 females). Zevalin therapy (ZT)constitute intravenous Rituximab (250 mg/m2 ) on day1 and day8 followed on day8 by intravenous 3-4 μmCi/kg of Zevalin (depending on platelet count). Labeled Zevalin (> 90%) prepared on the day of administration. Inclusive criteria for ZT were: stage III/IV refractory/relapsed disease, transformation of FL to higher grade, patients with high risk of relapse, patients not tolerating/refusing chemotherapy or when chemotherapy was contraindicated (bone marrow (BM) hypoplasia). Patients were excluded if they had > 25% BM involvement, platelet count <100,000/mm3, absolute neutrophil count <1500/mm3. Patients followed initially by weekly blood counts for 2 months and later with serial CT scan according to the International Working Group (IWG) recommendations. Ga 67 and MRI scans done in selective cases. Results: Patient followed after ZT for a mean period of 1.3 ± 0.66 years (range 4 months to 2 years). According to IWG criteria, in FL patients, 5 achieved complete response (CR), 1 had partial response (overall response rate (ORR) of 75%) and 2 had stable disease (SD). 1 patient with SD relapse 15 months after ZT. In DLBL patients, 2 patients achieved CR (ORR 50%) and remain in CR, the other 2 had progressive disease (PD) of which one later turned out to be a patient of Mantle cell lymphoma; the other had high dose chemotherapy (HDCT) with BM transplantation (BMT) prior to ZT. No immediate side effects were reported after ZT. 4 patients suffered grade IV thrombocytopenia/ neutropenia requiring supportive treatment; all others had mild to moderate hematological toxicity (HT) requiring no active management. 1 patient with BM hypoplasia (-ve for BM involvement) and another with HDCT and BMT before ZT suffered grade IV HT but recover within 2 months. Other 2 suffering grade IV HT had BM involvement before ZT and take 3 months to recover. Conclusion: Initial Experience with ZT is encouraging and will help establish/improve selection criteria in future. Therapy was well tolerated and show better ORR in FL compared to DLBL patients. Patients with BM involvement took longer time to recover
Abstract: The detection of myocardial ischemia in patients with preexisting left bundle branch block (LBBB) remains problematic. Myocardial perfusion scintigraphy (MPS) with Dipyridamole is the preferred non-invasive diagnostic modality for this group of patients. Materials and Methods: Seventy six patients with preexisting LBBB underwent sestamibi perfusion imaging with dipyridamole infusion protocol (0.56 mg/kg). Stress and rest SPECT studies were acquired using single head ECAM (Siemens) and double head Toshiba GCA-7200A gamma cameras. Images were interpreted by consensus of two experienced observers and classified as, low risk group (normal MPS, small reversible/small fixed defect) and high-risk group (a large severe fixed or reversible defect and dilated LV cavity). 76 patients with mean age of 53±10 years (range=39-72 years) were included in the study. These patients were followed up for 24 months Â} 8 months and occurrences of hard cardiac events (MI or cardiac death) were asked by telephones. Results: Out of 76 patients 52 had low-risk scans (68%) and 24 had high-risk scans (32%). In low risk group cardiac deaths were observed in 1/52 (1.9%) and non-fatal MIs were seen in 2/52 (3.8%). In high-risk scans, 5 suffered cardiac death (20.8%) and non-fatal MIs in 3 (12.5%). Over all survival rate was 98.1% in the low-risk group compared with 79.16% in the high-risk group with a significant difference (p=0.0338). Conversely, the negative predictive value of a normal myocardial perfusion scintigraphy for the occurrence of death was 100%. Conclusion: Myocardial perfusion imaging with dipyridamole stress provides important prognostic information in patients with left bundle-branch block, which is incremental to clinical assessment.
