Clinical impact of dual-tracer FDOPA and FDG PET/CT for the evaluation of patients with parkinsonian syndromes

Parkinsonian syndromes include typical cases of idiopathic Parkinson's disease (PD) and atypical parkinsonian syndromes (APS) associated with cognitive and vegetative disorders, which are more challenging to diagnose. The aim of this study was to assess -the value of dual-tracer imaging 6-fluoro-(18F)-L-DOPA (FDOPA) and fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT), performed in routine patients demonstrating extrapyramidal signs and cognitive complains, for the diagnosis and management of parkinsonian syndromes.We retrospectively included 143 consecutive patients who underwent both FDOPA PET/CT (for the evaluation of parkinsonism) and FDG PET/CT (for the evaluation of cognitive complaints) in the same institution. The suspected clinical diagnosis before imaging and the final post-imaging diagnosis were collected by a dedicated questionnaire.FDOPA was pathological in 90.2% of cases, including 74.1% of PD, 3.5% of parkinsonian dementia and 7% of APS. FDG was normal or near normal in 58.7% of patients. A pattern of diffuse cortical hypometabolism was observed in the remaining patients, more frequently in APS than in PD patients (P = .001). Importantly, in 7.7% of cases dual-tracer PET/CT allowed to decide between several diagnostic hypotheses and led to a new diagnosis in 14.0%. Therefore, the management of these patients was modified, with clinical re-evaluation in a specialized unit and a control of neuropsychological tests and imaging.Dual-tracer PET/CT imaging may be a precious help in the diagnosis and management of parkinsonian syndromes.

High-dose transdermal nicotine in Parkinson's disease patients: a randomized, open-label, blinded-endpoint evaluation phase 2 study

BACKGROUND AND PURPOSE

Studies of the effects of nicotine on motor symptoms in Parkinson's disease (PD) brought out discordant results. The aim of the present study was to evaluate the efficacy and safety of high doses of transdermal nicotine on motor symptoms in PD.

METHODS

Forty PD patients were randomly assigned to a treated and untreated arm in an open-label study. Treated patients received increasing doses of nicotine to reach 90 mg/day by 11 weeks. This dosage was maintained for 28 weeks (W39) and then reduced over 6 weeks. Final evaluation was performed 6 weeks after washout. The main outcome measure was the OFF-DOPA Unified Parkinson's Disease Rating Scale (UPDRS) motor score measured on video recordings by raters blinded to the medication status of the patients.

RESULTS

There was no significant difference in OFF-DOPA UPDRS motor scores between the nicotine-treated and non-treated groups, neither at W39 (19.4 ± 9.3 vs. 21.5 ± 14.2) nor considering W39 differences from baseline (-1.5 ± 12.1 vs. +0.9 ± 12.1). The 39-item Parkinson's disease questionnaire scores decreased in nicotine-treated patients and increased in non-treated patients, but the difference was not significant. Overall tolerability was acceptable, and 12/20 treated patients reached the maximal dosage.

CONCLUSIONS

High doses of transdermal nicotine were tolerated, but our study failed to demonstrate significant improvement in UPDRS motor scores. Improvement in unblinded secondary outcomes (UPDRS-II, UPDRS-IV, doses of l-DOPA equivalents) suggest a possible benefit for patients treated with nicotine, which should be confirmed in larger double blind, placebo-controlled studies.

[18F]-NaF PET/CT imaging in cardiac amyloidosis

Cardiac amyloidosis (CA) is recognized as a common cause of restrictive cardiomyopathy and heart failure due to the deposition of insoluble proteins in the myocardial interstitium. We emphasize the role of [18F]-sodium fluoride (NaF) PET/CT as a potential noninvasive tool to identify and differentiate the transthyretin-related cardiac amyloidosis from the light-chain cardiac amyloidosis. We report cases of a 73-year-old man and a 75-year-old woman followed in our center for congestive heart failure with marked alteration of the left ventricular ejection fraction due to familial transthyretin Val122Ile cardiac amyloidosis and light-chain cardiac amyloidosis, respectively, confirmed on endomyocardial biopsy.

