Prediction of radiation-related cardiotoxicity using F-18 FDG PET in non-small-cell lung cancer

Background

Radiation-related cardiotoxicity has been refocused nowadays as the follow-up was increased amomg the patients with advanced lung cancer. The early recognition of the occult cardiotoxicity enables the early intervention preventing clinically significant cardiac events or worsening of severity.

Purpose

We aim to search whether the F-18 fluorodeoxyglucose positron emission tomography (FDG PET) performed immediately after radiotherapy could predict the late cardiac events.

Methods

We retrospectively enrolled 133 patients with locally advanced, unresectable stage III NSCLC who underwent F-18 fluorodeoxyglucose positron emission tomography (FDG PET) immediately after CCRT for the response evaluation and survived at least for 6 months. Heart was recontoured according to the RTOG 0617 secondary analysis atlas for the dose volume analysis. Standardized uptake values (SUV) of the left ventricular myocardium were measured on FDG PET images. The patients were regularly followed up for the disease progression and complications. The primary end-point was the cardiac events grade ≥2 based on the Common Terminology Criteria for Adverse Events (version 5.0).

Results

FDG PET was performed at median interval of 11 days after CCRT. Fourty-two patients experienced cardiotoxicity during a median follow-up of 47 months (range, 12 – 123 months). In univariable analysis, mean heart dose, maximum SUV of the left ventricle (LV SUVmax), white blood cell count, and diabetes were associated with the risk of cardiotoxicity. In multivariable analysis, only higher mean heart dose (>11.1 Gy, hazard ratio 3.930 [95% confidence interval 1.933–7.988]; p=0.0002) and higher LV SUVmax (>12.84, 2.189 [1.162–4.124]; p=0.0152) were independently associated with increased risk of cardiotoxicity. In subgroup analyses, LV SUVmax remained predictive of cardiotoxicity among those with higher mean heart dose, but not among those with lower mean heart dose.

Conclusion

Early FDG PET after CCRT for NSCLC could predict the late cardiac events, especially in patients with high dose cardiac irradiation.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): This work was supported by a grant of the Basic Science Research Program through the National Research Foundation funded by the Ministry of Education, Republic of Korea (Principal Investigator: Sang-Geon Cho)

Correction to: Nuclear medicine services after COVID-19: gearing up back to normality

The authors P. Orellana and N. El-Haj were inadvertently deleted in the original paper.

Diagnostic Value of Lesion-specific Measurement of Myocardial Blood Flow Using Hybrid PET/CT

BACKGROUND

We evaluated whether lesion-specific measurement of myocardial blood flow (MBF) and flow reserve (MFR) by hybrid imaging of myocardial perfusion positron emission tomography (PET) and coronary computed tomography (CT) can provide additional diagnostic value.

METHODS

Forty-three patients with stable angina underwent N-13 ammonia PET and coronary CT before invasive coronary angiography (CAG). The lesion-specific MBF was calculated from the average MBF of the myocardial segments downstream of a coronary stenosis using hybrid PET/CT images. The hyperemic MBF, resting MBF, and MFR were measured for the left anterior descending artery (LAD) using conventional and lesion-specific methods. The diagnostic accuracy was compared between the two methods for significant LAD stenoses (≥ 70% reference diameter on CAG).

RESULTS

There were 19 significant LAD stenoses. The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were 71%, 68%, 74%, 65%, and 70% for conventional hyperemic MBF (optimal cutoff = 2.15 mL/min/g), 79%, 63%, 74%, 65%, and 70% for conventional MFR (optimal cutoff = 1.82), 83%, 74%, 80%, 78%, and 80% for lesion-specific hyperemic MBF (optimal cutoff = 1.75 mL/min/g), and 79%, 79%, 83%, 75%, and 79% for lesion-specific MFR (optimal cutoff = 1.86), respectively. The lesion-specific measurement was more accurate and had a better linear correlation with anatomical stenosis severity for both hyperemic MBF and MFR.

CONCLUSIONS

Lesion-specific measurement using hybrid PET/CT imaging showed significant improvement in the diagnostic accuracy of PET-measured hyperemic MBF and MFR.