Abstract: The mastectomy site is usually assessed by clinical examination and ultrasonography for recurrence of breast cancer, however post surgical and radiotherapy changes limit the accuracy of these methods. MRI has been used successfully; however it remains an expensive modality and may not be readily available. Scintimammography is an alternative method which has the advantage of not being affected by post operative morphological changes. The aim of this study was that to evaluate the usefulness of planar 99mTc-MIBI Scintimammography and supine 99mTc-MIBI SPECT in the detection of chest wall recurrence post mastectomy. Materials and Methods: The study population comprised of 26 patients (mean age, 47.15yr; median age 47; age range, 22-77 yrs) with suspected chest wall recurrence of breast cancer on clinical examination. All patients received a 740-1000 MBq bolus IV injection of 99mTc- MIBI preferably in pedal vein. At 5-10 min post injection planar images were obtained in prone lateral and supine anterior position using double head gamma camera. After planar imaging supine SPECT was performed (64 projection, 64x 64 matrix, 30 sec/frame). MIBI uptake was scored as follows: 1: as normal uptake (compared with contralateral side); 2: focal low uptake (equivocal); 3: focal high uptake (positive). All patients underwent excision biopsy or FNAC for tissue diagnosis. FNAC was considered enough if unequivocally positive. Results: Out of twenty-six patients, planar Scintimammography was found true positive in 14 and true negative in 7. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 77.77%, 87.5%, 93.33%, 63.63% and 80.76% respectively (p<0.001). SPECT showed a significantly higher overall sensitivity than planar imaging (88.88% vs. 77.77%; p<0.001). SPECT and planar imaging showed the same specificity (87.5%). SPECT showed a significantly higher negative predictive value and accuracy than planar imaging (77.77% vs. 63.63% and 88.46% vs. 80.761%, respectively; p<0.05 Mc.Nemar results). Conclusion: Scintimammography is a reliable diagnostic tool and appears accurate in the detection of chest wall recurrence, SPECT is widely available method improving the low sensitivity of planar scintimammography.
Abstract: Objective: study the utility of dual phase Tc-99m MIDI scintimammography in prediction of chemotherapeutic response in locally advanced breast cancer. Materials and Methods: This was a prospective cohort study performed at Karachi Institute of Radiotherapy And Nuclear Medicine (KIRAN), September 2004 till March 2005. A total of 32 female (mean age, 46.3yr; median age 46 yrs; age range, 33-65 yrs) with breast cancer being planned for the FAC neoadjuvant chemotherapy. All subjects received a 740 MBq bolus intravenous injection of Tc-99m MIBI preferably in pedal vein. 10min and 3 hours post injection planar images were obtained. MIBI washout was scored as follows: >30% as a positive prognostic test (predicting a poor response to chemotherapy) and <30% as negative prognostic test (predicting a good response to chemotherapy). Qualitative analysis of MIBI scans Was also performed and was categorized as visual washout or visual no washout. The criteria for the good and bad response was the reduction in >50% and <50% reduction in the tumor burden respectively.Results: Quantitative dual phase Tc-99m MIDI scintimammography was found to be a good predictor of chemotherapeutic response in breast cancer. There were true positive in 8 patients and true negative in 19 patients with Sens. 72 %, Spec. 90 %, PPV 80 %, NPV 86 5% (p< 0.03) (Chi-square Test). ROC curve analysis demonstrates 30% as a cut-off value for the wash-out in quantitative dual phase MIBI for the prediction of the chemotherapeutic response. In comparison qualitative scintiinammography had Sens. 82 %, Spec. 53 %, PPV 29 % NPV 93 % and (p< 0.38). Statistical difference was found between early and delayed uptake ratios in the responders and non-responders (Wilcoxan Sign Rank Test). Conclusion: It is concluded that dual phase Tc-99m MmI scintimammography is helpful in predicting the chemotherapeutic response in locally advanced breast cancer.
