Adrenocortical Cancer in the Real World: A Comprehensive Analysis of Clinical Features and Management from the Turkish Oncology Group (TOG)

INTRODUCTION

Adrenocortical carcinoma (ACC) is a rare yet highly malignant tumor associated with significant morbidity and mortality. This study aims to delineate the clinical features, survival patterns, and treatment modalities of ACC, providing insights into the disease's prognosis.

MATERIALS AND METHODS

A retrospective analysis of 157 ACC patients was performed to assess treatment methodologies, demographic patterns, pathological and clinical attributes, and laboratory results. The data were extracted from the hospital's database. Survival analyses were conducted using the Kaplan-Meier method, with univariate and multivariate analyses being performed through the log-rank test and Cox regression analyses.

RESULTS

The median age was 45, and 89.4% had symptoms at the time of diagnosis. The median tumor size was 12 cm. A total of 117 (79.6%) patients underwent surgery. A positive surgical border was detected in 26 (24.1%) patients. Adjuvant therapy was administered to 44.4% of patients. The median overall survival for the entire cohort was 44.3 months. Median OS was found to be 87.3 months (95% confidence interval [CI] 74.4-100.2) in stage 2, 25.8 (95% CI 6.5-45.1) months in stage 3, and 13.3 (95% CI 7.0-19.6) months in stage 4 disease. Cox regression analysis identified age, Ki67 value, Eastern Cooperative Oncology Group performance status, and hormonal activity as significant factors associated with survival in patients with nonmetastatic disease. In metastatic disease, only patients who underwent surgery exhibited significantly improved overall survival in univariate analyses.

CONCLUSION

ACC is an uncommon tumor with a generally poor prognosis. Understanding the defining prognostic factors in both localized and metastatic diseases is vital. This study underscores age, Ki67 value, Eastern Cooperative Oncology Group performance status, and hormonal activity as key prognostic determinants for localized disease, offering critical insights into the complexities of ACC management and potential avenues for targeted therapeutic interventions.

Prognostic value of Gustave Roussy immune score in operable pancreatic adenocarcinoma

Background

The Gustave Roussy immune score (GRIm score) is a laboratory index developed to predict survival in nonsmall cell lung cancer patients undergoing immunotherapy and has shown that the pretreatment value is an independent prognostic factor for survival. In this study, we aimed to determine prognostic significance of GRIm score for pancreatic adenocarcinoma that have not been determined in the literature for pancreatic cancer before. The reason for choosing this scoring is to show that the immune scoring system works as a prognostic marker in pancreatic cancer known as immune-desert tumor via immune properties of microenvironment.

Methods

Medical records of patients with histologically confirmed pancreatic ductal adenocarcinoma, who were treated and followed up between December 2007 and July 2019 at our clinic, were reviewed retrospectively. GRIm scores of each patient were calculated at the time of diagnosis. Survival analysis were performed according to risk groups.

Results

A total of 138 patients were included in the study. While 111 (80.4%) patients were in the low-risk group; 27 (19.6%) were in high-risk group according to GRIm score. Median OS was 36.9 months (95% Confidence interval (CI): 25.42-48.56) in lower GRIm scores, and it was 11.1 months (95% CI: 6.83-15.44) in higher GRIm scores (P = 0.002). One-two-three-year OS rates were 85% versus 47%, 64% versus 39%, 53% versus 27% for low versus high GRIm scores, respectively. The multivariate analysis revealed that high GRIm score was an independent poor prognostic factor.

Conclusion

GRIm can be used as a noninvasive, easily applicable, practical prognostic factor in pancreatic cancer patients.

Real-life experience of patients with sarcomatoid renal cell carcinoma: a multicenter retrospective study

Sarcomatoid renal cell carcinoma (sRCC) is a rare variant of renal cell carcinoma (RCC) and is associated with a poor prognosis. We reviewed the outcomes of patients from oncology centers in Turkey. Our aim is to share our real-life experience and to contribute to the literature. The demographic and clinical features, treatment, and survival outcomes of 148 patients with sRCC were analyzed. The median age at the time of diagnosis was 58 years (range: 19-83 years). Most patients (62.8%) had clear-cell histology. Most patients were in the intermediate Memorial Sloan-Kettering Cancer Center (MSKCC) risk group (67.6%) and were stage 4 at the time of diagnosis (63.5%). The most common sites of metastasis were the lung (60.1%), lymph nodes (47.3%), and bone (35.8%). The patients received a median of two lines (range: 0-6) of treatment. The most common side effects were fatigue, hematological side effects, hypertension, and hypothyroidism. The median follow-up was 20.9 months (range: 1-162 months). The median overall survival (OS) was 30.8 months (95% confidence interval: 24.9-36.7 months). In multivariate analysis, high MSKCC scores, sarcomatoid differentiation rates >50%, having stage 4 disease, and having lung metastasis at the time of diagnosis were independent factors for poor prognosis affecting OS. No difference was observed between patients who received tyrosine kinase inhibitor (TKI) as the first or second-line treatments. Similarly, no difference between TKI and immunotherapy as the second-line treatment. In conclusion, sRCC is a rare variant of RCC with a poor prognosis and response to treatment. Larger-scale prospective studies are needed to define an optimal treatment approach for longer survival in this aggressive variant.