Cardioprotective effect of fimasartan, a new angiotensin receptor blocker, in a porcine model of acute myocardial infarction

Cardioprotective effect of fimasartan, a new angiotensin receptor blocker (ARB), was evaluated in a porcine model of acute myocardial infarction (MI). Fifty swine were randomized to group 1 (sham, n=10), group 2 (no angiotensin-converting enzyme inhibitor [ACEI] or ARB, n=10), group 3 (perindopril 2 mg daily, n=10), group 4 (valsartan 40 mg daily, n=10), or group 5 (fimasartan 30 mg daily, n=10). Acute MI was induced by occlusion of the left anterior descending artery for 50 min. Echocardiography, single photon emission computed tomography (SPECT), and F-18 fluorodeoxyglucose cardiac positron emission tomography (PET) were performed at baseline, 1 week, and 4 weeks. Iodine-123 meta-iodobenzylguanidine (MIBG) scan was done at 6 weeks for visualization of cardiac sympathetic activity. Left ventricular function and volumes at 4 weeks were similar between the 5 groups. No difference was observed in groups 2 to 5 in SPECT perfusion defect, matched and mismatched segments between SPECT and PET at 1 week and 4 weeks. MIBG scan showed similar uptake between the 5 groups. Pathologic analysis showed similar infarct size in groups 2 to 5. Infarct size reduction was not observed with use of fimasartan as well as other ACEI and ARB in a porcine model of acute MI.

Sero-epidemiology of hepatitis A virus infection among healthcare workers in Korean hospitals

Hepatitis A virus (HAV) has been increasingly reported in Korea as has an outbreak in Korean healthcare workers (HCWs). This 2008 study evaluated the sero-epidemiology of HAV infections among 3696 HCWs in four Korean hospitals. HCWs were tested for immunoglobulin G anti-HAV antibodies using commercially available kits. Data including demographic characteristics, occupation, workplace and serological status for other hepatitis viruses were collected. Statistical analyses were conducted to identify variables related to HAV seropositivity. Among the 3696 participants, 2742 (74%) were women and the majority (96%) were aged 20-39 years (median: 28; range: 19-68). Eighteen percent were physicians, 46% nurses, 10% nurses' aides, 11% paramedical technicians and 15% administrative staff. Seropositivity for HAV significantly increased with age (P<0.001): 1.8% for < or =24 years, 14.7% for 25-29 years, 41.8% for 30-34 years, 75.5% for 35-39 years, and 93.7% for > or =40 years. Among those aged 20-39 years, age-specific HAV seroprevalence was significantly lower in physicians than in the other occupational groups (P<0.001). In Korea, mass vaccination to HCWs aged < or =29 years or screening for seropositivity and vaccinating non-immune subjects aged 30-39 years should be considered, especially in physicians.

Effects of beta-radiation using a holmium-166 coated balloon on neointimal hyperplasia in a porcine coronary stent restenosis model

Brachytherapy is a promising method of preventing and treating coronary stent restenosis. The present study was designed to observe the therapeutic effects of a radioactive balloon loaded with Holmium-166 ((166)Ho) in a porcine coronary stent restenosis model. A radioisotope of (166)Ho was coated onto the balloon surface using polyurethane (20 Gy at 0.5 mm depth). Stent overdilation injuries were induced in 2 coronary arteries in each pig (n=8). Four weeks after the injury, control balloon dilation was performed in one coronary artery (Group I) and radiation therapy using the (166)Ho coated balloon in the other coronary artery (Group II) in each pig. Follow-up coronary angiography and histopathologic assessment were performed at 4 weeks after the radiation therapy or the control balloon dilations. With regard to complete blood cell counts, liver function tests, lipid profiles and coagulation tests, there were no differences between the baseline and after radiation. On quantitative coronary angiographic analysis, reference and target artery diameter showed no differences between the 2 groups before, or 4 and 8 weeks after stenting. On histopathologic analysis of groups I and II, the injury score was 1.34+/-0.09 and 1.32+/-0.10, the area of internal elastic lamina was 4.99+/-0.17 mm(2) and 4.82+/-0.20 mm(2), and the luminal area was 3.20+/-0.10 mm(2) and 3.45+/-0.14 mm(2), respectively (p=NS). The neointimal area was 1.78+/-0.11 mm(2) in group I and 1.36+/-0.12 mm(2) in group II (p=0.017), and the histopathologic area of stenosis was 35.1+/-1.6% in group I and 27.6+/-1.9% in group II (p=0.005). In conclusion, beta-radiation of the stented porcine coronary artery using a radioactive (166)Ho coated balloon inhibited stent restenosis without any side effects.

Simultaneous coronary - subclavian and vertebral - subclavian steal syndrome

Atherosclerotic disease of the coronary artery may simultaneously involve the subclavian artery, and a significant stenosis of the left subclavian artery may result in recurrent myocardial ischemia in patients with patent left internal mammary artery (LIMA) grafts because of 'coronary steal' through the LIMA. Isometric exercise of the left arm may improve myocardial perfusion through vertebral - subclavian steal by flow reversal in the ipsilateral vertebral artery because of the change in the pressure gradient between the circle of Willis and the distal subclavian artery. The present patient had coronary steal through a LIMA after coronary artery bypass surgery and a transient vertebral - subclavian steal with improved myocardial perfusion as a result of exercise of the left arm.

