Clinical governance improves the quality of nuclear medicine reporting.

OBJECTIVE: To assess the quality of nuclear medicine reporting, within a private UK hospital, of five physicians from four different National Health Service trusts and compare it with a similar previous clinical governance exercise. METHODS: Reports (n=140) were shown anonymously to all five physicians, including the one who produced the report. Each physician ranked them on a scale of 1-5, with 1 and 5 corresponding to complete disagreement and complete agreement, respectively. All reports with at least one score of <4 were subjected to consensus review by all five physicians and subsequently given a consensus score. RESULTS: Six hundred and ninety-one audit opinions were present out of a possible 700 (98.7%). Forty-three reports were reviewed, of which 11 received a consensus score of <4 (7.9%). This is not significantly different from the proportion of nontrivial errors in our earlier study (10.2%). Only three reports were present, however, with a score of <3 (2.1%), significantly fewer (P<0.02) than the proportion of nontrivial errors in our earlier study. No scores of 1 were recorded. No reporter attracted significantly more scores of <4 compared with the overall proportion of such scores. A score given by an auditing physician which was 2 or more points different from the consensus score was defined as a suboptimal audit. Forty-four of 691 suboptimal audits (6.4%) were present, significantly fewer than the proportion of suboptimal audits in our earlier study (9.7%; P<0.03). CONCLUSION: Studies such as these provide a useful framework for monitoring performance. This improved significantly in this study as compared with our previous audit.

Technetium-99m-labelled sulesomab (LeukoScan) in the evaluation of soft tissue infections.

OBJECTIVE: To perform a retrospective review of all patients receiving technetium-99m ((99m)Tc)-labelled sulesomab over a 4-year period to determine if soft tissue infections can be accurately identified. METHODS AND MATERIALS: We reviewed the results of 124 (99m)Tc-sulesomab studies performed over a 4-year period. Of these, 34 were performed for undiagnosed fever in which soft tissue infection was suspected to be the main cause. The patients' clinical notes, microbiology reports and other imaging findings were reviewed to determine the clinical outcome following the scan. The scans were regarded as being true-positives if (i) uptake correlated with the site from which fluid or tissue was obtained and which grew bacteria, and/or (ii) the site of abnormality was reported as having an infection on other imaging or (iii) there was a clinical correlation with the referring clinician's evaluation of the patient. Planar imaging was performed using standard protocols, together with single-photon emission computed tomography (if required) at 1 and 4 h after injection of 20-30 mCi (740-1,110 MBq) (99m)Tc-sulesomab. RESULTS: Three patients were unevaluable. In the remaining 31 patients, 21 (99m)Tc-sulesomab studies were regarded as true-positives and 6 patients had true-negative scans. One patient had a false-positive scan (abnormal uptake with negative microbiology) and 3 had false-negative scans (infection confirmed but a negative scan). CONCLUSION: In suspected soft tissue infection, (99m)Tc-sulesomab imaging has a sensitivity of 88% with a specificity of 86% and overall accuracy of 87%. (99m)Tc-sulesomab provides an accurate method of imaging for suspected soft tissue infection, which is also fast and convenient, as cell labelling is not required.

Late recurrent urinary tract infections may produce renal allograft scarring even in the absence of symptoms or vesicoureteric reflux.

BACKGROUND: The significance of late urinary tract infections (UTIs) after renal transplantation and their association with scarring and graft dysfunction remains controversial. We sought to define the prevalence of renal scarring in allograft recipients with a history of late recurrent UTIs, to determine whether the presence of vesicoureteric reflux (VUR) confers an increased risk of scarring and to establish whether scarring correlates with graft dysfunction. METHODS: Among 307 renal allograft recipients, we identified 56 (18%) with late recurrent UTIs (> or =3/year). A total of 32 patients had undergone further investigation by both 2,3 dimercapto-succinic acid single-photon emission computed tomography (99mTc-DMSA SPECT) scan and micturating cystourethrogram (MCUG). RESULTS: Of the 32 patients, 24 (75%) had scars on 99mTc-DMSA SPECT and 15 (47%) had reflux on MCUG. Thirteen of these 15 patients with reflux (87%) had scars, although there was no significant correlation between number of scars and degree of reflux. Eleven of 17 patients (65%) with UTIs but without VUR had scars, as did 12 of 14 (86%) with previous graft pyelonephritis. The pattern of scarring (typically multiple focal cortical defects) suggested infection as the cause. This pattern was not seen in a contemporary cohort with vascular occlusions and was rarely seen in patients with chronic allograft nephropathy. Scarring was not associated with inferior graft survival (median follow-up, 15 years). CONCLUSIONS: In patients with late UTIs, renal scarring is a frequent finding. Scarring may occur even in asymptomatic patients without VUR. The lack of an effect on graft survival may reflect successful intervention with prophylactic antibiotics and surveillance urine cultures. Late recurrent UTIs may be damaging to renal allografts, even in the absence of reflux.

