Central nervous system relapse in high-risk stage 4 neuroblastoma: The HR-NBL1/SIOPEN trial experience

BACKGROUND

There is rising concern on the impact of new strategies, such as high-dose chemotherapy (HDC) and immunotherapy, on the pattern of relapse in high-risk neuroblastoma (HR-NBL). Our aim is to evaluate the incidence and identify risk factors for first recurrence in the central nervous system (CNS) in HR-NBL.

PATIENTS AND METHODS

Data from patients with stage 4V HR-NBL included from February 2002 to June 2015 in the prospective HR-NBL trial of the European International Society of Pediatric Oncology Neuroblastoma Group were analysed. Characteristics at diagnosis, treatment and the pattern of first relapse were studied. CNS imaging at relapse was centrally reviewed.

RESULTS

The 1977 included patients had a median age of 3 years (1 day-20 years); 1163 were boys. Among the 1161 first relapses, 53 were in the CNS, with an overall incidence of 2.7%, representing 6.2% of all metastatic relapses. One- and three-year post-relapse overall survival was 25 ± 6% and 8 ± 4%, respectively. Higher risk of CNS recurrence was associated with female sex (hazard ratio [HR] = 2.0 [95% confidence interval {CI}: 1.1-3.5]; P = 0.016), MYCN-amplification (HR = 2.4 [95% CI: 1.2-4.4]; P = 0.008), liver (HR = 2.5 [95% CI: 1.2-5.1]; P = 0.01) or >1 metastatic compartment involvement (HR = 7.1 [95% CI: 1.0-48.4]; P = 0.047) at diagnosis. Neither HDC nor immunotherapy was associated with higher risk of CNS recurrence. Stable incidence of CNS relapse was reported over time.

CONCLUSIONS

The risk of CNS recurrence is linked to both patient and disease characteristics, with neither impact of HDC nor immunotherapy. These findings support the current treatment strategy and do not justify a CNS prophylactic treatment.

Malignant Pheochromocytoma in Multiple Endocrine Neoplasia Type 2B Syndrome. Case Report and Review of the Literature

A malignant behavior (i.e., distant metastatic spread) has been recorded in 3-4% of pheochromocytomas occurring in the context of multiple endocrine neoplasia type 2A syndrome, but has never been documented in patients with the type 2B form. In this report we describe a case of malignant pheochromocytoma arising in the latter syndrome setting. The patient, a white young male, had the full-blown syndrome, including multicentric, bilateral medullary thyroid carcinoma metastatic to regional lymph nodes, mucosal neuromas, digestive ganglioneuromatosis, marfanoid habitus, and bumpy lips. Three and a half years after surgical resection of an apparently benign adrenal pheochromocytoma he developed widespread osseous metastases. The presence of hypertensive crises and high urinary catecholamine excretion rates, coupled to moderate hypercalcitoninemia, normal circulating carcinoembryonic antigen levels, negative whole-body 99mTc-(V) dimercaptosuccinic acid scan, and absence of neck or mediastinal disease by magnetic resonance imaging, proved that the metastases were from his previous adrenal and not thyroid tumor. Furthermore, since the bone metastases strongly accumulated 131I-metaiodobenzylguanidine, several courses of the radiocompound were given, which resulted in an objective, though partial, tumor regression.

Bone Lesion in a Patient with Transplanted Liver for a Metastatic Carcinoid. The Role of Somatostatin Receptor Scintigraphy

A patient who had previously undergone ileal resection and liver transplantation for a gastroenteropancreatic (GEP) tumor was evaluated with somatostatin receptor scintigraphy (SRS) using 111In-DTPA-D-Phe1-pentetreotide. Eighteen months after surgery, during follow-up procedures, conventional imaging techniques (ultrasound, computed tomography, magnetic resonance imaging) only showed a relapse in the gastropancre-atic lymph nodes, while SRS demonstrated skeletal spread. This case report emphasizes the clinical impact of SRS on the management of patients affected by neuroendocrine gastroenteropancreatic tumors.

Association of Cea Test and Liver Scan in Detection of Hepatic Metastases of Gastrointestinal Carcinoma

The authors evaluate the combined use of liver scan and the CEA test in the diagnosis of hepatic metastases of carcinoma of the gastrointestinal tract. Association of the two tests is justified by the fact that the liver scan is very specific but not very sensitive, whereas the CEA test is more sensitive and not very specific. The sensitivity of the CEA test, on the other hand, can be increased by increasing the threshold of normality. However, the associated diagnostic use of the liver scan and the CEA test gives a loss of specificity with respect to the use of the liver scan alone. The present study, carried out on a series of 376 patients affected by gastrointestinal tumors of which 79 were of the stomach (9 with hepatic metastases), 133 of the colon and higher sigmoid (25 with hepatic metastases), and 164 of the lower sigmoid and rectum (29 with hepatic metastases), proposed to establish by use of a statistical method the optimal threshold of the CEA test that would give the best diagnostic specificity of the combined CEA test and liver scan without any relevant loss of sensitivity. A threshold of 26 ng/ml of the CEA test gave a specificity of 92 %, a sensitivity of 80 %, and an accuracy of 90 %. The authors think that in the detection of liver metastases of gastrointestinal tumors, the combined test can be more helpful the less the probability, for a given patient, for other metastatic localizations.

Sentinel Node Biopsy in Patients with Cutaneous Melanoma of the Head and Neck

Biopsy of head and neck sentinel nodes (SNs) can be technically problematic due to the unpredictable and variable drainage patterns of this anatomic region. The aim of the present study was to evaluate the feasibility of SN biopsy for cutaneous melanoma of the head and neck. We performed SN biopsy in 17 patients affected by stage I cutaneous melanoma of the head and neck on the basis of lymphoscintigraphy, blue dye and gamma probe. A total of 24 procedures were performed. Drainage to more than one lymphatic basin was observed in five patients (two basins in three cases and three basins in two cases) and in all cases SN biopsy was performed in all basins. The biopsy distribution by site was: six cervical nodes, five parotid nodes, four supraclavicular and submandibular nodes, three auricular and axillary nodes. The SN identification rate was 87.5% (21/24); metastases were discovered in four cases, with a positivity rate of 23.6%. At the time of writing, 1 patient is alive with local disease, 3 patients are dead and 13 are alive and free of disease with a follow-up ranging from 1 to 40 months (median, 21 months) following SN biopsy. In our opinion preoperative lymphoscintigraphy and the intraoperative use of a gamma probe are useful for the identification of lymphatic drainage of cutaneous melanoma of the head and neck.

