Umbilical metastatic deposit from recurrent cholangiocarcinoma: F18-FDG PET-CT findings.

A 69-year-old woman was diagnosed with stage IIIA advanced Type IV Klatskin cholangiocarcinoma, which was treated with radical choledochectomy, extended right hepatectomy and left hepaticojejunostomy. About six months after surgery, she presented with painless jaundice. A 2-18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (F18-FDG PET-CT) was performed, which detected an FDG-avid umbilical metastatic nodule. We describe the F18-FDG PET-CT features of umbilical metastatic nodule in recurrent cholangiocarcinoma. It is sometimes difficult to detect the lesions when they present with non-specific soft tissue thickening on routine CT imaging. F18-FDG PET-CT would probably render these lesions easier to detect and interpret.

Role of Tc-99m DMSA (V) scanning and serum calcitonin monitoring in the management of medullary thyroid carcinoma.

INTRODUCTION: Medullary thyroid carcinoma (MTC) is a rare disease. Serum calcitonin levels and Tc-99m DMSA (V) scans are used in the follow-up of these patients after surgical resection. We present our experience in the follow-up of these patients at a tertiary institution. METHODS: A retrospective review of the medical records was performed. Patients with histologically-proven MTC, and who had serum calcitonin assays and DMSA (V) scans in their postoperative follow-up, were included. RESULTS: There were 17 patients with 56 DMSA (V) scans. Four out of seven patients with elevated preoperative calcitonin measurements had calcitonin normalisation within six months of surgery, and have remained disease-free. Two patients had persistently elevated calcitonin levels after six months, which predated positive DMSA (V) scans. Results of DMSA (V) scans and serum calcitonin levels were concordant in 38 of 48 instances (79.2 percent) and discordant in 10 of 48 instances (20.8 percent). Sensitivity of DMSA (V) scans for detecting recurrence was 71.4 percent. There were no false-positive scans. CONCLUSION: Serum calcitonin level is a sensitive and specific indicator of disease recurrence in postoperative follow-up of patients with MTC. Early (within six months) normalisation of calcitonin levels postsurgery may predict subsequent disease-free status. Discordant results between serum calcitonin levels and DMSA (V) scans may be due to undetectable lesions and follow-up scans or alternative radionuclide imaging may be required.

Effect of inhalation of salbutamol, beclomethasone dipropionate & ipratropium bromide on mucociliary clearance in some patients with chronic stable bronchial asthma.

BACKGROUND & OBJECTIVES: Asthma is now regarded as an inflammatory disease and bronchial inflammation may disrupt mucociliary function. Inhaled drugs may act by improving mucociliary function. The aim of the study was to investigate the effect of salbutamol, ipratropium bromide and beclomethasone on mucociliary clearance in patients with chronic stable asthma and to compare the efficacy of these drugs on mucociliary clearance. METHODS: Ten patients with chronic stable asthma were enrolled in the study, but two patients did not complete the study. Patients with bronchial asthma were chosen on clinical grounds. (99m)Tc phytate radioaerosol generated through a nebulizer, was given to each patient on four days. After each administration the radioactivity over the thorax was constantly measured in sequential frame mode for 120 min. Radioactivity in the thorax was also measured after 24 h. A base-line pulmonary function test with reversibility was obtained. Salbutamol, ipratropium bromide, beclomethasone dipropionate and placebo inhalation were given randomly to each patient on four days. RESULTS: The mean age of patients (n = 8) was 36 +/- 9.3 yr and mean duration of symptoms was 5 +/- 6.6 yr. There was no visual impression that mucociliary clearance was enhanced with any of the drugs. The time activity curves did not show any visually recognisable change in slope. In only one patient the curve tended to show a steeper slope with ipratropium inhalation. In the rest of the patients the curves showed no difference at all with medication when compared with placebo. All the quantitative indices analyzed by two-way ANOVA at the end of one and two hours were comparable for the three test drugs and placebo. None of the three test drugs demonstrated statistically significant mucociliary clearance effect compared with placebo. However, the temporal difference in airways clearance efficiency (ACE) was significant with beclomethasone and ipratropium bromide. INTERPRETATION & CONCLUSION: Inhalation of any of the three drugs tested did not produce any immediate improvement in mucociliary clearance as compared to placebo in patients with stable bronchial asthma suggesting the need for further studies using higher doses of drugs for longer duration in a large sample.

Scintigraphic patterns of lymphocele in post-renal transplant.

