Time to Procedure, Nuclear Imaging and Clinicopathological Characteristics as Predictive Factors for Sentinel Lymph Node Metastasis in Cutaneous Melanoma: A Single-Center Analysis.

OBJECTIVE: Sentinel lymph node (SLN) biopsy is a widely accepted staging procedure for cutaneous melanoma patients who are at risk of clinically occult nodal metastases. Numerous predictive factors for regional lymph node metastases have been identified; however, few have been found to be reproducibly significant. Also, the role of blue dye in identification was questioned in recent trials. Time to procedure was also found to be predictive of SLN positivity, but this was not confirmed in other studies. In our study, predictive factors for metastatic involvement of SLN were analyzed, together with the role of addition blue dye in imaging on detection rate and false-negative SLN rate. An impact of time interval to procedure on the rate of SLN positivity was also explored. METHODS: Data analysis was done in 362 cutaneous melanoma patients who underwent lymphoscintigraphy and SLN biopsy at our institution from 2010 to 2016, with a median follow-up of 29 months (1-98 months). To delineate the relation of each variable (demographical, time to procedure, and clinical and pathological variables, as well as the presence of in-transit nodes, the number of draining basins, and SLN localization on scintigraphy) with positive SLN status, we used univariate logistic regression with odds ratios representing effect size. RESULTS: Metastatic involvement SLN was found in 67 (18.8%) of 356 patients. Detection rate was similar with or without further intraoperative SLN identification with blue dye (98.8% vs 98.17%, P > 0.05). Time to procedure was not associated with higher SLN positivity rate (P > 0.05). In univariate analysis, Breslow thickness (P < 0.001), primary ulceration lesion (P = 0.001), and lymphovascular invasion (P = 0.006) were strongly correlated with SLN positivity, as well as the site of primary tumor (P = 0.024), tumor-infiltrating lymphocytes (TILs) (P = 0.021), and sex (P = 0.026). In multivariate analysis, Breslow thickness and TILs were found to be significant independent predictors of SLN status (P < 0.05). CONCLUSIONS: Addition of blue dye did not improve SLN detection rate; time to procedure was not found to be associated with higher SLN biopsy positivity rates. Breslow thickness and TILs, as a marker of immune response to tumor, were consistently found to be significant independent predictors of SLN status.

Renal output efficiency and normalized residual activity examined by technetium-99m-DTPA renography have by far greater specificity to diagnose obstructive disease as compared to other conventional parameters of the renogram. First such study of output efficiency.

OBJECTIVE: The aim of this study was to assess the diagnostic ability of renal output efficiency (OE), normalized residual activity (NORA) and conventional interpretation of the diethylene triamine pentaacetic acid (99mTc-DTPA) diuretic renogram (CIR) in diagnosing urine flow obstruction. SUBJECTS AND METHODS: Group A consisted of 73 obstructed kidneys and Group B of 80 kidneys with dilated upper urinary tract. Forty eight kidneys were examined as the control Group C. A 40min acquisition with 240 of 10sec images was applied. Furosemide was administered after 20min (F+20). Post-void image was acquired at 50min. Output efficiency was calculated at 20min (OE20) and 20min after furosemide test (OE40) and NORA at 20min (NORA20) and on the post-micturition acquisition (NORAPM). RESULTS: Both the above parameters (OE40 and NORAPM) had high sensitivity (92% and 97%), specificity (99% for both) and accuracy (95% and 98%) in differentiating between obstructed and dilated unobstructed kidneys. The test of NORAPM correctly reclassified 40 out of 41 indeterminate or false positive results of the conventional interpretations of renograms (CIR) as obstructed (12 cases) or dilated (28 cases). Cut-off values for obstruction were <80% and ≥0.23 for OE40 and NORAPM, respectively. Compared to CIR, both parameters showed better specificity, especially NORAPM. CONCLUSION: Factors of OE40 and especially NORAPM of the renogram by 99mTc-DTPA were able to diagnose urine outflow obstruction better than CIR. Specifically, these factors well differentiated obstruction from urinary tract dilatation.

Positive 99mTc-MIBI and the subtraction parathyroid scan are related to intact parathyroid hormone but not to total plasma calcium in primary hyperparathyroidism.

