Clinical outcomes for Saudi and Egyptian patients receiving deceased donor liver transplantation in China.

Long waiting list times in liver transplant programs in Saudi Arabia and unavailability of deceased donor transplantation in Egypt have led several patients to seek transplantation in China. All patients who received transplants in China and followed in three centers from January 2003-January 2007 were included. All patients' charts were reviewed. Mortality and morbidity were compared to those transplanted in King Faisal Specialist Hospital & Research Centre (KFSH&RC) during the same period. Seventy-four adult patients were included (46 Saudi nationals; 28 Egyptians). One-year and 3-year cumulative patient survival rates were 83% and 62%, respectively compared to 92% and 84% in KFSH&RC. One-year and 3-year cumulative graft survival rates were 81% and 59%, respectively compared to 90% and 84% in KFSH&RC. Compared to KFSH&RC, the incidence of complications was significantly higher especially biliary complications, sepsis, metastasis and acquired HBV infection posttransplant. Requirements of postoperative interventions and hospital admissions were also significantly greater. Our data show high mortality and morbidity rates in Saudi and Egyptian patients receiving transplants in China. This could be related to more liberal selection criteria, use of donation after cardiac death (DCD) donors or possibly more limited posttransplant care.

Impact of PET/CT on initial staging, restaging and treatment management of anal cancer: a clinical case with literature review.

Distant extrapelvic metastases appear in approximately in 10% of the patients with squamous cell anal cancer (SCAC) and survival depends on the treatment strategy. Exact staging leads to optimal planning of multimodality therapy and the adequate evaluation of treatment response can improve the prognosis of the disease. Diagnosis and staging of SCAC are commonly performed using contrast-enhanced computerized tomography(CT) and interpretation of the findings for tumor biological behavior. F18-fluoro-2 deoxy-D glucose positron emission tomography((18)F-FDG PET) reveals aspects of tumor function and allows metabolic measurements. Combined PET/CT scans permit exact localization with anatomical criteria of the hypermetabolic (18)F-FDG avid malignant lesions. We present a patient with SCAC in whom, according to PET/CT findings, the initial stage was changed from II (T2N0M0) to III A (T2N2M0). Radiation therapy (RT) and chemotherapy achieved a good therapeutic response but early follow up revealed new paraaortic lymph node (LN) metastases, as well as an uncommon left supraclavicular LN metastasis from the same primary carcinoma. The disease was restaged as stage IV (T2N2M1) and radiation therapy was substituted by chemotherapy.

Importance of Tc-99m sulfur colloid liver-spleen scans performed before indium-111 labeled leukocyte imaging for localization of abdominal infection.

INTRODUCTION: The localization of intraabdominal abscesses is a difficult imaging problem in nuclear medicine, especially when the location of the abscess is in the area of the liver and spleen. The need for performing Tc-99m sulfur colloid liver-spleen scans before injecting indium-111 leukocytes for improved lesion detection and characterization versus performing In-111 leukocyte scans alone has been questioned in the literature MATERIALS AND METHODS: We present 3 patients with intraabdominal abscesses in the liver-spleen area, in which liver-spleen scans were performed before In-111 leukocyte scans. The findings of all were correlated with computed tomography and interventional procedures. RESULTS: In all patients, the Tc-99m liver-spleen scan helped for accurate recognition of the location of the abscess, correlated with computed tomography findings, and were helpful for intervention and exclusion of the other sources of infection. CONCLUSION: Data from these 3 patients reinforces the need for Tc-99m sulfur colloid liver-spleen scans before performing In-111 WBC scans for better localization and interventional treatment of intraabdominal abscesses.

Neck and whole-body scanning with 5-mCi dose of (123)I as diagnostic tracer in patients with well-differentiated thyroid cancer.