Iodine-131 metaiodobenzylguanidine (I-131 MIBG) diagnosis and therapy of pheochromocytoma and paraganglioma: current problems, critical issues and presentation of a sample case

Iodine-131 metaiodobenzylguanidine (I-131 MIBG) has been used for the diagnosis and treatment of malignant pheochromocytomas (PHEO) and paragangliomas (PGL) since 1980's. Despite increasing amount of experience with iodine-131 (I-131) MIBG therapy, many important questions still exist. In this article, we will discuss the current problems learned from clinical experience in diagnosis and therapy of PHEO/PGL with I-131 MIBG, and present a sample case to emphasize the critical aspects for an optimal treatment strategy.

Malignant pheochromocytoma and paraganglioma: future considerations for therapy

Pheochromocytoma and paraganglioma are rare neuroendocrine tumors. Knowledge about such neoplasms ameliorated in the last 10-15 years with the discovery of increasing number of germ line mutations even in apparently sporadic cases. Seemingly, genetic tests are going to be an integral part of diagnostic procedures. Standard therapies (advanced surgery, radiometabolic therapy, chemotherapy and radiotherapy) have revealed suboptimal results in tumor size reduction and survival. Currently, there is no standard therapeutic protocol and thus some patients end up with overtreatment while others are undertreated. An effective molecular target therapy aiming at permanent control of these highly complex neoplasms should be the aim of future efforts. In clinical setting investigatory trials with multiple drug therapies targeting a variety of different parallel pathways should be available. Successful management requires a multidisciplinary teamwork.

Gallium-68 DOTANOC imaging in paraganglioma/pheochromocytoma: presentation of sample cases and review of the literature

Gallium-68 DOTANOC is a high affinity somatostatin receptor ligand, first introduced in 2005 for imaging neuroendocrine tumors. Due to its technically simple production, broad availability, favourable biodistribution and advantageous dosimetry, although not approved yet in all European countries, gallium-68 DOTANOC has rapidly gained acceptance in the diagnostic and therapeutic work-flow of different types of neuroendocrine tumors. Principal indications in clinical practice in countries where it is officially approved include diagnosis and staging, restaging after treatment, identification of sites of unknown primary and selection of patients with neuroendocrine tumors eligible for therapy with somatostatin analogues.

Treatment with tandem [(90)Y]DOTA-TATE and [(177)Lu] DOTA-TATE of neuroendocrine tumors refractory to conventional therapy: preliminary results

AIM

Neuroendocrine tumors over-express somatostatin receptors and literature data have demonstrated the efficacy of the peptide receptor radionuclide therapy with somatostatin analogues labelled with high activities of b-emitting radioisotopes, such as (90)Y and (177)Lu. Yttrium-90 is a pure high energy b-emitter while (177)Lu is a b/g emitter of medium energy. We decided to evaluate an original tandem treatment based on administration of radiolabeled [DOTA(0),Tyr(3)]octreotate (DOTA-TATE) alternating (177)Lu and 90Y. Aim of this study was to evaluate the feasibility, the efficacy and the toxicity of this treatment in neuroendocrine tumors expressing somatostatin receptors relapsed or refractory to conventional therapies.

METHODS

Patients were treated with four therapeutic cycles alternating [(177)Lu]DOTA-TATE (5.55 GBq) and [(90)Y]DOTA-TATE (2.6 GBq). Dosimetric evaluation after administration of [(177)Lu]DOTA-TATE allows to calculate the absorbed doses in healthy organs. Blood samples were collected at 5 min, 1, 6, 24, 48, 72, 96 h and scintigraphy was performed once a day for four days after administration. Toxicity was evaluated considering hematological parameters and renal toxicity was evaluated also by the glomerular filtration rate (GFR). Efficacy related with RECIST criteria.

RESULTS

Up to now 26 patients entered the study and 16 patients completed all cycles. Treatment was well tolerated with no adverse event registered. No damage to healthy organs was revealed in accordance with the calculated absorbed doses. We had a partial response in 10/15 patients evaluated three months after the fourth treatment.

CONCLUSIONS

Up to now only a few patients participated in and concluded this study; preliminary results are encouraging and indicate the feasibility of the study.

(131)I-MIBG treatment of pheochromocytoma: low versus intermediate activity regimens of therapy

AIM

Since the second half of the 1980s, (131)I-MIBG has been widely used for treatment of patients with malignant pheochromocytoma. In 1991, at the International Meeting in Rome, it was agreed that (131)I-MIBG therapy induces significant tumor responses in about 30-50% of cases, long-term stabilization of disease in several cases and significant reduction of cathecolamine-related symptoms in almost all patients. Nevertheless, more than 20 years later, its therapeutic use in malignant phaeochromocytoma has not yet been standardized. Aim of the present study was to compare the use of low versus intermediate activity of MIBG to achieve better results in a shorter time with higher activities.

METHODS

Two different modalities of (131)I-MIBG therapy were performed: before 2001, 12 patients (Group 1) received a fixed activity of 5.55 GBq/session. From 2001 to 2009, 16 patients (Group 2) were treated with 9.25-12.95 GBq/session.

RESULTS

As expected, the overall response rate in Group 2 are slightly better. The most important result of increasing the single session activity was the shorter median time to achieve a significant response (7 versus 19 months), which was obtained with a lower median cumulative activity (11 versus 22 GBq) in a lower median number of sessions (2 versus 7).

CONCLUSIONS

We demonstrated that intermediate single session activity shortened to one third the global treatment time, with similar efficacy and a moderate increment of toxicity. Consequently, the increase of (131)I-MIBG activity, without reaching myeloablative levels, can be recommended for standard treatment of pheochromocytoma and paraganglioma patients.

