Cost-effectiveness analysis of personalised versus standard dosimetry for selective internal radiation therapy with TheraSphere in patients with hepatocellular carcinoma

Aims

To perform a cost-effectiveness analysis (CEA) comparing personalised dosimetry with standard dosimetry in the context of selective internal radiation therapy (SIRT) with TheraSphere for the management of adult patients with locally advanced hepatocellular carcinoma (HCC) from the Italian Healthcare Service perspective.

Materials and methods

A partition survival model was developed to project costs and the quality-adjusted life years (QALYs) over a lifetime horizon. Clinical inputs were retrieved from a published randomised controlled trial. Health resource utilisation inputs were extracted from the questionnaires administered to clinicians in three oncology centres in Italy, respectively. Cost parameters were based on Italian official tariffs.

Results

Over a lifetime horizon, the model estimated the average QALYs of 1.292 and 0.578, respectively, for patients undergoing personalised and standard dosimetry approaches. The estimated mean costs per patient were €23,487 and €19,877, respectively. The incremental cost-utility ratio (ICUR) of personalised versus standard dosimetry approaches was €5,056/QALY.

Conclusions

Personalised dosimetry may be considered a cost-effective option compared to standard dosimetry for patients undergoing SIRT for HCC in Italy. These findings provide evidence for clinicians and payers on the value of personalised dosimetry as a treatment option for patients with HCC.

Event-free survival after 68 Ga-PSMA-11 PET/CT in recurrent hormone-sensitive prostate cancer (HSPC) patients eligible for salvage therapy

Background/aim

Prostate-specific-membrane-antigen/positron emission tomography (PSMA-PET) detects with high accuracy disease-recurrence, leading to changes in the management of biochemically-recurrent (BCR) prostate cancer (PCa). However, data regarding the oncological outcomes of patients who performed PSMA-PET are needed. The aim of this study was to evaluate the incidence of clinically relevant events during follow-up in patients who performed PSMA-PET for BCR after radical treatment.

Materials and methods

This analysis included consecutive, hormone-sensitive, hormone-free, recurrent PCa patients (HSPC) enrolled through a prospective study. All patients were eligible for salvage therapy, having at least 24 months of follow-up after PSMA-PET. The primary endpoint was the Event-Free Survival (EFS), defined as the time between the PSMA-PET and the date of event/last follow-up. The Kaplan–Meier method was used to estimate the EFS curves. EFS was also investigated by Cox proportional hazards regression. Events were defined as death, radiological progression, or PSA recurrence after therapy.

Results

One-hundred and seventy-six (n = 176) patients were analyzed (median PSA 0.62 [IQR: 0.43–1.00] ng/mL; median follow-up of 35.4 [IQR: 26.5–40.3] months). The EFS was 78.8% at 1 year, 65.2% (2 years), and 52.2% (3 years). Patients experiencing events during study follow-up had a significantly higher median PSA (0.81 [IQR: 0.53–1.28] vs 0.51 [IQR: 0.36–0.80] ng/mL) and a lower PSA doubling time (PSAdt) (5.4 [IQR: 3.7–11.6] vs 12.7 [IQR: 6.6–24.3] months) (p < 0.001) compared to event-free patients. The Kaplan–Meier curves showed that PSA > 0.5 ng/mL, PSAdt ≤ 6 months, and a positive PSMA-PET result were associated with a higher event rate (p < 0.01). No significant differences of event rates were observed in patients who received changes in therapy management after PSMA-PET vs. patients who did not receive therapy changes. Finally, PSA > 0.5 ng/mL and PSAdt ≤ 6 months were statistically significant event-predictors in multivariate model (p < 0.001).

Conclusion

Low PSA and long PSAdt were significant predictors of longer EFS. A lower incidence of events was observed in patients having negative PSMA-PET, since longer EFS was significantly more probable in case of a negative scan.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-022-05741-9.

Predictive Value of Baseline [18F]FDG PET/CT for Response to Systemic Therapy in Patients with Advanced Melanoma

Background/Aim: To evaluate the association between baseline [18F]FDG-PET/CT tumor burden parameters and disease progression rate after first-line target therapy or immunotherapy in advanced melanoma patients. Materials and Methods: Forty four melanoma patients, who underwent [18F]FDG-PET/CT before first-line target therapy (28/44) or immunotherapy (16/44), were retrospectively analyzed. Whole-body and per-district metabolic tumor volume (MTV) and total lesion glycolysis (TLG) were calculated. Therapy response was assessed according to RECIST 1.1 on CT scan at 3 (early) and 12 (late) months. PET parameters were compared using the Mann–Whitney test. Optimal cut-offs for predicting progression were defined using the ROC curve. PFS and OS were studied using Kaplan–Meier analysis. Results: Median (IQR) MTVwb and TLGwb were 13.1 mL and 72.4, respectively. Non-responder patients were 38/44, 26/28 and 12/16 at early evaluation, and 33/44, 21/28 and 12/16 at late evaluation in the whole-cohort, target, and immunotherapy subgroup, respectively. At late evaluation, MTVbone and TLGbone were higher in non-responders compared to responder patients (all p < 0.037) in the whole-cohort and target subgroup and MTVwb and TLGwb (all p < 0.022) in target subgroup. No significant differences were found for the immunotherapy subgroup. No metabolic parameters were able to predict PFS. Controversially, MTVlfn, TLGlfn, MTVsoft + lfn, TLGsoft + lfn, MTVwb and TLGwb were significantly associated (all p < 0.05) with OS in both the whole-cohort and target therapy subgroup. Conclusions: Higher values of whole-body and bone metabolic parameters were correlated with poorer outcome, while higher values of whole-body, lymph node and soft tissue metabolic parameters were correlated with OS.

68Ga-Prostate-Specific Membrane Antigen 11 PET/CT Detects Residual Glioblastoma After Radical Surgery in a Patient With Synchronous Recurrent Prostate Cancer: A Case Report

Prostate-specific membrane antigen (PSMA) is a transmembrane enzyme also known as folate hydrolase 1 highly expressed by prostate cancer (PCa) cells. However, PSMA overexpression by tumor-associated neovasculature of a variety of solid tumors, including glioblastoma (GBM), has also been proven. This clinical case reports about a 67-year-old man with a history of PCa who underwent radical surgery for GBM and performed a Ga-PSMA-11 PET/CT to restage PCa. PET imaging showed PSMA uptake in GBM residual disease after surgery. This finding suggests a possible role of PSMA inhibitors as diagnostic and therapeutic agents in patients affected by GBM.

68Ga-PSMA-11 PET/CT in recurrent hormone-sensitive prostate cancer (HSPC): a prospective single-centre study in patients eligible for salvage therapy

OBJECTIVES

The primary objective is to assess the efficacy of ⁶⁸Ga-PSMA-11-PET/CT to detect recurrent location(s) in hormone-sensitive prostate cancer (PCa). Secondary objectives are (1) to evaluate changes in clinical management; (2) to determine which covariates independently predict positive scan; (3) to assess ⁶⁸Ga-PSMA-11-PET/CT performance in different settings of PSA relapse.