OBJECTIVE: To determine whether a 5-mCi dose of 123I can be used as an effective radiotracer for assessing the presence of remnant thyroid tissue and for searching for metastatic lesions in patients with well-differentiated thyroid cancer as well as to attempt to ascertain whether a scan performed only at 4 hours is sufficient for accurate diagnosis and might replace the conventional protocol of scanning at both 4 hours and 24 hours. METHODS: We prospectively studied 27 patients who had undergone near-total thyroidectomy and had a documented diagnosis of well-differentiated thyroid carcinoma. Patients underwent scanning after receiving a 5-mCi dose of 123I, at a time when they had discontinued thyroid replacement therapy and had a thyrotropin level in excess of 30 mIU/mL. Whole-body images at 4 hours and 24 hours were obtained and were compared with posttherapy scans obtained 5 to 7 days after administration of 131I. Scans were interpreted by two board-certified nuclear medicine physicians. RESULTS: Of the 27 patients, 2 (7.4%) showed discordance between the 123I scan performed at 24 hours and the posttherapy 131I scan. When 4-hour images after administration of 123I were compared with the posttherapy 131I scans, a discordance rate of 14.8% (4 of 27 patients) was noted. In addition, two of these four patients showed lesions on the 24-hour images that were not seen on the 4-hour images (one with new lung metastatic involvement and the other with a local recurrence in the lower neck area). The prognosis and treatment of these two patients were substantially changed by the result of the 24-hour images. CONCLUSION: On comparison of scans obtained after administration of a 5-mCi dose of 123I with those obtained after 131I therapy, we conclude that 5 mCi of 123I produces images that have excellent quality and resolution and also compare favorably with those obtained after 131I therapy. Furthermore, a decrease in the dose of 123I from 10 mCi to 5 mCi lowered the cost of the study without compromising the diagnostic accuracy or image quality. Finally, use of 24-hour images will occasionally disclose additional areas of radioiodine uptake not detected on the 4-hour scans and is therefore recommended.

Metastatic thyroid cancer occurring as an unknown primary lesion: the role of F-18 FDG positron emission tomography.

Thyroid cancer can appear as metastatic disease of an unknown primary origin, and fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomographic (PET) studies are helpful in the workup evaluation of these patients. The authors describe two patients who had metastatic disease from an unknown primary lesion. F-18 FDG PET studies played an important role in localizing the primary malignant site in the thyroid gland. The utility of F-18 FDG imaging in decreasing the number of procedures, cost, and inconvenience to patients is shown clearly in both cases.

Role of repeated F-18 fluorodeoxyglucose imaging in management of patients with bone and soft tissue sarcoma.

AIM OF THE STUDY: To assess the impact of repeated F-18 FDG studies on the management of patients with bone and soft tissue (B&S) sarcomas. MATERIAL AND METHODS: Twenty patients with B&S tissue tumors (11 M and 9 F age 17-72 years) had 52 F-18 FDG Dual Head Coincidence Imaging (DHCI) studies. 7 patients were followed for 6 months to 2 years clinically after removal of the primary tumor. Thirteen patients were evaluated for suspected recurrences. Patient's preparation, F-18 FDG injection and imaging procedure were done according to department protocol. Attenuation corrected images were interpreted visually by 3 trained physicians. Tumor to background ratios were calculated for all lesions. RESULTS: In 13 patients having both studies, baseline FDG and CT/MRI were concordant in 8 patients, FDG detected more lesions in 3 patients but it did not detect 4 metastatic pulmonary nodules in 2 patients. Follow up studies showed stable disease in 10 patients while 6 patients who showed worsening disease needed to change their chemotherapy. Surgery was avoided in 2 patients and 2 patients showed improved response. CONCLUSION: Repeated F-18 FDG DHCI examinations proved to have an impact on the clinical management of patients with malignant bone and soft tissue sarcoma. It helps to differentiate postoperative changes from local recurrence.

Tc-99m MAG3 scintigraphy in unusually dilated bilateral extrarenal pelves.

The authors report the findings of a radionuclide diuretic renogram in a patient with markedly dilated pelves bilaterally that filled most of the abdominal cavity. With the patient in the sitting position, at the end of the furosemide injection, there was good delineation and filling of the dilated calyces. These findings are unusual because of the extensive pelvicaliceal dilatation, and they emphasize the importance of the sitting position.

Unusual presentation of solitary bone metastasis from breast carcinoma mimicking acute osteomyelitis of the left midtibial shaft.

The authors report an unusual presentation of a solitary bone metastasis in the left midtibial shaft with no other skeletal involvement in a patient with breast carcinoma. The incidence of solitary bone metastasis below the knees is rare. Clinically, the lesion was tender when palpated. A bone scan revealed increased blood flow and blood pool activity, with intense midtibial bony uptake in delayed images. These findings are similar to those of acute osteomyelitis. Biopsy revealed bony metastasis from the patient's breast carcinoma.

Discrepancy between Ga-67 citrate and F-18 fluorodeoxyglucose positron emission tomographic scans in pulmonary infection.