Individualized dosimetry in the management of metastatic differentiated thyroid cancer

AIM

This paper analyzes the available data on the dosimetric approach and describes the use of dosimetry in the Division of Nuclear Medicine of the National Cancer Institute in Milan. Dosimetry is rarely performed when planning radio-iodine activity, although most of the available guidelines do mention this possibility, without giving any well defined indication. Aim of the present research was to validate the usefulness of dosimetry in the management of metastatic thyroid cancer. Benua (1962) set the limit of blood absorbed dose at 2 Gy to avoid hematological toxicity. Maxon (1983) determined at 80 Gy the dose to achieve complete destruction of a metastatic lesion. Dorn (2003) combined red marrow and lesion dosimetry showing that high activity administrations with less that 3 Gy to the red marrow are a safe and more effective with respect to fixed activities administrations. Lee (2008) reported 50% responses with high activity administrations based on blood dosimetry, in 47 patients which were unsuccessfully previously treated with fixed activities. Sgouros (2005) and Song (2006) introduced key parameters as Biological Effective Dose and Uniform Equivalent Dose in order to describe the effects of continuous low dose rate irradiation and non uniform activity uptake, typical of nuclear medicine treatments.

METHODS

Red marrow and lesion dosimetry (planar view) were performed during the treatment, without changing the fixed activity schema.

RESULTS

This experience demonstrate first of all, that dosimetry is feasible in the clinical routine, and that it can provide the clinician with important information, no matter its often quoted limited numerical accuracy. A total of 17/20 lesion doses below 80 Gy have been detected. Three/17 (doses between 40 and 80 Gy) disappeared in the follow-up scintigram. Two/17 were undetectable at computed tomography or nuclear magnetic resonance. These data suggest that repetition of treatment on a lesion drastically reduces its uptake, with a loss of therapeutic efficacy along the sequence of fixed activity administrations.

CONCLUSIONS

The usefulness of dosimetry should not be assessed only on the basis of patient survival or therapeutic efficacy; the possibility to avoid useless treatments should also be considered. According to the authors, individualized dosimetry could improve the management of metastatic differentiated thyroid cancer. Even post-therapeutic dosimetry, as performed at this institution, has a significant impact on clinical decision-making. The question for the future is how to include dosimetry into the patient management framework.

Redifferentiating agents in non-radioiodine avid cancer

Thyroid cancer is the most common malignant cancer of the endocrine system. Treatment for well differentiated forms include surgery and radioactive iodine ablation. When cancer cells exhibit a less differentiated phenotype they may no longer be able to accumulate iodine, making 131-I administration ineffective. Recent studies have demonstrated the important role of therapeutic agents that have redifferentiating potential, leading to reactivation and expression of thyrocyte-specific genes, including those responsible for iodine uptake. This review will discuss the results of the most recent studies on drugs with redifferentiating properties and their application in patients with radioiodine refractory thyroid cancer.

MIBG for diagnosis and therapy of medullary thyroid carcinoma: is there still a role?

Medullary thyroid carcinoma (MTC) is a relatively rare neuroendocrine tumour originating from the parafollicular C cells and releases calcitonin (hCt), carcinoembryonic antigen (CEA) and occasionally other substances. In 20-30% of cases MTC presents a germline mutation of the RET proto-oncogene and occurs in 3 different hereditary forms: familial MTC, multiple endocrine neoplasia (MEN) 2A and MEN 2B syndrome. Prognosis of MTC is largely related to tumour extension at disease onset. Surgery remains the most effective therapy for potential cure. Overall survival is strictly linked to the occurrence of relapse. After surgery, serum hCt remains the most sensitive test for occult disease. Diagnostic imaging work-up includes ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), bone scintigraphy, as the more frequent sites of recurrence or metastases are cervical and mediastinal lymph nodes, lungs, liver and bone. Nuclear medicine procedures include (111)In-labelled somatostatin analogs, radioiodinated metaiodobenzylguanidine (MIBG), and several PET radiopharmaceuticals. Experience with radionuclide therapy in MTC is restricted to few patients treated with (131)I-MIBG or (90)Y-DOTATOC. Since 1987, 1 027 diagnostic MIBG scans were performed in the Department Department of Diagnostic Imaging and Therapy of the Istituto Nazionale Tumori IRCCS Foundation (Milan, Italy), 85 of which for MTC, with a sensitivity of 38.7% in patients with evidence of disease and 30.7 % if all patients were considered. Since 1994, 13 MTC patients were treated with MIBG with 4 partial responses and 4 stable diseases. Patients with liver or bone involvement responded to therapy and showed long-term partial remission of disease, others showed stability of disease, which was apparently unrelated to therapy. Improvement of efficacy can be achieved through dosimetric calculation of administered activity.

Lymphoscintigraphy with intraoperative gamma probe sentinel node detection: clinical impact in patients with head and neck melanomas

AIM

The aims of this paper were to evaluate the clinical relevance of lymphoscintigraphy with intraoperative gamma-probe detection in identifying sentinel nodes (SNs) and to study the prognostic value of SN biopsy in head and neck melanoma patients.

METHODS

Sixty-one patients had lymphoscintigraphy with intradermal injections of 99mTc-Nanocoll (40 MBq), 24 h before surgery. Tumor-positive SNs patients underwent total lymph node dissection. Postoperative histological examination was performed. Patients were followed up for 1 to 5 years (median 3 years). The tumor relapses and the overall survival were evaluated by means of statistical methods.

RESULTS

Lymphoscintigraphy showed lymphatic distribution to more than one basin in 45 patients (74%), in 15 patients one basin was visualized and no basin in 1 patient. In 41 patients the SN was negative for metastases, while in 20 was positive. In a high percentage of patients (30%), metastatic involvement occurred in more than one lymph node basin. During follow-up in the negative SN group, 40 patients remained disease free and 1 relapsed. In the positive SN group, 10 patients remained disease free and 10 relapsed. Recurrence time ranged from 6 to 11 months. The overall survival of the SNs negative group was significantly higher than the positive SN group.