Prognostic significance of 18F-FDG PET/CT indices in metastatic renal cell cancer and evaluation of revised IMDC risk model by including 18F-FDG PET-CT parameters

Background

Prognostic markers in metastatic renal cell cancer (mRCC) are still insufficient. Any prognostic model objectively determines disease burden.

Purpose

To investigate the relationship between 18-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) parameters and outcomes in mRCC, and to define a revised International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) model for the intermediate-risk group.

Material and Methods

A retrospective study of mRCC was conducted. To investigate the prognostic significance of 18F-FDG PET/CT parameters, maximum standardized uptake value (SUVmax), total lesion glycolysis (TLG), and metabolic tumor volume (MTV) were determined in pre-treatment images. Cutoff values were defined by ROC curve analyses and their association with outcomes was analyzed. Additionally, a TLG-adjusted IMDC model was created by stratifying intermediate-risk group patients according to TLG levels.

Results

The study included 52 patients. The disease control rate (DCR) was 61.5% and median overall survival (OS) was 18 months (95% confidence interval=9.2–25.8). In the univariate analyses, IMDC score, MTV, and TLG were prognostic factors for Disease Control Rate (DCR), and Eastern Cooperative Oncology Group (ECOG)-Performance Status (PS), IMDC score, lactate dehydrogenase (LDH), treatment option, MTV, and TLG were prognostic factors for OS ( P < 0.05 each). In the multivariate analyses, MTV was an independent prognostic factor for DCR, and ECOG-PS, LDH, IMDC score, and TLG were independent prognostic factors for OS. According to the revised-IMDC model, the intermediate-favorable group showed longer OS than the intermediate-unfavorable group.

Conclusion

Pretreatment MTV was independent prognostic factor for DCR and ECOG-PS, LDH, IMDC score, and TLG were independent prognostic factors for OS. Revised-IMDC model could identify patients with a worse prognosis among the IMDC intermediate-risk group.

Role of baseline 68Ga-PSMA PET/CT-derived whole-body volumetric parameters in predicting survival outcomes of metastatic castration-resistant prostate cancer patients receiving first-line treatment

OBJECTIVE

We aimed to evaluate whether baseline ⁶⁸Ga-PSMA PET/CT-derived whole-body volumetric parameters could be used as predictive biomarkers for survival in metastatic castration-resistant prostate cancer (mCRPC) patients receiving first-line treatment.

MATERIALS AND METHODS

This retrospective study included 54 mCRPC patients, who underwent baseline ⁶⁸Ga-PSMA PET/CT imaging within 1 month before starting first-line treatment. Pre-treatment prostate-specific antigen (PSA) levels and treatments were recorded. SUVmax, SUVmean, whole-body PSMA-derived tumor volume (wbPSMA-TV), and whole-body total lesion PSMA (wbTL-PSMA) were calculated for all patients. PSA response was defined as a decline of ≥ 50% from pre-treatment value at 12 weeks. Overall survival (OS) was measured from the start of the first-line treatment for mCRPC.

RESULTS

Docetaxel and abiraterone/enzalutamide were administered to 32 and 22 patients in the first-line setting, respectively. wbPSMA-TV (rho = 0.582, p = 0.004) and wbTL-PSMA (rho = 0.564, p = 0.007) showed moderate positive correlations with PSA levels. Older age (p = 0.02), higher wbPSMA-TV (p = 0.007), higher PSA (p = 0.01), higher number of bone metastases (p = 0.02), and lack of PSA response (p = 0.03) were significantly associated with an increased risk of mortality. Multivariate analysis determined wbPSMA-TV (HR: 1.003, 95% CI 1.001-1.004, p = 0.001) and PSA response (HR: 2.241, 95% CI 1.189-4.222, p = 0.01) as independent predictors of OS.

