Transthyretin Amyloidosis Cardiomyopathy in Greece: Clinical Insights from the National Referral Center

BACKGROUND

Clinical characteristics and outcomes of patients with transthyretin amyloidosis cardiomyopathy (ATTR-CM) vary by region, necessitating the acquisition of country-specific evidence for proper management.

METHODS

This is an observational study including sequential patients presenting in the Amyloidosis Reference Center of Greece, from 01/2014 to 12/2022. ATTR-CM was diagnosed by positive scintigraphy and exclusion of light-chain amyloidosis or positive biopsy typing. Genetic testing was performed in all cases.

RESULTS

One-hundred and nine ATTR-CM patients were included (median age, 81 years) of which 15 carried TTR mutations (27% Val30Met). Most patients (82%) presented with heart failure and 59% with atrial fibrillation, while 10% had aortic stenosis. Importantly, 78 (71.6%) had clinically significant extracardiac manifestations (45% musculoskeletal disorder, 40% peripheral neuropathy and 33% gastrointestinal symptoms). Sixty-five (60%) received disease-specific treatment with tafamidis. Estimated median survival was 48 months; advanced NYHA class, National Amyloidosis Center stage, eGFR<45 ml/kg/1.73m2, NT-pro-BNP>5000 pg/mL were associated with worse survival, while tafamidis treatment was associated with improved survival in patients with IVS≥ 12 mm.

DISCUSSION

These are the first data describing the characteristics, management, and outcomes of patients with ATTR-CM in Greece, which could influence local guidelines.

SHORT TITLE

Transthyretin cardiomyopathy in Greece.

Impact of COVID-19 Pandemic on Cardiovascular Testing in Asia

Background

The coronavirus disease-2019 (COVID-19) pandemic significantly affected management of cardiovascular disease around the world. The effect of the pandemic on volume of cardiovascular diagnostic procedures is not known.

Objectives

This study sought to evaluate the effects of the early phase of the COVID-19 pandemic on cardiovascular diagnostic procedures and safety practices in Asia.

Methods

The International Atomic Energy Agency conducted a worldwide survey to assess changes in cardiovascular procedure volume and safety practices caused by COVID-19. Testing volumes were reported for March 2020 and April 2020 and were compared to those from March 2019. Data from 180 centers across 33 Asian countries were grouped into 4 subregions for comparison.

Results

Procedure volumes decreased by 47% from March 2019 to March 2020, showing recovery from March 2020 to April 2020 in Eastern Asia, particularly in China. The majority of centers cancelled outpatient activities and increased time per study. Practice changes included implementing physical distancing and restricting visitors. Although COVID testing was not commonly performed, it was conducted in one-third of facilities in Eastern Asia. The most severe reductions in procedure volumes were observed in lower-income countries, where volumes decreased 81% from March 2019 to April 2020.

Conclusions

The COVID-19 pandemic in Asia caused significant reductions in cardiovascular diagnostic procedures, particularly in low-income countries. Further studies on effects of COVID-19 on cardiovascular outcomes and changes in care delivery are warranted.

Technetium-99m labelled red blood cells scintigraphy and not iminodiacetic acid cholescintigraphy facilitates the discrimination of hepatic cirrhosis from fibrosis

OBJECTIVE

This pilot study was designed to investigate the efficacy of technetium-99m labelled red blood cells ((99m)Tc-RBC) compared with (99m)Tc-mebrofenin cholescintigraphy ((99m)Tc-MHS), in the diagnosis of hepatic dysfunction at early stages.

SUBJECTS AND METHODS

Twenty four patients, 8 with hepatic fibrosis and 16 with cirrhosis, at Child-Pugh stage A to C and 20 age-matched controls were examined by (99m)Tc-RBC and by (99m)Tc-MHS. Dynamic acquisition and static images were semiquantitatively analused by studying the liver-to-heart (L/H) ratio estimated by both the (99m)Tc-RBC and (99m)Tc-MHS methods. The L/H ratios were compared between fibrosis, cirrhotic stages and controls, by Student's t test. Linear regression analysis of the L/H ratios for both methods has been applied in the whole study population.

RESULTS

Labelled RBC could statistically differentiate fibrotic from normal liver parenchyma (P<0.001), whereas the (99m)Tc-MHS could not (P: 0.13). The L/H ratios of cirrhotic lesions using both methods were significantly lower than those in controls: (P<0.000001 for (99m)Tc-RBC and P<0.0001 for (99m)Tc-MHS). Statistically significant difference was demonstrated by both modalities between fibrotic and cirrhotic lesions ((99m)Tc-RBC: P: 0.003 and (99m)Tc-MHS: P: 0.024).