Focal pulmonary uptake during Tc-99m myocardial perfusion SPECT imaging

PURPOSE

To evaluate the incidence and origin of abnormal focal pulmonary uptake during myocardial perfusion SPECT imaging (MSPECT).

METHODS

For evaluation of chest pain, 790 men and 581 women (mean age, 56 +/- 13 years) underwent MSPECT. All of them received adenosine for pharmacologic stress and Tc-99m tetrofosmin (TF, n = 817) or Tc-99m sestamibi (MIBI, n = 554) for myocardial perfusion imaging.

RESULTS

Review of chest radiography with or without computed tomography revealed 111 (8.1%) focal pulmonary diseases. Among them, 38 (34.2%) showed focal pulmonary uptake (TF, 22; MIBI, 16); 27 (30.7%) of 88 showed previous pulmonary tuberculosis; 2 of 10 (20%) benign pulmonary nodules; 4 of 5 (80%) metastatic lung cancers; 2 of 4 (50%) primary lung cancers; and 3 of 4 (75%) pneumonias. No difference in uptake was noted for the two imaging agents. Intensity of uptake did not vary with origin of the uptake. Focal abnormal pulmonary uptake was found in 2.8% of patients undergoing MSPECT and in 34.2% of patients in whom radiological examinations showed regional pulmonary disease. In patients with abnormal pulmonary uptake on MSPECT, 16% had a malignant lesion, whereas 75% of patients with a pulmonary nodule shown on radiography and focal pulmonary uptake on MSPECT had a malignant lesion.

CONCLUSIONS

Although the incidence of abnormal pulmonary uptake during MSPECT was very low, the incidence of malignant lesions in the patients with nodular pulmonary uptake was relatively high.

Different cutoff values of Cyfra 21-1 for cavitary and noncavitary lung cancers

STUDY OBJECTIVES

Cell lysis and tumor necrosis release cytokeratin, a tumor marker of lung cancer, into the serum. The serum cytokeratin level can also be elevated in benign cavitary lung diseases. The purpose of this study was to evaluate whether Cyfra 21-1 can differentiate malignant lung diseases from benign diseases with cavitary lesions.

DESIGN

This study is a retrospective review of the case records of patients with lung lesions seen during a 4-year period from January 1993 to May 1996.

SETTING AND PATIENTS

Serum Cyfra 21-1 levels were measured in 306 patients with lung cancer (n = 143) or benign lung disease (n = 163). The patients were grouped according to radiologic evidence of cavitary lung lesions. Lung cancer included both non-small cell (n = 123) and small cell (n = 20) lung cancers, and the benign diseases include tuberculosis (n = 87), abscess (n = 26), pneumonia (n = 4), and others (n = 46).

MEASUREMENTS AND RESULTS

Although Cyfra 21-1 clearly differentiated cavitary lung cancer (15.0, 9.1-29.8 ng/ml, median and interquartile range, n = 39) from benign cavitary disease (P < 0.001), and noncavitary lung cancer from benign noncavitary disease (1.7, 0.9-2.6 ng/ml, n = 108, P < 0.001), it could not differentiate noncavitary lung cancer (5.0, 2.1-12.4 ng/ml, n = 104) from benign cavitary diseases (3.3, 1.4-8.3 ng/ml, n = 55, P = 0.45).

CONCLUSIONS

Serum Cyfra 21-1 is a useful tumor marker for differentiating benign from malignant lung diseases. However, different cutoff values are needed, depending on the presence of cavitary lesions. We recommend cutoff values of 30 ng/ml for cavitary lung diseases and 6 ng/ml for noncavitary lung diseases. If there are no radiologic data, a cutoff value of 15 ng/ml is recommended.

Comparison of Tc-99m sestamibi, serum neuron-specific enolase and lactate dehydrogenase as predictors of response to chemotherapy in small cell lung cancer

Neuron-specific enolase (NSE) and lactate dehydrogenase (LDH) are tumor markers of small cell lung cancer (SCLC) which were reported to predict outcome of patients with SCLC. We previously reported that dipyridamole-modulated Tc-99m sestamibi (dipyridamole-MIBI) single photon emission computed tomography (SPECT) could predict the response to chemotherapy in SCLC patients. The purpose of this study was to compare dipyridamole-MIBI and pretreatment serum levels of NSE and LDH for the prediction of response to chemotherapy in SCLC. Twenty-eight SCLC patients underwent dipyridamole-MIBI SPECT 3 to 7 days before starting chemotherapy (80 mg/m2 etoposide and 80 mg/m2 cisplatin every 3 or 4 weeks for at lease two cycles). Serum levels of NSE and LDH were also measured at the same day of the imaging. Tomographic images before and after 0.84 mg/kg dipyridamole infusion were acquired 1 hour after injection of 370 (10 mCi) and 1,110 (30 mCi) MBq MIBI, respectively. The response to chemotherapy was grouped as specified as complete (CR), partial response (PR), no change (NC), and progressive disease (PD), according to the change in tumor size on chest roentgenography and CT. Patients showing CR and PR were classified as responders, and those who showed NC and PD were considered nonresponders. Among the 28 patients, 15 were responders (2 CR, 13 PR) and 13 were nonresponders (11 NC, 2 PD). The change of tumor-to-normal lung ratio (T:NL) after infusion of dipyridamole was significantly higher in responders as compared with nonresponders (0.38 +/- 0.64 vs. -0.38 +/- 0.50, respectively, p = 0.002). However, pretreatment serum NSE and LDH levels did not correlate with the response to chemotherapy. Increase of T:NL after dipyridamole infusion was a strong negative predictor of chemotherapeutic response in SCLC patients, while NSE and LDH could not predict it.