CONCLUSION

The wbPSMA-TV may be a useful tool to reflect tumor burden and predict survival outcomes in patients with mCRPC.

Real-world assessment of quality-of-life in patients with breast cancer treated with adjuvant endocrine therapy

Objective: The aim of this study was to investigate quality-of-life (QoL) in breast cancer (BC) patients treated with adjuvant endocrine therapy (AET). Methods: We designed a cross-sectional study of 233 BC patients treated with AET and used the Functional Assessment of Cancer Therapy - Breast questionnaire. Results: No significant difference was observed between endocrine agents. Duration of AET did not affect QoL. In the entire cohort, multivariate analysis determined age (p = 0.034) and switching treatment from tamoxifen to aromatase inhibitors (p = 0.049) as significant positive coefficients of QoL, while comorbidity (p = 0.072) tended to be associated with lower scores. Education level (p = 0.001) and chemotherapy (p = 0.04) were significant predictors of QoL in the tamoxifen group, while comorbidity (p = 0.04), surgery type (p = 0.02), radiotherapy (p = 0.006) and stage (p = 0.009) had a significant impact on QoL in aromatase inhibitors group. Conclusion: Evaluating the well-being of BC patients by QoL questionnaires is of great importance to identify particular subgroups that may require supportive care.

Efficacy and safety of trastuzumab emtansine in older patients with HER2-positive advanced breast cancer: a real-world study

INTRODUCTION

Ado-trastuzumab emtansine (T-DM1) is an antibody-drug conjugate and its survival advantage has been shown in advanced human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, clinical trials underrepresent patients ⩾65 years of age, leading to a lack of information in this population. We analyzed the real-world outcomes of older women who were treated with T-DM1 therapy.

METHODS

We performed a multicenter, observational, retrospective analysis of patients aged ⩾65 years treated with T-DM1. A total of 93 patients from 10 cancer centers were involved in the study. Our goal was to determine the survival, response rates, and toxicity profile in T-DM1-treated patients, as well as the factors that influence survival.

RESULTS

Median follow-up was 12.2 months. Objective response rate was 29%. Median progression-free survival (PFS) and overall survival (OS) were 8.47 and 15.0 months, respectively. In multivariate analysis, Eastern Cooperative Oncology Group Performance Score 2 was found to be an independent prognostic factor for worse PFS (hazard ratio [HR] 1.81, p = 0.032) and OS (HR 2.33, p = 0.006). Any adverse event (AE) was seen in 92.5% of patients; grade 3 or 4 AEs were seen in 30.1%. Dose reduction or treatment discontinuation rates were 11.8% and 6.5%, respectively.

CONCLUSION

The efficacy of T-DM1 was acceptable and it was generally well-tolerated among older patients with advanced HER2-positive breast cancer.

Real-life comparison of the afatinib and first-generation tyrosine kinase inhibitors in nonsmall cell lung cancer harboring EGFR exon 19 deletion: a Turk Oncology Group (TOG) study

BACKGROUND

The new second-generation tyrosine kinase inhibitors (TKIs) have superior survival outcome and worse toxicity profile when compared with first-generation TKIs according to the results of clinical trials. However, there are limited studies that investigate the efficacy and safety of the new generation TKIs in real-world patients. Thus, we aimed to compare the efficacy and safety of the afatinib, an irreversible inhibitor of ErbB family receptor, and first-generation TKIs in real-world patients.

MATERIALS AND METHODS

We included advanced nonsmall cell lung cancer (NSCLC) patients who had EGFR exon 19del mutation and treated with afatinib or first-generation TKIs as upfront treatment between 2016 and 2020. All patient's information was collected retrospectively. The study cohort was divided as afatinib arm and erlotinib/gefitinib arm.

RESULTS

A total of 283 patients at the 24 oncology centers were included. The 89 and 193 of whom were treated with afatinib and erlotinib/gefitinib, respectively. After 12.9 months (mo) of follow-up, the median PFS was statistically longer in the afatinib arm than erlotinib/gefitinib arm (19.3 mo vs. 11.9 mo, p: 0.046) and the survival advantage was more profound in younger patients (< 65 years). The 24-mo overall survival rate was 76.1% and 49.5% in the afatinib arm and erlotinib/gefitinib arm, respectively. Although all-grade adverse event (AE) rates were similar between the two arms, grade 3-4 AE rates were higher in the afatinib arm (30.7% vs. 15.2%; p: 0.004).