Gallium citrate uptake is a marker of breast malignancy: true or false?

A 34-year old lady had a (67)Gallium citrate scan and demonstrated uptake by both of her breasts--diffuse in the right breast, but focal in the left breast at the "9 o'clock position". Core biopsy from both breasts showed fibroadenoma and no malignant cells were found. Though uptake of (67)Gallium citrate is normally associated with malignancy or infection there may be other causes of uptake and follow-up biopsy should be performed.

Long-term efficacy of low activity meta-[131I]iodobenzylguanidine therapy in patients with disseminated neuroendocrine tumours depends on initial response.

BACKGROUND: meta-[131I]Iodobenzylguanidine (131I-MIBG) has been used to treat patients with disseminated neuroendocrine tumours (NET). However, so far there is limited information related to the efficacy of this agent beyond the normal 6-month assessment period. Before we can assume that such treatment would be beneficial to patients with these tumours the outcome of the patients over a longer time course should be determined. In many centres financial or radiation protection constraints mean that lower activities of 131I-MIBG have to be used at each administration, therefore instead of giving a single administration of a higher activity 131I-MIBG a series of multiple lower activity administrations are used. METHODS: The case records of 25 patients who had received 131I-MIBG over a 4-year period, from 1 June 1997 to 30 June 2001, were reviewed. Overall time of clinical follow-up range from 1 to 60 months, with a mean of 16 months). There were 16 female and nine male patients (mean age 55.6 years; range, 30-79 years). Most of patients had carcinoid (17), two had phaeochromocytoma, two gastrinoma and two an undifferentiated NET, one had malignant paraganglioma and one had medullary cell carcinoma of the thyroid. All had avid uptake for 123I-MIBG on diagnostic scanning. The minimum number of treatments received was 1 in 4 patients (with activities of 2.0 to 3.4 GBq); the maximum was 11 treatments (with cumulative activities as high as 29.1 GBq). Treatment was given using an infusion pump and was normally repeated at 12- to 16-week intervals (mean number of treatments per patient, 4). Response to therapy was determined by changes in the size of the tumour on computed tomography and/or magnetic resonance imaging using the response evaluation criteria in solid tumours (RECIST). Toxicity was measured using blood and urine tests of renal, hepatic, thyroid and bone marrow function. The median time from the last treatment to progression of disease and death (if applicable) was also calculated. RESULTS: No significant or long-lasting toxicity was encountered. At 6 months after the patient's last treatment, 18 patients (72%) had no evidence for progression. Twelve months after their last treatment 12 (48%) patients had no evidence for progression. At 18 months after the patient's last treatment, only seven patients (28%) had no progression of their disease. Overall, the median progression-free survival was 15 months. In those patients with stability or response at 6 months there was a prolonged progression-free survival and overall survival. In those with progression of disease at 6 months, at the 6-month assessment point, there had been four deaths (16%), at 12 months, there were three additional cancer deaths and finally at 18 months, there were a further five deaths. The median survival was 18 months. In those patients who died the mean time interval between disease progression and death was 4.6 months (range 0-12 months). CONCLUSION: Of the patients treated with low-activity 131I-MIBG 68% had significant benefit for at least 6 months post-treatment. In these patients with progressive and extensive disease this technique provided prolonged progression-free and overall survival with minimal side effects especially if an initial response to treatment was seen.

Validation and impact of a new technique for assessment of glomerular filtration rate in patients with liver disease.

OBJECTIVES: Previously we have proposed a technique for the measurement of plasma clearance in patients with ascites. The impact of using the technique was assessed and the results compared with those from a reference technique in 111 patients having glomerular filtration rate measurements as part of their workup for liver transplantation. METHODS: Results of calculations using the new technique were compared with plasma clearance measurements obtained using a conventional slope-intercept technique and with clearance measurements based on urine collection. Discrepancies between the results of plasma clearance and urinary clearance assessments were investigated by using an uncollimated gamma camera to measure the total retention of the tracer. RESULTS: Conventional slope-intercept calculations overestimated clearance compared with the new technique by more than 20% in 21% of the patients. Significant differences between the results of the two methods were more likely in patients with more severe ascites. Results of urine collection-based measurements of Cr-51 EDTA clearance were frequently significantly lower than measurements using the new technique, whereas measurements of urinary clearance of creatinine were higher. Gamma camera measurements suggest that discrepancies between total and urinary clearance of Cr-51 EDTA are due to incomplete urine collection. CONCLUSION: The new technique is a practical method for assessment of kidney function and should be used in patients with liver disease who have or may have ascites.