OBJECTIVE: Primary hyperparathyroidism (pHPT) is characterised by increased parathyroid hormone (PTH) secretion and consequently increased plasma calcium. During the last few decades parathyroid scintigraphy (PS), is applied in almost all patients with pPHT before surgery and specifically before minimally invasive parathyroidectomy. The aim of this study was to find the best cut-off levels of total plasma calcium and intact PTH (iPTH) that correlate with positive technetium-99m-methoxy isobutyl isonitrile (99mTc-MIBI) PS and with positive subtraction PS (SPS) in patients with pHPT and thus the positive diagnostic value of these PS. SUBJECTS AND METHODS: We studied 50 patients, operated for pHPT, aged from 22-78 years, (median age 60 years), 45 female and 5 male, with a total number of 57 parathyroid glands (PG), (46 adenomas and 11 hyperplasias). All patients underwent SPS before surgery. Static scintigrams of the head, neck and chest were performed 15min after the intravenous (i.v.) injection of 740MBq of 99mTc-MIBI. Late scintigrams of the head, neck and chest were performed 2h and 3h after the injection of 99mTc-MIBI. Four to 24h after the washout of 99mTc-MIBI from the parathyroid and the thyroid glands, we injected i.v. 185MBq of 99mTc-pertechnetate (99mTcP) and after 15min we performed the PS. Normalization and motion correction of the early 99mTc-MIBI scan and the 99mTcP followed. We then subtracted the 99mTcP from the 99mTc-MIBI scan. The areas of increased uptake on the 99mTc-MIBI scan visible at the early and late or at the subtraction images represented the hyperfunctioning tissue of the enlarged and hyperfunctioning parathyroid glands. Scintigraphic findings were graded subjectively, from 1 to 5 depending on the degree of the uptake of the radiopharmaceutical. Normal iPTH levels were between 10.0-65.0pg/mL and normal total plasma calcium between 2.13-2.65mmoL/L. RESULTS: Of all patients 12/50 and 38/50 had both PS positive grade 4 and very positive grade 5 findings respectively. In all patients iPTH levels ranged from 54 to 837pg/mL, median value 187.0±133.8pg/mL, and total plasma calcium ranged from 2.40 to 3.83mmoL/L, median value, 2.87±0.237mmoL/L. In 43 patients, both calcium and the iPTH levels were elevated. Strong positive correlation was found between scintigraphic findings and levels of iPTH: P=0.003. A significant relation between plasma calcium levels and different grades of scintigraphic findings was not found, although significant correlation was found between iPTH and plasma calcium levels (P=0.021). CONCLUSION: In patients with pHPT, the 99mTc-MIBI PS and the subtraction PS showed a strong correlation to iPTH (P=0.003) but not to total plasma calcium levels indicating the importance of both the 99mTc-MIBI and the subtraction parathyroid scans to indicate pHPT.

Bone scintigraphy can diagnose osteoporotic vertebral compression fractures better than conventional radiography.

OBJECTIVE: Most difficult and very frequent complications of osteoporosis are vertebral compression fractures (VCF). Bone scintigraphy with 99mTc-phosphonates enables early detection of vertebral compression fractures in the first 72 hours of occuring. Typical scintigraphic findings is markedly increased radiotracer uptake in the linear pattern, throughout collapsed vertebral body. Bone scintigraphy is usefull in follow-up of vertebral fractures healing, showing reduction of radiotracer uptake in fractured vertebrae. In patients with osteoporosis and suspition of VCF, we detected compression vertebral fracture by bone scintigraphy and compare it with conventional radiography findings. PATIENTS AND METHOD: Bone scintigraphy was done in 40 patients with osteoporosis and suspition of compression vertebral fractures, 32 women and 8 men, mean age, 71 years. Three hours after iv. injection of 740MBq of 99mTc-DPD to the patients, a whole body scintigraphy was done. Standard radiographic views AP, lateral, and oblique were done in all patients. RESULTS: Radiography findings were positive for vertebral compression fracture in 28 patients (70%), and with bone scintigraphy in 36 patients (90%). In one patient with healed-old vertebral fracture, with positive radiographic finding, scintigraphic finding was negative. Bone scintigraphy incidentally diagnosed bone metastases in 3 patients. CONCLUSION: Bone scintigraphy has a very high sensitivity for detection of vertebral compression fractures in osteoporotic patients. Conventional radiography showed a much lower sensitivity and could not differentiate acute from old vertebral compression fractures.

Diuresis renography and ultrasonography in children with antenatally detected hydronephrosis can support diagnoses and suggest related surgery treatment.

OBJECTIVE: Prenatal ultrasound (US) screening detects the hydronephrosis (HN)-dilatation of fetal renal collecting system in 1%-5% of all pregnancies. In most children, HN is detected by prenatal US screening between 18-20 gestational week. Pelvi- ureteric junction (PUJ) stenosis is the most common etiological factor of prenatal HN and requires postnatal follow-up. Diuresis renography plays important role in the follow-up by complementing morphological information obtained by US with the data about differential renal function (DRF) and drainage. We studied the association between ultrasound parameters and results of diuresis renography in first diagnosed PUJ stenosis and the predictive factors of pyeloplasty in order to evaluate the usefulness of diuresis renography in these children postnatally. PATIENTS AND METHODS: Children with antenatally detected HN attributed to presumed PUJ stenosis were investigated with mercapto-acetyltriglycine (MAG3) diuresis renography. Parents gave informed consent for the procedure. The inclusion criteria were: age up to 4 years, diagnosis of prenatal HN determined by US during pregnancy based on the antero-posterior diameter (APD) of renal pyelon and at least one post-natal US which confirmed diagnosis. Exclusion criteria were: APD of pyelon <10mm, previous surgical treatment of HN, vesicoureteral reflux excluded by micturating cystourethrography, and patients having any anomaly of the contralateral kidney. Sixty two patients 43 boys, 19 girls, median age 16 months were selected. They were divided into three groups based on the size of pyelon, three groups based on the calyceal size and two groups according to thickness of parenchyma. Renography was performed for 24 minutes after the iv. application of 99mTc MAG3, 144 ten-sec images were applied. Furosemide was administered after 2 min. (F+2). Post-void static images were acquired at 60min. The non-commercial software developed by International Atomic Energy Agency was applied to process the studies. The criteria for pathological findings (poor or no drainage) were the renographic curve maintaining a plateau, Normalized Residual Activity (NORA) at 20. min.>1.62, Output efficiency (OE) at 20. min.<71%, postmicturating NORA >0.11. The DRF was considered normal within the range of 45%-55%. RESULTS: Good drainage had 74% of children, partial drainage 11%, and poor 15%. There was a clear association between the size of pyelon, calyces, parenchyma thickness and drainage. There was also a clear association between the calyceal size, parenchyma thickness and DRF. Differential renal function was <45% in 18% of children. A relation between the type of drainage and DRF was not determined. Thus, 66.7% of those with poor drainage had preserved DRF. Seven out of nine children with poor drainage underwent pyeloplasty. The threshold for pyeloplasty was the pyelon of 18mm and calyces of 10mm. The model of the multivariate logistic regression which included ultrasound parameters (APD of pyelon, calyces size and parenchymal thickness), drainage and DRF, which were significant predictors in univariate analysis, showed that only drainage was an independent predictor for the need of pyeloplasty. CONCLUSION: Antero-posterior diameter of the pyelon <15mm indicates a favorable course of congenital HN in most children. Pattern of drainage obtained by diuresis renography was the only independent predictor for the need of pyeloplasty.

