Risk management of radioiodine treatment in differentiated thyroid cancer.

INTRODUCTION: Patient safety is paramount in providing quality healthcare and constitutes a global concern for healthcare systems. Radioiodine treatment to patients with well-differentiated thyroid cancer is not without risks. The aim of this study is to identify, evaluate and mitigate the risks associated with this procedure. MATERIALS AND METHODS: A single-centre descriptive study was conducted in which risk management was carried out by establishing a risk map using FMEA methodology. RESULTS: Based on the process map 6 sub-processes and 23 failure modes in the three phases of the treatment process were analysed. According to risk priority number (RPN), the sub-process with the highest risk was administrative management (RPN 82), followed by treatment per se and post-treatment imaging (both with RPN 70). An overall process RPN of 300 (156 pre-treatment, 74 treatment and 70 post-treatment) was obtained. Failures directly related to the patient pose a high risk. The implementation of verification systems, performing tasks earlier and providing quality medical information are the most relevant preventive measures to be implemented. CONCLUSIONS: The application of the FMEA methodology in the risk management for radioiodine treatment is a valuable tool for improving the quality and safety of this process. The risk map has been able to identify failures at different stages, assess their causes and effects, prioritise the risks identified and implement preventive and corrective measures that can be monitored, ensuring the effectiveness of the actions taken.

[Fibrous dysplasia of the bone. Contribution of nuclear medicine in the diagnosis of suspicion of sarcomatous degeneration]. / Displasia fibrosa ósea. Aportación de la Medicina Nuclear al diagnóstico de sospecha de degeneración sarcomatosa.

Fibrous dysplasia (FD) is a relatively frequent benign disease of the bone in which there is a maturation disorder of the bone-forming mesenchyme where the lamellar bone marrow is replaced with abnormal fibrous tissue. Its diagnosis is often an accidental finding when X-ray studies or bone scans are performed for other reasons since it is usually asymptomatic. There may be complications such as deformities, pathological fractures and exceptionally malignant transformation. The differential diagnosis between malignancy and FD can be complicated and lead to late diagnosis when sarcomatous degeneration already exists. In this context, the positron tomography with (18)F-fluorodeoxyglucose (FDG-PET) may be useful in the monitoring of this condition. We present two cases of patients diagnosed of FD with suspicion of malignization of their bone lesions who were referred to Nuclear Medicin.

[18F-fluorodeoxyglucose positron emission tomography in the evaluation of therapy response assessment in lymphomas. Systematic literature review and meta-analysis]. / Tomografía de positrones con 18F-fluorodesoxiglucosa en la valoración de la respuesta de los linfomas al tratamiento. Revisión sistemática de la literatura y metaanálisis.

This systematic review of literature analyze the utility of positron emission tomography (PET or PET-CT) with 18F-fluorodeoxyglucose, as a diagnostic tool in the assessment of response to chemotherapy and immunotherapy in lymphomas, in terms of diagnostic accuracy in prospective publications. A literature search was conducted in major databases and through manual review from the reference lists of articles that were recovered. The methodological quality of the selected items was evaluated using the QUADAS questionnaire. 9 publications were analyzed after the filtering process. The methodological quality of the same was broadly acceptable. In patients with LH, the negative predictive value of FDG-PET after 2-3 cycles of chemotherapy, was ranged between 93.4% (95% CI, 92.6-94.3) and 100% (95% CI, 99.3-100%), and after the treatment, the negative predictive value of PET-FDG, was between 94.3% (95% CI, 92.8-95.7) and 100% (95% CI, 97.1-100). In patients with residual masses and LH, the meta-analysis of results showed a sensitivity of 100% (95% CI, 0.753-1) and a specificity of 84% (95% CI, 0.699-0.934). PET-FDG seems to be a useful tool to evaluate the response to treatment of patients with lymphoma. However, it recommended further prospective studies and that possibly conducted in hybrid PET-CT scans, to determine its usefulness.

[Usefulness of labelled red-cell scintigraphy in Blue Rubber-Bleb Nevus syndrome]. / Utilidad de la gammagrafía con hematíes marcados en el síndrome de Blue Rubber Bleb Nevus.

Blue Rubber Bleb Nevus syndrome is a rare disorder characterized by distinctive cutaneous and gastrointestinal venous malformations that usually cause episodes of occult gastrointestinal haemorrhage and iron deficiency anaemia. We describe an 8-year-old girl who had multiple cutaneous venous malformations since birth. She also suffered from several episodes of severe chronic iron deficiency anaemia and required blood transfusions. To evaluate the presence of gastrointestinal bleeding secondary to intestinal angiomatosis, we decided to perform 99mTc-labelled red blood cell scintigraphy, which confirmed cutaneous venous malformations and also showed gastrointestinal vascular lesions that suggested the diagnosis of Blue Rubber Bleb Nevus Syndrome.