CONCLUSIONS

This approach was able to distinguish: a) patients with tumor-negative SNs with a favorable clinical course (98% did not relapse, P<0.001); b) patients with tumor-positive SNs with a high rate of tumor relapse (50%, P<0.001). Therefore SN biopsy may give information about prognosis in head and neck melanoma patients.

Headache and intracranial hypotension: neuroradiological findings

The cardinal and classic features of postural headache and low cerebrospinal fluid (CSF) pressure in intracranial hypotension may not dominate the clinical picture of the syndrome and may be associated with additional various neurological symptoms and signs. Reports of unusual clinical presentations continue to appear in the literature. Despite the considerable variability of the clinical spectrum, neuroradiological studies reveal more constant and characteristic features. Brain MRI findings include intracranial pachymeningeal thickening and post-contrast enhancement, subdural fluid collections and downward displacement or "sagging" of the brain. Spinal MRI findings include collapse of the dural sac with a festooned appearance, intense epidural enhancement owing to dilatation of the epidural venous plexus, and possible epidural fluid collections. In fact, spinal studies may demonstrate CSF leakage from spinal dural defects, which are considered the most common cause of the syndrome. Myelo-MR may suggest the possible point of CSF leakage, by demonstrating an irregular root sleeve; myelo-CT and radioisotope myelocisternography (RMC) are often needed to confirm the point of CSF leakage. Neuroimaging studies are, therefore, essential for suggesting and confirming the diagnosis.

Gallium scan in adolescents and children with Hodgkin's disease (HD). Treatment response assessment and prognostic value

AIM

The aim of the present paper is to describe the accuracy of gallium ((67)Ga) scintigraphy in adolescents and children with Hodgkin's disease (HD). We have studied the diagnostic value of this nuclear imaging technique at disease presentation (staging) and its prognostic value based on changes in (67)Ga uptake observed after treatment (response assessment).

METHODS

From April 1985 to July 1999 74 consecutive untreated patients with a median age of 13 y underwent (67)Ga scans 48-72 h after injection of 37-111 MBq of (67)Ga-citrate. Planar whole-body scintigraphy was performed, supplemented with single photon emission tomography (SPET) of the mediastinum from 1996 onwards. Three patients did not undergo further scintigraphic examination because they were treated with radical surgery. After the 1st examination 71 of the 74 patients were monitored by 1-3 (67)Ga scans during the course of their disease. All of them had at least one (67)Ga scintigraphy at the end of the induction phase of chemotherapy, before any other therapeutic regimens were planned.

RESULTS

At disease presentation (67)Ga scintigraphy was positive in all patients, detecting 285 of 335 (85.0%) lymph nodal sites of disease. The best sensitivity was observed in the mediastinum (100%; 63/63) and the laterocervical supraclavicular region (85.6%; 125/146); it was lower for axillary (72.7%; 16/22) and retroperitoneal (68.7%; 11/16) lymph node masses. In detecting visceral involvement the sensitivity of (67)Ga scintigraphy was 66.6% (8/12) for lung and 80% (4/5) for bone involvement. Among 71 patients in follow-up, 2 showed rapid progression of disease during induction therapy while 69 patients were monitored for a long period. The response to therapy has been classified according to the changes observed on nuclear medicine or radiological images as complete response (CR) or partial response (PR). On the basis of (67)Ga scans 55 patients (72.4%) were considered as having a CR, while with radiological modalities (chest X-ray, CT, MRI) CR was observed in only 29 patients (40.8%). PR or progression was found with (67)Ga scintigraphy in 16 patients (22.5%) and with radiological modalities in 42 patients (59.1%). (67)Ga scan was concordant with clinical outcome in 97% (28/29). The diagnostic effectiveness of this imaging technique has been analysed by comparing the scintigraphic or radiological changes at the 1st scintigraphic/radiological follow-up examination after induction therapy with the clinical outcome. In this population the relapse rate was 50% (8/16) in the group that did not achieve a CR according to post-treatment (67)Ga scintigraphy, while it was only 10.9% (6/55) in the group that achieved a CR on the basis of scintigraphy findings. The overall survival (OS) and disease-free survival (DFS) were calculated by means of Kaplan-Meier cumulative survival plotting. When the 2 groups of patients with complete (CR) or incomplete normalisation (PR or progression) of (67)Ga scintigraphy were compared, both OS and DFS were found to be statistically different (p=0.0001 and p=0.0004, respectively). By contrast, no statistical difference was found when the radiological findings were considered as the criterion for assessment of tumour response. On the basis of X-ray results the relapse rate was 13.7% in patients with negative post-therapy findings and 23.8% in patients with positive radiological imaging.

CONCLUSION

Our data demonstrate the high value of (67)Ga scintigraphy in HD staging in paediatric patients. In addition, evaluation of the (67)Ga uptake is very useful as a prognostic parameter; changes in (67)Ga uptake after therapy indicate a favourable prognosis, whereas children still positive on post-treatment (67)Ga scintigrams should be given more aggressive treatment.

[Radioisotopic imaging of neuroendocrine tumours. Which radiopharmaceutical and which diagnostic procedure?]