Lymphocele is a common cause of fluid collection in post-renal transplant patients. Most of these patients are routinely followed up with 99mTc diethylenetriaminepentaacetate renal dynamic scintigraphy. The present study retrospectively reviews the range of findings with renal dynamic scintigraphy in documented lymphoceles. A lymphocele was diagnosed when there was a pelvic collection on ultrasonography with a similar biochemical composition to plasma. Four types of scintigraphy patterns were noted in lymphocele in a total of 13 patients. In nine patients there was an initial photopenic area, which progressively filled up with tracer activity equal to that of the background level in delayed images. In two other patients, the activity in the initial photopenic area exceeded the background activity in delayed images. A persistently photopenic area was seen in early and delayed images in the two remaining patients. In addition, a rim of increased tracer activity was noted surrounding the photopenic area in four patients in the early images. In conclusion, an initial photopenic area (with or without a surrounding rim of increased tracer activity), which fills up with tracer in delayed images seems to be the most common pattern seen in lymphoceles in scintigraphic studies of renal transplants. The presence of a rim sign may add confidence to the reporting of a collection as a lymphocele.

Imaging bacterial infection with (99m)Tc-ciprofloxacin (Infecton).

AIMS: The diagnosis of deep seated bacterial infections, such as intra-abdominal abscesses, endocarditis, and osteomyelitis, can be difficult and delayed, thereby compromising effective treatment. This study assessed the efficacy of a new radioimaging agent, Tc-99m ciprofloxacin (Infecton), in accurately detecting sites of bacterial infection. METHODS: Eight hundred and seventy nine patients with suspected bacterial infection underwent Infecton imaging and microbiological evaluation. The sensitivity and specificity of Infecton in detecting sites of bacterial infection were determined with respect to Centres of Disease Control, World Health Organisation, and Dukes's criteria. RESULTS: Five hundred and seventy four positive and 295 negative images were produced. These included 528 true positives, 46 false positives, 205 true negatives and 90 false negatives, giving an overall sensitivity of 85.4% and a specificity of 81.7% for detecting infective foci. Sensitivity was higher (87.6%) in microbiologically confirmed infections. CONCLUSIONS: Infecton is a sensitive technique, which aids in the earlier detection and treatment of a wide variety of deep seated bacterial infections. The ability to localise infective foci accurately is also important for surgical intervention, such as drainage of abscesses. In addition, serial imaging with Infecton might be useful in monitoring clinical response and optimising the duration of antimicrobial treatment.

Is (99m)Tc-sestamibi scintimammography complementary to conventional mammography for detecting breast cancer in patients with palpable masses?

UNLABELLED: The aim of this trial was to evaluate in developing countries from different regions the diagnostic performance of (99m)Tc-sestamibi scintimammography (SM) in palpable breast lesions and to verify the clinical usefulness of a joint evaluation with mammography and SM. METHODS: From 10 countries, a total of 238 patients with palpable breast masses (n = 245) were included in this prospective multicenter trial. Prone SM was performed 10 min and 60-90 min (157 patients) after injection using an isotime acquisition of 10 min. Mammography was assessed by the same dedicated imaging radiologist according to breast imaging reporting and data system (BI-RADS) categories for malignancy and breast density. Masked SM findings and mammography findings were checked for a correlation with histopathology findings for excisional biopsy samples. Diagnostic values for breast cancer detection were calculated per lesion. RESULTS: Histopathology revealed 189 cancerous lesions and 56 benign lesions. The sensitivity and specificity of SM were 0.83 and 0.77, respectively. SM diagnostic values did not depend on the incidence of breast cancer in the country of origin or on the timing of imaging (early vs. delayed scans). On mammography, the technique yielded a sensitivity and specificity of 0.85 and 0.66, with 27 mammograms classified as BI-RADS category 1, 33 as category 2, 5 as category 3, 56 as category 4, and 124 as category 5. Thirty-seven lesions were considered to show increased radiologic density. No significant difference was found in SM diagnostic values among different BI-RADS categories or between the groups with low and high breast density. A sensitivity of 96% was calculated when SM and mammography results were combined, with 75% of all false-negative mammography findings classified as true-positive results by SM. CONCLUSION: SM complements mammography in patients with palpable masses and negative mammography findings.

Clinical features of differentiated thyroid carcinoma in children and adolescents from a sub-Himalayan iodine-deficient endemic zone.