Abstract: Objective: The interpretation of images in a postsurgical breast can be extremely complex and difficult because masses, calcifications, and architectural distortion can mimic cancer. Scintimammography has been proposed because it is not affected by the morphological changes and can potentially be used in patients after lumpectomy with positive margins to assess residual uptake and also for multifocal disease and nodal involvement. Patients and Methods: The population comprised of 21 patients (mean age, 47.15yr; median age 47; age range, 22-77 yrs) who had lumpectomy and referred for further management. All patients received a 740-1000 MBq bolus IV injection of 99mTc-MIBI preferably in pedal vein. At 5-10 min post injection planar images were obtained in prone lateral and supine anterior position using double head gamma camera. MIBI uptake was scored as follows: 1: as normal uptake (compared with contralateral side); 2: focal low intense uptake (equivocal); 3: focal high intense uptake (positive). All patients had either excision biopsy or FNAC for tissue diagnosis. Results: Out of twenty-one, scintimammography planar was found true positive in 13 and true negative in 6. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 92.85%, 85.71%, 92.85%, 85.71% and 90.47% respectively (p<0.001). Conclusion: Scintimammography with 99mTc sestamibi is valuable in detecting residual disease and assessing the extent of breast cancer, particularly where there is multi-focal or bilateral disease which may not be fully diagnosed by mammography.
Abstract: Breast Cancer is the most common cancer among women and the second leading cause of death in women after lung cancer. Patients who have treated for breast cancer may develop recurrence of primary cancer. The principal aim of the study is to see the utility of Tc-99m MIBI scintimammography in evaluation of loco-regional recurrence of breast cancer in comparison with X-ray mammography and breast ultrasound. Materials & Methods: The study was conducted at Karachi Institute of Radiotherapy and Nuclear Medicine. A total of 42 patients (mean age, 45.55 yrs. median age 43.5 yrs. range, 22-77 yrs.) with suspected locoregional recurrence on clinical examination were included in this study. Plannar scintimmamography (SMM), X-ray mammography (XMM) (where applicable) and ultrasound (US) of breast were performed in these patients. The diagnosis was confirmed on histopathology. Results: Plannar SMM was found true positive in 24 patients and true negative in 12 patients with sensitivity (Sens.) 82.75%, Specificity (Spec.) 92.3%, PPV 96%, NPV 70.58% and accuracy 85.71% (p<0.001). In comparison XMM had Sens. 45.83%, Spec. 66.7%, PPV 78.57%, NPV 31.57% and accuracy 51.51% (p<0.41). US had Sens. 65.51%, Spec. 69.23%, PPV 82.6%, NPV 47.36% and accuracy 66.66% (p<0.05). SMM findings were correlated with XMM and US by applying the pearson correlation. No significant correlation was found between SMM with XMM and US (r = 0.27 and 0.23). ROC curve analysis demonstrated that SMM should be the test of choice among the three. Conclusions: It is concluded from the study that SMM has better diagnostic accuracy than XMM and US in the detection of loco-regional breast cancer recurrence.
Abstract: Objective: To detect the early signs of bone loss associated with osteoporosis in the work-up of post- menopausal women that affects millions of women in our community.
Material and Methods: This cross-sectional survey study uses data over a 6-months period (November-April 2005) in 100 consecutive post-menopausal women, which are categorized according to the onset of age of menopause who were referred to in our institute for the DEXA scan. The exclusion criteriaâs are surgical menopause or history of drugs intake i.e; steroid and thyroxine. Bone densitometry scan are performed over the standard sites i.e., femoral neck and lumbar spines. Results: Patients are divided into two groups i.e.; Premature menopause < 45 yrs (n=39) and natural menopause ³45 yrs (n=61). Bone mineral density (BMD) results are reported on WHO criteria T-score (young normal adults of the same sex). The difference between the patient's score and the norm is expressed in standard deviations (SD) above or below the mean. In general, T-scores provide information needed for clinical decision-making and form the basis for the diagnoses Osteopenia and Osteoporosis. Usually, 1 SD equals a 10% to 12% difference in bone density and fractureâs risk is double for every SD below the young adult reference range. In our study population, when the value of the two analyzed zones was considered, four patients (13%) and seventeen women (25%) had a normal BMD, thirteen women (39%) and eighteen women (26%) had osteopenia, while fifteen women (48%) and thirty-four women (49%) had osteoporosis in both groups respectively. Correlation of DEXA results between two groups were calculated by using the Pearson test, which was found to be significant (r = 0.96, p <0.05). Conclusion: DEXA is effective, precise and safe method for the estimation of bone mineral density. This study conclude that DEXA has a due role in the screening of bone densitometry not only in nature menopausal women but also premature menopausal women which have to live longer with hormone deficiency and are at greater risk of early bone loss as compared to normal menopause. Therefore, bone densitometry needs re-evaluation for the premature menopausal age group women as well as the women with positive risk factors.