CONCLUSION

Our study although in a limited number of patients suggested that as opposed to (99m)Tc-MHS, scintigraphic evaluation by (99m)Tc-RBC could be useful in the discrimination of patients with liver fibrosis, cirrhosis and normal controls.

Imaging of cardiac amyloidosis by (99m)Tc-PYP scintigraphy

OBJECTIVE

Cardiac amyloidosis (CA) is an underestimated and underdiagnosed cause of cardiac insufficiency. Despite being often considered as a solitary entity attributable to extracellular deposition of fibrillary proteins, there exist at least two different pathophysiologic backgrounds, with different clinical course and treatment. a) In light-chain cardiac amyloidosis (immunoglobulin light-chain amyloidosis-AL) the fibrils consist of light-chain immunoglobulins produced by a clonal plasma cell population in bone marrow. b) In CA related to transthyretin (transthyretin-related amyloidosis - ATTR), whether familial amyloid cardiomyopathy or senile systemic amyloidosis, monomers or dimers of the normally tetrameric protein of transthyretin are deposited in the myocardium. Today, definitive diagnosis of cardiac amyloid disease is based on endomyocardial biopsy in conjunction with immunohistochemical parameters or, in ambiguous cases, with mass spectroscopy. Several radiotracers have been hitherto tried in the detection of CA.

SUBJECTS AND METHODS

In this pilot study technetium-99m pyrophosphate ((99m)Tc-PYP) was administered to patients suffering from CA, aiming to differentiate scintigraphically between AL and ATTR. Twelve patients (8 males, aged [mean±SD] 70,6±13,2y; 4 females, aged 65,7±9,9y) were enrolled for the discrimination between AL and ATTR. Diagnosis was confirmed by biopsy combined with the clinical and laboratory evaluation of the patients. Myocardial scintigraphy (planar and tomographic imaging) was conducted at 1, 2 and/or 3h after intravenous administration of 555-925MBq (99m)Tc-PYP. Myocardial radiotracer uptake was evaluated optically and also by a semiquantitative method. Two regions of interest (ROI) were drawn: one over the heart and another over the contralateral hemithorax, to calculate the corresponding heart-to-contralateral (H/CL) count ratio. According to established reference standards, a cut-off H/CL value of 1.5 best discriminates between the two conditions. (99m)Tc-PYP scintigraphy revealed diffuse intense myocardial uptake upon visual evaluation that was also verified semi-quantitatively in 6 patients, all of which had ATTR. Faint or no myocardial tracer uptake was found in 4 patients who were diagnosed with AL. Two AL patients had a borderline positive scan on visual evaluation but their H/CL ratios did not exceed the value of 1.5. In three patients, we also attempted scintigraphy with the tracer pentavalent (99m)Tc-dimercaptosuccinic acid. Results and possible mechanisms of uptake are discussed. The sensitivity and specificity of scintigraphy with (99m)Tc-PYP was high, albeit the small number of patients.

IN CONCLUSION

These preliminary results are compatible with current international literature, and demonstrate that scintigraphy with (99m)Tc-PYP may prove a simple, non-invasive and widely available method in the identification of patients with the ATTR subtype, thus optimizing therapeutic decisions.

Serum calcitonin gene-related neuropeptide (CGRP) in patients with benign and malignant breast lesions: Correlation with mammographic breast density

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Background: The aim of this study was to assess the variation of the serum neo-angiogenic neuropeptide CGRP in patients with benign and malignant breast lesions and to evaluate its possible correlation with mammographic findings.

Methods: Our study included forty eight women with histologically confirmed breast lesions: mild epithelial hyperplasia (MEH): n=12, florid epithelial hyperplasia (FEH): n=5, atypical hyperplasia (AH): n=4, ductal carcinoma in situ (DCIS): n=5, mixed in situ with invasive ductal carcinoma (DCIS+IDC): n=9 and pure IDC: n=13. Serum CGRP levels were measured by RIA methods and compared among the various groups by Mann-Whitney test. Mammographic breasy density (BD%) was calculated using computer-assisted methods and was correlated with serum CGRP concentration by applying linear regression analysis.