MATERIALS AND METHODS

Inclusion criteria include (1) histologically diagnosed PCa; (2) previous radical therapy; (3) proven biochemical recurrence (BCR) or biochemical persistence (BCP); (4) hormone-sensitive PCa (HSPC); (5) androgen deprivation therapy (ADT)-free for at least 6 months; (6) PSA < 1.5 ng/mL or any PSA in case of negative choline-PET/CT (n = 38). Changes in clinical management were defined by multidisciplinary tumour-board. Clinical settings were BCP (group-1, n = 25); first-time BCR (group-2, n = 121); BCR after salvage therapy (group-3, n = 77).

RESULTS

Two hundred twenty-three (223) consecutive patients were enrolled: median PSA = 0.65 ng/mL (0.2-8.9) and median PSAdt = 9.3 months (0.4-144.6). 96.9% received RP as primary therapy. ⁶⁸Ga-PSMA-11-PET/CT positivity rate was 39.9% (CI95% 33.5-46.7%). Disease confined to pelvis was detected in 23.3% of cases. At least one distant lesion was observed in 16.6% of cases. Secondary objectives are as follows: (1) changes in clinical management were observed in 34.5% of patients; (2) PSA, PSAdt and T stage > 3a were independent predictors (all p < 0.03); (3) ⁶⁸Ga-PSMA-11-PET/CT positivity rate was 56% (in group 1, 36.3% in group 2, 40.3% in group 3.

CONCLUSION

This study attested the overall good performance of ⁶⁸Ga-PSMA-11-PET/CT to detect PCa locations in HSPC patients eligible for salvage therapy, influencing the therapy management in 35.4% of cases. Furthermore, patient characteristics are influencing factors of ⁶⁸Ga-PSMA-11-PET/CT positivity rate and should be considered to reduce false negative scan.

Sentinel Node Detection in Breast Carcinoma

Aims and Background

The standard procedure for the evaluation of axillary nodal involvement in patients with breast cancer is still complete lymph node dissection. However, about 70% of patients are found to be free of metastatic disease while axillary node dissection may cause significant morbidity. Lymphatic mapping and sentinel lymph node (SLN) biopsy are changing this situation.

Methods and Study Design

In a period of 18 months we studied 201 patients with breast cancer, excluding patients with palpable axillary nodes, tumors >2.5 cm in diameter, multifocal or multicentric cancer, pregnant patients and patients over 80 years of age. Before surgery 99mTc-labeled colloid and vital blue dye were injected into the breast to identify the SLN. In lymph nodes dissected during surgery the metastatic status was examined by sections at reduced intervals. Only patients with SLNs that were histologically positive for metastases underwent axillary dissection.

Results

We localized one or more SLNs in 194 of 201 (96.5%) patients; when both techniques were utilized the success rate was 100%. Histologically, 21% of patients showed SLN metastases (7.8% micrometastases) and 68% of these had metastases also in other axillary nodes. None of the patients with negative SLNs developed metastases during follow-up.

Conclusions

At present there is no definite evidence that negative SLN biopsy is invariably correlated with negative axillary status; however, our study and those of others demonstrate that SLN biopsy is an accurate method of axillary staging.

Radiolabeled Localization of the Sentinel Lymph Node: Dosimetric Evaluation in Personnel Involved in the Procedure

Aims and Background

Peritumoral injection of 99mTc-labeled colloids for lymphoscintigraphy and radioguided surgery does not entail any relevant radiation burden to the patients. The real issue about radiation protection concerns the personnel involved in the procedure besides the nuclear medicine personnel. The aim of our study was to evaluate the cumulative doses to personnel involved during the injection of radiolabeled compounds under ultrasound or stereotactic guidance and the radiation burden to the personnel involved in the surgical incision of the tumor 24 hours after the administration of 99mTc-labeled colloids.

Methods and Study Design

We performed environmental contamination tests (SMEAR TEST) and exposure evaluation in the operating room.

Results

In the operating room the removed activity in the analyzed samples was less than 0.5Bq/g and exposure to the personnel was less than 6μSv/h. The evaluations made during ultrasound guidance demonstrated an equivalent and effective dose less than 20μSv.

Conclusions

Our results show that during ultrasound or stereotactic administration of radiolabeled compounds the radiation burden to the personnel involved in the procedure is virtually negligible. The surgeons too are exposed to a negligible radiation dose.

The Sentinel Node in Anal Carcinoma

Aims and Background

Anal cancer is a rare condition. The inguinal lymph nodes are the most common site of metastasis in this neoplasm. The inguinal lymph node status is an important prognostic indicator and the presence of metastases is an independent prognostic factor for local failure and overall mortality. Depending on the primary tumor size and histological differentiation, metastasis to superficial inguinal lymph nodes occurs in 15-25% of cases.

Methods and Study Design

To evaluate the inguinal lymph node status we performed a search for the sentinel node in a female patient affected by squamous anal carcinoma.

Results

Identification and examination of the sentinel node was positive and postoperative histology showed the presence of bilateral lymph node metastases.

Conclusions

We suggest that examination of the sentinel node in anal cancer could be an efficient way to establish the inguinal lymph node status, which would help the clinician to plan and perform adequate treatment.

Preliminary Study of Sentinel Node Identification with 99mTc Colloid and Blue Dye in Patients with Endometrial Cancer

Aims and Background

Intraoperative lymphatic mapping and sentinel node (SLN) biopsy have generated a tremendous amount of interest and are already established as part of the standard practice in the surgical management of breast cancer and melanoma. To reduce extensive radical procedures and decrease the morbidity in the treatment of gynecologic malignancies, much effort is being made to use less aggressive interventions. The purpose of our study was to determine the feasibility of SLN mapping in a group of patients with endometrial cancer at early stages.

Method and study design

Between September 2000 and May 2001 11 patients with endometrial cancer FIGO stage Ib (n = 10) and Ha (n = 1) underwent laparoscopic SLN detection during laparoscopy-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy and bilateral systematic pelvic lymphadenectomy. Radioactive isotope injection was performed 24 hours before surgery and blue dye injection was performed just before surgery in the cervix at 3, 6, 9 and 12 hours. A 350 mm laparoscopic gamma scintyprobe MR 100 type 11, 99mTc settled (Pol Hi Tech), was used intraoperatively for SLN detection.

Results

Seventeen (17) SLNs were detected with lymphoscintigraphy (six bilateral and five unilateral). At laparoscopic surgery we found the same locations belonging at internal iliac lymph nodes (the so-called Lebeuf-Godard area, lateral to the inferior vesical artery, ventral to the origin of the uterine artery and medial or caudal to the external iliac vein). Fourteen (14) SLNs were negative on histological analysis and three were positive for micrometastases (mean SLN sections = 60). All other pelvic lymph nodes were negative at histological analysis. The same SLN locations detected with the gamma scintyprobe were observed at laparoscopy after patent blue dye injection.