Myocardial infarction with Moyamoya disease and pituitary gigantism in a young female patient

Myocardial infarction is very rare in young female patients with systemic vascular disorders. Moyamoya disease is a cerebrovascular disease associated with an abnormal vascular network. This report presents a 19-year-old female patient who suffered from chest pain and exertional dyspnea for 2 months prior to admission. She had a history of Moyamoya disease and pituitary gigantism since childhood. Her ejection fraction on echocardiogram was 20% and a perfusion defect with partial reversibility in the anterior wall was demonstrated on stress single photon emission computed tomography (SPECT). Diagnostic coronary angiogram revealed critical stenosis in the middle left anterior descending artery, which was treated by coronary stenting. Her subjective symptoms were relieved and the perfusion defect seen on SPECT decreased after coronary intervention.

Determination of Myocardial Viability with ECG-Gated Fluorodeoxyglucose F-18 Positron Emission Tomography

OBJECTIVE: We hypothesize that ECG-gated positron emission tomography (PET) using Fluorodeoxyglucose F-18 (FDG) alone can determine myocardial viability by identifying dysfunctional myocardium with preserved glucose metabolism. We compared the contraction-metabolism pattern of gated FDG PET with the perfusion-metabolism pattern of conventional PET using N-13 ammonia (NH(3)) as a perfusion agent and FDG as a glucose metabolism agent in 21 consecutive patients with chronic coronary artery disease with left ventricular dysfunction (mean ejection fraction 23.6 +/- 7.7%).METHODS: The left ventricle was divided into 17 segments. Uptakes of NH(3) and FDG were scored from absent (0) to normal (4), and wall motion was scored from dyskinesia (-1) to normal (3). Scores were determined by the visual interpretation of the majority of 3 blinded expert readers. Viable myocardium was defined by normal or mildly reduced uptakes of both NH(3) and FDG, perfusion-metabolism mismatch on NH(3)-FDG PET, or normal to mildly reduced uptake of FDG with regional dysfunction on gated FDG PET.RESULTS: Gated FDG PET identified 184 segments as viable, all of which were determined as viable by NH(3)-FDG PET. Among 125 segments identified as nonviable by NH(3)-FDG PET, 76 segments were determined as nonviable by NH(3)-FDG PET. The results provided a positive and negative predictive value of gated FDG PET for the determination of myocardial viability to be 100% and 60.8%, respectively.CONCLUSIONS: Gated FDG PET has a high positive predictive value (100%) for the identification of viable myocardium.

Double-phase Tc-99m sestamibi scintimammography to assess angiogenesis and P-glycoprotein expression in patients with untreated breast cancer

This study evaluated the relation of Tc-99m sestamibi (MIBI) uptake and washout in untreated breast cancer with immunohistochemically determined angiogenesis and P-glycoprotein expression. Thirty-one patients with untreated breast cancer were studied prospectively. Tc-99m MIBI scintigraphy and immunohistochemical analyses of angiogenesis and P-glycoprotein expression were used to evaluate surgically removed tumor tissues. Anterior and both lateral planar images were acquired 10 and 180 minutes after intravenous injection of 740 MBq (20 mCi) Tc-99m MIBI. The tumor-to-normal breast ratio (T:N) and washout index (early T:N - late T:N divided by early T:N) were calculated. A significant correlation was found between angiogenesis and T:N at early and late images. Pearson's correlation coefficients and probability values were r = 0.54, P = 0.002 at early images and r = 0.47, P = 0.008 at late images. The T:N of both early and late images were not different among different groups of P-glycoprotein expression (P = 0.367 and P = 0.113, respectively), although the washout index was significantly different among the groups (P = 0.001). A strong correlation was found between the washout index and P-glycoprotein expression (r = 0.67, P < 0.01). Double-phase scintimammography to assess the early tumoral uptake and washout of Tc-99m MIBI can be used as a simple functional test for in vivo imaging of tumoral angiogenesis and P-glycoprotein expression in patients with untreated breast cancer.