Results: Serum CGRP concentration (mean±SD: pg/mL) in the various groups, was: MEH: 96.8±22.5, FEH: 135.5±33.5, AH: 139±44.4, DCIS: 131.4±37.5, DCIS+IDC: 1167.5±927.5, pure IDC: 198±82. DCIS+IDC lesions presented statistically significantly higher serum CGRP levels (versus: MEH p<0.001, FEH p<0.001, AH p<0.001, DCIS p<0.001 and IDC p<0.001). Serum CGRP concentration presented statistically significant correlation with BD% (r=0.947, p<0.0001).

Conclusions: Statistically increased serum CGRP concentration was determined in women with DCIS+IDC lesions. The significant correlation between serum CGRP levels and BD, enhances the suggestion that DCIS+IDC represents a distinct pathological entity, associated with an interactive mechanism between BD and serum CGRP expression. Therefore, serum CGRP levels could constitute a future useful preoperative index of the nature or type of suspicious mammographic lesions, in order to schedule the appropriate therapeutic treatment, and potentially propounds the perspective of adjunctive therapeutic administration of anti-CGRP peptides.

[Is major depression in middle-aged men correlated with bone density decrease? A study on Greek population]

During the last 10 years there has been an increasing interest in studying the coexistence of osteoporosis and depression in the male population, due to the increased morbidity and mortality in the patients' life. The present retrospective study evaluates the effect of major depression on the bone density of Greek middle-aged men. By using the method of dual-energy X-rays absorptiometry (DEXA) we reviewed the bone mineral density (BMD) studies performed in the lumbar spine (LS) and/or femoral neck, in 97 men of the white race, aged 55 years with mean age±standard deviation (SD)= 65±10.6 years, and body mass index (BMI) 30.2±4. The patients were divided in two groups, based on the coexistence (Group A) or absence of major depression (Group B). In group A men, the incidence of osteoporosis was 34.8% and osteopenia 39.5%, while in group B the corresponding percentages were 9.3% and 42.6%. Statistically significant difference was observed in mean BMD between Group A (0.876±0.170) and Group B (0.961±0.136) at the level of P=0.008, and also in mean T score (-1.72±1.57 versus -1.06±1.17) at the level of P value: 0.02 in both groups, while the diagnosis of osteoporosis between the two groups was statistically significantly different too (P=0.001. Pearson R: 0.3, P=0.004). Furthermore, the model of multiple linear regression and ANOVA table revealed statistically significantly depression of 0.252 and 0.575 units in mean BMD value and mean T score respectively in man with major depression in comparison to a mentally healthy man of the same age and BMI (regression coefficient b, P< 0.02). In conclusion, we observed statistically significant difference in mean BMD and mean T score values between major depression and mentally healthy men. Moreover, almost triple relative risk for the development of osteoporosis was shown in men with depression as compared to mentally healthy men (RR: 3.8, P=0.02). Cortisone intake, hypertension and smoking were statistically independent factors for male depression and BMD. The clarification of the underlying interactive mechanism between major depression, sympathetic system activation, age and bone resorption is important.

Increased breast density correlates with the proliferation-seeking radiotracer (99m)Tc(V)-DMSA uptake in florid epithelial hyperplasia and in mixed ductal carcinoma in situ with invasive ductal carcinoma but not in pure invasive ductal carcinoma or in mild epithelial hyperplasia

The purpose of this study was to assess the relationship of mammographic breast density (BD) and cell proliferation/focal adhesion kinase activation-seeking radiotracer technetium 99m pentavalent dimercaptosuccinic acid (99mTc(V)-DMSA) uptake in women with different breast histologies, that is, mild epithelial hyperplasia (MEH), florid epithelial hyperplasia (FEH), mixed ductal carcinoma in situ with invasive ductal carcinoma (DCIS + IDC), and pure IDC. Fifty-five women with histologically confirmed mammary pathologies were submitted preoperatively to mammography and 99mTc(V)-DMSA scintimammography. The percentage and intensity of 99mTc(V)-DMSA uptake and the percentage of BD were calculated by computer-assisted methods and compared (t-test) between the breast pathologies. In breasts with increased BD, FEH and DCIS + IDC were found. On the contrary, pure IDC and MEH were identified in breasts with significantly lower BD values. In breasts with increased 99mTc(V)-DMSA area and intensity of uptake, FEH was the main lesion found compared to all other histologies. Linear regression analysis between BD and 99mTc(V)-DMSA uptake area and intensity revealed significant coefficients of correlation (r  =  .689, p < .001 and r  =  .582, p < .001, respectively). Increased BD correlates with the presence of FEH and mixed DCIS + IDC but not with pure IDC or MEH. Its close relationship to 99mTc(V)-DMSA, which also showed an affinity to FEH, indicates that stromal microenvironment may constitute a specific substrate leading to progression to different subtypes of cancerous lesions originating from different pathways.