Technetium-99m-dimercaptosuccinic acid renal scintigraphy can guide clinical management in congenital hydronephrosis.

OBJECTIVE: The purpose of this study was to evaluate damage of the kidney with technetium-99m-dimercaptosuccinic acid (99mTc-DMSA) scintigraphy in children with congenital hydronephrosis (CH) and the influence of other postnatal associated diagnoses on abnormal 99mTc-DMSA findings. SUBJECTS AND METHODS: 99mTc-DMSA scintigraphy in 54 children (17 girls and 37 boys), aged from 2 months to 5 years (median 11 months) with 66 congenital hydronephrotic renal units (RU) (42 unilateral hydronephrosis-29 boys and 13 girls; 12 bilateral hydronephrosis-8 boys and 4 girls) was performed. Male/female ratio was 2,2:1, unilateral/bilateral hydronephrosis ratio was 4:1. Hydronephrosis classified into three groups according to ultrasound measurement of the antero-posterior pelvic diameter APD): mild (APD 5-9.9mm) was present in 13/66RU, moderate (APD 10-14.9mm) in 25/66RU, and severe (APD≥15mm) in 28/66RU. Simple hydronephrosis was present in 15RU, and the postnatal associated clinical diagnosis were vesicoureteric reflux (VUR) in 21, pelviureteric junction (PUJ) obstruction in 7, pyelon et ureter duplex in 11, megaureter in 11 and posterior urethra valves in 1RU, respectively. Static renal scintigraphy was performed 2 to 3 hours after intravenous (iv) injection of 99mTc-DMSA using a dose of 50µCi/kg (1.85MBq/kg; minimal dose: 300µCi). Four views (posterior, left and right posterior oblique and anterior) were obtained with a head gamma camera "Orbiter" filtered with high resolution parallel whole collimator. All images were stored in an Pegasys computer with a matrix size of 256×256. The relative kidney uptake (RKU) between the left and right kidney was calculated as an average number counts from anterior and posterior view. Renal pathology was defined as inhomogenous or focal/multifocal uptake defects of radiopharmaceutical in hydronephrotic kidney or as split renal uptake of <40%, and poor kidney function was defined as split renal uptake <10%. Descriptive and analytical statistics (SPSS version 20.0) was performed. Analytical statistics implied the non-parametric Mann-Whitney test for determination of statistically significant difference between the normal and pathological findings on 99mTc-DMS scan. The default level of significance was P<.05. RESULTS: Our 99mTc-DMSA scintigraphy findings in children with ANH were: decreased or enlarged kidney with inhomogeneous kidney uptake radiopharmaceutical in 22, irregular shape kidney with inhomogeneous accumulation of radiopharmaceutical in 3, connected (fused) kidney in 1 patient, and poorly or nonvisual kidney in 14RU respectively (total 40/66RU with pathological 99mTc-DMSA finding, 60,6%). Relative accumulation in hydronephrotic kidney was less or equal to 40% in 17RU, less than 10% in 14RU and inhomogeneous radiopharmaceutical uptake with relative accumulation over 40% was detected in 9RU. Regular kidney morphology with homogeneous accumulation of radiopharmaceutical (normal DMSA scintigraphy finding) were found in 26/66RU (39,4%). Statistically significant correlation between the degree of the hydronephrosis (APD) and 99mTc-DMSA scan findings (P<0.001) and between the degree of the VUR and DMSA scan finding (P=0.002) was established. In our study, other associated diagnosis were not statistically correlated with pathological findings on 99mTc-DMSA scan due to low number of patients. CONCLUSION: On the basis of these results (60% pathological findings) we recommend DMSA scintigraphy in the evaluation renal pathology in children with congenital hydronephrosis. Greater number of patients is needed for the estimation of the associated diagnosis (other than VUR) influence on the renal parenchymal damage in children with CH.

The importance of angiotensin II type 1 receptor gene polymorphism to losartan treatment in improving glomerulopathy in type 1 diabetic patients.