Conclusions

Our preliminary data suggest that combined 99mTc-labeled colloid and vital blue-dye techniques are feasible for SLN detection in endometrial cancer; they represent a very promising tool to transform the management of early-stage endometrial cancer. The clinical validity of this combined technique should be evaluated prospectively.

Sentinel Lymph Node and Breast Cancer Staging: Final Results of the Turin Multicenter Study

Aim of the study

Validation of the sentinel node (SN) technique in breast cancer by means of lymphoscintigraphy.

Materials and methods

From December 1996 to January 1999 102 T1-T2 breast carcinoma cases were recruited in Turin. 99mTc-human serum albumin colloids were injected subdermally the day before surgery (mean activity, 5.2 ± 2.5 MBq). Scintigraphic imaging was performed after injection. After identification of the SN during surgery by a hand-held gamma probe, the SN was excised and sent for histologic examination. SN histology was compared with that of other axillary nodes.

Results

The SN detection rate was 86.3%; among 88 cases with an identified SN, 37 (42%) had axillary metastases; the SN was metastatic in 35 cases (sensitivity, 94.6%); in 51.3% of pN+ cases (19/37) the SN was the only metastatic site. In two of the 53 negative SNs, SN histology did not match with that of the remaining axilla (negative predictive value, 96.2%; staging accuracy, 97.7%).

Conclusions

Our results agree with those reported in the literature; however, except in clinical trials and experienced structures axillary lymph node dissection should not be abandoned when mandatory for prognostic purposes, considering that at present SN biopsy alone is not completely accurate for axillary staging, especially in the absence of an adequate learning period.

Yttrium-90 ibritumomab tiuxetan (Zevalin) followed by BEAM (Z-BEAM) conditioning regimen and autologous stem cell transplantation (ASCT) in relapsed or refractory high-risk B-cell non-Hodgkin lymphoma (NHL): a single institution Italian experience

Chemo-refractory NHL has a very poor outcome; the addiction of RIT to salvage regiment pre ASCT had recently demonstrated promising results.We performed a retrospective sequential study to determine the feasibility of standard Zevalin with BEAM in high-risk relapse/refractory NHL. A matched cohort analysis with a group treated with standard BEAM without Zevalin was performed as secondary endpoint. Between October 2006 and January 2013, 37 NHL patients at high risk for progression or early (< 1 year) or multiple relapses were treated with Z-BEAM and ASCT after R-DHAP or R-ICE as salvage therapy. Clinical characteristics were 19 refractory and 18 early or multiple relapse; 16 patients received 1, and 21 had 2 or more previous rituximab-containing chemotherapy. At the end of treatment, response was CR 22 (59%), PR 10 (27%), PD 4 (11%), and toxic death (TD) 1 (3%). With a median follow up of 61 months, 3-year PFS was 61% and OS 61%. Fifteen patients died, 12 of lymphoma. Comparison with 21 treated with BEAM alone showed a numerical higher 3-yr PFS rate in favor of Z-BEAM but not statistically significant (57 vs 48%). With the limitation of the small sample subgroup analysis, a significant benefit was observed in relapsed patients for PFS (78% Z-BEAM vs 22% BEAM p = 0.016) and OS (83% Z-BEAM vs 22% BEAM p = 0.001). In relapsed/refractory high-risk NHL, Z-BEAM+ASCT is able to achieve a good ORR. Three-year PFS is promising for early relapsed patients but is not satisfactory for those with refractory disease.

Interventional locoregional treatment and metabolic response: advantages of using PET/CT in the evaluation of response to treatment

INTRODUCTION

Interventional oncology locoregional therapies are validated treatment modalities for primary and secondary tumors in liver, lung, kidney and bone. At this time, there is no accordance in the choice of imaging modality to assess treatment response. Morphological imaging and RECIST 1.1 criteria based on size variation are limited by several critical points. On the other hand the role of functional imaging, in particular by [18F]-fluorodeoxyglucose ([18F]-FDG) positron emission tomography (PET), in both staging and response evaluation of locoregional treatments remains unclear because of the heterogeneous nature of available data. The aim of this paper was to summarize the available literature illustrating the state of art of metabolic evaluation of response after locoregional therapies in the three major organs of interest: liver, lung and bone.

EVIDENCE ACQUISITION

Medline database was searched for relevant original paper evaluating the role of [18F]-FDG PET in interventional oncology treatment published up to June 2017 excluding case reports.

EVIDENCE SYNTHESIS

Finally 41 studies papers evaluating the role of [18F]-FDG PET in both staging and in response evaluation of locoregional treatments focused on liver tumoral lesions (N.=29), on lung lesions (N.=10) and on bone lesions (N.=2) were considered for this review.

CONCLUSIONS

PET/CT appears to perform well in the assessment of response to interventional therapies compared to conventional imaging, not only in terms of response evaluation but also as a possible prognostic tool. Nevertheless further prospective, homogenous studies are required to confirm these data, in particular for lung and bone lesions.

Using PET-CT in the restaging of primitive mediastinal B-cell lymphoma (PMBCL) after chemotherapy: which criteria should we use?

AIM

Primitive mediastinal B-cell lymphoma (PMBCL) is a relatively rare form of non-Hodgkin lymphoma (NHL), typically concerning the youngster, with an aggressive course and poor prognosis. The therapy generally consists of high dose chemotherapy followed by radiotherapy. PET-CT is used at staging, restaging after chemotherapy and after radiotherapy, or when relapse is suspected. Aim of the study was to compare different criteria in the evaluation of response to chemotherapy in this setting.

METHODS

Thirty-eight patients with PMBCL (15 M, 23 F, median age 33 yrs [range 18-79]), all treated with chemo-immunotherapy and radiotherapy, who had undergone baseline (b-PET) and end of chemotherapy (f-CHT-PET) 18F-FDG-PET-CT scans at our institution between July 2004 and September 2014 were retrospectively re-evaluated; the median follow-up was 42 months (range 4-109), at which 4/38 (11%) had died, 5/38 (13%) were in partial response (PR) and 29/38 (76%) were in complete response (CR). The primary endpoint was progression-free survival (PFS), while the secondary one was overall survival (OS), according to the Cheson criteria. SUV max of the mediastinal disease mass at staging, of the residual mass at CT after chemo-immunotherapy, SUV max of the liver and of the mediastinal blood pool (MBP) were calculated for all patients.

RESULTS

In our population, we observed that: 1) visual criteria performs better when positivity-negativity threshold is set at point 3 of the 5-point scale (5-PS); 2) semiquantitative approach by use of Δ SUV max performs better when the threshold is set at 66% decrease: in fact, at Δ SUV max analysis with 66% decrease, 9 patients resulted positive at the test (Δ SUV max ≤66%), 29 negative (Δ SUV max >66%).