Northern India is an identified sub-Himalayan iodine-deficient endemic zone. We retrospectively analysed the case files of children with differentiated thyroid carcinoma from this endemic zone and attempted to define the disease in terms of its presentation, clinical course and outcome of radioiodine therapy. Between 1967 and June 2000, 1135 patients with thyroid cancer were treated in our centre and 80 (7%) were less than 20 years of age. There were 45 females and 35 males. Histologically, 85% of patients had papillary carcinoma and the rest follicular carcinoma. Cervical lymph node involvement was seen in 66% of patients, and distant metastasis, mainly pulmonary, in 29%. In children less than 10 years of age, 75% of patients had distant metastasis at the time of presentation. The post-surgery 48 h radioiodine neck uptake was 12.2+/-9.6%. Ninety-six per cent of the residual thyroid, 90% of nodal metastases and 57% of pulmonary metastases were ablated. Although nine patients had nodal recurrence between surgery and radioiodine treatment, no recurrence was observed thereafter, and three disease-related deaths (all in children less than 10 years of age) were seen in the mean follow-up of 6 years. We conclude that, except for the relatively higher incidence of follicular thyroid cancer and the higher mortality in the less than 10 year age group, the course and outcome of differentiated thyroid carcinoma in children from iodine-deficient areas is no different from that in children in iodine-sufficient areas.

Radioiodine kinetics and thyroid function following the universal salt iodization policy.

BACKGROUND: Universal salt iodization was introduced in Delhi in 1989. The present study quantifies the change in iodine kinetics as a result of this. The previous values were reported 10-30 years earlier, when Delhi was iodine deficient. METHODS: Thirty subjects (18 men and 12 women, 17-48 years of age) who were residents of Delhi and had no thyroid disorder, were recruited from our outpatient clinic in 1999. The 24-hour urinary excretion of iodine and the iodine content of salt consumed at home by these subjects were estimated. Kinetic studies of iodine using radiotracer 131I were done to determine thyroid iodine clearance, renal iodine clearance, percentage uptake and absolute iodine uptake by the thyroid gland, and plasma inorganic iodine. RESULTS: The median 24-hour urinary iodine excretion was 341.3 micrograms. The mean (SD) thyroid uptake of radioactive iodine was 4.9 (2.3)% at 2 hours and 19.1 (8.0)% at 24 hours. The median calculated plasma inorganic iodine was 1.36 micrograms/dl, absolute iodine intake 6.5 micrograms/hour and thyroid iodine clearance was 4.8 ml/minute (geometric means 1.68 micrograms/dl, 8.5 micrograms/hour and 8.1 ml/minute, respectively). The serum thyroid hormones and thyroid stimulating hormone were within normal limits. CONCLUSION: Compared to the values reported 10-30 years ago when the population was iodine deficient, the present urinary iodine excretion, plasma inorganic iodine and absolute iodine intake have increased, while the percentage thyroid uptake of iodine ingested and thyroid clearance have decreased. The lack of change in the serum thyroid hormone levels after 10 years of universal salt iodization indicates that iodine consumption has had no adverse effect on thyroid function in these normal individuals. These changes are consistent with the increase in iodine consumption. Since the iodine ingestion in a community may change with time, assessment of iodine kinetics should be done periodically in different regions of the country.

Individual kidney glomerular filtration rate in the interpretation of non-diagnostic curves on captopril renography.

Captopril renography is known to have low sensitivity in the detection of renovascular disease in patients with bilateral renovascular disease and in patients with unilateral renovascular disease with a small kidney. In these groups of patients, we have tried to make the standard captopril renogram more objective by simultaneously estimating the individual kidney glomerular filtration rate (IKGFR). Twenty-five patients (10 bilateral, 15 unilateral) with angiographically proven renal artery stenosis (RAS) were studied. Ten renal units in five hypertensive patients with normal renal arteries were used as controls. A fall of more than 10% in IKGFR post-captopril was considered a positive result. The sensitivities of renogram and IKGFR in patients with bilateral RAS were 52.9% and 88.2% respectively. In patients with unilateral RAS, the sensitivities of renogram and IKGFR were 30% and 80% respectively. A significant fall in IKGFR was noted in eight of the 15 'normal' renal units of the unilateral RAS group. In conclusion, individual kidney GFR estimation in combination with captopril renography improved significantly the sensitivity in patients with symmetrical bilateral RAS and unilateral RAS with a small, poorly functioning kidney. A fall in GFR in the normal counterpart of a unilateral RAS kidney may be indicative of ongoing damage in the non-involved kidney.

Bone scanning for bone metastasis in carcinoma cervix.

AIM: Bone metastasis in cervical cancer is rare. With the aim of defining the frequency of bony metastasis in patients of carcinoma cervix, with clinical suspicion of metastasis, we performed bone scan in 38 such patients. RESULTS: Twelve out of the 38 patients were confirmed as having metastasis. All the patients were also detected by bone scan (100% sensitivity). CONCLUSION: Bone scan should be investigation of choice for screening patients of carcinoma cervix with symptoms suggestive of metastasis in all stage of the disease. Bone scan is the most sensitive method for detection of bone metastasis. Bone scan offers the additional advantages of allowing a review of the kidney size to look for ureteric involvement and subsequent hydronephrosis.