Dipyridamole modulated Tc-99m sestamibi lung SPECT in small cell lung cancer

PURPOSE

In this study, the authors wanted to determine whether dipyridamole-modulated MIBI (dipyridamole-MIBI) could enhance the prediction of the response to chemotherapy in patients with small cell lung cancer.

METHODS

Twenty-seven patients with biopsy-proved small cell lung cancer (25 men, 2 women; mean age, 61 +/- 7 years) underwent dipyridamole-MIBI SPECT 3 to 7 days before starting chemotherapy (80 mg/m2 etoposide and 80 mg/m2 cisplatin every 3 or 4 weeks for at least two cycles). Tomographic images before and after dipyridamole (0.84 mg/kg) were acquired 1 hour after injection of 370 (10 mCi) and 1,110 (30 mCi) MBq MIBI, respectively. The response to chemotherapy was grouped as specified as complete response (CR), partial (PR), no change (NC), or progressive disease (PD), according to the change in tumor size on chest roentgenography and CT. Patients showing CR and PR were classified as responders, and those who showed NC and PD were considered nonresponders.

RESULTS

Among the 27 patients, 22 were responders (3 CR, 19 PR) and 5 were nonresponders (3 NC, 2 PD). The tumor-to-normal lung ratio (T:NL) of responders was significantly higher than that of nonresponders. The diagnostic accuracy of the T:NL ratio to differentiate responders and nonresponders was 33.3%, with a cutoff value of 2.5, which was significantly improved to 77.8% when an increased T:NL ratio after dipyridamole was assigned to a nonresponder. Furthermore, all patients with CR showed diminished T:NL ratios after dipyridamole, and all patients with NR showed an increased T:NL ratio after dipyridamole.

CONCLUSION

Dipyridamole-MIBI SPECT could enhance the prediction of response to chemotherapy in patients with small cell lung cancer.

Technetium-99m-MIBI uptake in small cell lung cancer

Patients with small cell lung cancer (SCLC) often fail to respond to chemotherapy due to multidrug resistance (MDR). Technetium-99m-MIBI was reported to be a suitable transport substrate of P-glycoprotein, which is a cytoplasmic membrane protein encoded by the MDR gene. The purpose of this study was to evaluate whether or not the degree of MIBI uptake in SCLC or its retention on delayed imaging correlated with response to chemotherapy.

METHODS

Twenty-five patients (19 men, 6 women; mean age 59 +/- 10 yr) with biopsy-proven SCLC had MIBI SPECT 3-7 days before starting chemotherapy. Imaging was acquired 1 and 4 hr after injection of 740 MBq MIBI using a single-head rotating gamma camera. Tumor-to-normal lung uptake ratio (T/NL) was measured. Percent retention (%R) was measured as: %R = 100 x (T/NL at 4 hr)/(T/NL at 1 hr). All patients received VAP chemotherapy (VP-16 100 mg/m2, adriamycin 40 mg/m2, cisplatin 25 mg/m2) every 4 wk for at least three times. Response to chemotherapy was grouped as complete remission, partial remission and no remission according to the change of tumor size on chest radiograph and CT images. Differences in T/NL and %R among the three groups were analyzed using ANOVA.

RESULTS

T/NL of patients with complete remission (n = 7) and partial remission (n = 10) were significantly higher than that of no remission (n = 8) in 1 hr and 4 hr. T/NL at 1 hr in three groups were 2.75 +/- 0.78, 2.35 +/- 0.31 and 1.65 +/- 0.36, respectively. T/NL at 4 hr in three groups was 2.61 +/- 0.94, 2.48 +/- 0.50 and 1.66 +/- 0.42, respectively. However, %R was not different among three groups. Percent retention in three groups was 109.40 +/- 22.10, 96.71 +/- 14.25 and 103.59 +/- 28.43, respectively.

CONCLUSION

SCLC with a higher MIBI uptake was more likely to respond to chemotherapy than that with a lower uptake. However, there was a considerable overlap of MIBI uptake among subjects. No significant correlation between the MIBI retention between 1 hr and 4 hr, and the response to chemotherapy was noted.

Combining ADA, protein and IFN-gamma best allows discrimination between tuberculous and malignant pleural effusion

BACKGROUND

The purpose of this study is to assess the usefulness of various enzymes, cytokines and biochemical studies of pleural fluid for the differential diagnosis of tuberculosis from malignant pleural effusions, and to clarify the role of combining diagnostic tests.