CONCLUSION

In our population Δ SUV max could be working well in these patients because the baseline values are very high and very homogeneous. Our data, though limited in numerosity of patients and events, suggests that in this particular setting the use of the 5-PS reporting system could not be the best tool available; on the other hand, Δ SUV max could prove to be reliable in the evaluation of response to chemotherapy.

A novel biomarker-based analysis reliably predicts nodal metastases in anal carcinoma: preliminary evidence of therapeutic impact

AIM

Routine prophylactic inguinal irradiation in anal cancer may cause significant toxicity associated with overtreatment bias. The aim of this study was to determine the risk of regional node metastases in anal carcinoma by identifying predictive molecular biomarkers.

METHOD

Clinicohistopathological data from 50 pretreatment anal carcinoma biopsies were collected. Immunohistochemical analyses with antibodies against Ki67, p53, epidermal growth factor receptor (EGFR) and YKL-40 were performed. Statistical correlations between biomarkers and clinicopathological features and outcomes were studied. Sentinel lymph node biopsy was performed in a subset of 36 patients.

RESULTS

All patients had undergone synchronous radiochemotherapy; tumour recurrence had developed in 26%, and 16% had died. YKL-40 tumour expression correlated with lymph node metastasis, whereas no inguinal node metastases were found in any of the (14%) patients presenting with a YKL-40/EGFR-negative tumour. YKL-40 expression and node metastasis were both significantly associated with shorter overall and disease-free survival. Tumour grade significantly correlated with disease-free survival only. HIV, tumour histological type, Ki67, p53 and EGFR were not associated with outcome.

CONCLUSION

YKL-40 expression in anal carcinoma is correlated with a poor outcome and can predict lymph node metastases. The combined absence of YKL-40 and EGFR expression in a first biopsy of anal carcinoma reliably selects a subset of patients without inguinal metastases. Such patients could be spared sentinel lymph node biopsy and/or inguinal radiotherapy.

Radiation therapy in primary mediastinal B-cell lymphoma with positron emission tomography positivity after rituximab chemotherapy

PURPOSE

To investigate the role of radiation therapy (RT) in patients affected with primary mediastinal B-cell lymphoma (PMBCL) with residual (18)fluorodeoxyglucose positron emission tomography ((18)FDG-PET)-positive disease after rituximab chemotherapy (R-CT).

METHODS AND MATERIALS

Thirty-seven patients treated with R-CT and RT, all with (18)FDG-PET scan at diagnosis and before RT, were included. All (18)FDG-PET scans were reviewed, and responses were classified according to the Deauville 5-point scoring system. Outcomes measures were overall survival (OS) and progression-free survival (PFS), estimated for the whole cohort and for subgroups according to (18)FDG-PET score after R-CT.

RESULTS

The median follow-up time was 40.9 months. Three patients were assigned to Deauville score 1 (8.1%), 9 to score 2 (24.3%), 7 to score 3 (19%), 14 to score 4 (37.8%), and 4 to score 5 (10.8%). After RT, all patients with score 3-4 experienced a complete response (CR). Among patients with score 5, 1 was in CR (25%), 2 had persistent positivity (50%), and 1 showed progressive disease (25%). A total of 4 patients experienced progression or relapse: 1 of 33 (3%) with scores 1-4, and 3 of 4 (75%) with score 5. The 3-year OS and PFS of the whole cohort were 89.8% and 88.7%, respectively. OS was significantly different between scores 1-3 and scores 4-5 (100% vs 77% at 3 years, P<.05). Patients with a score of 5 had a significantly worse outcome than did all other patients (OS at 2 years, 33.3% vs 100%).

CONCLUSIONS

Approximately 50% of PMBCL patients show residual disease at (18)FDG-PET scan after R-CT. RT is able to convert to CR approximately 85% of these patients, but those with a Deauville score of 5 (10%) appear at high risk of progression and death, and they might be candidates for intensified programs.

Value of staging squamous cell carcinoma of the anal margin and canal using the sentinel lymph node procedure: an update of the series and a review of the literature

Background:

Inguinal metastases in patients affected by anal cancer are an independent prognostic factor for local failure and overall mortality. Since 2001, sentinel lymph node biopsy was applied in these patients. This original study reports an update of personal and previous published series, which were compared with Literature to value the incidence of inguinal metastases T-stage related and the overall incidence of false negative inguinal metastases at sentinel node.

Methods:

In all, 63 patients diagnosed with anal cancer submitted to inguinal sentinel node. Furthermore a research in the Pub Med database was performed to find papers regarding this technique.

Results:

In our series, detection rate was 98.4%. Inguinal metastases were evidentiated in 13 patients (20.6%). Our median follow-up was 35 months. In our series, no false negative nodes were observed.

Conclusion:

Sentinel node technique in the detection of inguinal metastases in patients affected by anal cancer should be considered as a standard of care. It is indicated for all T stages in order to select patients to be submitted to inguinal radiotherapy, avoiding related morbidity in negative ones. An overall 3.7% rate of false negative must be considered acceptable.

Bone marrow disease detection with FDG-PET/CT and bone marrow biopsy during the staging of malignant lymphoma: results from a large multicentre study

AIM

To compare the accuracy of bone marrow biopsy (BMb) and positron emission tomography (PET) in bone marrow disease (BMD) detection, in a large multicentre population of patients with new diagnosis of malignant lymphoma.

METHODS

PET and BMb were performed to complete disease staging in 337 consecutive patients: 130 Hodgkin's disease (HD), 207 aggressive non Hodgkin's lymphoma (NHL). Sensitivity, specificity and accuracy of both techniques in BMD detection were evaluated and compared.

RESULTS

87 patients with BMD (25 positives at both exams, 27 only at the BMb and 35 only at the PET study). PET vs. BMb were reordered: sensitivity: 69% vs. 59.8%; specificity: 99.2% vs. 100%; accuracy: 91.4% vs. 89.6%; positive predictive value: 96.8% vs. 100%; negative predictive value: 90.2% vs. 87.7%.

CONCLUSION

The sensitivity of PET and BMb is similar (69% and 60%, respectively), PET and BMb are complementary: in fact out of 87 patients with confirmed BMD only 25 are positive at both exams, while 27 only at the BMb and 35 only at the PET exam; the integration of PET findings with BMb ones increases the diagnostic accuracy. Consequentially PET is essential during the staging of malignant lymphomas.

FDG-PET in the assessment of patients with follicular lymphoma treated by ibritumomab tiuxetan Y 90: multicentric study

BACKGROUND

The aim of this study is the 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG)-positron emission tomography (PET) evaluation following radioimmunotherapy (RIT) with ibritumomab tiuxetan Y 90 in patients with non-Hodgkin's follicular lymphoma (FL).

MATERIALS AND METHODS

We retrospectively analyzed data from 59 relapsed or refractory FL patients treated with ibritumomab tiuxetan Y 90 in four different PET centers who had a PET scan carried out before and after RIT. Possible predictive factors of progression-free survival (PFS) were studied through univariate and multivariate analysis.