The authors describe a patient with the acquired immunodeficiency syndrome who had active pulmonary tuberculosis and was receiving anti-tuberculosis treatment. High-grade fever and a right-sided pleural effusion had recently developed. Results of a Ga-67 scan were negative for any focal infection in the chest. Fluorine-18 fluorodeoxyglucose positron emission tomography showed increased uptake in the right lower lung field, which correlated with the diagnosis of concomitant bacterial pneumonia. Anti-tuberculosis treatment can decrease the sensitivity of the Ga-67 scan and could have contributed to this discrepancy. The authors predict that the fluorine-18 fluorodeoxyglucose positron emission tomographic scan will play an important diagnostic role in the management of such a selected group of patients.

Attenuation-Correction Induced Artifact in F-18 FDG PET Imaging Following Total Knee Replacement.

Purpose: The clinical use of PET FDG in the work-up of patients with bone and soft tissue malignant tumors is rapidly increasing. The recognition of any source of artifact, therefore, is important to avoid interpretation pitfalls.Procedures: Two patients with complete knee joint replacement by metallic prosthesis in the course of their treatment for malignant bone and soft tissue sarcoma were evaluated by PET F-18 FDG imaging using a dual head coincidence gamma camera.Results: Both studies demonstrated in the attenuation-corrected images intense increase activity at the joint space between the metallic prosthetic surfaces at the level of the knee joint. No uptake, however, was noted in the same location on the non-attenuation-corrected images. Subsequent bone and thallium-201 scans confirmed the absence of tumor recurrence in the first patient. The second patient had multiple follow up F-18 FDG scans over a period of 16 months that show no changes from the baseline study.Conclusion: In the F-18 FDG PET images of patients with total knee metallic prosthesis, an intense activity tends to be seen in the joint space, only in the attenuation-corrected images. Such pattern of uptake is considered artifactual and should always be verified in the non-attenuated images.

SPECT brain perfusion findings in mild or moderate traumatic brain injury.

BACKGROUND: The purpose of this manuscript is to present the findings in the largest series of SPECT brain perfusion imaging reported to date for mild or moderate traumatic brain injury. PATIENTS AND METHODS: This is a retrospective evaluation of 228 SPECT brain perfusion-imaging studies of patients who suffered mild or moderate traumatic brain injury with or without loss of consciousness (LOC). All patients had no past medical history of previous brain trauma, neurological, or psychiatric diseases, HIV, alcohol or drug abuse. The patient population included 135 males and 93 females. The ages ranged from 11-88 years (mean 40.8). The most common complaints were characteristic of the postconcussion syndrome: headaches 139/228 (61%); dizziness 61/228 (27%); and memory problems 63/228 (28%). LOC status was reported to be positive in 121/228 (53%), negative in 41/228 (18%), and unknown for 63/228 (28%). RESULTS: Normal studies accounted for 52/228 (23%). For abnormal studies (176/228 or 77%) the findings were as follows: basal ganglia hypoperfusion 338 lesions (55.2%); frontal lobe hypoperfusion 146 (23.8%); temporal lobes hypoperfusion 80 (13%); parietal lobes hypoperfusion 20 (3.7%); insular and or occipital lobes hypoperfusion 28 (4.6%). Patients' symptoms correlated with the SPECT brain perfusion findings. The SPECT BPI studies in 122/228 (54%) were done early within 3 months of the date of the accident, and for the remainder, 106/228 (46%) over 3 months and less than 3 years from the date of the injury. In early imaging, 382 lesions were detected; in 92 patients (average 4.2 lesions per study) imaging after 3 months detected 230 lesions: in 84 patients (average 2.7 lesions per study). CONCLUSIONS: Basal ganglia hypoperfusion is the most common abnormality following mild or moderate traumatic brain injury (p = 0.006), and is more common in patients complaining of memory problem (p = 0.0005) and dizziness (p = 0.003). Early imaging can detect more lesions than delayed imaging (p = 0.0011). SPECT brain perfusion abnormalities can occur in the absence of LOC.

SPET brain perfusion imaging in mild traumatic brain injury without loss of consciousness and normal computed tomography.