DISCUSSION

In our real-world study, afatinib has superior survival outcomes despite worse toxicity profile as inconsistent with clinical study results and it is the good upfront treatment option for younger patients and elderly patients who have good performance status.

Is insulin resistance a predictor for complete response in breast cancer patients who underwent neoadjuvant treatment?

PURPOSE

Neoadjuvant chemotherapy is the standard front-line treatment modality in locally advanced breast cancer. Achieving pathological complete response (pCR) is a significant prognostic factor for prolonged disease-free and overall survival. Insulin resistance is defined as a pathological condition in which insulin effect is impaired in peripheral target tissues such as the skeletal muscle, liver, and adipose tissue. The relationship between breast cancer and insulin resistance is controversial. In this study, our aim is to evaluate the role of insulin resistance, body mass index (BMI), metabolic syndrome, and inflammation markers to predict complete response in breast cancer patients who underwent neoadjuvant treatment.

METHODS

Data from 55 locally advanced non-diabetic breast cancer patients, treated with neoadjuvant chemotherapy between 2015 and 2017, were retrospectively evaluated. Homeostatic model assessment, IR = insulin resistance (HOMA-IR) was calculated by using the obtained insulin and fasting blood glucose values before neoadjuvant chemotherapy (fasting insulin × fasting glucose/405). We considered a cut-off of 2.5 for insulin resistance. The systemic inflammatory index (SII), neutrophil-lymphocyte ratio (NLR), and platelet-lymphocyte ratio (PLR) were calculated.

RESULTS

Twenty-five patients had no insulin resistance. The most common pathologic subtype (56%) was hormone receptor (HR) positive and human epidermal growth factor receptor-2 (Her-2)-negative invasive ductal carcinoma. Sixteen (29%) patients had a pathological complete response (pCR). We found that the probability of pCR in patients with insulin resistance was 4.7 times lower than that in patients without insulin resistance [OR: 4.7 (95%CI 1.7-17.2), p = 0.01].

CONCLUSION

Our results revealed that insulin resistance may have a negative effect on pathological complete response (pCR) following neoadjuvant therapy particularly with hormone-positive and Her-2-negative cases of non-diabetic breast cancer.

A rare case of gastric cancer with bilateral breast metastasis during pregnancy

BACKGROUND

Gastric cancer is rare during pregnancy and often diagnosed at a later stage due to overlapping symptoms of pregnancy. Breast metastasis of gastric cancer is another uncommon entity. We present a rare case of breast metastasis of gastric cancer during pregnancy.

CASE REPORT

A 26-year-old female was diagnosed with gastric cancer at 14 weeks of gestation and underwent total gastrectomy. She rejected adjuvant chemotherapy and continued pregnancy without any follow-up. Cancer recurred in bilateral breasts at 34th week of gestation mimicking primary inflammatory breast cancer.

MANAGEMENT AND OUTCOME

It was difficult to diagnose breast metastasis during pregnancy because of overlapping pregnancy symptoms. Following an unresponsive period to antibiotherapy, a fine needle biopsy on breast was performed and signet cell adenocarcinoma metastasis was determined. We started chemotherapy after delivery. There was a near complete response after first line of chemotherapy. Unfortunately, cancer was relapsed within three months and we started second-line chemotherapy.

DISCUSSION

To our knowledge, this is the fourth case reported in medical literature of gastric cancer presented with breast metastasis during pregnancy. We will try to draw attention to diagnosis, treatment and different presentation of gastric cancer during pregnancy with review of the literature.

Does primary tumor localization has prognostic importance in seminoma patients?: Turkish Oncology Group Study

PURPOSE

The purpose of this study was to determine whether primary tumor localization may be a risk factor for relapse and survival in seminomatous germ cell tumors (GCT) patients.

METHODS

In our study, 612 seminomatous GCT patients diagnosed in 22 centers between 01.01.1989 and 03.02.2019 were retrospectively evaluated. Patient interview information, patient files and electronic system data were used for the study.

RESULTS

The primary tumor was localized in the right testis in 305 (49.9%) patients and in 307 (50.1%) in the left testis. Mean age of the patients was 36 years (range 16-85±10.4). The median follow-up period was 47 months (1-298). Recurrence was observed in 78 (12.7%) patients and 29 (4.7%) died during the follow-up period. Four-year overall survival (OS) was 95.4% and 4-year progression-free survival (PFS) was 84.5%. The relationship between localization and relapse was significant in 197 patients with stage 2 and stage 3 (p=0.003). In this patient group, 41 (20.8%) relapses were observed. Thirty (73.2%) of the relapses were in the right testis and 11 (26.8%) in the left testis. Four-year OS was 92.1% in patients with right tumor; and 98.7% in patients with left tumor (p=0.007). When 612 patients were evaluated with a mean follow-up of 4 years, there was a 6.6% survival advantage in patients with left testicular tumor and this difference was significant (p=0.007).

