Differentiated thyroid carcinoma in children: Clinical characteristics and long-term follow-up

Differentiated thyroid cancer (DTC) is rare in children, but it still remains the most common endocrine malignancy in children. The aim of this study was to analyze treatment response to radioactive iodine (RAI) therapy, clinical outcomes, recurrences, survival analysis, and long-term follow-up. We retrospectively reviewed the medical records of 43 pediatric patients (≤17 years of age) with DTC diagnosis after thyroidectomy who were treated with RAI. The follow-up protocol consisted of detailed clinical examination, testing of thyroid function, determination of serum thyroglobulin (Tg), and anti-Tg antibodies, and neck ultrasonography application. Forty-three pediatric patients (34 females and 9 males) treated with RAI for DTC in our institute. The median follow-up period was 54 months. The histologic classification was papillary thyroid cancer in 41 patients and the remaining 2 patients had follicular thyroid cancer. After the long-term follow-up, complete remission, partial remission, and recurrent-persistent disease were observed in 37 patients, 3 patients, and 3 patients, respectively. Among the series, 1 death occurred due to multiple metastases. The mortality rate is 2.56%. Total thyroidectomy followed by RAI appears to be the most effective treatment for patients with pediatric DTC in terms of reducing the rate of relapse and improving surveillance for recurrent disease.

The Value of Attenuation Correction in Hybrid Cardiac SPECT/CT on Inferior Wall According to Body Mass Index

The purpose of this study was to evaluate the diagnostic value of attenuation-corrected single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) on the inferior wall compared to uncorrected (NC) SPECT MPI between obese and nonobese patients. A total of 157 consecutive patients (122 males and 35 females, with median age: 57.4 ± 11 years) who underwent AC technetium 99m-methoxyisobutylisonitrile (AC Tc99m-sestamibi) SPECT MPI were included to the study. A hybrid SPECT and transmission computed tomography (CT) system was used for the diagnosis with 1-day protocol, and stress imaging was performed first. During attenuation correction (AC) processing on a Xeleris Workstation using Myovation cardiac software with ordered subset expectation maximization (OSEM), iterative reconstruction with attenuation correction (IRAC) and NC images filtered back projection (FBP) were used. For statistical purposes, P < 0.05 was considered significant. This study included 73 patients with body mass index (BMI) <30 and 84 patients with BMI ≥ 30. In patients with higher BMI, increased amount of both visual and semiquantitative attenuation of the inferior wall was detected. IRAC reconstruction corrects the diaphragm attenuation of the inferior wall better than FBP. AC with OSEM iterative reconstruction significantly improves the diagnostic value of stress-only SPECT MPI in patients with normal weight and those who are obese, but the improvements are significantly greater in obese patients. Stress-only SPECT imaging with AC provides shorter and lower radiation exposure.

Prediction of survival and evaluation of diagnostic accuracy whole body 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography in the detection carcinoma of unknown primary origin

PURPOSE

The aim of the current study was to determine the diagnostic accuracy of whole-body 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) in detecting carcinoma of unknown primary (CUP).

MATERIALS AND METHODS

A total of 7,636 patients were investigated by FDG-PET/CT examinations at our Institution. We retrospectively evaluated the file records of 432 patients who were referred to FDG PET/CT imaging with a diagnosis of cancer of unknown primary, and included 316 of the patients with histopathologic verification at the final diagnosis. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. The Kaplan-Meier test was used for survival analysis. Median survival rate was calculated to evaluate the prognostic value of the FDG-PET/ CT findings.

RESULTS

In the search for a primary, FDG-PET/CT findings correctly diagnosed lesions as the site of the primary true positive in 238 cases, 10 findings diagnosed no site of a primary and none was subsequently proven true negative, 12 diagnoses were false positive and 56 were false negative. The sensitivity of FDG-PET/CT is 81% and the specificity 45%. Positive predictive value, negative predictive value and diagnostic accuracy were 95%, 15% and 78%, respectively.