Abstract: Objective: Thyroid disease and osteoporosis are common problems often managed by primary care physicians. Despite many studies, confusion still exists about the effect of thyroid hormone on skeletal health. The aim of this prospective study is to determine whether long-term thyroxine therapy in the premenopausal period is a risk factor for the development of secondary osteoporosis and hence the increased risk of fractures in premenopausal women. Material & Methods: We have assessed the effect of long-term thyroxine treatment in a group of 26 premenopausal women {Indications for treatment were hypothyroidism (n = 14), thyroidectomy for differentiated thyroid cancer (n = 3) and toxic goiter (n = 9)} who are taking either replacement (serum TSH between 0.3-5.0 mU/l) or suppressive (serum TSH < 0.1 mU/l) doses of L-thyroxine. These 26 patients were matched with controls for age, sex and body mass index. In all subjects bone mineral density (BMD) was measured at the antero-posterior lumbar spine and left hip (femoral neck, greater trochanter and inter-trochentric area) using dual-energy X-ray absorptiometry. Results: Patients on long-term thyroxine therapy have (mean duration of treatment 5.0±3.0 years, range 1-13 years) at doses (mean 175±25) micrograms/day. Out of 26 patients, 13 were on suppressive dose of thyroxine while another 13 were on replacement doses. A significant difference was noted in BMD (g/cm2) values of lumbar spine between suppressive and replacement groups (-1.33 vs -0.42, p=0.025), while no difference was found in total hip (-0.83 vs. -0.39, p=0.087). Conclusions: We conclude that, in premenopausal women receiving long-term levothyroxine treatment, there is evidence for a loss in bone mineral density in patients receiving suppressive doses of thyroxine. No evidence of reduced bone mineral density was found in patients on replacement therapy. Furthermore, the lumbar spine was found to have more deleterious effect of thyroxine in suppressive doses as compared to femoral neck and hip. Therefore, patients receiving long-term levothyroxine treatment should be closely monitored and bone densitometry should be performed in patients at risk for osteoporosis.
Abstract: Objective: For the last three decades myocardial perfusion imaging (MPI) has become an important tool not only in the diagnosis but also in the decision-making regarding the management of coronary artery disease. It is considered as the door keeper for the cardiac catheterization. Numerous studies have shown an event rate of < 1% per year associated with a normal MPI with adequate stress. The aim of this study was to evaluate the prognostic value of a normal MPI in our population. Material and Method: This study included 413 patients with normal MPI (with adequate stress) performed with sestaMIBI. Out of 413 patients, 217 were male and 196 were female with mean age 52.4 ± 9.8 years (median 52 years). The study was indicated for chest pain diagnosis in 330 (80%) and for the assessment of functional capacity in remaining 83 (20%) patients. The cardiac risk factors were prevalent including hypertension in 92 (22.3%), diabetes in 52 (12.6%) and dyslipidemia in 52 (12.6%). Furthermore, 21.5% patients had 2 or more than 2 risk factors. 248 (60%) individuals underwent dynamic stress following Bruce or Modified Bruce Protocol and end points were achievement of >85% target heart rate, chest pain or appearance of significant ECG changes. Remaining 165 (40%) individuals had dipyridamole intervention (standard protocol). A stress-rest (one day protocol) SPECT study was acquired using single head ECAM (Siemens) and double head Toshiba GCA-7200A gamma cameras. These patients were followed up for 18 months ± 5 months and occurrences of hard cardiac events (MI or cardiac death) were asked by telephones. Results: The observed cardiac deaths were 3/413 (0.73%) and non-fatal MIs were seen in 4/413 (0.97%) on 18 months follow up. For women and men, the average cardiac survival was 99.0% and 99.5% respectively (p=0.001). Additionally for patientsâ undergone exercise, the annualized survival rate was 99.6% and 98.8% for those who had dipyridamole intervention. Conclusion: A normal sestaMIBI SPECT study with adequate stress is associated with annualized cardiac death rate of 0.73%v and a negative predictive value of 98.3%. Furthermore, these statistics of our population are comparable with most of the published studies.