OBJECTIVE: Diabetic nephropathy (DN) is a clinical syndrome characterized by persistent albuminuria, increasing arterial blood pressure and progressive decline in glomerular filtration rate (GFR). When persistent albuminuria is established, antihypertensive treatment becomes most important factor in slowing the progression of diabetic glomerulopathy. Aim of this study was to examine if renoprotective response to losartan therapy, in patients with diabetic nephropathy, depends on 1166 A/C gene polymorphism for its target receptor, angiotensin II type 1 receptor (AT1R). SUBJECTS AND METHODS: The study included 35 patients with diabetes mellitus type 1 and high urinary albumin excretion rate (>30mg/24h) genotyped for the 1166 A/C gene polymorphism for the AT1R. The participants were segregated into three genotype groups according to combinations of A or C allele: AA-16, AC-15 and CC-4 patients. The patients received losartan 50mg daily for 4 weeks, following 100mg daily for 8 weeks. At baseline and after losartan therapy period, blood pressure, GFR (Gates method) and filtration fraction (FF) were calculated. FF was calculated by dividing GFR by ERPF (Schlegels method). RESULTS: GFR remained unchanged in all genotype groups. FF was significantly reduced from baseline by 0.018±0.024 (P=0.012) only in the AC group. In the AA genotype FF was reduced from baseline by 0.017±0.03 (P=0.052) and in the CC group by 0.01±0.008 (P=0.092). In the AA group, systolic blood pressure declined from 136±24mmHg at baseline, to an average of 121±18mmHg at the end of the study (P=0.001). The AC group achieved reduction from 131±10mmHg at baseline to 115±7mmHg (P=0.001) during the investigation period. In the AA genotype group losartan reduced diastolic blood pressure from 86±13mmHg at baseline to 78±8mmHg (P=0.004), and in the AC genotype from 88±5mmHg at baseline to 11.7±5.6mmHg during the investigation period (P=0.001). In the CC genotype diastolic blood pressure reduction remained nonsignificant (P=0.066). CONCLUSION: The results of our small sample size study provide the evidence that 1166 A/C AT1R polymorphism could be associated with the renoprotective response to losartan therapy.

Validation of numerical outputs of IAEA software by the analysis of diuretic nephrogram in children with antenatally detected hydronephrosis.

UNLABELLED: Diuretic nephrogram is important diagnostic tool in the postnatal follow-up of asymptomatic antenatally detected hydronephrosis (HN). In the last decades, two quantitative indices of renal excretion, output efficiency and the residual kidney counts normalized to the 1-2min counts (normalized residual activity, NORA) have been proposed, that enhance the accuracy of technique to detect kidneys with obstruction. Unfortunately, in many nuclear medicine departments in developing countries the obsolete computer systems do not give the opportunity of sophisticated analysis of nephrogram. Almost a decade ago, the Nuclear Medicine Section of the International Atomic Energy Agency (IAEA) has developed non-commercial software for nephrogram processing on a simple p-computer, which allows access to the developments in this field. However, till now, the software has not been widely implemented in the nuclear medicine institutions in developing countries. Furthermore, the accuracy of numerical outputs of the software has not been assessed in comparison with commercial software. The aims of this study in children were: a) to calculate, by means of the International Atomic Energy Agency (IAEA) software, the values of the technetium-99m mercapto-acetyl-triglycine ((99m)Tc MAG3) parameters in three categories of kidneys: normal kidneys, obstructed kidneys and hypotonic unobstructed kidneys and b) to assess the accuracy of the obtained numerical parameters by comparing with the values published by other authors. Investigation was carried out on a sample of 62 children: 43 boys and 19 girls (median age: 16 months) with antenatally detected HN attributed to pelviureteric junction (PUJ) stenosis. Neither of kidneys had undergone pyeloplasty prior to our investigation. 130 nephrogram curves were analyzed. 22-minutes acquisition with 132 10sec images was applied. Furosemide was administered after 2min (F+2). Post-void static image was acquired at 60min. Two observers analyzed each study and classified kidneys into three categories. Group 1: 84 kidneys contralateral to hydronephrotic kidney, without structural abnormality on previous diagnostics; Group 2: 30 hypotonic non-obstructed kidneys; Group 3: 16 obstructed kidneys. Parameters analyzed were: output efficiency (OE), residual kidney counts at 20min normalized to the 1-2min counts (NORA20) and residual kidney counts on post-micturition acquisition normalized to the 1-2min counts (NORAPM). Results were presented as mean±SD. For group 1 they were: OE: 95±1.5%; NORA20: 0.25±0.06; NORAPM: 0.02±0.007. Results for group 2 were: OE: 87±7.8%; NORA20: 0.57±0.19; NORAPM: 0.03±0.02. For group 3: OE: 56±9.6%; NORA20: 2.16±0.33; NORAPM: 0.27±0.13. Linear regression analysis showed significant inverse linear correlation between NORA20 and ROE20 (R=-0.982; y=99.6-21.1x) at 0.01 level. ROC analysis revealed cutoff values of predicting obstruction at 71%, 1.62 and 0.11 for OE, NORA20 and NORAPM, respectively. CONCLUSION: We have calculated in children by means of the IAEA software the values of three advanced parameters of the (99m)Tc MAG3 F+2 diuresis nephrogram for normal kidneys, hypotonic non-obstructed and obstructed kidneys. The overall results provided evidence of excellent agreement of obtained results with previously reported values of the quantitative parameters of renal washout. The parameters of IAEA software has been shown to be reliable in assessing kidney drainage. The nuclear medicine section of the IAEA should be encouraged to produce final version of the software and to release it through IAEA Web site.

Lymphoscintigraphy and sentinel lymph node biopsy, in cutaneous melanoma staging and treatment decisions.