CONCLUSIONS

Whole-body FDG-PET/CT imaging is proven to be useful method in the search for the primary focus and metastases in patients with cancer of unknown primary.

Unilateral ovarian metastasis from gastric mucinous adenocarcinoma visualized on FDG PET/CT

Krukenberg tumor is a metastatic ovarian tumor with primary focus usually seen in the gastrointestinal tract. Metastatic involvement of the ovary is an uncommon manifestation of malignancy. We report a [18F]-fluoro-2-deoxy-D-glucose positron-emission tomography/computed tomography (FDG PET/CT) appearance of solitary unilateral ovarian metastasis in a 44-year-old woman with a history of mucinous adenocarcinoma type of gastric carcinoma. Total hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathological verification determined metastasis of mucinous adenocarcinoma with components of signet-ring cell carcinoma in the right ovary.

Evaluation of anxiety and depression in patients prior to myocardial perfusion scintigraphy

OBJECTIVE

In myocardial perfusion scintigraphy (MPS) negative results indicate coronary artery diseases which might cause prominent anxiety and other psychological reactions. The aim of this study was to determine anxiety and depression levels of patients prior to MPS procedures.

METHODS

The Hospital Anxiety Depression Scale(HADS) and the State and Trait Anxiety Inventory I and II were used to evaluate the anxiety and depression levels of the patients. Descriptive analyses and independent sample t-test were used for statistical assessment.

RESULTS

The mean score of HADS-anxiety score prior to MPS was 8.1 ± 4.2, whereas the mean HADS depression score was 6.1 ± 3.7. The mean state anxiety score prior to MPS was 39.7 ± 10.6 and the mean trait anxiety score was 45.02 ± 9.1. HAD and state and trait anxiety scores were found to be significantly higher in female patients than male patients and non-smoker patients than smoker patients. Other risk factors such as having bypass operation, myocardial infarction, hypercholesterolemia, diabetes and hypertension were not related to depression and anxiety scores.

CONCLUSION

The results in this study suggest a role for MPS as a risk factor for higher state anxiety. The MPS procedures might lead to an increase in anxiety levels of patients which is possibly associated with anticipation anxiety felt during waiting period and expectation life-threatening.

Intraocular and orbital metastasis as a rare form of clinical presentation of insular thyroid cancer

Insular carcinoma of thyroid is a rare tumor, which accounts for 4 to 6% of thyroid malignancies. Clinically and morphologically it is considered to be in an intermediate position between well-differentiated carcinoma of the thyroid (papillary or follicular) and undifferentiated or anaplastic carcinoma of the thyroid. Capsular and blood vessel invasion is seen frequently, and metastases to regional lymph nodes, lungs and bones are common. The initial presentation of distant metastasis in patients with thyroid cancer is rare. Thus metastatic thyroid carcinoma rarely involves the orbit. We report a rare case of choroidal metastasis from insular thyroid carcinoma.

Urinary MMP-9/NGAL complex in children with acute cystitis

The matrix metalloproteinase-9 (MMP-9) and neutrophil gelatinase associated lipocalin (NGAL) are shown to increase in an inflammatory situation. Based on our previous reports that NGAL can be detected in the urine of children with urinary tract infection (UTI), we also asked whether MMP-9/NGAL complex could be detected in the urine of children with UTI. This multicenter, prospective study was conducted between October 2009 and October 2010. Seventy-one patients with symptomatic culture proven UTI, 37 asymptomatic children with contaminated urine and 37 healthy children were recruited. Mean uMMP-9/NGAL/Cr levels were significantly higher in the UTI group than in the control group (p < 0.0001). According to ROC analysis, the optimal cut-off level was 0.08 ng/mg to predict UTI. Using a cut-off value, sensitivity and specificity were 98.6 and 97.3%, respectively. The mean levels of uMMP-9/NGAL/cr in the UTI group were also significantly higher than those in the contamination group (p < 0.0001). There was no statistically significant difference between contamination group and the control group (p = 0.21). The mean uMMP-9/NGAL/Cr in the UTI group were significantly higher before treatment than after treatment (p < 0.0001). The area under the curve was 0.997 (SE: 0.002, 95% CI: 0.993 to 1.001) for uMMP-9/NGAL/Cr. Urinary MMP-9/NGAL/Cr level was also correlated with positive urine nitrite test, positive urine leukocyte esterase reaction and renal scarring (p = 0.0001, p = 0.0001, p = 0.04, respectively) whereas was not correlated to leukocytosis and positive CRP level in serum. Urine MMP-9/NGAL/cr can be used as a diagnostic biomarker for UTI in children. Identification of NGAL-MMP-9/cr levels in the urine of suspected UTI patients may also be useful to differentiate between contamination and infection and for monitoring of treatment response in children.