Neuroendocrine tumours can be visualized by several nuclear medicine modalities based on different mechanisms of cellular uptake. The most widely used radiopharmaceutical are the metaiodobenzylguanidine (123I/131I MIBG) and pentetreotide (111In pentetreotide). The first tracer follows the metabolic pathway of norephinephrine while the second one binds to somatostatin receptors which are expressed with high intensity on the neuroendocrine tissue. Some radiopharmaceuticals (Anti-CEA, Anti-CgA, Anti-GD2 monoclonal antibodies) have today only an experimental value, others such as 99mTc(V)DMSA had in the past very limited indications (medullary thyroid cancer) but at present their production is going to be stopped. An interesting series of new peptides showing a great affinity for the receptors/structures expressed by the neuroendocrine tissue is under evaluation in order to obtain a better tumour specificity. Among the positron-emitting radiopharmaceuticals, the 18F-fluorodeoxyglucose (FDG), in spite it is considered the most widely used tracer for clinical PET in oncology, did not show a satisfactory uptake in the well differentiated neuroendocrine tissues. On the contrary 18F-FDG is the best radiopharmaceutical to visualize those rare poorly differentiated neurondocrine tumours with a high proliferative index. For this reason also in this area, new radiopharmaceuticals have been studies and developed. A serotonin precursor 5-hydroxytryptophan (5-HTP) labelled with 11C has shown an increased uptake in carcinoids. Another radiopharmaceutical in development for PET is 11C L-DOPA which seems to be useful in visualizing endocrine pancreatic tumours. 18F-DOPA whole body PET may be a more promising imaging approach. Aim of this review is to summarize the potential of nuclear medicine techniques in the diagnosis of neuroendocrine tumours and to stresses the renewed role of nuclear medicine in the management of this disease.

Role of 131I-metaiodobenzylguanidine (MIBG) in the treatment of neuroendocrine tumours. Experience of the National Cancer Institute of Milan

BACKGROUND

45 patients with neuroendocrine tumours (22 neuroblastomas, 10 phaeochromocytomas, 3 para-gangliomas, 6 medullary thyroid carcinomas and 4 carcinoids) underwent 131I-MIBG therapy.

METHODS

All patients, with the exception of 5 phaeochromocytoma cases with nonoperable disease, had previously been treated with conventional therapies. Patients had a previous diagnostic scintigraphy with 131I-MIBG (activity 20-44.4 MBq) or with 123I-MIBG (activity 74-222 MBq). The therapeutic activity for adults ranged from 3.7 to 7.4 GBq of 131I-MIBG; for children from 2.7 to 5.5 GBq. All treatments were repeated at not less than 4-weekly intervals. The neuroblastoma patients were divided into two groups: the first included 14 patients with advanced metastatic disease not responding to previous treatments; the second included 8 patients with documented residual neuroblastoma tissue that could not be surgically removed after first-line therapy.

RESULTS

In neuroblastoma patients with advanced disease resistant to previous therapies 2 out of 14 showed a partial response, 9 stable disease and 3 progression of cancer. In neuroblastoma patients with residual disease (7 evaluable out of 8) we obtained 3 partial responses; a stable response was observed in 3 patients. The results of MIBG therapy in the group of phaeochromocytoma patients (9 evaluable out of 10) consisted of 3 partial responses, 5 stable disease and 1 progression. Evaluation of the response carried out on the basis of biochemical parameters increased the responses and MIBG therapy showed good effectiveness in controlling the functional symptoms. In the group of paraganglioma patients we observed 1 complete, 1 partial and 1 stable response. In patients with medullary thyroid carcinoma a partial response was observed in 1 patient with mediastinal metastases and 2 disease stabilisations were seen in another 2 patients. Patients with carcinoids who underwent MIBG therapy showed 3 disease stabilisations. The overall toxicity was acceptable, especially considering that the majority of our patients had had previous myelotoxic treatments (chemotherapy and/or radiotherapy, alone or in combination).

CONCLUSIONS

On the basis of our experience we can conclude that 131I-MIBG therapy is effective and also well tolerated.

Imaging of neuroendocrine gastro-entero-pancreatic tumours using radiolabelled somatostatin analogues

Neuroendocrine tumours of the gastro-entero-pancreatic tract are an uncommon clinical entity and are believed to arise from the endocrine cells of the gastrointestinal tract. Somatostatin receptor imaging is a diagnostic tool which allows visualization of somatostatin receptor bearing tumours. This scintigraphic procedure is performed with indium-111 labelled octreotide, a somatostatin analogue, chelated with diethylene triamine penta-acetic acid. Radionuclide imaging consists in detecting the biodistribution of somatostatin receptors, normally expressed on the cell surface of neuroendocrine gastro-entero-pancreatic tumours. To date, five types of this receptor have been cloned: indium-111-labelled-pentetreotide can visualize tumours expressing type 2 and 5 receptors. The results of our study, which involved 81 neuroendocrine gastro-entero-pancreatic tumour patients, confirm the superior sensitivity of somatostatin receptor imaging (61%) for primary tumour evaluation with respect to conventional imaging modalities such as computed tomography (40%) or ultrasound (28%). Scintigraphic findings in metastatic liver disease proved to have a sensitivity of 89% for somatostatin receptor imaging, versus 81% and 88% for computed tomography and ultrasound, respectively. In 23% of patients, lesions were found with somatostatin receptor imaging which had been missed using the other diagnostic modalities; in 26% of the patients the therapeutic approach was modified after somatostatin receptor imaging.

Delayed intestinal visualization at hepatobiliary scintigraphy is associated with response to long-term treatment with ursodeoxycholic acid in patients with cystic fibrosis-associated liver disease

BACKGROUND/AIMS

Abnormalities of biliary drainage have been documented at hepatobiliary scintigraphy in many but not all patients studied with cystic fibrosis-associated liver disease. Ursodeoxycholic acid was shown to be beneficial in this disease, mainly by improving biliary secretion. Therefore, patients with impaired biliary drainage are expected to obtain the greatest benefit from this treatment.

METHODS

We evaluated the effects of long-term treatment with ursodeoxycholic acid in 36 patients with cystic fibrosis-associated liver disease, and compared the response in patients presenting a normal (n=18) or delayed time of intestinal visualization (n=18) at baseline hepatobiliary scintigraphy.

RESULTS

The mean treatment duration was 58+/-26 (S.D.) months and 63+/-29 months in the groups with normal or delayed time of intestinal visualization, respectively. The time of intestinal visualization decreased (57+/-23%, p<0.001) from baseline in patients with initially abnormal values and became normal in four (22%). Treatment failure, i.e. lack of sustained normalization of serum liver enzymes or the occurrence of a clinically relevant adverse event, was more frequently observed in patients with a normal time of intestinal visualization at baseline (OR, 5.50; 95% CI, 1.32-22.7). When only clinically relevant adverse events were considered, they occurred in six of the latter patients (liver transplantation in one case, development of ultrasographic or endoscopic signs of portal hypertension in six cases), but in only one patient (development of portal hypertension) in the group with delayed time of intestinal visualization (OR, 10.82; 95% CI, 1.17-100.4).