RESULTS

The post-RIT PET documented 45.8% complete responders (CR), 25.4% partial responders (PR) and 28.8% nonresponders [stable disease + progressive disease], with an overall survival of 71.2% (range 59.5%-90.9%). With a median follow-up period of 23 months, the univariate analysis documented a statistically significant relation between disease extent before RIT and response to treatment with respect to PFS (P = 0.015), while all the other prognostic factors showed no significant correlation. When carrying out the multivariate analysis, post-RIT PET resulted as the lonely independent predictor of PFS (P < 0.00001).

CONCLUSIONS

RIT is an effective therapy in FL patients, as confirmed in our study too. Disease extension before treatment and response to RIT, as assessed by FDG-PET, result as main predictors of PFS, with the post-RIT PET result being the only independent predictive factor.

Feasibility of the sentinel node biopsy in anal cancer

AIM

Anal cancer is a rare neoplasm. According to a European Organization for Research and Treatment of Cancer multivariate analysis, synchronous inguinal lymph node metastasis occurs in 10-25% of patients and constitutes an independent prognostic factor for local failure and overall mortality.

METHODS

Inguinal lymph node status was assessed using the sentinel node technique in 35 patients with anal cancer.

RESULTS

Histology revealed 23 squamous carcinomas, 10 basaloid carcinomas, 1 squamous carcinoma with basaloid areas and 1 spinocellular epithelioma associated with areas of Bowen's disease. Disease stage was T1 in 5 patients, T2 in 18, T3 in 11 and T4 in 1 patient. Lympho-scintigraphy using a GE Millennium gamma camera was performed after peritumoral injection of 37 MBq of 99mTc colloid. Surgical sentinel node biopsy with a portable Scintiprobe MR 100 (Politech, Carsoli, Italy) had a detection rate of 97.1%. Inguinal metastases were detected in 7 (20%) patients, in 2 of which metastasis was bilateral.

CONCLUSIONS

Given the correlation between prognosis and node involvement, sentinel node biopsy can be considered a simple method for adequate pretreatment staging of anal carcinoma. Use of the technique could avert the need for prophylactic inguinal radiotherapy in N0-N1 patients, thus reducing the morbidity associated with inguinal radiotherapy. Consistent follow-up is required to evaluate long-term results:

Lymphoscintigraphic localization of sentinel node in early colorectal cancer: results of a monocentric study

BACKGROUND AND OBJECTIVES

Evaluation of the feasibility of the sentinel node technique in early colorectal neoplasms and its overall accuracy in predicting nodal metastases.

METHODS

Thirty-five patients with colon or rectal lesions or degenerate polyps not radically excised by endoscopy were included. Lymphatic mapping was performed with 99mTc labeled albumin colloid injected submucosally by an endoscopic route the afternoon before the surgical procedure. The day of the intervention, 2.5% patent blue V dye (S.A.L.F: Italy) was injected circumferentially around the tumor. A hand held gamma detecting probe (Scintiprobe m100, Pol-Hi-Tech, Italy) was employed to detect "hot" nodes, in vivo and ex vivo. All sentinel nodes were embedded separately for haematoxylin and eosin staining. No IHC or PCR techniques were employed.

RESULTS

Sentinel lymph nodes (SLN) were successfully identified in 35 out of 35 patients. Concordance between SLN and nodal status was observed in 32 out of 35 cases (91.4%); four patients (11.4%) were upstaged. Three skip nodal metastases were observed (false-negative rate: 8.5%).

CONCLUSIONS

The sentinel node technique with blue dye and radiotracer seems valuable in early colorectal cancers detected by screening programs: a good organization and a learning curve are needed, as further multicentric studies.

[The technique of sentinel lymph nodes in patients with anus neoplasm]

Anal cancer is a rare neoplasm, representing 1-2% of all large bowel cancers. Surgical excision by abdominoperineal resection has been the standard treatment. In the 1920s and 1930s inguinal node dissection was included in the surgical management of these patients. In the 1950s it was evident that the morbidity associated with lymphnode dissection was much greater than any survival benefit and this procedure was abandoned. Since 1974 "multimodality treatment" with a combination of radiation and chemotherapy has become the standard treatment. Synchronous inguinal lymph node metastases occur in 10-25% of patients and metachronous metastases have been reported in 5-25% of cases. Inguinal lymph node metastases are an independent prognostic factor for local failure and overall mortality by a multivariate analysis of EORTC. In order to assess inguinal lymph node status we applied the sentinel node technique to patients affected by anal cancer. Fifteen patients were studied with a lymphoscintigraphy after peritumoral injection of 37 MBq of Tc-99m colloid. A surgical biopsy of sentinel node was performed in all patients with a detection rate of 100%. Inguinal metastases occurred in 4 patients (26.6%), and in 2 cases metastases were located bilaterally. Twelve patients (80%) were treated in local anesthesia and they were dismissed the same day of surgical procedure. No major complication occurred. Considering the strong correlation between prognosis and node involvement, we consider this technique an important and simple method for evaluating the lymph node status and for an adequate pre-treatment staging of anal carcinoma. fundamental in the choice of radiation plane. In particular inguinal radiotherapy could be reserved for N1 patients only. avoiding the morbidity related to this procedure in N0 patients. Further studies are required to confirm these results and a consistent follow-up will be necessary to evaluate long-term results particularly in those patients (N0) who have not been treated with prophylactic inguinal radiotherapy.

[Verrucous carcinoma of the anus or Buschke-Lowenstein tumor of the anus: staging and treatment. Report of 3 cases]

INTRODUCTION

Giant condyloma acuminatum or Buschke Lowenstein tumor of the anorectal and perianal regions is an uncommon entity that commonly affects genitalia. These are slow-growing, expansive, cauliflower-like, destructive lesions that could propagate to vulvar and vaginal region, rectum and bladder. The hallmark of the disease is the high rate of recurrence (66%) and malignant transformation (56%). No distant metastases usually occur. The median number of recurrences are 2 (range, 1-7).

MATERIALS AND METHODS

At the Oncological Surgical Department, University of Turin, three patients were diagnosed with a Buschke Lowenstein tumor. In two cases immunodeficiency was evidentiated (HIV in one case and ciclosporin treatment in the second one). The lesions were up to 15 cm of diameter and in one case scrotum was invaded. In another case a lesion in sacral region was observed. All patients were studied with anoproctoscopy, CT scan, pelvic magnetic resonance and lymphoscintigraphy for following biopsy of inguinal sentinel node for potential malignancy. All patients were submitted to extensive local surgical treatment.

RESULTS

No mortality was observed. In one case we observed a late anal stenosis treated with local dilatations. No more complications were observed. One patient with a small persistence of the disease was treated with cryotherapy. All inguinal nodes revealed negative to definitive histological exam, that confirmed the diagnosis of Buschke Lowenstein tumor of the primary lesion.