METHODS

The study group included 39 cases with tuberculous effusions and 31 cases with malignant effusions, whose diagnoses were confirmed by pleural biopsy, cytology or microbiological methods. We compared pleural fluid levels of ADA, TNF-alpha, IFN-gamma, IL-2, IL-6, IL-8, pH, protein, glucose, cholesterol, triglyceride, amylase and lactic dehydrogenase between tuberculous and malignant effusions. Using stepwise logistic regression analysis, we evaluated the benefit of combining various parameters. Receiver operating characteristic(ROC) curves of ADA, cytokines and equations generated from regression analyses were plotted and compared with the area under curve(AUC). Cut-off values showing the best diagnostic accuracy were selected and compared.

RESULTS

Compared to malignant effusion, tuberculous effusion showed significantly higher levels of ADA, IFN-gamma, TNF-alpha and IL-2. There was a good correlation between IFN-gamma and TNF-alpha. By stepwise logistic regression analysis, IFN-gamma, protein and ADA were independent variables predicting tuberculous from malignant effusions. The diagnostic accuracy and AUC of regression equation was greater than any other single parameters.

CONCLUSION

For the differential diagnosis of tuberculosis and malignant pleural effusions, combining ADA, protein and IFN-gamma best allows discrimination.

A comparison of serum CYFRA 21-1 and SCC Ag in the diagnosis of squamous cell lung carcinoma

To evaluate the usefulness of CYFRA 21-1 and SCC Ag in the diagnosis of squamous cell carcinoma (SQC) of the lung, we tested sera from 124 patients with lung cancers (squamous cell ca 72, adenoca 22, large cell ca 4, small cell ca 18 and undetermined 8) and 78 patients with inflammatory lung diseases (bronchitis 24, bronchiectasis 29, tuberculosis 19 and others 6) using immunoradiometric assay kit for cytokeratin fragment 19 (CYFRA 21-1) and radioimmunoassay kit for SCC Ag. The serum CYFRA 21-1 and SCC Ag were significantly higher in lung cancer patients compared with control subjects. However, the significant difference was restricted only to SQC. In patients with SQC, CYFRA 21-1 and SCC Ag showed significantly higher levels according to the advanced anatomic stages (stage I-IIIa vs. stage IIIb, IV, p < 0.05). There was a good correlation between CYFRA 21-1 and SCC Ag (r = 0.41, p < 0.001). Receiver operating characteristic (ROC) curves were generated from results of both tumor markers and areas under the curves (AUC) were calculated. AUC of CYFRA 21-1 (0.93) were significantly larger than that of SCC Ag (0.77) for the diagnosis of SQC (p < 0.05). Therefore, we conclude that CYFRA 21-1 is superior to SCC Ag in the diagnosis of squamous cell carcinoma of the lung.

Gastric juice ammonia vs CLO test for diagnosis of Helicobacter pylori infection

The aim of the present study was to compare the gastric juice ammonia test to the CLO test for the diagnosis of H. pylori infection in culture-proven cases by receiver operating characteristic (ROC) curve analysis. We studied 75 subjects (44 with chronic gastritis, 10 with gastric ulcer, 6 with duodenal ulcer, 8 with gastric cancer, and 7 normal) by endoscopy with biopsy for tissue diagnosis, culture of H. pylori. CLO test, and by gastric juice ammonia determinations. The culture-positive group had significantly higher intragastric ammonia levels (13.7 +/- 5.8 mg/dl) than the negative group (4.9 +/- 2.4 mg/dl, P < 0.01). In ROC curve analysis, the gastric juice ammonia test showed higher true positive and lower false positive ratios than the CLO test (P < 0.05). In conclusion, the measurement of intragastric juice ammonia levels was considered to be simpler, quicker, and overall a more valuable method for diagnosing H. pylori infection.

Differentiation of malignant from benign pancreatic mass by Tl-201 abdominal SPECT

The aim of the present study was to evaluate the ability of Tl-201 abdominal SPECT to differentiate between chronic focal pancreatitis and pancreatic malignancy. Seventeen patients (12 men, 5 women; mean age, 56 years; 9 pancreatic cancer, 8 chronic pancreatitis) with pancreatic mass were prospectively investigated with Tl-201 abdominal SPECT. In all patients, CT and/or US could not clarify the nature of the pancreatic mass. Focal hot uptake was present in 8 of 9 patients with pancreatic cancer, while it was present in 2 of 8 patients with chronic pancreatitis. Therefore, the sensitivity and specificity of the present study were 89% and 75%, respectively. A significant difference of Tl-201 uptakes was noted between benign and malignant masses (p < 0.05). Therefore, we concluded that Tl-201 abdominal SPECT was a useful test in differentiation of malignant from benign pancreatic mass, especially when the differentiation could not be made by other imaging modalities.

Safety of dipyridamole testing in 73,806 patients: the Multicenter Dipyridamole Safety Study

BACKGROUND

Dipyridamole imaging is widely used as an alternative to exercise testing to identify and risk stratify patients with coronary artery disease. Safety data on intravenous dipyridamole stress testing has been derived largely from individual institutional data.