[The role of bone scintigraphy in two cases of hereditary multiple exostoses]. / Papel de la gammagrafía ósea en dos casos de exóstosis múltiple hereditaria.

We present the cases of two patients aged 18 and 40 years, with no previous personal history of interest. The only symptoms reported by the first patient in the previous year were episodes of pain and stiffness without inflammation in the right knee and third finger of the right hand. These episodes lasted two to three weeks. Our second patient presented numbness in the lower left limb over the previous year. The analytical study was normal. The patients were diagnosed with hereditary multiple exostoses, based on the clinical, radiological and scintigraphic findings. The bone scintigraphy enabled whole body images to be obtained in a single examination and may be used for the differential diagnosis of other osteoarticular conditions, as well as for the follow-up and assessment of the response to treatment.

[Positron emission tomography with 18F-fluorodeoxyglucose in patients with uterine sarcoma]. / Tomografía por emisión de positrones con 18F-fluordesoxiglucosa en pacientes con sarcoma uterino.

OBJECTIVE: Describe our experience with 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), in patients with uterine sarcomas, under suspicion of recurrence and in tumour staging after hysterectomy as an incidental pathology finding. MATERIAL AND METHODS: A retrospective review, between april 2002 and january 2006, of FDG-PET performed in 10 patients with clinical diagnosis of uterine sarcoma was made (7 patients under recurrence suspicion and three under initial staging). Mean age was 52.2 yrs. Evolution time after initial diagnosis vary from one month to 15 yrs (median time: 14 months). Lesions were classified as 8 leiomyosarcomas and 2 carcinosarcomas. FIGO staging were establish resulting 5 patients stage I, 1 patient stage III, and 4 patients stage IV. RESULTS: 4 of 7 patients under suspicion of recurrence showed discrepancies between positron emission tomography (PET) and conventional imaging techniques (CIT) information. FDG-PET was negative in three cases of non-conclusive CT. PET was negative in one case with pulmonary metastases. The 3 staging studies were concordant both FDG-PET and CIT images. Pathological information was obtained in 5 cases, and a mean time of 14 months of clinical follow up was made. CONCLUSIONS: FDG-PET can be useful in the follow up of uterine sarcoma patients, and also when it is an incidental finding in other causes hysterectomy.

[Positron emission tomography with fluordesoxyglucose-F18 in follow-up of endometrial cancer]. / Tomografía de emisión de positrones con fluordesoxiglucosa-F18 en el seguimiento del cáncer de endometrio.

OBJECTIVE: To assess the utility of FDG-PET in the follow-up of patients treated for endometrial cancer and with suspicion of recurrence according to conventional imaging methods (CT, MRI) and/or elevation of serum tumour markers. MATERIALS AND METHODS: Between April 2002 and December 2005, eleven patients underwent 17 FDG-PET studies (six with 2 studies); mean age was 63.4 yrs (range, 52-69 yrs) and time since diagnosis ranged from 11 months to 12 yrs (mean of 56 months). Initially, seven patients were in stage I, three in stage III and one in stage IV (FIGO classification). Histologically, they corresponded to 8 endometrioid carcinomas and 3 non endometrioid carcinomas. RESULTS: FDG-PET showed infradiaphragmatic uptake in 3 patients and disseminated disease in 7 cases. FDG-PET showed no uptake in one patient. CT (n = 7) or MRI (n = 7) detected infradiaphragmatic lesions in 5 patients and visceral lesions in 2. In 11 patients, tumour markers were elevated (CA125, n = 9; CA19.9, n = 2; CA15.3, n = 2). In 7 patients, FDG-PET modified the information yielded by conventional imaging techniques and in 4 patients, the FDG-PET contributed no additional information. In 2 patients, histologic confirmation of the lesions was obtained and in 9 patients, there were clinical follow-up (from 3 to 20 months, mean of 8.7 months) and imaging studies. CONCLUSIONS: FDG-PET is superior to CT and MRI for detecting recurrences in the follow-up of patients with endometrial cancer.

Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with operable breast cancer and positive axillary nodes at initial diagnosis.