CONCLUSIONS

Delayed intestinal visualization at hepatobiliary scintigraphy in patients with cystic fibrosis-associated liver disease seems to predict a better response to ursodeoxycholic acid.

Can bone metabolism markers be adopted as an alternative to scintigraphic imaging in monitoring bone metastases from breast cancer?

Bone scintigraphy plays a major role in the diagnosis of bone metastases. The clinical utility of new biochemical markers of bone metabolism has recently been investigated in various bone diseases. This study evaluated the role of some bone metabolism markers in comparison with bone scan in the follow-up of breast cancer patients. We studied 149 patients with breast cancer, 33 (22%) of whom had bone metastases. IRMAs were used for the evaluation of blood levels of osteocalcin, bone alkaline phosphatase (BAP), the C-terminal propeptide of type I procollagen and the C-terminal cross-linked telopeptide of type I collagen (ICTP). Multivariate regression analysis showed that menopausal status (P=0.007) and metastatic bone lesions (P=0.001) affected bone marker levels. When considering post-menopausal women, the only subset in which bone metabolism marker behaviour could be reliably investigated, we found a high degree of overlap in marker distribution for scan-positive and scan-negative patients. Discrimination between scan-negative and scan-positive patients based on the above markers, taken singly or jointly, was assessed by means of logistic discriminant analysis. The best discrimination was achieved with BAP, closely followed by ICTP. BAP and ICTP together gave a slight improvement over the use of the two markers separately. However, even in this case the degree of discrimination was poor and its clinical utility was limited. In fact, to achieve a specificity of 95%, the sensitivity of the test was about 20%; conversely, with a sensitivity of 95%, the specificity was below 10%. In conclusion, based on our findings, we believe that blood levels of the investigated markers cannot replace bone scintigraphy in the follow-up of breast cancer patients for the early detection of bone metastases.

Follicular cell carcinoma of the thyroid in a child after bone marrow transplantation for acute lymphoblastic leukemia

Follicular cell carcinoma (FCC) of the thyroid is rarely found during childhood. We report a 12 1/2-year-old girl with acute lymphoblastic leukemia, who developed rapidly growing FCC of the thyroid, 3 years after bone marrow transplantation. The role of chemotherapy in the induction of such secondary tumors after transplantation is discussed, and a proposal for the approach to these patients is suggested.

Extended-field radiotherapy in favorable stage IA-IIA Hodgkin's disease (prognostic role of stage)

PURPOSE

The study was undertaken to evaluate the long-term results in a favorable subset of patients with pathological Stage IA-IIA treated with irradiation alone.

METHODS AND MATERIALS

One hundred and forty-seven adults with laparotomy- Staged IA-IIA "favorable" Hodgkin's disease were treated with primary subtotal nodal irradiation. Patients with infradiaphragmatic presentation were irradiated through paraortic and inguino-iliac node chains (inverted Y field) followed by prophylactic mediastinal and supraclavicular fields.

RESULTS

Actuarial overall survival (OS) at 7 years (median follow-up 77 months) was: 93% for the whole series, 94% for Stage I, and 92% for Stage II. The freedom from first progression (FFP) (80% for the whole series) showed a statistically significant difference (p = 0.008) between Stage I (88%) and Stage II (71%). By univariate analysis, stage alone had an independent prognostic significance for OS and FFP. Of the 29 relapsed patients, 8 were previously classified as Stage I and 21 as Stage II; 16 of 29 (55%) of the relapses occurred in the pelvis and 9 in extranodal sites. After salvage treatment with chemotherapy all patients achieved a second complete remission. Seven second malignancies (two acute nonlymphocytic leukemias, one preleukemic syndrome, and four solid tumors) have been detected so far. Hypothyroidism was observed in 16% of patients and a reversible pulmonary restrictive syndrome in 14% of cases, respectively.

CONCLUSIONS

Within 7 years from radiation therapy, about one-quarter of the patients with Stage II disease will experience a relapse and need intensive salvage chemotherapy. This is not invariably successful and safe, for it may be complicated by either acute or potentially fatal long-term adverse effects, such as second malignancies and cardiac or pulmonary sequelae, in about 5% of patients. The high frequency of relapse in Stage IIA patients suggests a combined modality approach with relatively short-term chemotherapy not including alkylating agents.

Scintigraphic detection of melanoma metastases with a radiolabeled benzamide ([iodine-123]-(S)-IBZM)

Iodine-123-(S)-2-hydroxy-3-iodo-6-methoxy-N-[(1-ethyl-2-pyrrolidinyl) methyl] benzamide ([123I]-(S)-IBZM) is a radiolabeled benzamide usually employed to study neuropsychiatric disorders, such as schizophrenia and Parkinson's disease. The ectodermic origin of melanocytes and the presence of melanin in the substantia nigra are the theoretic basis of the experimental use of this class of tracers for melanoma imaging.

METHODS

Eleven patients with proven metastatic melanoma entered the study. Whole-body and planar scintigrams were performed 2, 4 and 24 hr after intravenous injection of a mean tracer activity of 205 MBq. The dosimetric evaluation was performed by the Medical Internal Radiation Dose Committee method.

RESULTS

The [123I]-(S)-IBZM scans allowed the detection of all six cutaneous lesions, five of six superficial pathologic lymph nodes, four of five pulmonary and one of two hepatic metastases. The maximum tumor-to-background ratio was 2.6 in planar images. The hepatobiliary excretion of the tracer may limit detection of intra-abdominal lesions. Dosimetry is similar to data for nononcologic patients.

CONCLUSION

Although it is unclear if the mechanism of radiopharmaceutical uptake in melanoma is due to binding to membrane receptors or due to interactions with intracellular structures, radiolabeled benzamide is a promising tracer to detect melanoma.