METHODS AND RESULTS

Data were collected retrospectively by 85 coinvestigators from 73,806 patients who underwent intravenous dipyridamole stress imaging in 59 hospitals and 19 countries to determine the incidence of major adverse reactions during testing. The dose of dipyridamole infused was 0.56 mg/kg in 64,740 patients, 0.74 mg/kg in 6551 patients, and 0.84 mg/kg in 2515 patients. Combined major adverse events among the entire 73,806 patients included seven cardiac deaths (0.95 per 10,000), 13 nonfatal myocardial infarctions (1.76 per 10,000), six nonfatal sustained ventricular arrhythmias (0.81 per 10,000) (ventricular tachycardia in two and ventricular fibrillation in four), nine transient cerebral ischemic attacks (1.22 per 10,000), (with speech or motor deficit), one stroke, and nine severe bronchospasms (1.22 per 10,000) (one intubation and eight near intubations). In addition to the safety data, detailed demographic, peripheral hemodynamic, side effect, and concomitant drug data were examined in a subgroup of 3751 patients. End points from subsets of patients were compared with those of the group as a whole. Multivariate analysis revealed that dipyridamole-induced chest pain was more common in patients less than 70 years old (p = 0.0017), those with a history of coronary revascularization (p = 0.002), or patients taking aspirin (p = 0.0001). Minor noncardiac side effects were less frequent among the elderly (p = 0.0053) and more frequent in women (p = 0.0001) and patients taking maintenance aspirin (p = 0.0034). When a patient was judged on the basis of the adequacy of hemodynamic response to be a dipyridamole "nonresponder" (< 10 mm Hg drop in systolic blood pressure and 10 beats/min increase in heart rate), the only significant predictor was angiotensin-converting enzyme inhibitor intake (p = 0.0025). Inferoposterior hypoperfusion was significantly more frequent in patients with dipyridamole-induced hypotension: 57% (44/77) (p < 0.0001) of those who had hypotension and 89% (8/9) (p = 0.0076) who had severe symptomatic bradyarrhythmias displayed inferoposterior defects on thallium scanning. Caffeine levels were determined in 391 consecutive patients: levels greater than 5 mg/L were observed in only eight patients (2%), suggesting that methylxanthine levels sufficient to alter the hemodynamic response to dipyridamole resulting in suboptimal hyperemic stress are unlikely when patients take nothing by mouth after midnight.

CONCLUSION

The risk of serious dipyridamole-induced side effects is very low and is comparable to that reported for exercise testing in a similar patient population.

Tc-99m MIBI uptake in simultaneous thyroid and lung cancers

The authors present a patient with simultaneous follicular thyroid and small-cell lung cancers, both of which showed Tc-99m MIBI uptake. CT scans showed two masses: one involving the right lower neck including the right supraclavicular area and the right superior mediastinum, and the other involving the peripheral portion of the right upper lobe of the lung. I-131 imaging showed increased uptake in the right neck mass only. Tc-99m MIBI imaging, which was performed for evaluation of chest pain, showed intense uptake in the neck mass (tumor to heart ratios in planar and tomographic images were 0.92 and 0.96, respectively), and less uptake in the lung mass (tumor to heart ratios in planar and tomographic images were 0.53 and 0.40, respectively). Biopsy of the right supraclavicular mass revealed a follicular carcinoma, and a bronchoscopic biopsy of the right upper lobe mass revealed a small cell carcinoma.

Cimetidine improves the accuracy of creatinine clearance as an indicator for glomerular filtration rate

BACKGROUND

Although endogenous creatinine clearance is often used as an indicator for the glomerular filtration rate (GFR), it may result in an overestimation due to its tubular secretion. Since cimetidine is known to inhibit tubular secretion of creatinine, it may improve the accuracy of the creatinine clearance in measuring GFR.

METHODS

Creatinine clearance (Ccr) was compared with iothalamate clearance (C1oth) during oral administration of either placebo or cimetidine in 25 patients with varying degrees of renal dysfunction.

RESULTS

Cimetidine itself had no effect on C1oth but decreased Ccr, improving its validity, as measured by a significant decrease of Ccr/C1oth from 1.72 during placebo to 1.17 during cimetidine administration. The degree of overestimation measured by the Ccr was more pronounced in those with more severe renal dysfunction. A significant inverse correlation was noted between Ccr/C1oth and GFR. No apparent side effect due to cimetidine was noted.

CONCLUSIONS

These results suggest that cimetidine improves the accuracy of Ccr as an indicator for GFR in patients with varying degrees of renal dysfunction.