Functional imaging of hepatocellular carcinoma using diffusion-weighted MRI and (18)F-FDG PET/CT in patients on waiting-list for liver transplantation

Background

To compare the apparent diffusion coefficient (ADC) on diffusion-weighted imaging (DWI) with the standardized uptake values (SUV) measured by¹⁸F-FDG-PET/CT in naïve hepatocellular carcinoma (HCC) nodules, and to determine whether these markers are associated with tumours at high-risk of aggressiveness.

Methods

From 2007 to 2010, all patients with HCC on the waiting list for liver transplantation and who underwent both FDG-PET/CT and 1.5-T DWI-MRI (b values: 0, 200, 400, and 800 s/mm²) were included in this institutional review board-approved retrospective study. Tumour size, tumour ADC, tumour-to-liver ADC ratio (ADC_T/L), maximal tumour SUV and tumour-to-liver SUV ratio (SUV_T/L) were measured and compared to serum alpha-fetoprotein (AFP) levels, tumour size and differentiation grade on explanted specimens.

Results

A total of 37 HCC nodules in 28 patients were available for correlation between MRI and PET/CT, 7 of which (in 7 patients) showed a SUV_T/L > 1.15. We did not find any correlation between tumour ADC or ADC_T/L and tumour SUV or SUV_T/L. To note, SUV_T/L was positively correlated with AFP levels (R = 0.95, P ≤ 0.0001), while ADC_T/L was not (P = 0.73). Twenty-four patients (with 32 nodules) underwent liver transplantation. In this subgroup, an increased SUV_T/L ratio was associated with larger tumours (average size, 32 ± 14 mm; range, 18–60 mm; P < 0.0001) and with poor differentiation on pathology (grades 3 and 4; P = 0.04), while ADC_T/L was neither associated with tumour size or differentiation grade.

Conclusions

ADC and SUV measures in HCC nodules are not correlated. SUV_T/L ratio correlates with AFP levels, tumour size and poor differentiation, and should probably be integrated as a co-variable in a predictive outcome model of patients on the waiting-list for liver transplantation.

Clinical routine use of dopamine transporter imaging in 516 consecutive patients

[(123)I]-FP-CIT is a single photon emission computed tomography (SPECT) ligand showing in vivo the loss of dopaminergic terminals in the brain and is now available in the market. Despite several systematic studies in clinically inconclusive cases, the use of such imaging in clinical routine is scarcely reported. We analyzed 516 files of subjects with movement disorders who were consecutively examined using [(123)I]-FP-CIT scan and determined whether the use of imaging was appropriate and if it improved clinical diagnosis or care of the patient. In addition, we determined if appropriate use was related to subspecialties in Neurology, e.g., movement disorders' specialists vs. general neurologists, and if appropriate use was increasing over time. Among the 516 scans, 18% were in agreement with the license, 62% were classified as appropriate and 37% were considered inappropriate. A change of management was obvious in 60% of patients, but in 92% of those with an appropriate request vs. 13% of patients with an inappropriate request. Movement disorders' specialists had more appropriate requests than other practitioners. Eventually, comparing the first 100 vs. the last 100 quantified SPECT, performed more than 2.5 years apart, we found no difference for the appropriateness of the examination. The use of [(123)I]-FP-CIT imaging in clinical routine does not fit a restrictive license. An inappropriate use is seen in nearly 40% of cases, which reduces the real cost-effectiveness of the technique suggesting a need for continuing medical education on the topic.

Clinical impact of contrast-enhanced computed tomography combined with low-dose (18)F-fluorodeoxyglucose positron emission tomography/computed tomography on routine lymphoma patient management

This study evaluated the clinical impact of contrast-enhanced computed tomography (CECT) on routine management of patients with lymphoma. Over a 1-year period, 237 CECT scans were performed prospectively in 163 patients after low-dose (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT). Scans were performed at staging (n = 41), interim (n = 73), post-therapy (n = 115) and follow-up (n = 8). Clinical impact was determined from the multidisciplinary committee reports. CECT had no clinical impact in 219 cases (92%). A clear impact was noted in only 3%, i.e. up-staging of lymphoma (n = 2) and diagnosis of deep vein thrombosis (n = 5). A debatable impact was noted in the remaining 11 cases, consisting of additional investigations, either without therapeutic impact (n = 8), or resulting in delay of therapy onset (n = 2) or ablative surgery (n = 1). CECT delivered an average 33.5 ± 3.8 mSv vs. 17.7 ± 2.8 mSv for PET/CT. In conclusion, the clinical impact of CECT seems limited, although scarce, life-threatening conditions were diagnosed. Imaging of lymphoma needs optimization to reduce radiation exposure.