Ibuprofen induces reduction of the proliferation-seeking radiotracer 99mTc-(V)DMSA uptake in severe epithelial breast hyperplasia without atypia

The purpose of this study was to investigate if ibuprofen intake can influence mammary uptake of the proliferation-seeking radiotracer technetium 99m-pentavalent dimercaptosuccinic acid (99mTc-(V)DMSA) in women with severe epithelial and atypical epithelial breast hyperplasia. Eight patients with histologically confirmed severe epithelial breast hyperplasia with (n  =  4) and without atypia (n  =  4) were submitted prospectively to 99mTc-(V)DMSA scintimammography before and after a 4-week course of 400 mg ibuprofen daily oral intake. Lesion to background ratios 60 minutes postinjection were calculated and compared (t-test) before and after ibuprofen administration. Prior to ibuprofen, the patients with severe epithelial hyperplasia displayed a significantly higher 99mTc-(V)DMSA uptake ratio compared to those with atypical epithelial hyperplasia (2.40 ± 0.32 vs 1.67 ± 0.09, respectively; p  =  .003). They also exhibited a more substantial percent decline in tracer uptake postibuprofen compared to women with atypical epithelial hyperplasia (62.0 ± 7.1 vs 15.0 ± 0.2, respectively; p  =  .001). Ibuprofen induces significant uptake reduction of the proliferation-seeking radiotracer 99mTc-(V)DMSA in severe epithelial breast hyperplasia without atypia. This agent could therefore constitute a potential imaging tool for monitoring chemoprophylaxis effectiveness in women at the early stages of malignant transformation.

[Cutaneous melanoma; diagnostic procedures and their evaluation in diagnosing and mapping sentinel nodes. Part 2]

The second part of this review describes the advantages, and evaluates the radionuclide-guided methods for sentinel lymph node localization and also evaluates the intraoperative application of the blue dye technique in melanoma. By combining the two techniques, the detection rate rises to 96%-98%. The presence of cancer cells in the sentinel node is histopathologically shown by using hematoxylin-eosin and by using sensitive techniques for the detection of micrometastases. Immunohistochemical tech-niques specific for epithelial markers and polymerase chain reaction examination are also applied. Sentinel lymph node biopsy suggests whether regional elective lymphade-nectomy shall be performed.

[Cutaneous malignant melanoma; diagnostic procedures and their evaluation in diagnosing and mapping sentinel nodes]

Cutaneous malignant melanoma represents 4% of all the malignant neoplasms. Nevertheless, 79% of the fatal malignant skin diseases are attributed to melanoma. In melanoma patients, the most important prognostic factor is the regional lymph node invasion. The present article describes the classical diagnostic, staging and therapeutic strategies in melanoma patients. In the realm of cutaneous melanoma, pre-operative lymphoscintigraphy and the intra-operative gamma-probe detection, removal and biopsy of the sentinel lymph node(s), comprise convenient, procedures, virtually lacking morbidity. The definition of sentinel includes the first lymph node or nodes, draining the lymph from the primary lesion, thereby attributed with the highest probability of harbouring migrating metastatic cells. A sentinel lymph node negative for malignancy accurately "predicts" the absence of melanoma cell invasion in all the rest regional and distant lymphatic basins. The method aims in the best discrimination of high-risk patients, as candidates for selective lymphadenectomy, with or without adjunctive treatment. Radionuclide-guided lymphatic mapping and surgery is based on the phagocytosis of colloidal-based radiopharmaceuticals by the macrophages encountered in functional tumour-infiltrated sentinel nodes. The nuclear methods successfully add to the staging and the potential surgical treatment of the disease.

[Lymphatic system and lymphoscintigraphy]

Starting from Hippocrates era, the lymphatic system has been an interesting area of study for its anatomy, physiology, pathophysiology and imaging. The present review describes the history of the lymphatic system and lymphoscintigraphy. Lymphoscintigraphy comprises a simple, non-invasive imaging method of the lymphatic system and the sentinel lymph node or nodes. Additionally the intra-operative gamma-probe detection and the blue dye technique are also presented. The nuclear methods have been incorporated in the algorithm of the diagnostic approach and the therapeutic treatment of cutaneous melanoma and breast cancer, while further experience is warranted in other solid malignancies.