OBJECTIVE: Sentinel lymph node biopsy (SLNB) is a widely accepted method in the management of clinically localized cutaneous melanomas. The aim of this study was to report the results on patients scheduled for preoperative lymphoscintigraphy and SLNB for staging and further treatment planning. SUBJECTS AND METHODS: Two hundred and one patients (115 male and 86 female, median age 57 years, range 9-81) with cutaneous melanoma having undergone SLB at Military Medical Academy between November 2010 and October 2014, were recruited for retrospective study. Dual labeling method (Tc-99m Nanocolloid (blue dye) was used. In order to delineate the relation between patients' tumors and scintigraphic characteristics with positive SLN findings, we examined all variables by univariate logistic regression with odd ratios representing the size effect. RESULTS: The overall identification rate of SLN was 98.5%. One or more positive SLN were seen in 47 (23.4%) of the patients. Drainage to one regional basin was noticed in 176 (88%) and multiple drainage regions, up to three, was noticed in 24 patients (12%). Transit lymph nodes were detected in 20 patients (10%). The characteristics that were assotiated significatly with sentinel lymph node metastases were Breslow thickness, nodular melanoma histological subtype and acral localization. CONCLUSION: Besides the well established primary tumor thickness being a predictor of SLN malignancy, we observed: acral body site location and nodular melanoma histological subtype to be significant independent factors in increasing the risk for regional metastases. Our results suport the clinical usefulness of SLNB within a multidisciplinary approach (dermatooncology, plastic/head and neck surgery, pathology, nuclear medicine), as a reliable method in staging and for treatment planning in melanoma patients.

Evaluation of diagnostic parameters from parotid and submandibular dynamic salivary glands scintigraphy and unstimulated sialometry in Sjögren's syndrome.

Our aim was to validate eight scintigraphic salivary gland (SG) parameters, as diagnostic parameters in patients with Sjögren's syndrome (SS). We used the standardized stimulated dynamic salivary gland scintigraphy (DSGS) protocol and correlated this with the unstimulated whole sialometry (UWS) functions. The DSGS and UWS tests meeting the European and the USA diagnostic classification criteria for SS were applied in twenty patients and in ten normal controls. The DSGS tests were performed 60min after the intravenous (i.v.) injection of 370MBq of technetium-99m-pertechnetate ((99m)TcO(-)4) and after per os stimulation with a 0.5g tablet of ascorbic acid administered 40min after the injection. Using time-activity curves, eight different parameters were calculated for each parotid gland (PG) and each submandibular salivary gland (SMG): a) time at maximum counts (Tmax), b) time at minimum counts (Tmin), c) maximum accumulation (MA), d) accumulation velocity (AV), e) maximum secretion (MS), f) maximum stimulated secretion (MSS), g) stimulated secretion velocity (SSV), and h) uptake ratio (UR). Values of UWS below 2.5mL/15min, were considered abnormal. All these parameters, as for the PG, showed significant abnormality in SS patients (P<0.001), especially of the secretion function. All SMG parameters also showed a significant abnormality (P<0.001), but especially of the accumulation function. There was a greater impairment of the above parameters in SMG than in PG in the SS patients. Sensitivity of the standardized DSGS was 100%, specificity 80%, negative prognostic value 100%, and positive prognostic value 91%. Sensitivity of UWS was 75%. In conclusion, this paper suggested that the best diagnostic parameters for the SS patients were those of: a) the maximum secretion, b) the maximum stimulated secretion for both the parotid and the submandibular glands, c) maximum accumulation and d) accumulation velocity of submandibular glands. The times at maximum and at minimum counts were non diagnostic.

Clinical value of immunoscintigraphy in the rectal carcinomas: immunoscintigraphy of rectal carcinomas.

BACKGROUND/AIM: The aim of this study was to evaluate the clinical reliability of the immunoscintigraphy with radiolabeled monoclonal antibodies for the detection of metastases and recurrences of rectal carcinomas. METHODOLOGY: A total of 65 patients underwent immunoscintigraphy with radiolabeled monoclonal antibodies. Indication for that examination was suspicious rectal cancer or suspicious rectal cancer recurrence and/or metastases. RESULTS: The method proved to have 92.7% sensitivity, specificity 83.3%, positive predictive value 90.5%, negative predictive value 87.0% and accuracy 89.2%. There was a statistically significant relationship between immunoscintigraphy findings and rectoscopy findings (rs=0.415, p=0.013), as well as significant relationship between immunoscintigraphy findings and US findings (rs=0.332, p=0.001). Tumor marker levels were in positive correlation with findings of immunoscintigraphy (rs=0.845, p=0.001), especially raised CEA level (rs=0.816, p=0.004). Patients with higher CA19-9 level had higher Duke's stage (p=0.025). CONCLUSIONS: We can conclude that immunoscintigraphy can be helpful in the detection of metastases and recurrences of colon carcinomas.

Five benign myoskeletal diseases in paediatrics and the role of nuclear medicine. Do they differ from those in adults?

In this paper we discuss trauma, osteomyelitis, fibrous dysplasia, Legg-Calvé-Perthes disease and osteopetrosis in children. Pathophysiology, incidence, clinical signs, diagnosis and specific trteatment of these diseases are described. We have focused on diagnostic imaging techniques which can be applied in children: X-rays, magnetic resonance imaging bone scintigraphy with technetium- 99m-methylene diphosphonate ((99m)Tc-MDP) and positron emission tomography (PET) with fluorine-18 fluorodesoxyglucose ((18)F-FDG) and fluorine-18 fluoro sodium fluoride ((18)F-NaF). In conclusion, bone scintigraphy with (99m)Tc-MDP and better with PET ((18)F-FDG and (18)F-NaF) can support diagnosis of most of these myoskeletal diseases in children. Radiology is usually applied for local lesions examinations. Magnetic resonance imaging can be used in specific cases in periosteal and bone marrow lesions and CT may be avoided due to its radiation burden, in children.