Abstract: Objective: The aim of this study is to assess the influence of sublingual nitrate administration on myocardial uptake of 99mTechnetium sestaMIBI in order to determine whether nitrates enhance the detection of viable myocardium in patients with coronary artery disease (CAD) and to compare the results with standard 201Thallium rest redistribution imaging in same patients. Methods: Thirty-five patients (31 men, 4 women; mean age 52±9 years, median = 50), with previous history of myocardial infarction and left ventricular dysfunction, who had been referred for coronary artery revascularization, were studied. Myocardial single-photon emission computed tomography (SPECT) images were obtained of all patients 45 minutes after injection of 740 MBq 99mTc sestaMIBI at baseline (Baseline sestaMIBI study) and after 15 minutes of sublingual glyceral trinitrate (Nitrate sestaMIBI study), using a 2-day protocol. Within 1 week of the sestaMIBI study, rest-redistribution 201Thallium SPECT was performed after the injection of 111 MBq 201Tl and SPECT images were acquired 10 min (rest) and 4 h (redistribution) after injection. For each study, visual as well as semi-quantitative analysis was performed in 7 segments. Viability was defined as the presence of tracer uptake of >55% of the peak activity at rest or after reversibility. Reversibility was indicated by an increase in tracer uptake of â¥10% of peak activity after nitrate sestaMIBI or redistribution 201Tl studies. Results: Total 245 segments were analyzed in 35 patients. Of the 77 non-viable segments with severely perfusion defect (Tracer activity <55%) on rest sestaMIBI study, 29 (37%) were reversible, showing increased tracer uptake after nitrate sestaMIBI study (from 33.5%±7% to 57%±10% of peak activity; p<0.01). Reversible defects after nitrate sestaMIBI study were observed in 21 (37%) of the 35 patients. 45 segments (63%) were irreversible, showing no change in tracer uptake (from 30%±9% to 33%±4% of peak activity; P>0.05). The concordance for viable segments detection between sestaMIBI and redistribution Tl-201 studies was found in 232 out of 245 segments (95.24%), with significant kappa =0.746 ± 0.079 SE. Conclusion: The data suggest that use of nitrate augmented 99mTechnetium sestaMIBI protocol in Cardiac SPECT imaging results in improved detection of viable but hypoperfused segments and achieves results similar to those from standard 201Tl rest and redistribution protocol.
Abstract: Objective: The presence of LBBB constitutes a difficulty for the evaluation of patients with suspected or known coronary artery disease. ECG is non-diagnostic in the presence of LBBB. Material and Methods: A total of 22 patients with baseline LBBB were included in the study. Images were analyzed quantitatively and visually for the presence of fixed or reversible perfusion defects. 12 had normal coronaries on angiography while 10 had significant coronary artery stenosis in one or more coronary artery territories. Results: The sensitivity and specificity of Tc-MIBI scintigraphy for the detection of CAD in the LAD territory were found to be 92% and 62.5% respectively when anterior wall and or apical and or septal hypoperfusion was taken to represent CAD in LAD territory. For LCX and RCA it was 90, 88 and 88, 92 respectively. Conclusion: Myocardial perfusion imaging is of great value in the diagnosis, evaluation of coronary artery disease in the presence of LBBB. Further we noted that in contrast to true positive finding, false positive findings are seldom demonstrated in LAD territory.