AIM: To evaluate the utility of the sentinel lymph node biopsy (SLNB) in patients with operable breast cancer and positive axillary nodes at initial diagnosis treated with neoadjuvant chemotherapy (NAC). MATERIAL AND METHODS: A prospective study was performed from January 2008 to December 2012 in 52 women, mean age 50.7 years, with infiltrating breast carcinoma T1-3, N1, M0 (1 bilateral, 7 multifocal) treated with epirubicin/cyclophosphamide, docetaxel and trastuzumab in Her2/neu-positive patients. Axillary evaluation included physical examination, axillary ultrasound, and ultrasound-guided core needle biopsy of any suspicious lymph node. The day before surgery, 74-111 MBq of (99m)Tc-albumin nanocolloid was injected periareolarly. All patients underwent breast surgery, with SLNB and complete axillary lymph node dissection (ALND). The SLNs were examined by frozen sections, hematoxylin-eosin staining, immunohistochemical analysis or one-step nucleic acid amplification assay (OSNA). RESULTS: Mean tumor size: 3.5 cm. Histologic type: 81.1% invasive ductal carcinoma. Complete response of primary tumor was clinical 43.4%, pathological 41.5%. All patients were clinically node-negative after NAC. Pathological complete response of axillary node was 42.2%. SLN identification rate was 84.9%. Axilla was positive in the pathology study in 6 of 8 patients without nanocolloid migration. SLN accurately represented the axillary status in 95.5%. False negative rate was 8.3%. SLN was the only positive node in 68.2% of patients. Mean number of SLN removed was 1.9 and of nodes resected from the ALND 13.2. CONCLUSION: SLN biopsy after NAC is a feasible and accurate tool in patients with operable breast cancer T1-3, N1 and clinically node-negative after therapy.

Sentinel lymph node biopsy in patients with operable breast cancer treated with neoadjuvant chemotherapy.

AIM: To evaluate the accuracy of sentinel lymph node biopsy (SLNB) in operable breast cancer patients treated with neoadjuvant chemotherapy (NAC). MATERIALS AND METHODS: Between January 2008-2011, 88 women, mean age 49.4 years, with infiltrating breast carcinoma, were studied prospectively. Patients were T1-3, N0-1, M0. Prior to surgery, the patients received chemotherapy (epirubicin/cyclophosphamide, docetaxel), and trastuzumab in Her2/neu-positive patients. Axillary status was established by physical examination, ultrasound-guided core needle biopsy of any suspicious lymph node. The day before surgery, 74-111 MBq of (99m)Tc-albumin nanocolloid was injected periareolarly. All patients underwent breast surgery, with SLNB, followed by complete axillary lymph node dissection (ALND). Sentinel lymph node (SLN) were examined by frozen sections, hematoxylin-eosin staining and immunohistochemical analysis or One Step Nucleic Acid Amplification (OSNA). RESULTS: Mean tumor size: 3.5 cm. Histologic type: 69 invasive ductal, 16 invasive lobular and 3 others. Thirty seven patients had clinical/ultrasound node-positive at presentation. Clinical response of primary tumor to NAC: complete in 38, partial in 45, and stable disease in 5 patients. A pathological complete response was achieved in 25. All patients were clinically node-negative after NAC. SLN identification rate was 92.0%. Six of 7 patients in whom SLN was not found had clinical/ultrasound positive axilla before NAC. SLN accurately determined the axillary status in 96.5%. False negative rate was 8.3%. In 69.4% of patients, SLN was the only positive node. The mean number of SLN removed was 1.7 and nodes resected from the ALND were 13.2. CONCLUSION: SLN biopsy after NAC can predict the axillary status with a high accuracy in patients with breast cancer, avoiding unnecessary ALND.

[Diagnostic value of cardiac 123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy in Lewy body disorders]. / Valor diagnóstico de la gammagrafía cardíaca con 123I-metaiodobenzilguanidina en las enfermedades con cuerpos de Lewy.

INTRODUCTION: Lewy body disorders such as Parkinson's disease (PD) and Lewy body dementia (LBD) are associated with cardiac sympathetic denervation, which can be visualized on 123I-MIBG scintigraphy. Our objectives were to study the diagnostic value of this technique in Lewy body disorders and its relationship with PD clinical variables. PATIENTS AND METHODS: We studied 90 patients: 51 with PD, 19 with LBD, 9 with multiple system atrophy (MSA) and 11 controls. Scintigraphy images were qualitatively evaluated and early and delayed heart-to-mediastinum ratios (HMR) were calculated. The main confounding factors (ischemic heart disease, diabetes, hypertension and drugs) were controlled by multivariate linear regression analysis. We investigated correlations between scintigraphy variables and PD variables. RESULTS: The delayed HMR, which showed better discriminative ability was 2.03 +/- 0.32 in controls, 1.37 +/- 0.30 in PD (p<0.001 vs controls), 1.47+/-0.45 in LBD (p=0.001 vs controls) and 1.69+/-0.28 in MSA (p=0.02 vs controls; p=0.004 vs PD). This ratio was influenced by PD/LBD diagnosis (beta= -0.638; p<0.001) and to a lesser degree, by ischemic heart disease (beta= -0.244; p=0.028). Optimal cut-off value between PD/LBD and controls was 1.71 (83% sensitivity and 82% specificity). Within the PD group, those with a family history of PD/LB showed higher delayed HMR values (1.65+/-0.34 vs 1.30+/-0.24 without history; p<0.001) and proportion with normal scintigraphy (56% vs 5%; p=0.001). CONCLUSIONS: Cardiac 123I-MIBG scintigraphy is useful in the diagnosis of Lewy body disorders, although its value in PD is conditioned by having a family history of PD.