Interobserver reproducibility of mercaptoacetyltriglicine renography in children and adults with suspected obstruction: parameters of drainage and function calculated by International Atomic Energy Agency software.

OBJECTIVE: The aim of this study was to estimate interobserver reproducibility of Tc-99m mercaptoacetyltriglycine renography in children and adults by assessing the parameters of the International Atomic Energy Agency (IAEA) software for the analysis of dynamic renal studies. METHODS: The renograms of 65 children and 65 adults covered a wide age range, different quality of drainage, overall function and differential renal function (DRF). Three observers were processing parameters of the IAEA software. Normalized residual activity at 20 min (NORA20), NORA on the postmicturition acquisition (NORApm), PM to maximum renal count ratio (PM/max), output efficiency at 20 min (OE20), OE 20 min after diuretic stimulation (OEF + 20), whole kidney mean transit time (MTT) and DRF by integral and Rutland-Patlak were calculated by observers. RESULTS: The overall agreement between three observers was almost perfect [the average intraclass correlation coefficient (ICC) above 0.99] in children and adults, with no significant difference between the parameters of renal drainage, transit and DRF. ICCs for all parameters were higher than 0.980 in children under 12 months, even slightly greater for PM/max and OEF+20. In children with poor/incomplete drainage and DRF below 40%, ICCs were above 0.98. In the subgroup of adults with impaired overall tubular extraction rate, level of reproducibility was almost perfect. Slightly lower but still insignificant values of ICC were presented in adults with poor/incomplete drainage. CONCLUSION: Our results indicate an excellent interobserver reproducibility for all quantitative parameters of IAEA software in both pediatric and adult patients.

Impact of micturating cystourethrography and DMSA renal scintigraphy on the investigation scheme in children with urinary tract infection.

OBJECTIVE: The relationships among urinary tract infection (UTI), vesicoureteral reflux (VUR), and permanent renal damage in children are not fully understood. The aim of this study was to evaluate the incidence of renal scarring in children with a history of UTI and to determine the change in the probability of permanent renal damage owing to the presence of VUR documented on micturating cystourethrography (MCU). METHODS: We analyzed 201 children (400 renal units, two children with solitary kidney). Seventy-four boys and 127 girls (aged 7 months to 7 years, median 2.5 years) with culture verified UTI were referred for technetium-labeled dimercaptosuccinic (DMSA) renal scintigraphy 4-6 months after acute UTI. MCU was also performed mostly 1 month prior to DMSA. Statistical analysis was performed using chi2 test or Fisher's exact test. Likelihood ratio (LR) positive and negative, diagnostic odds ratio (DOR), and post-test probability of (no) disease were calculated for VUR on MCU versus scarring on DMSA. RESULTS: Vesicoureteral reflux was found in 158 (39.5%) kidneys, and evaluated as grades I, II, III, IV, and V in 3, 70, 43, 25, and 17 refluxing renal units (RRU), respectively. Permanent renal damage according to DMSA was seen in 15.2% (61/400) kidneys. Scarring was shown in 29.7% (47/158) of kidneys with VUR and in 5.8% (14/242) kidneys without VUR (P<0.0001). LR positive was 2.353 (95% CI 1.889, 2.865), LR negative 0.341 (95% CI 0.209, 0.523), and DOR 6.895 (95% CI 3.533, 14.093). Rate of scarring significantly increased with VUR of grades III, IV, and V. There was no significant difference in the incidence of scarring in kidneys without VUR and RRU with low-grade (I and II) VUR (P=0.306). The presence of VUR on MCU increased the chance of renal damage on DMSA by about 15%, whereas negative MCU increased the chance of no-renal involvement by 9%. CONCLUSIONS: Micturating cystourethrography should not be used as a first-line test to rule out the permanent renal damage owing to UTI. The priority of imaging strategy should be focused on early identification of renal lesions to prevent further deterioration.

Technetium-99m-tetrofosmin in diagnosis of breast cancer and axillary lymph node involvement.

BACKGROUND: The aim of this study was to evaluate the accuracy of breast cancer seeking agent Tc-99m-Tetrofosmin in the detection of breast malignancy and axillary lymph node metastases. MATERIAL AND METHODS: Twenty-eight female patients (mean age 52.4) with 30 breast lesions suspected of malignancy were enrolled in the study. All the patients underwent clinical investigation, Tc-99m Tetrofosmin scintimammography (SMM), mammography (MM) and biopsy/surgery for final histopathologic diagnosis. Patients were injected intravenously with 555 MBq of Tc-99m Tetrofosmin, cubitally, in the contralateral arm to the side of suspicious lesion. Seven minute static scans or at least 2.0 million counts were obtained using single head gamma camera (Orbiter 75, Siemens). Planar images were acquired in left and right prone lateral view as well as in the supine position for an anterior view of chest and axillary region. RESULTS: SMM scans of 30 breast lesions were compared to the definitive histopathology findings (HP) using decision matrix. In the group of 23 patients with positive SMM scans 19 had breast malignancy: 15 infiltrating ductal cancer, three patients with one infiltrating lobular, one papillary, one colloidal cancer and one patient with cystosarcoma phyllodes-malignant type. SMM detected primary breast malignancy with 95% sensitivity, 60% specificity and 83% accuracy. Axillary dissection was performed in 19/20 with malignant disease. The number of lymph nodes extracted and HP evaluated varied from 4 to 23 per patient. Metastatic involvement was confirmed by HP in 9 out of 20 patients. SMM detected axillary metastases with 55% sensitivity and 80% accuracy. CONCLUSION: Our results showed that SMM might be useful as a complementary test to improve the sensitivity and specificity of conventional imaging modalities, although SMM in the staging of breast carcinoma was less reliable. Further studies to evaluate the role of SMM in metastatic node involvement are necessary.