CONCLUSIONS

Buschke Lowenstein tumors are rare but extensive lesions difficult to treat. Local surgery with elettrocautery or laser is the first treatment of choice, even if abdominoperineal amputation sec. Miles could be considered in case of extremely extensive lesions or multiple and extensive recurrences. Others treatments proposed are radiotherapy, chemotherapy, interferon, iniquimod and so on. Other studies are requested to value the best treatment.

[Lymphoscintigraphic localization of sentinel lymph nodes in colorectal carcinoma in early stage: results of a single center study and proposal of a multicenter protocol]

In colorectal cancer the sentinel node dissection may help to identify any unusual mesenteric lymphatic drainage pattern from the primary tumor site (ex/skip metastases); assuming that accurate pathological staging is critical for therapeutic decisions we are conducing a study to evaluate the feasibility of the sentinel node technique in colorectal neoplasms and its overall accuracy in predicting regional lymph nodes metastases for appropriate staging. From February 2001 to September 2004 we included in this study 30 patients with rectal lesions or degenerate colonic polyps not radically excised by endoscopy. Lymphatic mapping was performed with low molecular weight albumin colloid labelled with 500Mci of 99mTc in a 2 ml volume and injected submucosally by an endoscopic route at the four cardinal points around the tumor, the afternoon before the surgical procedure, both in case of colonic or rectal lesions. Scintigraphic images were obtained with a gamma camera fitted with a general purpose collimator. The day of the intervention, a hand held gamma detecting probe (Scintiprobe m100, Pol-Hi-Tech, Italy) was employed to detect the "hot" nodes, in vivo and ex vivo. These lymph nodes were tagged with a stitch in vivo; the specimen was removed by a standard resection and SLN were dissected ex vivo and sent separately for pathological examination. In case of rectal lesions, the sentinel nodes were searched ex vivo into mesorectal fat in case. All lymph nodes, including blue or hot ones, were embedded separately for preparation of paraffin sections and haematoxylin and eosin staining. Sentinel lymph node were submitted to multi-seriate sections in order to look for micrometastases. Using the radioactive tracer, sentinel lymph nodes were successfully identified in 27 out of 30 patients. Concordance between SLNs and nodal status was observed in 23 out of 27 cases (85%); two patients (7.4%) were upstaged, as SLN was the only site of metastases. In another two cases we observed no concordance between negative sentinel node and non sentinel nodes (false negative rate, 7.4%). Starting from this experience we are proposing a multicentric trial concerning the value of sentinel node technique in rectal cancer and in early colorectal cancers detected by screening programs.

Impact of axillary nodal metastases on lymphatic mapping and sentinel lymph node identification rate in patients with early stage breast cancer

PURPOSE

The aim of this study was to define the impact of the presence of axillary nodal metastases on lymphatic mapping and sentinel lymph node (SLN) identification rate in patients with early breast cancer.

METHODS

Two hundred and forty-six lymphatic mapping procedures were performed with both labelled nanocolloid and blue dye, followed by SLN biopsy and/or complete axillary dissection. The following parameters were recorded: patient's age, tumour laterality and location, tumour size, tumour histology, tumour stage, tumour grade, lymphovascular invasion, radiotracer injection site (subdermal-peritumoural/peri-areolar), SLN visualisation at lymphoscintigraphy, SLN metastases (presence/absence, size) and other axillary metastases (presence/absence, number). Discriminant analysis was used to analyse the data.

RESULTS

SLNs were identified by labelled nanocolloid alone in 94.7% of tumours, by blue dye alone in 93.5% and by the combined technique in 99.2%. Discriminant analysis showed the gamma probe SLN identification rate to be significantly limited by the presence of axillary nodal metastases. In particular, the size of SLN metastases and the number of other axillary metastases were the most important variables in reducing the gamma probe SLN identification rate (p = 0.004 and p = 0.002, respectively). On the other hand, high tumour grade was the only parameter limiting the blue dye SLN identification rate.

CONCLUSION

The accuracy of lymphatic mapping with labelled nanocolloid is limited by the presence of axillary nodal metastases, and particularly by the degree of SLN tumoural invasion and the presence and number of other axillary nodal metastases. Neither of these elements seems to interfere with the blue dye identification rate. The combination of the two tracers maximises the SLN identification rate.

99mTc-HMPAO-leukocyte scintigraphy in patients with symptomatic total hip or knee arthroplasty: improved diagnostic accuracy by means of semiquantitative evaluation

The aim of this study was to evaluate the diagnostic value, in suspected infectious prostheses, of (99m)Tc-labeled hexamethylpropyleneamine oxime ((99m)Tc-HMPAO) leukocyte scintigraphy interpreted with the addition of a semiquantitative analysis.

METHODS

By means of a retrospective review, we included a group of 78 consecutive patients with suspected hip or knee prosthesis infection. We performed 91 (99m)Tc-HMPAO-leukocyte scintigraphies and examined 95 localizations that were suspect. Images were acquired at 3 different time points after the injection of the labeled leukocytes: 50 min (early images), 4 h, and 24 h (late images). The scintigraphic examinations were independently evaluated by 3 observers; qualitative and semiquantitative analyses were performed. The final diagnosis of infection was based on surgical, histologic, and bacteriologic data and follow-up.

RESULTS

On qualitative analysis, sensitivity, specificity, and accuracy were 80.4%-87%, 65.3%-71.4%, and 75.8%-77.9%, respectively. On semiquantitative analysis, sensitivity, specificity, and accuracy were 95.6%, 95.8%, and 95.8%, respectively. The analysis of 95% confidential intervals showed statistically significant differences in specificity and accuracy between semiquantitative and qualitative analyses.

CONCLUSION

In those patients who underwent (99m)Tc-HMPAO-leukocyte scintigraphy for suspected hip or knee prosthesis infection, the addition of a semiquantitative evaluation to the qualitative analysis of early and late images leads to a significant improvement in both specificity and accuracy.

Sentinel lymph node detection in patients with early-stage breast cancer: comparison of periareolar and subdermal/peritumoral injection techniques

Periareolar (PA) injection offers several potential advantages over other techniques for visualizing sentinel lymph nodes (SLNs) in patients with early breast cancer. However, few studies have been published on this procedure. This study was designed to validate PA injection technique and compare it with the subdermal/peritumoral (SD/PT) injection technique.

METHODS

The study included 324 patients in whom 330 breast cancers (T) had been identified by biopsy. This population was divided in 4 groups: (A) 148 patients (150 T) in whom lymphatic mapping was performed by injecting radiotracer with the SD/PT technique; (B) 59 patients (60 T) in whom lymphatic mapping was performed with a combination of blue dye injected with the PA technique and radiotracer injected with the SD/PT technique; (C) 58 patients (60 T) in whom blue dye was injected subdermally and radiotracer was injected periareolarly; and (D) 59 patients (60 T) in whom both blue dye and radiotracer were injected periareolarly.