CONCLUSION

Survival rates of patients with primary right testicular localization were worse compared with left testicular localization, and relapse rates were higher in stage 2 and 3 patients with right testicular localization.

How long should we continue crizotinib in ALK translocation-positive inflammatory myofibroblastic tumors? Long-term complete response with crizotinib and review of the literature

INTRODUCTION

Inflammatory myofibroblastic tumor is a rare disease which is typically seen in children and young adults. Approximately half of the inflammatory myofibroblastic tumors contain translocations that result in over-expression of anaplastic lymphoma kinase gene. Herein, we present two anaplastic lymphoma kinase-positive cases with long-term remission with crizotinib. We do not know how long these therapies need to be continued.

CASE REPORTS

We present two cases of inflammatory myofibroblastic tumor treated with anaplastic lymphoma kinase inhibitor therapies: an 8-year-old Turkish boy and a 21-year-old Caucasian man.

MANAGEMENT AND OUTCOME

Two cases, both with good tumor control under crizotinib, but one who progressed on drug holiday, responded again to the same drug, and had a very short period of response after restarting crizotinib.

CONCLUSION

A molecular-targeted drug (anaplastic lymphoma kinase inhibitor) was found to be extremely effective as selective therapy for inflammatory myofibroblastic tumor with anaplastic lymphoma kinase translocation. Here, we want to emphasize the continuation of this treatment after achieving a good response until progression or a major side effect.

The effects of taking chronic nitrate by drinking water on thyroid functions and morphology

Nitrate incorporation in humans takes place via drinking water and food. The water used for drinking and cooking in the goitrous areas is high in nitrate content. The aim of the present study was to evaluate both chronic effects and the dose-response relationship of nitrate on thyroid functions. A total of rats were divided into 5 work groups and sodium nitrate was added to their drinking water in different concentrations (0, 50, 100, 250 and 500 mg/l) over a 30-week period. The radioiodine uptake of thyroid was decreased in the 50 mg/l nitrate group, whereas it was increased in the 250 and 500 mg/l nitrate groups as compared to control. All hormones of thyroid gland except total thyroxine and thyroid-stimulating hormone were decreased in the 50, 250 and 500 mg/l nitrate groups. However, the level of total thyroxin was increased in the 100 mg/l nitrate group. Thyroid gland weights were increased in all experimental groups. Histomorphological changes were observed in the 250 and 500 mg/l nitrate groups. These findings suggest that nitrate impairs thyroid function involving the hypothalamo-hypophysio-thyroid axis. This observation could contribute to the current discussion about the acceptable daily intake of nitrate, as well as drinking water nitrate standard safety margins.

The value of the TIMI frame count method in the diagnosis of coronary no-reflow: a comparison with myocardial perfusion SPECT in patients with acute myocardial infarction

The state of no-reflow (i.e. inadequate myocardial tissue perfusion despite normal arterial flow proven in angiography after pharmacological or mechanical interventions) is considered to be a marker of a poor prognosis. Although the Thrombolysis in Myocardial Infarction (TIMI) flow grade is a valuable and widely used qualitative measure in angiography trials, it is limited by its subjective and categorical nature. Recently, the TIMI frame count method (TFC) was proposed for detecting no-reflow. In our study we aimed to compare TFC values with myocardial perfusion single photon emission computed tomography (SPECT) findings to investigate the additional role of the former method in the evaluation of no-reflow. Twenty patients (16 men and four women; mean age 58+/-9 years) with first acute myocardial infarction were included in the study after thrombolytic therapy. Coronary angiography (CAG) was performed 5-7 days later. The TIMI flow grade and TFC values were determined in angiography examinations. A TIMI flow of less than grade 3 and a TFC value >27 were considered to be pathologically decreased for coronary artery blood flow. Tc tetrofosmin myocardial rest SPECT was carried out 24 h after coronary angiography. SPECT images were scored on a four-point scale in 20 myocardial segments and the total defect score was calculated from the sum of defect scores in 20 segments. Wall motion was assessed using the wall motion score index in echocardiography (ECWSI). The occurrence rates of angiographic no-reflow, pathological TFC and perfusion defects in SPECT were calculated as 40% (8/20), 47% (8/17; non-measurable in three patients with TIMI grade 0), and 55% (11/20), respectively. Perfusion defects were present and the TIMI frame count value was increased in all patients with angiographic no-reflow (TIMI grade <3). The occurrence rate of perfusion defects and increased TFC was equal (42%) in all 12 patients having TIMI grade 3 flow. Increased TFC was demonstrated in four of five patients having perfusion defects and TIMI grade 3 flow (80% compatibility with SPECT). TIMI frame count and ECWSI values were significantly higher in patients having perfusion defects than in patients with normal perfusion ( <0.05). It is concluded that the TIMI frame count is a valuable method in the detection of patients with TIMI grade 3 flow, with no-reflow, and increases the specificity of coronary angiography in the evaluation of the response to thrombolytic therapy. A pathologically increased TFC value with TIMI grade 3 flow during CAG seems to be a good indication for the use of myocardial perfusion SPECT in the definitive diagnosis and/or follow-up of such patients.