Thymidine kinase (TK) activity as a prognostic parameter of survival in lymphoma patients

ATP-thymidine 5'-phosphotransferase (TK) is a cellular enzyme involved in DNA synthesis, activated during the G1/S phase of the cell cycle. Elevated TK serum levels can be found in cancer patients due to the active proliferation of tumor cells. TK serum activity was tested by a radioenzymatic technique (Prolifigen TK REA, Sangtec Medical, Sweden) based on the conversion of 125 I deoxyuridine to 125 I deoxyuridine monophosphate. A total of 181 patients were enrolled in this study: 133 lymphomas (Hodgkin, HL and Non-Hodgkin, NHL) 48 benign diseases including acute (n = 17) and chronic inflammatory diseases (n = 13), myocardial infarction (n = 11), liver cirrhosis (n = 2), renal failures (n = 2), and diabetes (n = 3). Lymphoma patients were classified according to the Ann Arbor staging system, and 103 NHL patients were classified according to the Working Formulation histologic grade (21 low, 72 intermediate, and 10 high grade lymphomas). The patients were treated with standard chemo-radiotherapeutic protocols according to the stage and the histologic grade; the evaluation of the response to the treatments and the follow-up were performed according to the serial examinations currently used in our Institute. Given a TK cut-off of 5 U/L, the diagnostic sensitivity of TK test at lymphoma presentation was 81.8% and 75.7% in HL and NHL patients, respectively. Values exceeding 50 U/L were found only in NHL patients. The overall sensitivity of TK resulted higher than that of LDH (16.7%), copper (42.6%), IgG (23.5%), IgM (26.8%) and IgA (9.8%).(ABSTRACT TRUNCATED AT 250 WORDS)

Papillary thyroid carcinoma after total body irradiation

Two children developed papillary thyroid carcinoma after allogeneic bone marrow transplantation (BMT) probably due to radiotherapy during remission and pretransplantation conditioning. Establishing a relationship between the cellular thyroid stimulating hormone (TSH) effect and development of carcinoma in cases with high serum TSH concentrations is difficult. After BMT, patients should be regularly followed up with thyroid ultrasound and, when nodularity is found, fine needle aspiration and/or open biopsy are recommended.

Congenital renal damage associated with primary vesicoureteral reflux detected prenatally in male infants

To assess the course of vesicoureteral reflux, we performed cystography, renal scintigraphy, and urography in all neonates with the prenatal diagnosis of renal pelvic dilation and revealed the presence of primary reflux (grades I to V) in 27 cases. Higher grades of reflux were associated with congenital renal damage, as shown by reduced tracer uptake during scintigraphy. Reflux was diagnosed more frequently in male infants (male/female ratio, 6:1), in many of whom bladder abnormalities were found by cystography. In another group of seven infants, in whom the reflux was associated with other urologic abnormalities, there was no sex prevalence. We conclude that severe primary reflux associated with hydronephrosis usually affects male infants and may be due to abnormal embryologic development of the male urethra, and that the kidney damage is primary and not the result of urinary tract infections. This pattern differs from that of vesicoureteric reflux diagnosed at an older age, which is observed most commonly in female patients.

Current role of gallium scan and magnetic resonance imaging in the management of mediastinal Hodgkin lymphoma

BACKGROUND

A residual mediastinal mass after treatment represents a common diagnostic problem in the management of patients with Hodgkin lymphoma (HD). Conventional diagnostic radiology, computed tomography (CT), or ultrasonography (US) do not adequately reflect changes as fibrosis or necrosis. Gallium-67 (67Ga) imaging has been proven to be useful for the evaluation of HD in the mediastinum. The authors compared the ability of gallium scan and magnetic resonance imaging (MRI) to evaluate the mediastinal disease in the follow-up of patients with HD.

METHODS

Thirty-four patients previously treated for HD were investigated with gallium scan, MRI, and all the other investigations to evaluate the mediastinal region. Sixteen patients were in restaging after treatment, and 18 were investigated for suspected radiologic recurrence in the mediastinum (follow-up, 9-75 months). The results of gallium scan and MRI were matched with clinical findings during the follow-up.

RESULTS

A sensitivity of 85.7% for 67Ga and 92.8% for MRI was found, while the specificity was 100% for the scan and 80.6% for MRI. The predictive positive value that resulted was 100% for 67Ga and 68.4% for MRI.

CONCLUSIONS

Both examinations were accurate in assessing the activity of residual masses in the mediastinum after treatment. 67Ga showed a lower sensitivity in comparison with MRI, but 67Ga frequently overestimates the presence of pathologic tissue. The authors acknowledge the complementary role of these two tests, but if only one of these examinations can be performed for logistic or economic reasons, then gallium scan represents the single most adequate diagnostic procedure.

[123I]IBZM uptake in metastatic melanoma

In this report we describe our experience with [123I]IBZM ([123I]-(S)-2-hydroxy-3-iodo-6-methoxy-N-[(1-ethyl-2-pyrrolid inyl)methyl] benzamide), used to image the lesions in a female patient affected by metastatic melanoma. Marked uptake of [123I]IBZM in an area corresponding to a palpable lymph-nodal mass was observed in images collected 2 and 5 hours after i.v. tracer administration. Tumour to non-tumour ratios evaluated on planar maps were found to be 2.04 and 2.35, respectively. Surgical excision and histological examination of inguinal nodes confirmed the presence of melanoma lymph-nodal metastases. Although scintigraphy with radiolabelled [123I]IBZM is widely used for neuro-psychiatric disorders, we have found no reports in the literature of any application of this tracer in oncology. Even if the biological bases underlying the findings reported here remain unclear (although they are probably related to the neural crest origin of the melanocytes), the quality of imaging found suggests that this tracer may provide a new diagnostic tool for the imaging of melanoma tumours.