Long-term efficacy of high-activity 111in-pentetreotide therapy in patients with disseminated neuroendocrine tumors.

UNLABELLED: High-activity (111)In-pentetreotide has been used to treat patients with disseminated neuroendocrine tumors. There is, however, little information related to the efficacy of this agent beyond the normal 6-mo assessment period. Before we can assume that such treatment would be beneficial to patients with neuroendocrine tumors the outcome of the patients over a longer time course should be determined. METHODS: The case records of 16 patients who had received high activities of (111)In-pentetreotide (with cumulative activities as high as 36.6 GBq) over a 2.5-y period, from January 1, 1997, to June 30, 2000, were reviewed. There were 8 female and 8 male patients (age range, 32-76 y): 10 patients had carcinoid, 2 had medullary cell carcinoma of the thyroid, and 1 each had a gastrinoma, glucagonoma, fibrolamellar cancer, and malignant histiocytoma. The minimum number of treatments received was 1 in 2 patients (with activities of 3.1 and 7 GBq); the maximum was 10 treatments (total, 36.6 GBq). Treatment was given using an infusion pump and was repeated at 4- to 12-wk intervals (mean number of treatments per patient, 6). Response to therapy was determined by changes in the size of the tumor on CT using the response evaluation criteria in solid tumors. Toxicity was measured using blood and urine tests of renal, hepatic, thyroid, and bone marrow function. The mean and median time from the last treatment to progression of disease and death (if applicable) was also calculated. RESULTS: No significant or long-lasting toxicity was encountered. At 6 mo after the patient's last treatment, 5 patients (30%) had disease progression, 2 had complete responses, and 3 had partial responses. Twelve months after their last treatment, 9 patients (56%) had disease progression, and, at 18 mo, 11 patients (69%) had disease progression. The mean progression-free survival was 12.25 mo (median, 9 mo). For those who survived 6 mo after their last treatment, the mean survival was 15.75 mo (median, 16 mo). At the 6-mo assessment point, there had been 3 deaths (19%): 1 death was not related to cancer. At 12 mo, there was 1 additional cancer death. At 18 mo, there were 3 additional deaths (1 was not related to the patient's carcinoid tumor but was due to a second coexistent cancer). By the end of the 18-mo assessment period, 7 patients (44%) had died. The mean time interval between disease progression and death was 5 mo. CONCLUSION: In patients treated with high-activity (111)In-pentreotide, 70% had some benefit for at least 6 mo after the end of treatment; however, 31% of patients will have sustained benefit at 18 mo from this treatment. This was obtained without significant toxicity.

Diagnostic imaging of carcinoid metastases to the abdomen and pelvis.

BACKGROUND: Functional and anatomical imaging methods are currently the standard approach to the evaluation of carcinoid tumor extent. Due to the nature of carcinoid tumors ,there is not a single imaging procedure that is sufficient to detect the malignancy. The aim of the study was to compare the value of CT, MR and functional imaging study with(111) In-Octreotide (SRS) in carcinoid detection and evaluation of its extent as well as to work out the imaging studies diagnostic algorithm that could enhance diagnostic efficacy. MATERIAL/METHODS: A total of 34 patients with carcinoid tumor confirmed clinically,biochemically and/or histopathologically were enrolled into the study. Computed tomography (CT) examinations of the abdomen and pelvis were performed before and after administration of a contrast medium, the triple-phase liver scanning included. Magnetic Resonance Imaging (MRI)of the liver was performed according to the standardized protocol before and after administration of a contrast medium .Planar scintigraphy with(111) In Octreotide and SPECT were performed. In each case liver as well as lymph node metastases in the abdomen and pelvis were searched for. All results were reviewed independently. Clinical picture at follow-up and further imaging and/or histological studies confirmed or excluded the diagnosis of the disease. RESULTS: Twenty nine patients were diagnosed with carcinoid tumor. Liver metastases were found in 26 patients and lymph node metastases were detected in 18 of them. Complete diagnostic conformity as far as the diagnosis and extent of the disease are concerned was obtained only in 7 cases. Incorrect assessment of the disease extent was the source of discrepancy between the imaging studies results in most of the remaining 22 patients. The SRS and MR results of liver metastases detection were mostly consistent with one another. Both imaging modalities evaluated the extent of hepatic metastases incorrectly in 22%of the patients,as compared to 43% of the patients for CT. The highest proportion percentages of incorrect results of lymphatic involvement detection were 41%, 29%and 43%for MR, SRS and CT, respectively. CONCLUSIONS: The results of our study have indicated that application of a complex imaging algorithm enables higher accuracy of hepatic and lymph nodes metastases detection in carcinoid tumor patients. Combining the results of MR and SRS in evaluating the extent of the carcinoid disease seems to represent higher diagnostic value than relying on one of this method in combination with CT images.