Abstract: Objectives: Coronary artery disease (CAD) is the leading cause of death worldwide especially in diabetes as compared to patients without diabetes; patients with diabetes have higher rates of cardiac events and more silent ischemia. However, little is known regarding the diagnostic accuracy of myocardial perfusion SPECT in patients with diabetes. This study was undertaken to compare the diagnostic value of myocardial perfusion SPECT in patients with and without diabetes. Material & Methods: We conducted a study with 65 consecutively registered patients with diabetes and 72 patients without diabetes with known or suspected coronary artery disease undergoing myocardial perfusion SPECT with exercise or pharmacologic stress testing. All patients had coronary angiography within 6 months of the nuclear test and were followed up for at least 1 year.
Results: The angiographic data showed that patients with diabetes had less incidence of 1-vessel disease and a higher incidence of 3-vessel/left main artery diseases than patients without diabetes. The overall sensitivity and specificity, respectively, of SPECT for detecting CAD with the criterion of >50% diameter stenosis were 79% and 92% in diabetics, 82% and 87% in non-diabetics. Over the follow-up period, patients with diabetes had significantly higher rates of hard events (cardiac death or nonfatal myocardial infarction) and higher total event rates (hard events and late revascularization) compared with rates among patients without diabetes which revealed that nuclear testing added incremental value over clinical and historical variables among patients with diabetes. Conclusions: The results of this study indicated that myocardial perfusion SPECT has comparable accuracy for the diagnosis of CAD in diabetic and non-diabetic patients that is especially valuable for risk stratification and management of patients with diabetes.
Abstract: Objective: The principle aim is to study the early nephrotoxic effect of Cisplatinum by various methods of Glomerular Filtration Rate (GFR) estimation and to find their accuracies as well as their comparisons with reference method. Because the use of highly accurate filtration markers i.e. inulin to measure renal function has traditionally been limited by cumbersome and costly techniques the renal function is typically estimated by using specially derived prediction equations for Creatinine Clearance (CrCl). Materials and Methods: The renal functions were assessed on 36 patients (28 males and 8 females; age range being16-68 yrs) suffered from different types of cancer and received Cisplatinum in higher doses (mean dose of 114.027 mg/m2; and range of 75 to 200 mg/m2) in each cycle. The GFR was determined simultaneously by 6 methods; (1) 24 Hours Creatinine Clearance (24HCrCl); (2) Gamma camera uptake method after 99mTc-DTPA injection (Gates method); (3) Predicted Creatinine Clearance by Modification of Diet and Renal Diseases (MDRD); (4) Cockcroft-Gault's equation for GFR estimation (CG); (5) Plasma two Sample Clearance method after 99mTc-DTPA injection (PSC 2); (6) Plasma one Sample Clearance method after 99mTc-DTPA injection (PSC 1). PSC 2 was chosen as gold standard. Results: The average fall in GFR after Cisplatinum treatment was estimated 43.86 ml/min/1.73m2 (38%) and PSC 2 measured about 41% change from baseline and least biased by having SEE value of 2.02 ml/min/1.73m2 which favors its accuracy. The regression equation of the PSC 1 and the Gates against the PSC 2 was Y = 11.55 +0.905X (r = 0.958, p < 0.001, SEE = 2.6 ml/min/1.73 m2) and Y =8.77+ 0.935X (r = 0.91, p < 0.001, SEE= 2.8ml/min/1.73 m2), respectively. In comparison with the GFR by PSC 2, the PSC 1 and Gate's tended to overestimate the GFR by 4%, and 24HCrCl tended to overestimate the GFR by 32%. Conclusions: It is concluded that PSC 2 after 99mTc-DTPA injections is accurate enough for routine clinical use as an ideal GFR marker. The PSC 1 and Gates correlate well with PSC 2. However, the Gates is even less precise due to wider scattering than PSC 1. The 24HCrCl is not recommended as an ideal GFR marker due to more biased and least precision as well as its significant difference and poor correlation with PSC 2.