Erdheim-Chester disease: symmetric uptake in the (99m)Tc-MDP bone scan

Erdheim-Chester disease (E-C D) is a rare clinicopathologic entity with nearly pathognomonic radiographic features. About half of the affected exhibit extraskeletal manifestations, including involvement of the hypothalamus-pituitary axis, lung, heart, retroperitoneum, skin, liver, kidneys, spleen and orbit. This disease usually affects individuals in their fifties to their seventies and has a male preponderance. The lesions of E-C D consist of lipid-storing CD68 (+) and CD1a (-) non-Langerhans cell histiocytes, either localized to the bone or involving multiple systems of the body as well. Skeletal involvement is characteristically bilateral and symmetric, exhibiting an osteosclerotic pattern in the metaphysis and diaphysis of the long bones, usually sparing epiphysis. We recently had a 68 years old male patient with E-C D, with a mild and persistent knee pain, who was subjected to a 3-phase technetium-99m methylene diphosphonate ((99m)Tc-MDP) bone-scan and subsequently to gallium-67 citrate ((67)Ga-C) whole body scan. The characteristic symmetric pattern of these scans raised the question of E-CD disease. The patient showed an excellent symptomatic response to high-dose steroids. However, the symptoms recurred after discontinuation of treatment.

The potential role of Calcitonin Gene-Related Peptide (CGRP) in breast carcinogenesis and its correlation with 99mTc-(V)DMSA scintimammography

OBJECTIVES

Experimental data suggest a role for calcitonin gene-related peptide (CGRP) in normal breast development and angiogenesis. This pilot study correlated CGRP with neoangiogenesis and the uptake of the tumor-seeking, proliferation-imaging radiotracer pentavalent technetium-99m dimercaptosuccinate (99mTc-(V)DMSA) in invasive and preinvesive breast lesions.

METHODS

Among women evaluated preoperatively by 99mTc-(V)DMSA scintimammography, 29 invasive ductal carcinomas (IDCs) were retrospectively studied: 15 isolated (Group I); 14 mixed with preinvasive pathologies (ductal carcinoma in situ [DCIS] and/or epithelial hyperplasia [EH]; Group M). CGRP staining and neoangiogenesis were compared between invasive and DCIS/EH regions and were correlated. 99mTc-(V)DMSA displayed a diffusely increased uptake pattern corresponding to DCIS/EH; its lesion-to-background (L/B) ratio was compared between images acquired at 10 and 60 minutes and its retention ratio (RR) was correlated with CGRP.

RESULTS

Seven of 15 group I and 10 of 14 group M patients (58.6% of the population) were CGRP-positive. CGRP was prevalent in the DCIS/EH component of mixed-lesions (even in the surrounding normal epithelium of nearly half), with declining intensity as advancing from DCIS/EH to high-grade IDC. Similarly, neoangiogenesis was considerably higher in DCIS/EH than in group I pure IDCs. A significant CGRP-neoangiogenesis correlation was verified only in group I. The diffuse 99mTc-(V)DMSA uptake exhibited significant, time-related L/B increase and a RR positively correlating with CGRP.

CONCLUSIONS

CGRP expression and neoangiogenesis are intensified in mixed invasive-preinvasive breast lesions; an underlying relation may exist, requiring further investigation. CGRP also appears associated with 99mTc-(V)DMSA's propensity to depict preinvasive pathologies. This relationship could denote an additional proliferative role for CGRP.

[Indications and instructions to patients for a positron emission tomography-PET scan. The importance of the hybridic PET/CT-computerised tomography scan and which specialty should be responsible for its function]