Hydatid disease of the left femur: a case report

Osseous hydatid disease is a rare but serious condition. Treatment is difficult because of the progressive course of the bone involvement and generally admitted algorithm about osseous hydatid disease. We report a six-year follow-up of a case with involvement of the left femur, treated with an unconnected surgical method and albendazole. In this patient a 1 cm segment of the cortex between the trochanteric region to supracondylar area of the left femur was removed. The medullary cavity of the left femur was irrigated for 5 minutes with 20% hypersaline solution, and removed without causing any damage. The medullary cavity was curettaged meticulously and irrigated for 6 minutes with 0.9% saline solution. The bone defect was filled with bone cement. Albendazole was administered during the postoperative period. At the sixth year postoperatively, the patient was pain free. All serological tests were normal. Radiologic evaluation showed no evidence of disease recurrence. Meticulous preoperative planning, excision of all the cysts, and an effective regimen of chemotherapy will reduce recurrence. Bone scintigraphy is an important diagnostic method during the follow-up period.

Evaluation of lymphatic drainage of cold thyroid nodules with intratumoral injection of Tc-99m nanocolloid

PURPOSE

The lymphatic system may show variations throughout the entire body. Knowledge of the variations and aberrant lymph drainage are important when planning surgical treatment and radiotherapy. The aim of this study was to evaluate the intratumoral injection technique in the detection of lymphatic drainage of proved or possibly malignant cold thyroid nodules.

MATERIALS AND METHODS

The study group consisted of 13 patients with palpable solitary cold thyroid nodules. None of the patients had cystic nodules on ultrasound examination. After fine-needle aspiration biopsy (at least 3 days later), 15 MBq (0.4 mCi) Tc-99m nanocolloid particles in a small volume (0.2 ml) were injected into the nodule. Dynamic images (60 frame x 1 minute) were acquired during the first hour, followed by static anterior and lateral images at 90 and 120 minutes.

RESULTS

Radiopharmaceutical was present in the systemic circulation in two patients, possibly as a result of paratumoral injection. Eleven patients had intratumoral accumulation in early frames. Lymph nodes draining the thyroid nodule were visualized in 10 of 11 patients. In the dynamic acquisition period of 7 of 10 patients, the first draining lymph node could also be identified. Only 5 of 13 patients had malignant nodules. Lymphatic metastases were detected in one patient's specimens.

CONCLUSIONS

Preoperative visualization of lymphatic pathways may be used when planning for thyroid cancer surgery. Sentinel node detection could yield valuable additional information in these patients.

Pentavalent technetium-99m DMSA uptake in pseudofractures of osteomalacia

Tc-99m MDP and Tc-99m (V) DMSA images are described from a 49-year-old woman with chronic renal insufficiency complicated by osteomalacia. Clinical, biochemical, and radiologic bone profiles were compatible with osteomalacia. Osteomalacia is a condition associated with disorders in which mineralization of the organic matrix is defective. All bone lesions visualized with Tc-99m MDP also showed increased uptake of Tc-99m (V) DMSA. Tc-99m (V) DMSA accumulation has been reported in many malignant and some benign conditions. Pseudofractures in osteomalacia could be included in the spectrum of benign lesions that accumulate Tc-99m (V) DMSA.