Scintigraphic documentation of an improvement in hepatobiliary excretory function after treatment with ursodeoxycholic acid in patients with cystic fibrosis and associated liver disease

We have previously documented that ursodeoxycholic acid exerts a beneficial effect on liver function and bile acid metabolism in patients with cystic fibrosis. We hypothesized that the mechanism of action may be related in part to the choleretic properties of the administered bile acid. We therefore compared hepatobiliary scintigraphic images obtained before and 1 yr after initiation of ursodeoxycholic acid therapy to document an improvement in bile flow in 13 patients with cystic fibrosis and hepatobiliary involvement. Before therapy, hepatobiliary scintigraphy documented biliary stasis with retention of the isotope in intrahepatic and extrahepatic bile ducts in nine patients; during therapy, duct dilatation decreased substantially in eight patients, with decreased intrahepatic retention and more rapid biliary outflow of the tracer. The time of appearance of isotope in the intestine decreased (from a mean of 36.9 +/- 17.8 min to 18.8 +/- 9.0 min; p less than 0.01) in all patients in whom it had been abnormal, and the half-time of hepatic washout decreased from a mean of 35 +/- 20.7 min to 26 +/- 15.6 min (p less than 0.05). During ursodeoxycholic acid administration enrichment of bile was achieved, with the mean ursodeoxycholic acid percent composition increasing from 5.8% +/- 2.9% to 35.7% +/- 8.5%. Ursodeoxycholic acid became the predominant bile acid in serum. Liver function improved in all 10 of the patients with abnormal values at baseline. We conclude that hepatobiliary scintigraphy is of value in monitoring the therapeutic responses of cystic fibrosis patients with liver disease to ursodeoxycholic acid therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Single determination of CA 15.3 and bone scintigraphy in the diagnosis of skeletal metastases of breast cancer

Single determination of CA 15.3 and bone scintigraphy were performed on the same day as follow-up procedures in 864 patients with breast cancer. The sensitivity and specificity of bone scintigraphy for skeletal metastases were 99% and 88.8%, respectively. The overall sensitivity and specificity of CA 15.3 (cut-off for pathological values greater than 30 U/mL) for cancer recurrence or distant metastases were 69.2% and 92.1%, respectively. The sensitivity of CA 15.3 for bone metastases was lower (69.4%) than that of bone scintigraphy. This was mainly due to the relatively high proportion of false-negative CA 15.3 levels in patients with 1-2 bone metastases (sensitivity = 33.3%). According to this result, the circulating levels of CA 15.3 showed a good correlation with tumor extension and, in patients with bone metastases, with the number of skeletal lesions. As regards the contribution of CA 15.3 to the diagnosis of bone metastases, the demonstration of elevated CA 15.3 values in patients with positive bone scintigraphy could support the diagnosis of skeletal metastases. In fact, the positive predictive value of CA 15.3 in patients with positive bone scintigraphy was significantly higher than with only bone scintigraphy (53.8%) or CA 15.3 (50.4%). Finally, very high values of CA 15.3 in patients with known bone metastases could indicate the presence of visceral metastases (mean CA 15.3 in patients with bone metastases = 125.8 U/mL; mean CA 15.3 in patients with bone and visceral metastases = 420.5 U/mL).

[131I]metaiodobenzylguanidine therapy in carcinoid tumors

Our experience with [131I]metaiodobenzylguanidine (131I-MIBG) therapy in two patients with carcinoid tumor is described. These patients were selected because of multiple areas of uptake on 131I-MIBG scan, consistent with the extent of the disease. Both patients presented diarrhea and liver metastases. Para-aortical lymphonodes and skeletal metastases were present in the first and the second patient, respectively. Previous treatment involved r-alpha-interferon, surgery or radiotherapy. In both cases 131I-MIGB therapy was started in December 1990 and is still continuing. No haematologic or hepatic side-effects have been observed. Mild hypotension (90/60 mmHg) occurred in one patient during the first course of therapy and was resolved by corticoid treatment. A stabilization of disease and a progressive reduction of diarrhea have been observed in both patients. In the second patient an initial decrease in liver metastases was confirmed by ultrasonography 7 months after the beginning of therapy.

[131I]metaiodobenzylguanidine therapy in paraganglioma

Our experience with [131I]metaiodobenzylguanidine (131I-MIBG) therapy in a 10 year old boy is reported. At disease onset, in May 1988, this boy presented a large mass in the upper left abdominal quadrant, which was resected with a histopathological diagnosis of extra-adrenal malignant pheochromocytoma (paraganglioma). He subsequently underwent two further surgical resections and chemotherapy. When 131I-MIBG therapy was started, in June 1990, skeletal and abdominal metastases were present. These localizations were revealed by 131I-MIBG scans and confirmed by x-ray examination. At present 6 courses of therapy have been performed with a cumulative activity of 29.6 GBq. Side-effects have been limited to vomiting and mild thrombocytopenia, lasting 2 weeks during the second course of therapy. After 15 months of therapy, a progressive reduction of MIBG uptake, coupled with a stabilization of the lythic lesions, has been observed.

Experience with palliative [131I]metaiodobenzylguanidine therapy in advanced neuroblastoma

Our experience with palliative [131I]metabenzylguanidine (131I-MIBG) therapy in 7 patients (6 children and 1 adult) affected by advanced neuroblastoma is reported. All patients (classified as IV stage) showed a progression following initial intensive therapy, including chemotherapy and, in some cases, hemi-body irradiation and surgery for their primary tumor. 131I-MIBG activity ranged for a single course between 2.77 GBq to 5.55 GBq on the basis of age, intensity of uptake, and the hematological assessment. Four patients received only one course of therapy due to progressive disease (2), early death (1) or persistent thrombocytopenia unrelated to 131I-MIBG therapy (1). Two patients received two courses and showed a partial response lasting 4 months and stable disease lasting 3 months respectively. Therapy was thereafter discontinued due to progression. One patient received 4 courses of therapy (cumulative activity = 19.61 GBq) in 5 months. A partial response for 9 months in the bone metastases was documented, but the therapy was discontinued due to persistent thrombocytopenia (58,000 plts/microL) lasting 4 months. Thrombocytopenia was the major side-effect, occurring in 5/7 patients over 8 courses of therapy for a mean period of 37 days (7-120 d). Thus, in our experience thrombocytopenia is the major factor limiting the therapeutic effect of 131I-MIBG therapy in palliative treatment.