Indications and instructions to patients for performing a positron emission tomography - PET scan are mentioned. Although PET camera was developed in 1970 its clinical indications were established in about 1998. The hybridic PET/CT- computerized tomography scanner appeared in 2001 and its clinical indications are still under discussion. These discussions refer to both the use of PET/CT as an acquisition correction and anatomic localization device for PET images (AC/A) and to its use as a diagnostic CT scan (dCT). Most of the patients submitted for a PET scan have already done a dCT scan. This was the case in 286 out of the first 300 patients referred to "Evangelismos" hospital in Athens for a PET scan. These two scans can be matched electronically. Extra cost, space, personnel and radiation absorption dose especially in children, are additional factors to be considered in using the PET/CT scanner. The specialty of Nuclear Medicine is now based on the PET camera, its best part and main equipment for molecular imaging. It is very much easier and faster for a Nuclear Medicine physician who routinely reports tomographic PET and SPET images, to be familiar with the CT images than for a Radiologist to get to "know how" about the PET camera and the whole Nuclear Medicine Department. Nuclear Medicine is about open radiation sources, molecular imaging, specific radio-pharmacology, radiobiology, radiation protection etc, while on the other hand in some countries, Nuclear Physicians have already spent, as part of their official training, six months in a Radiology Department whose function is considered to be at least 25% about the CT scanner. We come to the conclusion that the PET/CT scanner should be under the responsibility of the Nuclear Medicine Department and the Radiologist should act as an advisor.

Scintimammographic detection of usual ductal breast hyperplasia with increased proliferation rate at risk for malignancy

OBJECTIVES

To estimate whether breast uptake of (99m)Tc-(V)DMSA and (99m)Tc-sestamibi in usual ductal epithelial breast hyperplasia (UDH) and apocrine metaplasia is related to cell proliferation rate (Ki-67) and oestrogen receptor (ER) expression, both of which are associated with the potential risk of evolving to malignancy.

METHODS

Among patients referred for suspicious breast findings on palpation and/or mammography and evaluated preoperatively with both radiopharmaceuticals, we retrospectively studied 17 (10 with UDH: group I; and seven with apocrine metaplasia: group II). Lesion-to-background (L/B) ratios in early and late acquisitions were calculated for both radiotracers in both groups, as well as their retention ratios. Ki-67 and oestrogen receptor expression were determined immunohistochemically. The late L/B ratios between the two tracers were compared, as were the late ratios for each tracer between Ki-67 < or = 3% and > 3%, and between ER < or = 15% and > 15%. Linear regression analysis was also performed between L/B and retention ratios and Ki-67 expression.

RESULTS

There was a significant increase of the (99m)Tc-(V)DMSA L/B ratio in late images as compared to the early images in group I (P<0.05), while in group II it was not significantly increased (P=0.084). (99m)Tc-sestamibi ratios did not demonstrate variability over time in either group (P=0.156 and 0.274, respectively). Significant coefficient correlation was found between the (99m)Tc-(V)DMSA L/B(late) ratios and retention ratios and Ki-67 levels only for group I (r=0.889, P<0.001 and r=0.802, P<0.01, respectively). The (99m)Tc-(V)DMSA L/B(late) ratios in group I were significantly higher when Ki-67 > 3% than when Ki-67 < or = 3% (P=0.016) but did not differ considerably between ER > 15% and < or = 15% (P=0.732).

CONCLUSION

(99m)Tc-(V)DMSA uptake in UDH correlates with Ki-67 expression. This could prove useful in identifying women with benign but high-risk breast pathologies who might benefit from chemoprophylaxis.

Spontaneous rupture of a type IVA choledochal cyst in a young adult during radiological imaging

A case of a 24-year-old male with jaundice and epigastric pain is reported. The patient underwent a thorough clinical, laboratory, and imaging investigation. Computerized tomography revealed a 9 cm×10 cm choledochal cyst. Magnetic resonance imaging and magnetic cholangiopancreatography were performed, during which he developed an “acute abdomen”, with radiological evidence of biliary peritoneal leak. Urgent surgery revealed rupture of the distended malformed common bile duct. A peritoneal drain was instilled and a more definitive surgical procedure was accordingly scheduled. Hepatobiliary scintigraphy following surgery verified these findings, as well as confirmed the adequacy of the urgent surgery. A combination of radiological and nuclear medicine techniques substantially contributes to the diagnosis of choledochal cyst rupture and the adequacy of surgical intervention.