Investigation of the vertebrobasilar arterial system in vertigo by vestibulocochlear test, SPECT and angiography

OBJECTIVE

Perfusion of the areas of cochleovestibular structures was investigated using Tc-99m HMPAO single photon emission computerized tomography (SPECT) in the young patients with vertigo presumed to have peripheral vestibular abnormalities and compared the results with cochleovestibular test results, and vertebrobasilar angiography findings.

METHODS AND PATIENTS

The study was performed on 20 patients with vertigo and 17 control subjects who had performed vertebral arteriography due to another disease. The patients with vertigo presumed to be on peripheral vestibular disorder were included in the study. Systemic and otorhinolaryngological examination were carried out. Audiovestibular function was evaluated in all patients and control subjects. Brain SPECT was performed with a one-head rotating gamma camera system from 64 projections into a 64x64 matrix, using low energy and high-resolution fan beam collimators with a sampling time of 30 s. The images taken from cerebellum, temporal, parietal and occipital lobes which are supplied by a vertebrobasilar system were compared visually with the other side and asymmetry in the perfusion was searched. After cochleovestibular tests and laboratory had been completed, vertebral arteriography was performed bilaterally in all patients. Results of digital subtraction angiography (DSA) and the vestibulocochlear test were compared with images of SPECT. Data analysis was done with Yates Chi(2) and percentages of sensitivity and specificity were calculated.

RESULTS

There was vestibular test and cochlear test abnormalities in eight and ten of the patients with vertigo, respectively. SPECT imaging showed hypoperfusion and decreased regional blood flow in 12 of the patients. There was statistically significant differences between the study and control groups in SPECT (P<0.05). Five patients showed abnormal findings in DSA examinations.

CONCLUSION

It is believed that SPECT may be helpful in the detection of vascular pathology in the patients with vertigo.

Evaluation of metastatic bone disease with pentavalent 99Tc(m)-dimercaptosuccinic acid: a comparison with whole-body scanning and 4/24 hour quantitation of vertebral lesions

The aim of this study was to establish the value of 99Tcm(V)-DMSA scintigraphy in the detection of metastatic bone lesions and compare the results to 99Tcm-MDP bone scintigraphy. Thirty-four patients presenting with metastatic bone disease (Group 1) and 12 controls with degenerative skeletal lesions (Group 2) were studied. Conventional bone scanning and 99Tcm(V)-DMSA whole-body scanning were performed on all patients. All scans were interpreted visually. Furthermore, lesion-to-normal bone ratios (L/N) in vertebral metastases on the 4 and 24 h bone scans were obtained in 58 lesions of cancer patients and in 23 benign (degenerative) vertebral lesions of the control group. 99Tcm-MDP L/N ratios at 24 h (3.08 +/- 0.32) were significantly higher than those at 4 h (2.48 +/- 0.24) in the malignant foci (P < 0.001). No significant difference was observed in benign lesions (P > 0.05). In 167 (164 metastatic, 3 traumatic) of 186 99Tcm-MDP positive lesions (90%) of Group 1, 99Tcm(V)-DMSA uptake was observed. The remaining 19 lesions (10%) were 99Tcm(V)-DMSA negative. Fourteen of these 19 sites were diagnosed as benign. The remaining five foci were malignant. In four lung cancer metastases showing no 99Tcm-MDP uptake, 99Tcm(V)-DMSA uptake was observed. There was no 99Tcm(V)-DMSA accumulation in any of the 99Tcm-MDP positive degenerative lesions of Group 2. All quantitatively evaluated (n = 42) vertebral metastatic foci and two compression fractures in Group 1 showed 99Tcm(V)-DMSA accumulation and an increased 99Tcm-MDP L/N ratio at 24 h. A total of 36 degenerative lesions (Groups 1 and 2) and one compression fracture (Group 1) showed neither 99Tcm(V)-DMSA uptake nor an increased 99Tcm-MDP L/N ratio at 24 h. Our results indicate that quantitative 4/24 h analysis of vertebral lesions on 99Tcm-MDP scans has a similar diagnostic value to 99Tcm(V)-DMSA imaging in the detection of bone metastases. However, the accumulation of 99Tcm(V)-DMSA in four lung cancer metastases showing no 99Tcm-MDP uptake is encouraging and justifies further research in patients with proven bone metastases and negative bone scans.