RESULTS

Concordances in the SLN detection rate between blue dye and radiotracer in groups B, C, and D were 98.1%, 100%, and 100%, respectively. The SLN identification rates with the PA technique were 98.3% and 95%, respectively, for radiotracer and blue dye. With the SD/PT technique, these rates were 90.5% and 88.3%, respectively, for radiotracer and blue dye. At lymphoscintigraphy, SLN visualization required the acquisition of late images (3 h after the injection) in 20% of patients who received PA injections and 39.5% of patients who received SD/PT injections.

CONCLUSION

These findings validate the PA injection technique and underline some of its reported advantages in comparison with the SD/PT technique.

Pre-operative lymphatic mapping and intra-operative sentinel lymph node detection in early stage endometrial cancer

Lymphatic mapping and sentinel lymph node (SLN) biopsy are becoming increasingly useful for the identification of tumour lymphatic spread in a wide variety of neoplasms, such as breast cancer and melanoma, reducing unnecessary radical lymph node resection. The aim of our study was to determine the feasibility of lymphatic mapping with both labelled colloid and patent blue violet in patients with early stage endometrial cancer. Sixteen consecutive patients with endometrial cancer, stage International Federation of Gynecology and Obstetrics (FIGO Ib), were included in the study. Lymphoscintigraphy and laparoscopically assisted intra-operative SLN detection were performed in all patients. In addition, to verify the prognostic role of this method, 12 of 16 patients were followed up for a period of at least 1 year. In 15 of 16 patients, 24 SLNs (all internal iliac lymph nodes) were detected at lymphoscintigraphy (six monolateral and nine bilateral). At histological analysis, three of the 24 were positive for micrometastases, whereas the remaining 21 were negative. No other surgically dissected lymph nodes presented metastases. At 1 year of follow-up, none of the 12 patients presented relapse of their disease. In conclusion, in endometrial cancer, both pre-operative lymphoscintigraphy and intra-operative gamma-probe detection of SLNs represent promising tools for the visualization of SLNs. The status of the latter may yield a correct representation of pelvic lymph node involvement, providing important information for further treatment.

Expression of somatostatin receptor types 2, 3 and 5 in biopsies and surgical specimens of human lung tumours. Correlation with preoperative octreotide scintigraphy

The increasingly popular use of somatostatin analogs in clinical practice for both diagnostic and therapeutic purposes prompted extensive investigations on somatostatin receptor (sst) expression in human tumors by autoradiography, nucleic acid analysis and, recently, immunohistochemistry (IHC). The currently employed radiotracer for scintigraphy (Octreoscan) is octreotide, a somatostatin analog having a high affinity for sst types 2, 3, and 5. In this study on 25 patients, we compared sst 2, 3, and 5 expression in surgical and biopsy specimens of lung tumors, as revealed by immunohistochemical and reverse transcriptase polymerase chain reaction (RT-PCR), with the octreoscan outcome (which was positive in 20/25 cases). By IHC, the tumors mainly expressed sst2 (17/25, 68%) at the cell membrane level, while sst 3 and 5 were detected in a fraction of cases (24% and 20%, respectively). Comparing RT-PCR and IHC data, a correlation was found in 83.3% of cases, while octreoscan findings and sst expression were correlated in 22/25 cases (88%). In addition, cytological and biopsy specimens expressed the same sst type found in the corresponding surgical sample, thus indicating that a cell membrane sst immunoreactivity in a biopsy reliably predicts the tumor-receptor profile before its resection. Finally, sst expression was not restricted to neuroendocrine lung tumors, but was also a feature of some non-neuroendocrine carcinomas, although to a lesser extent. The occasional expression of sst subtypes in intratumoral lymphocytes, endothelia and necrotic areas is an additional feature to be considered in the interpretation of Octreoscan findings, since the in vivo procedure does not allow to define the sst cellular distribution. IHC can therefore be usefully coupled to radionuclear investigations to better characterize the sst cellular location and subtype in lung tumors.

Breast cancer cellular proliferation indexes and 99mTc-sesta Mibi capture: what correlation?

Aim of this study was to verify existing correlations between breast cancer 99mTc-sestaMIBI cells uptake and their cytological characteristics. Forty-five patients with clinically and/or mammographically suspect breast cancer were enrolled. In all patients 99mTc-sestaMIBI scintimammography was performed and malignant lesions were detected in 44 cases and benign in one case. In positive uptake (PU) lesions with diameter <1.5cm, 85.7% showed a high tumor grade (II-III degrees) while in negative uptake (NU) lesions with diameter <1.5cm, 100% showed a low tumor grade (I degrees). In PU lesions, 70% had expressed a high value of Ki 67, while 100% of the NU lesions showed normal values. In this series, tumor diameter does not play a basic role, while the correlations between uptake and the histological grade (G) and/or cellular kinetics (Ki67) seem to be more important. Further studies are needed to confirm our present results.

Technetium-99m labelled macroaggregated albumin arterial catheter perfusion scintigraphy: prediction of gastrointestinal toxicity in hepatic arterial chemotherapy

Gastrointestinal toxicity from hepatic arterial infusion (HAI) of floxuridine in patients with liver metastases is probably due to extrahepatic perfusion or to partial escape of the drug from first-pass liver extraction. The aim of this study was to verify the role of technetium-99m-labelled macroaggregated albumin (99mTc-MAA) arterial catheter perfusion scintigraphy at the beginning of each chemotherapy cycle in decreasing or preventing gastrointestinal toxicity. We studied 167 consecutive patients. On the basis of the scintigraphic follow-up and the presence or absence of an intrahepatic arteriovenous shunt (IHAVS), we classified our patients into the following groups: (1) FU+ hepatic distribution pattern (DP), comprising 29 patients with regular scintigraphic follow-up who showed the expected distribution pattern at each control or a distribution pattern with transient alterations (extrahepatic escape) promptly reversed by the replacement of the catheter. Among these 29 patients there was one case of gastrointestinal toxicity. (2) FU- hepatic DP, comprising 128 patients who were evaluated with 99mTc-MAA only at the beginning of the first chemotherapy cycle, showed the expected distribution pattern and underwent HAI with no further scintigraphic evaluation. Among these 128 patients there were 28 cases of gastrointestinal toxicity. (3) FU+ pulmonary DP, comprising three patients with abnormally elevated pulmonary uptake (higher than 5%) and with regular scintigraphic follow-up. There were two cases of gastrointestinal toxicity among these three patients. (4) FU- pulmonary DP, comprising seven patients with abnormally elevated pulmonary uptake and without regular scintigraphic follow-up. There were four cases of gastrointestinal toxicity among these seven patients. The incidence of toxicity was significantly higher in group FU- hepatic DP than in group FU+ hepatic DP (21.9% vs 3.4%, P<0.05). In both the FU+ pulmonary DP and FU- pulmonary DP groups, the incidence of gastrointestinal toxicity was higher than 50%, with no significant difference between them. We conclude that, when performing 99mTc-MAA perfusion scintigraphy, the presence of an abnormally elevated pulmonary uptake (IHAVS higher than 5%) is the most relevant positive prognostic index for the development of gastrointestinal toxicity. Furthermore, in the absence of abnormal pulmonary uptake (IHAVS lower than 5%), strict scintigraphic follow-up is useful since it is able to promptly diagnose the presence of extrahepatic abdominal perfusion and thus to prevent the occurrence of gastrointestinal toxicity.