Tc-99m depreotide imaging of I-131-negative recurrent metastatic papillary thyroid carcinoma

The detection of radioiodine (I-131)-negative metastases of differentiated thyroid carcinoma (DTC) has been hitherto successfully tried by the well-known synthetic somatostatin analogue indium-111-labeled DTPA-octreotide (In-111 pentetreotide). The objective of this study was to evaluate the usefulness of scintiscan with the newer synthetic somatostatin analogue Tc-99m depreotide, in the restaging of papillary thyroid carcinoma (PTC) with detectable serum thyroglobulin (Tg) levels and negative I-131 whole-body scan (WBS). Whole-body planar and cervico-thoracic tomographic scintigraphy (single-photon emission tomography-SPET) with Tc-99m depreotide was performed in a 68-year-old male patient suffering from PTC stage III, with a mild increase in serum Tg levels coupled with a recent negative I-131 WBS. The findings were compared with those of neck ultrasonography (US) and computerized tomography (CT). Nodal neck dissection and histopathology provided the definitive diagnosis. Tc-99m depreotide scanning revealed foci of cervical lymph node metastases, which did not accumulate I-131. The findings were in accordance with neck US and CT. Histopathology established the diagnosis of metastatic cervical lymph node PTC. Lymph node immunoreactivity was positive for the somatostatin receptor subtypes 2, 5 and 3. Scintigraphy with Tc-99m depreotide could prove a useful adjunct to the armamentarium for the follow-up of PTC, especially in the setting of detectable serum Tg and negative I-131 WBS.

Monoclonal antibodies: old and new trends in breast cancer imaging and therapeutic approach

Over the last two decades, various research protocols were applied for scintigraphic imaging, prognosis and treatment of breast cancer, using monoclonal antibodies. Monoclonal antibodies approved by the United States Food and Drug Administration (FDA) include the anti-carcinoembryonic antigen (CEA), and B72.3, prepared against the tumour-associated glycoprotein, TAG-72. The recombinant humanized "cold" anti-HER2 monoclonal antibody (trastuzumab), which targets oncogene receptor HER2 has hitherto been the only monoclonal antibody widely used for the treatment of breast cancer in the USA, with or without chemotherapy. Trastuzumab is constructed against the HER2 oncogene receptor (also known as neu or c-erb-B2), which is overexpressed in 25%-30% of breast cancer cell lines and is associated with poor prognosis. Immuno-lymphoscintigraphy is also applied to guide and monitor the effect of treatment regimes. Radiolabelled, "hot" monoclonal antibodies are currently being applied for the treatment of primary or metastatic breast cancer, in experimental, pre-clinical, or clinical trials, in combination with traditional external beam radiotherapy and/or chemotherapy. Radioimmunotherapy comprises systemically administered monoclonal antibodies, linked to high-energy, beta-emitting radionuclides. Radioactive antibodies, in the form of yttrium-90 (90Y)-BrE-3, 90Y- m170 and 131I- or 90Y- labelled L6 antibody, are applied with adjuvant autologous peripheral blood stem cells transfusion, to prevent myelotoxicity. Partial or rarely complete responses to "hot" antibody treatment, of breast cancer have been reported. Innovative strategies using this combined-modality treatment hold promise for better disease-free and survival rates.

[A patient with MEN-IIA syndrome due to de novo mutation and papillary thyroid carcinoma; the role of 99m Tc-depreotide in diagnosing metastases and brief review of the literature]

Multiple endocrine neoplasia syndrome type II-A (MEN-IIA) is a rare endocrinological disorder occurring in 0.04% of the general population. The combination of papillary thyroid carcinoma with MEN-IIA appears even less frequently. We describe the case of a 21-year-old woman with pheochromocytoma of the left adrenal gland, medullary thyroid carcinoma, hyperplasia of the parathyroid glands and papillary thyroid carcinoma. MEN II-A syndrome resulted from de novo mutation of the RET proto-oncogene, which was detected in the DNA of peripheral blood leucocytes. Three months postoperatively calcitonin levels were normal, whilst increased serum thyroglobulin values prompted the need for further investigation. Whole body scanning with (131)I and with (99m)Tc-sestamibi and also US test of cervical lymph nodes, were negative. The synthetic analogue of somatostatin (99m)Tc-depreotide was used for whole body scintigraphy, cervical and thoracic tomographic scanning and revealed anterior cervical, upper mediastinal and right hilar foci of pathological uptake[Fig.1 and Table 1: see text]. These findings were compatible with findings from CT and MRI that followed in order to complete the diagnostic evaluation. The patient underwent surgical resection of the metastatic foci with uneventful postoperative course. Histology showed lymph node metastases originating from the papillary thyroid carcinoma. Ratio values >2 were abnormal (Fig. 2). Computer processing of the corresponding ROIs on healthy tissues produced the following normal values: Th/Arm: 1.874,, Med/Arm: 1.699, Hi/Arm: 1.141 (Fig. 3).