[Interpretation of sentinel node identification in vulvar cancer]

OBJECTIVE

Sentinel node (SN) identification in vulvar carcinoma would avoid groin dissection and its complications in early stages, but we first have to validate the method, as an unrecognised node metastasis is detrimental to survival.

PATIENTS AND METHODS

Since June 2002, 38 patients with T1 or T2 lesions underwent SN identification by radioactive tracer injection and scintigraphy with, on the following day, per operative use of a handheld probe +/- patent blue dye. In case of a midline lesion, a bilateral inguinal dissection was performed whatever the result of SN identification. SN free from disease were ultrastaged with immunohistochemistry.

RESULTS

1 or more SN were identified in 36 out of 38 patients. 64 groins were analysed, 15 with node metastases. In 9 out of these 15 cases the SN was metastatic, in 5 it had not been identified, and in 1 it was a false negative. In these last 6 cases, there were massively metastatic nodes in the groin. In 19 out of the 26 midline lesions the surgeon identified only unilateral SN. The side without SN contained metastatic nodes in 5 cases.

DISCUSSION AND CONCLUSION

Failure in SN identification is sometimes related to a massively invaded node. This should be taken into account especially in the management of midline tumors where a seemingly unilateral drainage at scintigraphy warrants nevertheless a surgical assessment of the mute groin.

EBSD FEG-SEM, TEM and XRD techniques applied to grain study of a commercially pure 1200 aluminum subjected to equal-channel angular-pressing

Microstructural evolution due to equal-channel angular-pressing (ECAP) with increasingly severe deformation was investigated in a commercially pure 1200 aluminum alloy. A true strain of eight produced sub-micrometer scale grains and very fine subgrains in the grain interior. The deformation process was documented and described using field-emission (FEG) gun scanning and transmission electron microscopy techniques. After eight ECAP passes, the high-angle grain boundaries accounted for approximately 70% of all boundaries. The fine spacing resolution of FEG scanning electron microscopy allowed detailed grain and subgrain statistical evaluation in the deformed microstructure; transmission electron microscopic inspection afforded appreciation of the role of very low-angle misorientation boundaries in the microstructure-refining process. ECAP results were compared with those produced by cold rolling. The material's texture evolved in a decreasing trend of Cube {001}100 intensities in favor of Cube rotated toward the normal-to-pressing direction {001}120, while Goss {110}001 and {111}110, {111}112 directions slightly increased with strain.

Sentinel node localization should be interpreted with caution in midline vulvar cancer

OBJECTIVE

Carcinomas of the vulva situated on the midline or close to it, are supposed to have a bilateral lymphatic drainage. The aim of this study was to evaluate sentinel node identification in these tumors.

METHODS

Between April 2002 and February 2004, 17 patients with operable vulvar cancer situated on, or close to the midline were entered in a prospective study. All patients underwent sentinel node identification with (99m)Tc-labelled nanocolloid (preoperative lymphoscintigraphy and intraoperative use of a handheld probe). Depending on the surgeon, intraoperative blue dye was associated. Radical excision of the tumor and routine bilateral lymphadenectomy were then performed. Sentinel nodes were sent separately for histologic examination. Negative sentinel nodes on hematoxylin/eosine were further examined with immunohistochemistry.

RESULTS

One or more sentinel nodes were identified in the 17 patients and in 21 of the 34 groins. In 5 patients, the sentinel nodes were metastatic. There was no false negative (negative sentinel node and metastatic non-sentinel node). In 13 patients, lymphoscintigraphy and then intraoperative identification suggested a unilateral drainage of the tumor with sentinel nodes localized in only one groin. Among these 13 patients, 3 groins with no sentinel node identified contained in fact massively metastatic nodes.