The evaluation of the external dose measurement of the patients treated with radioiodine therapy

The aim of the study is to compare the results of the external exposure and the range of the dose spread by the patients, hospitalized in two different groups of 3-4 d receiving radioiodine therapy because of having hyperthyroidism (HT) and thyroid cancer (TC). A total of 1989 patients were evaluated retrospectively. Of the total 1517 patients had TC and 472 had HT. External exposure value was taken at hospital discharge and the distance for external measurement was 1 m at the abdominal level. External exposure values of 99.7 % patients were <30 µSv h(-1) and of 0.3 %, >30 µSv h(-1). The results between patient groups with TC and HT at third and fourth days, and the dissimilarity of measurement results within third and fourth days in total patients, without discriminating the day difference, are statistically meaningful. Although 3-d isolation period for 30 µSv h(-1) limit is generally enough, it can be insufficient for some patients. Besides hospitalisation, the radiation safety training must be emphasised by establishing good communication with patients in order to protect their relatives and other people against radiation risk.

Tc-MDP bone scintigraphy in a case with sporodical tumoral calcinosis

Tumoral calcinosis is an uncommon and benign condition characterized by the presence of large calcific soft tissue deposits occurring predominantly in a periarticular location. It generally occurs as a complication of renal dialysis or trauma, and is rarely seen in familial and sporadic cases. Bone scintigraphy is a sensitive method for diagnosing tumoral calcinosis. A 28-year-old female patient with a history of operation due to tumoral calcinosis located bilateral hips, referred to our department. She had a tender palpable mass in the right knee and a fistulized incisional scar overlying the bilateral hip joints. A sporadic case of tumoral calcinosis with relapses was presented.

Early prediction of urinary tract infection with urinary neutrophil gelatinase associated lipocalin

Neutrophil gelatinase associated lipocalin (NGAL) is a protein identified in human neutrophil granules. The aim of the study was to assess whether urine level of NGAL (uNGAL) could represent a novel, reliable marker of urinary tract infection (UTI) and to determine the optimal cutoff level for uNGAL to predict UTI in children. Sixty patients with symptomatic UTI and 29 healthy controls were enrolled the study. Urine NGAL was measured by enzyme-linked immunosorbent assay. A dimercaptosuccinic acid (DMSA) radionuclide scan was performed within 7 days in the patients with UTI in an attempt to distinguish pyelonephritis from cystitis. Mean uNGAL level was significantly higher in the UTI group than in the controls (91.02 ng/ml vs 14.29 ng/ml, p = 0.0001) and using a cutoff 20 ng/ml for uNGAL for diagnosis of UTI, sensitivity, and specificity were 97% and 76%, respectively [area under the curve (AUC): 0.979]. Mean uNGAL/creatinine ratio (uNGAL/Cr) was also significantly higher in the UTI group [201.81 ng/mg creatinine (Cr) vs 18.08 ng/mg Cr; p = 0.0001], and using a cutoff 30 ng/mg Cr for uNGAL/Cr for diagnosis of UTI, sensitivity and specificity were 98% and 76%, respectively (AUC: 0.992). In conclusion, both uNGAL and uNGAL/Cr can be used as a novel, sensitive marker for early prediction of UTI in the absence of acute kidney injury and chronic kidney disease, and the optimal cutoff value for prediction of UTI is lower than the values determined for acute kidney injury. Further investigations with larger patient groups are required to confirm our results.