We present SPET brain perfusion findings in 32 patients who suffered mild traumatic brain injury without loss of consciousness and normal computed tomography. None of the patients had previous traumatic brain injury, CVA, HIV, psychiatric disorders or a history of alcohol or drug abuse. Their ages ranged from 11 to 61 years (mean = 42). The study was performed in 20 patients (62%) within 3 months of the date of injury and in 12 (38%) patients more than 3 months post-injury. Nineteen patients (60%) were involved in a motor vehicle accident, 10 patients (31%) sustained a fall and three patients (9%) received a blow to the head. The most common complaints were headaches in 26 patients (81%), memory deficits in 15 (47%), dizziness in 13 (41%) and sleep disorders in eight (25%). The studies were acquired approximately 2 h after an intravenous injection of 740 MBq (20.0 mCi) of 99Tcm-HMPAO. All images were acquired on a triple-headed gamma camera. The data were displayed on a 10-grade colour scale, with 2-pixel thickness (7.4 mm), and were reviewed blind to the patient's history of symptoms. The cerebellum was used as the reference site (100% maximum value). Any decrease in cerebral perfusion in the cortex or basal ganglia less than 70%, or less than 50% in the medial temporal lobe, compared to the cerebellar reference was considered abnormal. The results show that 13 (41%) had normal studies and 19 (59%) were abnormal (13 studies performed within 3 months of the date of injury and six studies performed more than 3 months post-injury). Analysis of the abnormal studies revealed that 17 showed 48 focal lesions and two showed diffuse supratentorial hypoperfusion (one from each of the early and delayed imaging groups). The 12 abnormal studies performed early had 37 focal lesions and averaged 3.1 lesions per patient, whereas there was a reduction to--an average of 2.2 lesions per patient in the five studies (total 11 lesions) performed more than 3 months post-injury. In the 17 abnormal studies with focal lesions, the following regions were involved in descending frequency: frontal lobes 58%, basal ganglia and thalami 47%, temporal lobes 26% and parietal lobes 16%. We conclude that: (1) SPET brain perfusion imaging is valuable and sensitive for the evaluation of cerebral perfusion changes following mild traumatic brain injury; (2) these changes can occur without loss of consciousness; (3) SPET brain perfusion imaging is more sensitive than computed tomography in detecting brain lesions; and (4) the changes may explain a neurological component of the patient's symptoms in the absence of morphological abnormalities using other imaging modalities.

Fluorine-18 fluorodeoxyglucose splenic uptake from extramedullary hematopoiesis after granulocyte colony-stimulating factor stimulation.

Two patients with sarcoma, one with recurrent osteosarcoma of the spine and the other with metastatic synovial cell sarcoma, were treated with high-dose chemotherapy that produced severe leukopenia. The patients received granulocyte colony-stimulating factor (G-CSF) to stimulate the bone marrow (480 mg given subcutaneously twice daily for 5 to 7 days); their responses were seen as a marked increase in peripheral leukocyte count with no change in the erythrocyte or platelet counts. The patients had fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging 24 hours after the end of G-CSF treatment. Diffusely increased uptake of F-18 FDG was seen in the bone marrow in both patients. In addition, markedly increased uptake in the spleen was noted in both, indicating that the spleen was the site of extramedullary hematopoiesis. The patients had no evidence of splenic metastases. The first patient had a history of irradiation to the dorsal spine, which was less responsive to G-CSF administration than was the nonirradiated lumbar spine.

Assessment of pulmonary lesions with 18F-fluorodeoxyglucose positron imaging using coincidence mode gamma cameras.

UNLABELLED: Accurate assessment of lung carcinoma remains a significant clinical problem, often leading to surgical procedures without curative potential. PET with 18F-fluorodeoxyglucose (FDG) has shown promise in differentiating benign from malignant lesions and in staging the extent of disease, resulting in improved treatment at a significant cost savings. This multicenter prospective study used dual-detector coincidence imaging with FDG to categorize pulmonary lesions as benign or malignant. The goal of this study was to determine the sensitivity and specificity of dual-detector coincidence imaging of FDG in patients with pulmonary lesions who were scheduled to have a diagnostic procedure for histopathologic confirmation. METHODS: A total of 96 patients with pulmonary lesions with a lesion size ranging from 1 to 7 cm with a mean of 3.44 cm based on their chest radiograph or CT scan were studied using FDG scans with a dual-detector coincidence detection system. An additional 24 patients were entered as control subjects. The studies of 120 subjects were interpreted in random order by three physicians experienced in the use of FDG in patients with lung cancer. Surgical pathology was used as the standard for identifying malignant lesions. RESULTS: There was 94% agreement between the readers in the independent interpretation of the FDG studies. In the 96 patients with pulmonary lesions, FDG studies were 97% sensitive and 80% specific in identifying proven malignant lesions. CONCLUSION: The results of this prospective study provide evidence that dual-detector coincidence imaging with FDG provides an accurate, sensitive and specific means of diagnosing malignancy in patients with pulmonary lesions.