CONCLUSION

Unilateral finding of a sentinel node in tumors of the midline does not preclude a metastatic node in the other groin. Lymph node assessment should remain bilateral in these lesions.

Assessment of myocardial reperfusion after myocardial infarction using automatic 3-dimensional quantification and template matching

Assessment of perfusion defect extent is essential for determining prognosis after a myocardial infarction (MI), but quantification methods usually rely on segmental analysis, which may lack accuracy. We present an automated voxel-based and template-based approach for precise quantification of perfusion defect extent and reperfusion evolution.

METHODS

Coronary angiography and stress/reinjection (201)Tl tomography were performed prospectively on 49 patients with recent MI (45 men; mean age +/- SD, 54 +/- 10 y), before and 3 mo after revascularization (40 angioplasties and 9 bypasses). Perfusion defect extent was quantified using expert 16-segment visual scoring of the slices and a 3-dimensional (3D) method with spatial normalization between times 1 and 2. Briefly, the latter automatically extracted myocardial edges, matched them to a reference template, and compared the perfusion intensity in each voxel with the intensity of the corresponding voxel in a control population of 100 healthy subjects.

RESULTS

Reocclusion occurred in 12 patients within 3 mo of surgery (all had undergone angioplasty). The perfusion gain between times 1 and 2, assessed by visual analysis, was significantly higher in permeable patients than in reoccluded patients: 12.4% +/- 13.3% and 2.3% +/- 8.2% of the initial stress defect, respectively (P = 0.02). Proportional gains, measured with the quantitative 3D method, were 4.5% +/- 3.6% and 1.9% +/- 2.7%, respectively (P = 0.02). Furthermore, the 3D method allowed measurement within the initial ischemic defect (reversible part of the stress defect at time 1), the extent of myocardium whose perfusion improved at time 2 (reperfusion), and the extent of myocardium whose perfusion remained unchanged (residual ischemia). A voxel-by-voxel analysis of these regions revealed that the proportion of reperfusion was significantly higher in permeable patients than in reoccluded patients: 60.0% +/- 21.3% versus 40.0% +/- 22.5%, respectively (P = 0.008). This was cumbersome to quantify using visual analysis and did not reach statistical significance, likely because of segmental division (partial-volume effect) and absence of spatial normalization.

CONCLUSION

The 3D voxel-based quantification allows satisfying assessment of reperfusion 3 mo after MI. Moreover, the automated analysis using spatial normalization should facilitate a reproducible assessment of large populations over time.

Quantitative lung perfusion scan as a predictor of aerosol distribution heterogeneity and disease severity in children with cystic fibrosis

BACKGROUND

The assessment of lung ventilation by radionuclide imaging has proved useful for the optimization of aerosol therapy in children with cystic fibrosis. Further analysis of lung perfusion may provide additional information.

METHODS

Quantitative analysis of regional lung aerosol distribution (Tc phytates) and perfusion (Tc macroaggregates) homogeneity was performed in 18 children with cystic fibrosis, using the third and fourth spatial moments (skew and Kurtosis) of count distribution. Patients were chosen from a prospective study whose goal was to compare the efficacy of two nebulization methods of a radiolabelled aerosol: one session involved a nebulizer activated by patient inspiratory flow (control session), whereas the other involved a nebulizer powered by a pressure support device (PS session).

RESULTS

Quantitative regional distribution of perfusion was similar to aerosol distribution, although skew and Kurtosis were lower, indicating better homogeneity. Perfusion skew was inversely correlated with pulmonary volumes and Shwachman score, even more significantly than ventilation skew. Using receiver operating characteristic curve analysis, a perfusion skew threshold of 0.67 was predictive of disease severity (FEV1 > or =60% or FEV1 <60%) with 86% sensitivity and 91% specificity. Furthermore, same skew threshold allowed the identification of patients who were 'PS responders' (greater amount of radioactivity deposited after the PS session) or 'PS non-responders' with 80% sensitivity and 77% specificity.

CONCLUSION

Quantification of regional lung perfusion is easy to perform and heterogeneity of the distribution is closely correlated to disease severity. Moreover, perfusion skew can identify patients who are likely to benefit from pressure support (to optimize aerosol therapy) and may be helpful for orienting potential non-responders towards alternative therapies.