Technetium-99m-dimercaptosuccinic acid renal scintigraphy in children with urinary tract infections.

The aim of this study was to determine the incidence of abnormal dimercaptosuccinic acid-Tc-99m ((99m)Tc-DMSA) renal scintigraphy findings in children with culture proved urinary tract infection (UTI) with or without vesicoureteral reflux (VUR). (99m)Tc-DMSA renal scintigraphy was performed in 343 children with culture documented UTI (247 girls and 96 boys) aged from three months to 14 years (middle age of 4.82 years). The children studied were all those submitted for renal scintiscan to the Institute of Nuclear Medicine, Military Medical Academy, Belgrade during a five-year period (2000-2004). Micturating cystoureterography (MCU) performed in all patients before (99m)Tc-DMSA scan, revealed VUR in 213 children, while in 130 children VUR was not detected by MCU. In 15 of the 213 children the grade of VUR was I, in 88 was II, in 57 was III, in 33 was IV and 20 children had grade V of VUR. Findings of (99m)Tc-DMSA renal scintigraphy were classified as: normal, equivocal and abnormal. Statistical analysis was performed using c(2)test. In all patients abnormal findings were detected in 38% (131/343), normal in 51% (174/343) and equivocal findings in 11% (38/343). In children with UTI and VUR the incidence of abnormal findings was 53% (112/213), of normal 37% (80/213) and of equivocal findings 10% (21/213). In children with UTI without VUR the incidence of abnormal findings was 15% (19/130), of normal findings 72% (94/130), and of equivocal findings 13% (17/130). The incidence of abnormal findings was significantly higher in children with UTI and VUR than in those with UTI without VUR (P<0.001). In children with VUR grades I, II, III, IV and V abnormal findings were 33%, 32%, 60%, 79% and 95% respectively. The incidence of abnormal findings was higher in children with VUR grades IV and V, than in grade I and II (P<0.001). Our results suggest that (99m)Tc-DMSA renal scintigraphy in children can discriminate between grade I-II and IV-V of VUR and also that in children with UTI and VUR abnormal findings in the scintiscan were more than three times higher than in children with UTI alone.

Diuretic 99mTc DTPA renography in assessment of renal function and drainage in infants with antenatally detected hydronephrosis.

BACKGROUND/AIM: The controversy over the postnatal management of infants with antenataly detected hydronephrosis (ANH) still exists. We presented the results of diuretic 99mTc diethylenetriamine pentaacetic acid (DTPA) renography in 30 infants with the antenatal diagnosis of unilateral renal pelvic dilatation. The aim of this study was to assess the renal function determined by the pattern of drainage and split renal function (SRF) on diuretic renography and to correlate these findings with anteroposterior pelvic diameter (APD) estimated by ultrasonography. METHODS: A total of 30 infants with 60 renal units (RU) (25 boys and 5 girls, median age 6.0 months, range 2-24) presented with unilateral hydronephrosis on ultrasound in the newborn period, underwent DTPA diuretic renal scintigraphy (F+15 protocol). The median APD evaluated on perinatal ultrasound was 15 mm (range 5-30). The postnatal associated clinical diagnosis were pelviureteric junction obstruction (PUJ), simple hydronephrosis, megaureter, vesicoureteral reflux (VUR) and posterior urethral valves in 11, 10, 6, 2 and 1 infant, respectively. Images and Tmax/2 after diuretic stimulation on the background subtracted renographic curves were used as the criteria for classifying the drainage as good, partial, and poor or no drainage. The SRF was calculated with the integral method. RESULTS: Good drainage was shown in 36/60, partial drainage in 13/60 and poor or no drainage in 11/60 RU. The SRF > 40% was observed in 55/60 RU, with no RU showing SRF lower than 23.5%. In infants with severe ANH the obstruction was not excluded in 94.1%. CONCLUSION: Diuretic renography in antenatally detected hydronephrosis should be a useful tool in postnatal follow up, especially in differentiating nonobstructive hydronephrosis from obstructive. It is also importanat to assess and monitor the SRF. Our results suggest that even in the presence of partial or no drainage, SRF may not be significantly impaired.

Correlation of subtraction parathyroid scintigraphy with weight, pathohistologic finding and oxyphil cell content of parathyroid glands in parathyroid hyperplasia.