Autoradiographic and immunohistochemical study on the proliferative kinetics of intestinal metaplasia

In order to elucidate the proliferative behavior of the intestinal metaplasia around gastric cancer, the authors used both in vitro tritiated thymidine (3H-thymidine) autoradiography and in vivo bromodeoxyuridine (BrdUrd) immunohistochemistry for labeling the proliferative cells of the normal pyloric glands and metaplastic gastric glands. The results of the methods were comparable: The labeling pattern and the rate of labeling were very similar. In the normal pyloric mucosa, the labeled cells were confined to the isthmus region, indicating that pyloric glandular cells are normally renewed from the isthmus region. On the other hand, a zone of the labeled cells was found in the lower half of the intestinalized mucosa, indicating that cell proliferation took place deep in the mucosa, just like the case of normal intestinal glands. The labeling indices of the pyloric mucosa were 19.4% by autoradiography and 18.0% by immunohistochemistry, and that of the intestinalized gastric glands were 25.2% by autoradiography and 24.2% by immunohistochemistry. In conclusion, both 3H-thymidine autoradiography and BrdUrd immunohistochemistry showed that the proliferative kinetics of the intestinalized gastric glands was similar to that of the normal intestinal glands rather than the pyloric glands, i.e. a lower level of proliferative zone and higher labeling index were present.

Adjuvant internal hepatic radiotherapy using colloidal 32P chromic phosphate in colorectal cancer

The purpose of the study is to investigate the value of adjuvant radiotherapy given in the form of colloidal chromic phosphate 32P suspension administered via portal vein, in preventing the growth of occult metastases in the liver. Twenty two patients (10 patients of treated group with 12 controls) were followed 12 months after operation. There was no significant change in the CBC and liver functions after administration of 32P labeled colloidal chromic phosphate. Although local recurrence rates were very similar in both groups of colorectal cancer (3/12 in the control group and 4/10 in the treated group), liver metastasis rates were quite different: 4/12 in the control group and none (0/10) in the treated group. In conclusion, 32P labeled colloidal chromic phosphate is expected to prevent liver metastases of completely resected colorectal cancer.

Early gastric cancer in Korea

We reviewed the 639 cases of early gastric cancer from nation-wide 16 medical centers. The proportion of early gastric cancer among surgically resected gastric carcinoma comprised 6 to 12 percent. Male to female ratio was 1.7 to 1 with male preponderance. Mean ages of the early gastric cancer was 49.0 years and most prevalent ages was 5th decade. Macroscopically type IIc was most prevalent, reaching 59.9 percent. Depressed type lesions was more frequent than elevated type lesions by four folds. The size of lesions less than 4 cm accounted for more than 80 percent. Most frequent site of lesions were lower third by the CMA classification and lesser curvature transectionally. Lymph node metastasis was observed in 10.9 percent of all cases and it was more frequent in large tumor size more than 4 cm, elevated type, and undifferentiated carcinoma. 5-year survival rate was 91.6 percent. Gastrofiberscopic examination was superior to that of radiological examination in the diagnosis of early gastric cancer.

Clinical features of Crohn's disease in Korea

Crohn's disease is a rare disease in Korea, and only 45 cases have been reported during the period of 34 years from 1952 to 1985. The male to female ratio was about 1.3 to 1 with a slight preponderance of males. The age at diagnosis ranged from 8 to 72 (mean 35.5) years, and the peak incidence occurred in the 3rd, 4th and 5th decades and declined thereafter. More than two thirds of the cases had a grossly demonstrable lesion involving the small bowel, including the terminal ileum. The proportion of patients with macroscopic disease continued to the large bowel alone was only 15%. Abdominal pain was common, presenting in 89% of the patients, while such symptoms as fever, hematochezia and diarrhea were not common. Abdominal mass was palpable in more than half the cases, which made it difficult to differentiate Crohn's disease from cancer of the colon, especially in cases with a predominant infiltration of the bowel wall and a secondary ulcer formation. That is one of the reasons why most cases in Korea have been reported by surgeons. A wide variety of complications were present, of which small bowel obstruction was the most common. Other complications were free perforation, malnutrition, fistula formation, hemorrhage and abscess formation, in decreasing order. The incidence of symptomatic perianal disease was only 11%, and this might be due to the small proportion of the disease confined to large bowel. Extraintestinal manifestations were also rare, and only three patients presented symptoms of arthritis. Other systemic features such as liver disease, skin lesion, eye complications were absent.

A clinical study of adult Japanese encephalitis in the Chonnam District, Korea, during summer of 1982--a difference between improved and expired cases

In the summer of 1982, we experienced a great number of patients with Japanese encephalitis compared with the previous years. We have studied 85 adult cases of Japanese encephalitis which were diagnosed clinically and/or serologically. A difference between improved and expired cases was also investigated. We found that deteriorated mental state, elevated SGOT (AST) level, lower hemagglutination-inhibition(H-I) titer, and a more acute onset of the illness were associated with higher mortality. The mortality rate in our cases was 35.3 percent.