Diagnostic value of 99mTc-HMDP bone scan in atypical osseous tuberculosis mimicking multiple secondary metastases

STUDY DESIGN

A case of atypical osseous tuberculosis (TB) mimicking multiple secondary metastases on radiologic and nuclear imaging is presented.

OBJECTIVES

To emphasize the contribution of nuclear bone scanning for the assessment of osseous tuberculosis in typical and atypical presentations.

SUMMARY AND BACKGROUND DATA

Skeletal locations of TB mostly involve the dorsolumbar spine and diagnosis is often delayed. The presence of multiple TB sites can mimic secondary metastases and biopsy remains the mainstay for final diagnosis.

METHODS

Clinical symptoms, lab tests, and imaging data are presented. Possible diagnoses are discussed. A review of imaging characteristics in cases of typical and atypical presentations of osseous TB is proposed.

RESULTS

A dorsal spine spondylitis was first diagnosed on a 56-year-old patient presenting neurologic deficit of the left arm. Fine needle aspiration identified bacterial infection but was negative for Mycobacterium tuberculosis. Whole-body bone scan allowed the identification of an asymptomatic sacroiliac lesion, which was accessible to biopsy and gave a final diagnosis.

CONCLUSION

Nuclear bone scanning should be kept in mind when assessing spinal pain in patients at high risk of TB infection or reactivation.

[The evaluation of the use of DEAE-dextran in glycemic control in diabetic patients in pregnancy]

Thirty pregnant women with a pre-gestational history of type II diabetes or sugar intolerance and recruited during the second trimester of pregnancy, were administered DEAE-dextran (1 g x 3 times a day) in association with compensatory insulin therapy. Results of the end of trial tests showed amelioration of all of the parameters studied. The sugar curve after 120' from glucose load (100 g at fasting), showed a highly significant decrease at T90. Triglycerides T0 vs T90 gave p = 0.0001, probably due to improved body utilization of the insulin. DEAE-dextran was well tolerated and all of the patients enrolled at the beginning, completed the trial.

[The prevention of an excitation-conduction block during acute myocardial ischemia: is there a role for prostacyclin or for histamine?]

We have investigated (multivariate Cox's model) the relative risk of stable excitation-conduction block (ECB) in right ventricular myocardial strips (2 x 5 x 1 mm) from 26 female guinea-pigs, bathed in a 2-compartment chamber (3 ml) on the anterior side of which modified Tyrode's solution (K+ 12 mM, HCO3- 9 mM, pH 7 +/- 0.05, pO2 80 +/- 10 mmHg and absence of glucose) is supraperfused (stimulation rate: 450 ms; wire in the posterior compartment), thus enabling simulation of electrophysiologic changes seen during acute myocardial ischemia. Using glass microelectrodes, action potential amplitude (APA), durations (APD50 and 90%), resting membrane potential (RMP) and upstroke velocity (Vmax) are investigated. The hypothesis was tested of prostacyclin and histamine involvement in the genesis of ischemia-induced ECB in this model. Either a weak prostacyclin stimulator (cicletanine 10(-5) M, IPSEN, Paris, F, in DMSO 1:100; n = 16) or a potent prostacyclin generation blocker (indomethacin 10(-5) M, Sigma, in DMSO 1:100; n = 10) and either DMSO alone (1:100; n = 16) or a specific histaminergic H1 receptor antagonist (terfenadine 10(-5) M, Sigma, in DMSO 1:100; n = 10) were supraperfused using a randomization scheme. Each animal was used twice and either a first or a second occlusion (supraperfusing the modified Tyrode's solution for 30 min) period was performed and the randomized substances were supraperfused, thus enabling obtention of n = 52 experiments for analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiolymphoid hyperplasia with eosinophilia: removal with carbon dioxide laser in a patient on chronic oral anticoagulants

A patient with angiolymphoid hyperplasia with eosinophilia of the arm is described. In spite of anticoagulant therapy, successful surgical removal of the lesion was carried out with carbon dioxide laser excision and vaporization.