Prediction of clinical outcome in treated neuroendocrine tumours of carcinoid type using functional volumes on 111In-pentetreotide SPECT imaging.

The quantification of the tumour volume is essential for the assessment of therapy-induced changes. Traditional methods of assessing the response of neuroendocrine tumours using radiological methods yield poor results, particularly within the liver. The aim of this study was to establish whether it would be possible to identify a method using functional volumes to predict the response of tumours to various therapies. Twenty-two patients with neuroendocrine tumours of carcinoid type in the liver were treated with chemotherapy, chemo-embolization or 90Y-radiolabelled somatostatin analogues. All patients underwent 111In-pentetreotide single-photon emission computed tomography (SPECT) and computed tomography (CT) scan pre- and post-treatment. The tumour functional volume, a measure of metabolically active tumour tissue, was calculated from the SPECT images using a 10-point display; regions of interest were drawn around 50% of the maximum tumour activity, slice by slice, and then multiplied by the slice thickness (9.3 mm). Any difference in functional volume was compared with the CT response, using the Response Evaluation Criteria in Solid Tumours (RECIST), and clinical outcome. At 6 months after treatment, 14 patients showed a good clinical response, as measured by a reduction in pain, flushing or abdominal symptoms; the functional volume of the tumours in these patients decreased by a mean of 25% (range, 1-52%). Of the eight patients who showed no symptomatic relief, or in whom symptoms worsened, the functional volume increased by a mean of 74%. Using a change in functional volume of more than 25% as significant, SPECT predicted 13 of the 22 (59%) clinical outcomes correctly; if a 10% change was used, 18 of the 22 (81.1%) clinical outcomes were correctly predicted. However, CT, using RECIST, only predicted eight of the 22 (36%) clinical outcomes correctly. The assessment of the total functional volume by SPECT quantification is more useful than CT in monitoring tumour response after treatment, and the changes in functional volumes after therapy correlate well with the clinical response.

Clinical audit in nuclear medicine.

BACKGROUND AND AIM: Clinical governance is important. Clinical audit is part of clinical governance. The aim of this study was to perform a clinical governance exercise, and the reporting arrangements at an independent hospital provided the opportunity to do this over two phases between 1999 and 2002. Six physicians from four different UK National Health Service (NHS) trusts participated. METHODS: Reports were shown anonymously to between two and five of the physicians who had not produced the report. Reports with at least one disagreement were reviewed by the group in order to reach concensus as to whether the disagreement was non-sustainable (NS), trivial (T) or non-trivial (NT), the last two, respectively, judged to make an insignificant or potentially significant impact on patient management. RESULTS: In phase 1,239 audits were produced on 83 reports (2.9 per report), and in phase 2, 636 on 137 reports (4.6 per report). In phase 1, 14 (17%) reports attracted at least one disagreement (NS, five; T, four; NT, five). Of 239 audits, there were 20 disagreements of which five were NS. Moreover, nine audits agreed with a report with a NT disagreement, giving 14 suboptimal audits (5.9%). In phase 2, 80 (58%) reports attracted at least one disagreement (NS, 31 (P<0.003 vs phase 1); T, 35 (P<0.001); NT, 14 (P>0.05)). Of 636 audits, there were 153 disagreements, of which 37 were NS (P<0.05 vs phase 1). Twenty-five audits agreed with a report with a NT disagreement, giving 62 suboptimal audits (9.7%) (P>0.05). Overall, 19/220 reports (8.6%) were thought NT, an error rate comparable to reporting elsewhere in radiology. After phase 1, auditors became more aggressive but the quality of auditing tended to decline, as did the quality of reporting (although not significantly). CONCLUSION: This study provides a useful framework for monitoring performance.

[Evaluation of scintimammography as an additional test to conventional mammography in detection of breast cancer]. / Wartosc scyntymammografii jako testu wspomagajacego badanie mammograficzne w diagnostyce raka sutka.