Spontaneous perforation of the common bile duct in infancy: role of Tc-99m mebrofenin hepatobiliary imaging.

A 2-month-old infant had jaundice that began 3 days after birth. The clinical features were suggestive of biliary obstruction. Tc-99m mebrofenin hepatobiliary imaging confirmed the diagnosis of spontaneous perforation of the common bile duct, and surgical intervention resulted in progressive recovery.

Gastro-intestinal effects of Indian spice mixture (Garam Masala).

Spices are a part of diet all over the world but the variety and quantity consumed in tropical countries is particularly significant. The intestinal transit time of Indians is shorter, and their stool weight larger than that of Europeans on a comparable fibre intake. Ingestion of chilli is associated with a faster whole gut transit time. There is hardly any human work on the effects of spices on intestinal transit or gastric emptying. To explore the effects of spices on gastro intestinal transit this study was conducted on 18 well nourished healthy human adult volunteers using Radiolabelled Idli with or without Garam Masala. On gastric scintigraphy the gastric emptying time was much faster in subjects when spicy meal was given. The t1/2 of the spicy meal, 40.09 +/- (p < 0.05) thus implying a faster transit through the stomach. In 17 out of the 18 subjects t1/2 of the spicy meal was consistently lower than that of spicefree meal. The lag phase of gastric emptying showed no significant difference. There was a tendency towards slower gastrocolic transit with Spicefree meal but more subjects need to be done to confirm this.

Double blind controlled trial of effect of cisapride on gastric emptying in diabetics.

AIMS: Diabetic gastroparesis is a common complication seen in 20-50% of patients due to autonomic neuropathy involving vagal supply. Cisapride, a specific gastrointestinal cholinomimetic agent may thus be effective. METHODS: Fifty-one diabetic patients (age 12-65 years) of disease duration > 5 years were assessed for symptomatic gastroparesis, other diabetic complications and glycemic control. Gastric emptying time (GET) was estimated using a solid meal method (99mTc labeled rice based idli) and patients randomized to receive either cisapride or placebo for a period of 2 weeks. Cisapride was administered in a dose of 10 mg TID. GET and symptom scores were reassessed on the therapy after 2 weeks. RESULTS: Twenty nine of 51 (56.8%) patients had gastroparesis. Mean GET in the gastroparesis group was 141 +/- 66 minutes compared to 24.53 +/- 10 minutes in the non gastroparesis group (p < 0.01). GET decreased by 72% amongst the patients who received cisapride compared to 23% in the placebo group (p < 0.001). Symptom scores also improved in the cisapride group; no adverse effects were noted. CONCLUSIONS: Cisapride improves the symptom score and the solid gastric emptying time in patients suffering from diabetic gastroparesis.

A distance-assisted training program for nuclear medicine technologists.

We have developed training materials for nuclear medicine technologists to be used in distance-assisted training programs. We have completed our first pilot project in Asia and report that there will be nearly 500 students around the world, in Asia, Africa, Central America and South America, using our materials during the coming year.

Masked polycythaemia vera in a patient with extrahepatic portal venous obstruction.

Myeloproliferative disorder (MPD) is an important cause of thrombosis of the hepatic and portal venous system. The diagnosis in many of these patients is missed as they have an atypical clinical presentation and may have a normal haematological profile at presentation. We report a 30-year-old patient with features of portal hypertension due to extrahepatic portal venous obstruction. She had a normal haemoglobin level and haematocrit at presentation, but the red cell mass was found to be elevated even in the presence of low serum iron levels. A diagnosis of polycythaemia vera as the underlying disease was made.

Somatic growth and renal function after unilateral nephrectomy for Wilms' tumor.

Solitary kidneys in renal donors and patients who have undergone unilateral nephrectomy for malignant disease have been reported to undergo hyperfiltration injury. This study was undertaken to evaluate the somatic growth and development of followed-up patient after Wilms' tumor to evaluate their renal function and identify any evidence of injury in the remaining kidney. The growth and development of all the children was found to be normal, as was DTPA clearance. Microalbuminuria in 24-h urinary collections was detected in 84% of the patients, indicating evidence of hyperfiltration injury. This study highlights the need for close monitoring of the renal function of long-term follow-up patients after Wilms' tumor in addition to the routine monitoring for tumor recurrence.