Comparison of Tc-99m MDP, Tc-99m HSA and Tc-99m HIG uptake in rheumatoid arthritis and its variants

Tc-99m polyclonal immunoglobulin-G has been shown to be a successful agent in the depiction of active inflammation in rheumatoid arthritis (RA). The objective of this study was to compare the uptake behaviors of Tc-99m HIG and Tc-99m MDP in RA and variants of rheumatoid arthritis (VRA). Seventeen patients with RA and 8 patients with VRA presenting with active inflammation were included in this study. Ten subjects with well-diagnosed degenerative joint disease constituted the control group. All joints in patients were also imaged with Tc-99m HSA to evaluate the vascularization status of the joints. Tc-99m HIG and HSA scans were obtained at 2, 4 and 24 hours after the injection of 555 MBq Tc-99m HIG and 296 MBq Tc-99m HSA. Conventional bone scans were performed 4 hours after the injection of 740 MBq Tc-99m MDP. Target-to-background (T/B) ratios were obtained exclusively over the joint regions. Tc-99m HIG T/B ratios of the active joints in RA were significantly higher than those of the non-active joints and the control group (p < 0.05). Tc-99m HIG T/B ratios in active joints showed a progressive increase between 2 and 24 hour images (p < 0.05). In contrast, Tc-99m HSA T/B ratios decreased in all active joints significantly (p < 0.05) except the ankle joint region (p > 0.05). The T/B ratios in Tc-99m MDP bone scans were higher in all active joints than in non-active RA joints and joints of controls but significantly differences were only detected in wrist and elbow joints. All clinically active joints in VRA patients accumulated Tc-99m HIG and HSA, and showed increased Tc-99m MDP uptake. These joints had a very similar Tc-99m HIG retention pattern to the RA joints. The detection rate of active joint inflammation with Tc-99m HIG was much higher than that with Tc-99m MDP. The increasing Tc-99m HIG uptake ratio between 2 and 24 hours in contrast to Tc-99m HSA indicates the presence of other binding mechanisms besides increased vascularity in RA.

Bilateral pulmonary artery aneurysms in a patient with Behcet syndrome: evaluation with radionuclide angiography and V/Q lung scanning

The case of a 14-year-old girl with Behcet syndrome is described. Besides painful and recurrent oral ulcerations, the patient had a cough and intermittent hemoptysis. The initial chest roentgenogram revealed bilateral parahilar opacities. CT and MRI scans of the thorax showed bilateral thrombosing aneurysms of the pulmonary arteries. Pulmonary blood flow imaging was performed after technegas ventilation lung scanning and Tc-99m MAA injection using a first-pass radionuclide angiography procedure. Altered blood flow in the left pulmonary artery was shown. Bilateral and well-defined ventilation/perfusion mismatched areas suggested a high probability of pulmonary embolism. Little additional information was obtained on subsequent contrast pulmonary angiography. The high incidence of pulmonary artery hypertension and associated vascular injury risk makes pulmonary angiography an unsafe procedure in patients with pulmonary Behcet syndrome. The need for pulmonary angiography could be obviated in such cases with the use of high-precision MRI and ventilation/perfusion lung scanning, including radionuclide pulmonary angiography.

Pulmonary Tc-99m tetrofosmin imaging: clinical experience with detecting malignant lesions and monitoring response to therapy

The authors prospectively investigated the uptake and kinetics of Tc-99m tetrofosmin (Tetro) in benign and malignant lung lesions and the effect of radiotherapy, chemotherapy, or both on Tc-99m Tetro uptake in malignant lung tumors. Dynamic and planar Tetro imaging were performed in 45 patients with pulmonary lesions during a period of 28 months (34 untreated malignant tumors, 11 benign lesions). Tetro uptake was visibly increased in 26 of 34 malignant tumors, with a mean lesion to contralateral normal tissue ratio of 1.44 +/- 0.29 and a tumor washout rate of 28.4 +/- 6.6% 30 minutes after injection. In 3 of 11 benign lesions, Tetro uptake was observed. Of the 26 patients with malignant tumors and positive Tetro uptake, nine had repeated imaging 6 to 8 weeks after therapy. The patients were treated with radiotherapy, chemotherapy, or both. Reduction in radiological tumor size was used as the clinical response parameter. In five of nine patients, the course of Tetro uptake in follow-up imaging was in accordance with that of radiological tumor size. Two of four remaining patients had only slight discordance between the alteration of Tetro uptake and radiological tumor size. The sensitivity of Tetro to detect malignant lung lesions in our patients was 77%. The specificity and accuracy of the method were 73% and 76%, respectively. Tetro has limited diagnostic value in detecting lung cancer. It may be useful to monitor the response to therapy in malignant lung tumors with initial tracer uptake. Broader trials on this matter are needed for further clarification.