Hepatic arterial infusion chemotherapy for unresectable confined liver metastases: prediction of systemic toxicity with the application of a scintigraphic and pharmacokinetic approach

PURPOSE

The incorrect positioning of the arterial Port-a-Cath or the presence of anatomic or functional hepatic arteriovenous shunting may explain the occurrence of systemic toxicity of hepatic arterial infusion of floxuridine in patients with liver metastases. The aim of our study was to predict the occurrence of systemic toxic effects from this treatment using a scintigraphic and pharmacokinetic approach.

METHODS

A group of 26 patients were studied. Before treatment, Tc-99m-labelled macroaggregated albumin arterial perfusion scintigraphy was performed to verify the correct positioning of the catheter, to evaluate the percentage of pulmonary uptake of the tracer, reflecting intrahepatic arteriovenous anatomic shunting, and to qualitatively assess the perfusion pattern of the metastases with respect to the normal liver parenchyma (SPECT images). Hepatic arteriovenous functional shunting was assessed through the bioavailability of intraarterially administered D-sorbitol. Treatment was then started and systemic toxic effects were evaluated according to WHO recommendations.

RESULTS

No correlation was found between anatomic shunting (</=10% in all patients) and systemic toxicity of treatment. The 9 patients with hypoperfused metastases experienced a significantly lower level of toxic effects (1 low-grade toxicity and 8 no toxicity) than the 17 with hyperperfused metastases (6 high-grade toxicity, 5 low-grade and 6 no toxicity; chi(2) = 7.170, P = 0.028). Functional shunting was significantly different in patients with high-grade, low-grade and no toxicity (46.5 +/- 19.9%, 15.8 +/- 12.7% and 16.5 +/- 10.3%, respectively; P<0.001 by analysis of variance). Moreover, functional shunting was significantly greater only in patients with hyperperfused metastases who developed high-grade toxicity.

CONCLUSIONS

A protocol combining scintigraphic and pharmacokinetic methods is of value in the individual patient in assessing the risk of high-grade systemic toxicity during hepatic arterial infusion of floxuridine. A flow-chart used in our ongoing prospective study for the evaluation of patients undergoing regional chemotherapy for liver metastases is included.

Extrahepatic regional chemotherapy: use of technetium-99m labeled macroaggregated albumin

The purpose of this study was to verify the applicability of nuclear techniques with technetium-99m labeled macroaggregated albumin (Tc-99m-MAA) in extrahepatic regional chemotherapy. Of 98 patients in whom arterial Port-a-caths were implanted by transcutaneous access, 13 were treated by regional extrahepatic chemotherapy (breast, one; pancreas, four; kidney, one; uterus, three; vagina, two; bladder, two). In all 13 patients, Tc-99m-MAA was slowly infused intraarterially. The examination showed the perfusion of the area with the neoplasm and excluded the presence of important misperfusions of Tc-99m-MAA to the nearest areas. To detect the presence of an arteriovenous shunt with systemic misperfusion, an anterior image of the thorax was obtained in all patients and an index of misperfusion was calculated. In 12 patients, the index was < 5%; in one patient it was about 40%. In conclusion, our preliminary experience concerns the monitoring of intraarterial infusion chemotherapy of extrahepatic districts. In all 13 patients, we evaluated the correct positioning of the intraarterial catheter and the distribution pattern of the arterial flow, with a semiquantitative indication of arteriovenous shunting. This method gave us an instrument of study that was inexpensive, harmless, and free of collateral complications.

[Preliminary results on the use of scintigraphy with radiolabelled octreotide as diagnostic method in neuroendocrine and nonendocrine neoplasms of the lung]

Personal experience on the use of 111In-DTPA-octreotide scintigraphy (Octreoscan) in the staging of neuroendocrine and non-neuroendocrine tumors of the lung is reported. From July 1995 to May 1996 26 scintigraphic studies were performed in patients affected by lung cancer at the Department of Thoracic Surgery and at the Service of Nuclear Medicine of the University of Turin. The scintigraphy allowed to detect the lesion in all the neuroendocrine tumors and in 63.2% of the non neuroendocrine ones. Their preliminary results are discussed and stress is laid on the importance of this scintigraphic procedure in the staging and the follow-up of neoplastic patients.

[Breast carcinoma and the axillary lymph node status: the use of 99mTc-sestamibi scintimammography for the diagnosis and preoperative staging. Preliminary results]

BACKGROUND

The purpose of this study is the sensitivity and specificity evaluation of the 99mTc-sestaMIBI scintimammography (SMM) in the diagnosis and pre-surgical staging of patients with clinical and/or radiological suspicion of breast cancer.

MATERIALS AND METHODS

Forty-five patients with clinical and/or mammographic breast cancer suspicion were enrolled. Prone lateral views of both mammalian glands and anterior of chest, to evaluate the axillary lymph node infiltration, were acquired 60 min after i.v. injection of 20-25 mCi of 99mTc-sestaMIBI.

RESULTS

Breast cancer was diagnosed by histological findings in 44 patients; benign disease in 1 case. The tumors diameter ranged from 0.3 to 4 cm. The SMM sensitivity in the detection of breast cancer was 90% and the VPP was 100%. The smallest diameter in these detected lesions was 0.5 cm. The pathologic examination showed metastatic axillary involvement in 15 patients. The SMM sensitivity in the detection of axillary lymph node metastases was 75%, specificity was 90%. For each lesion grading, mitosis number, 67Ki expression, diameter, were considered and correlated to 99mTC-sestaMIBI uptake. The 5 breast cancer non-uptake cases had low cytoproliferative indexes. According to our data it is possible to observe that there is a correlation between uptake and cellular proliferation.

CONCLUSIONS

The 99mTc-sestaMIBI SMM is a highly accuracy test in the breast cancer detection. The sensitivity in the axillary lymph node metastatic detection is just little below average according to the literature; it is possible that the results can improve with higher accrual of patients, operator experience and equipment improvement and the using of SPECT.

Pertechnetate release from a water/oil microemulsion and an aqueous solution after subcutaneous injection in rabbits

A water-oil microemulsion and an aqueous solution, both carrying pertechnetate, were injected subcutaneously in rabbits; release was observed by imaging the administration sites with a gamma-camera. Disappearance from the injection site of pertechnetate in aqueous solution was about ten times faster than that of pertechnetate in a microemulsion.