BACKGROUND/AIM: Parathyroid hyperplasia (PHP) is defined as an absolute increase in the mass of parenchymal cells of the parathyroid gland. PHP is classified as primary, secondary and tertiary. The enlargement of parathyroid glands (PG) is usually asymmetric, resulting in a "dominant" gland. In order to confirm the diagnosis, at least two glands should be examined histologically. Subtotal parathyroidectomy, i.e. removal of the three PG and leaving a small remnant of the forth, is the treatment of choice. High percent of PHP recurrence imposes the need for preoperative high sensitivity localizing procedures. Parathyroid scintigraphy localizes about 60% of hyperplastic glands. The aim of this study was to correlate findings of subtraction parathyroid scintigraphy (SPS) with weight, pathohistologic finding and oxyphil cell (OC) content of PG in patients with primary, secondary and tertiary parathyroid hyperplasia. METHODS: Twenty-seven patients with primary/secondary PHP underwent SPS before surgery. Scintigraphic results were graded from 1-5, in relation to the degree of uptake. SPS graded 3, 4 and 5 were considered positive. The number and weight of operated PG were evaluated macroscopically. Pathohistologic and cellular types were defined on standard stained hematoxylin-eosin slides. OC content was defined as a percent of OC and graded from 1 to 3: grade 1 < 10%, grade 2 > or = 10% and grade 3 > or = 20% of OC. RESULTS: SPS localized dominant gland in all patients with sensitivity 100%, and 51 from 73 hyperplastic PG, with sensitivity per gland of 70%. PG weighed 0.1 g to 6.7 g (median 1 g). A significant positive correlation (p < 0.0001) was found between the SPS results and PG weight. A significant positive correlation was found between PG weight and OC content (p = 0.0002). An insignificant correlation was found between SPS and OC content. Thirty-eight PG had < 10% of OC, 32 PG had > or = 10% and 3 PG had > or = 20% of OC. Four patients had diffuse PHP and 23 patients nodular PHP. There was no statistically significant difference in SPS results compared to hyperplasia type, and between OC content and hyperplasia type. A significant positive correlation (p = 0.05) was found between PG weight and hyperplasia type. CONCLUSION: A high positive correlation was found between SPS results and PG weight, PG weight and OC content and PG weight and hyperplasia type. Between SPS results and OC content, and between SPS results and hyperplasia type, an insignificant correlation was found. Our results showed that SPS is a reliable and very sensitive diagnostic tool in detecting abnormal PG in parathyroid hyperplasia, reaching 100% sensitivity in detecting a "dominant gland" and sensitivity per localized gland of 70%. Causes that affect increased uptake of liposolubile Tc99m radiopharmaceuticals (RF) in the hyperfunctional PG tissue and conditions which prevent RF admission into the PG cells still remain to be accurately and precisely determined.

123I-FP-CIT brain SPECT (DaTSCAN) imaging in the diagnosis of patients with movement disorders--first results.

BACKGROUND/AIM: 123I-FP-CIT brain single-photon emission computed tomography (SPECT), DaTSCAN imaging, offers a possibility to study structural and biochemical integrity of presinaptic dopaminergic neurotransmitter system. The aim of this study was to evaluate the usefulness of 123I-FP-CIT brain SPECT scintigraphy in patients with extrapyramidal diseases. METHODS: Fifteen patients (8 males and 7 females), aged 26-81 years, presenting with extrapyramidal symptoms entered the study. Out of them, 7 patients were diagnosed with definite clinical form of idiopathic Parkinson's disease (PD) or clinical probable for PD clinical stage 2-4 using the Hoehn & Yahr scale (H & Y); 6 patients were with atypical parkinsonism (AP), 1 patient with essential, and 1 with psychogenic tremor. SPECT was performed 180 min after injection of 185 MBq 123I FP-CIT using a dual head Gamma camera. Sixty four one minutes' frames were acquired using a noncircular rotation mode into a 128 x 128 image matrix. Transverse slices were reconstructed using a 0.6 order Butterworth filter. Visual interpretation was based on striatal uptake, left to right asymmetry and substructures most affected. The ratio of binding for the entire striatum, caudate and putamen to nonspecific binding in occipital cortex was calculated. SPECT findings were categorized as normal and abnormal (incipient, moderate and severe presinaptic deficit). RESULTS: 123I-FP-CIT uptake was reduced in the striatum of 6/7 patients with PD and 5/6 patients with AP. Two patients with PD and AP showed a negative finding. The remaining 2 negative results were obtained in the patients diagnosed with essential tremor and psychogenic tremor. The mean striato-occipital ratio (SDR) of the most affected side was lower in the patients with PD. CONCLUSION: Our first results confirm the usefulness of 123I-FP-CIT brain SPECT in differential diagnosis of extrapyramidal diseases.

90Y-labeled tin fluoride colloid as a promising therapeutic agent: preparation, characterization, and biological study in rats.

In this study, tin fluoride colloid (SnF-c) was prepared, labeled with yttrium-90 ((90)Y), and characterized with respect to its physicochemical properties and biological behavior in an animal model. Particle size of SnF-c, at constant concentration of SnF(2), was dependent on pH, concentration of sodium fluoride (NaF), temperature, and time. The particle size of SnF-c decreased with an increase in NaF concentration and a decrease in reaction mixture pH. Radiolabeling yield of (90)Y-SnF-c at higher temperature increased and it was greater than 98% for the preparation at 95 °C. The (90)Y-SnF-c demonstrated high in vitro stability both in human serum and human synovial fluid at 37 °C up to 7 days. In vivo distribution studies in healthy male Wistar rats of (90)Y-SnF-c (particles <1 µm), following intravenous administration, revealed that the localization takes place preferably in the liver. The (90)Y-SnF-c (particles >1 µm) was well retained in the synovial space for 96 h after intra-articular injection, whereas leakage of (90)Y from the joint was 1.96% over this period. Because of high labeling yield and stability, (90)Y-SnF-c might be a promising agent for radiosynovectomy or therapy of liver malignancies.