OBJECTIVES AND DESIGN: Scintimammography using Tc-99m MIBI is becoming established as a second line diagnostic test for the detection of breast cancer in patients with suspected primary disease. Though most published clinical studies compare scintimammography (SMM) with mammography (XMM), in clinical practice they are likely to be used sequentially with the scintimammography following the mammography. MATERIALS AND METHODS: To determine the possible accuracy of such an approach, receiver operator characteristic (ROC) curves were produced for SMM, XMM and a combination of both studies performed over 2 years period on 162 suspicious lesions in 154 patients with no previous history of breast cancer. Each scan was reported in 5 grades: 1-normal or definitely benign; 2-possibly normal or possibly benign; 3-equivoval; 4-probably cancer; 5-definitely cancer. The results have been verified by pathological examination of biopsy material obtained from each suspicious mass. RESULTS: There were 102 malignant breast tumours and 60 non-malignant breast lesions. SMM correctly diagnosed 89 breast cancers, and was false negative in 13 cases. It was true negative in 36 benign breast lesions. The sensitivity of SMM was 87%, specificity 65%, PPV 81% and NPV 75%. XMM diagnosed correctly 70 malignant tumours. The sensitivity, specificity, PPV and NPV for XMM were respectively: 69%, 72%, PPV 81% and NPV 57%. However, if a combination of the two methods is used the overall diagnostic accuracy was as follows: 92%, 80%, 89% and 86%. Evaluation of index area under ROC curve allows in both diagnostic methods XMM and SMM results as follows: 0.79 and 0.83. Additional sequence imaging allows 0.94. Combined XMM and SMM in suspected primary breast cancer patients has higher diagnostic accuracy than each method separately (p < 0.05). CONCLUSION: This study shows that the combination of mammography and scintimammography produces more accurate results than either modality alone this is how these test should be performed in clinical practice.

Development of a modified sampling and calculation method for isotope plasma clearance assessment of the glomerular filtration rate in patients with cirrhosis and ascites.

AIM: The aim of this study was to identify a practical sampling regimen and calculation method that could be used to measure the glomerular filtration rate in patients with ascites using plasma sampling. PATIENTS AND METHODS: Thirteen potential liver transplant patients with cirrhosis and ascites were injected with Cr-51 ethylenediaminetetraacetic acid, and plasma samples were obtained at up to 16 time points for each patient. Reference clearance values were calculated using the area under the plasma clearance curve, which was calculated using all the available data points. Clearance calculations were then performed using three and four data points from each patient and three different calculation methods to identify a sampling regimen and calculation method that yielded good agreement with the reference values. RESULTS: The reference clearances ranged from 6 to 80 ml/min. Sampling at 2, 4, 8 and 24 h and calculation of the area under the plasma clearance curve using a log-linear trapezoidal rule with extrapolation to zero and infinity yielded a relative root mean square difference from the reference of less than 7%. CONCLUSION: This method for measuring glomerular filtration rate in patients with cirrhosis and ascites was found to be more accurate than the slope-intercept technique and is a practical alternative to urine collection.

Massive gastrointestinal haemorrhage in isolated intestinal Henoch-Schonlein purpura with response to intravenous immunoglobulin infusion.

There is increasing recognition that Henoch-Schonlein purpura may present in an atypical form in which gastrointestinal symptoms may predominate, and classic cutaneous changes may be delayed or absent. This may lead to significant diagnostic delay. We report the case of a 9-year-old girl who presented acutely with life-threatening gastrointestinal haemorrhage from multiple intestinal sites, with no skin rash and only mild evidence of renal involvement. Henoch-Schonlein purpura was confirmed by finding IgA deposition on vessels within gastric and duodenal mucosa, while immunohistochemistry also identified dense focal T cell infiltration in gastric mucosa and within duodenal epithelium. After initial stabilisation, the patient became shocked due to further gastrointestinal haemorrhage. Isotope bleeding scan identified multiple bleeding sites. Her endoscopically confirmed gastritis was sufficiently severe to preclude corticosteroids, and she was thus treated with intravenous immunoglobulin. This therapy induced prompt and sustained resolution of symptoms, and she has remained well since. Our patient's response concords with previous reports in corticosteroid-resistant cases to suggest that severe intestinal Henoch-Schonlein purpura may respond preferentially to intravenous immunoglobulin (IVIG) therapy. In severe cases where there is significant gastritis, IVIG provides an effective alternative to corticosteroids that may be employed as first-line therapy.