Direct radionuclide cystography imaging in colovesical fistula due to inguinal hernia operation complication

Colovesical fistula is an abnormal connection between the enteric and urinary systems, usually sigmoid colon, caused by various conditions. One cause of colovesical fistula is iatrogenic injury, such as induced by inguinal hernia surgery. We present a case of colovesical fistula. A 57-year-old male was admitted to a local hospital with complaints of dysuria and pneumaturia. He had a past history of total extraperitoneal laparoscopic inguinal hernia repair operation 7 years previously for bilateral inguinal hernia. The case was assessed with radiologic and scintigraphic techniques. Radiologic techniques (plain abdominal radiography, intravenous pyelogram, ultrasound examination, double-contrast barium enema, CT, MRI) were inadequate to determine the colovesical fistula. The colovesical fistula was visualized with direct radionuclide voiding cystography as an alternative scintigraphic method.

Gamma probe (99m)Tc-pertechnetate assisted completion thyroidectomy vs conventional thyroidectomy in differentiated thyroid carcinoma

Patients undergoing partial thyroidectomy for benign diseases may need re-operation if differentiated thyroid carcinoma (DTC) is detected on histopathology. The aim of this study was to determine if using gamma probe during the above surgery in a procedure called: gamma probe completion thyroidectomy (GPCT) could support the diagnosis of DTC tissue and offer an advantage in the surgical treatment of DTC patients. We have studied 100 patients who after bilateral subtotal thyroidectomy for benign disease in several hospitals, were found to have DTC histopathologically and referred to our clinic for subsequent re-operation. Of these, 50 underwent conventional completion thyroidectomy (Group I) and 50 underwent GPCT (Group II). We compared retrospectively Group I and Group II in terms of volume of residual thyroid tissue, thyroid stimulating hormone (TSH) values, complication rates and incidence of tumor found in the residual thyroid. Our results showed that one month postoperatively, TSH was significantly higher in Group II (P<0.001). Volumes of residual thyroid were also significantly less in Group II (P<0.000). Complications and the incidence of tumor cells found in the residual thyroid tissue between the groups were not statistically different (P>0.05). In conclusion, GPCT in patients with DTC significantly increased the success of this operation in localizing and removing residual thyroid tissue.

Chronic bronchitis mimicking metastases from thyroid medullary carcinoma demonstrated by indium-111 pentetreotide scintigraphy

We present a case of medullary thyroid carcinoma (MTC) with pulmonary symptoms, elevated calcitonin and CEA levels. Both [¹¹¹In]pentetreotide (Octreoscan) scintigraphy and 2-deoxy-2-[¹⁸F]fluoro-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) scan revealed mild increased uptake of radionuclides in the upper lobe of the right lung compatible with metastases. Histopathological analysis showed it to be chronic bronchitis. The patient was followed without any treatment. Three months later, no pathological uptake on [¹¹¹In]pentetreotide (Octreoscan) was observed. False positive [¹¹¹In]pentetreotide uptake in the lungs was likely related to acute exacervation of the chronic bronchitis.

Prospective comparison of colour Doppler ultrasonography and testicular scintigraphy in acute scrotum

The aim of this prospective study was to compare the effectiveness of colour Doppler ultrasound and testicular scintigraphy in the differential diagnosis of acute scrotum. Ten patients were investigated by clinical examination initially and by both techniques afterwards. Scintigraphy was performed in a blind fashion. According to the findings, 3 patients were categorized as acute ischaemia and 7 as inflammation. The 3 patients diagnosed as ischaemia underwent surgical exploration. Both imaging techniques predicted ischaemia (100%). In the inflammation group conservative therapy and follow-up were chosen. Ultrasonography alone established the correct diagnosis in 7/7, whereas scintigraphy in 5/7 of the patients.