Additional value of integrated 18F-choline PET/4D contrast-enhanced CT in the localization of hyperfunctioning parathyroid glands and correlation with molecular profile.

PURPOSE: The localization of hyperfunctioning parathyroid gland(s) (HPTG) in patients with primary hyperparathyroidism (PHPT) with negative or inconclusive first-line imaging is a significant challenge. This study aimed to evaluate the role of integrated 18F-choline PET/4D contrast-enhanced computed tomography (4DCeCT) in these patients, compare its detection rate and sensitivity with those of 18F-choline PET/CT and (4DCeCT), and analyse the association between choline metabolism and morphological, biochemical and molecular parameters of HPTG. METHODS: We prospectively enrolled 44 PHPT patients with negative or inconclusive first-line imaging. 18F-Choline PET/CT and 4DCeCT were performed at the same time, and integrated 18F-choline PET/4DCeCT images were obtained after coregistration. Experienced physicians examined the images. The SUVratio and degree of contrast enhancement were recorded for each positive finding. Histopathology, laboratory and multidisciplinary follow-up were used as the standard of reference. Both the detection rates and sensitivities of the three imaging modalities were calculated retrospectively. Immunohistochemistry was performed to evaluate the molecular profile of HPTGs. RESULTS: 18F-Choline PET/4DCeCT was positive in 32 of 44 patients with PHPT (detection rate 72.7%), and 31 of 31 surgically treated patients (sensitivity 100%). These results were significantly (p < 0.05) better than those of 18F-choline PET/CT (56.8% and 80%, respectively) and those of 4DCeCT (54.5 and 74%, respectively). A significant correlation between SUV and calcium level was found. In a multivariate analysis, only calcium level was significantly associated with 18F-choline PET/4DCeCT findings. SUVratio and Ki67 expression were significantly correlated. CONCLUSION: Integrated 18F-choline PET/4DCeCT should be considered as an effective tool to detect PHPT in patients with negative or inconclusive first-line imaging. Choline metabolism is correlated with both calcium level and Ki67 expression in HPTG.

Thyroid nodules with indeterminate cytology: prospective comparison between 18F-FDG-PET/CT, multiparametric neck ultrasonography, 99mTc-MIBI scintigraphy and histology.

PURPOSE: To evaluate the role of (18)F-flurodeoxiglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) in predicting malignancy of thyroid nodules with indeterminate cytology. PATIENTS AND METHODS: We analysed 87 patients who have been scheduled to undergo surgery for thyroid nodule with indeterminate cytology. All patients underwent (18)F-FDG-PET/CT, multiparametric neck ultrasonography (MPUS), and (99m)Tc-methoxyisobutylisonitrile scintigraphy ((99m)Tc-MIBI-scan). Histopathology was the standard of reference. We compared the sensitivity (SE), specificity (SP), accuracy (AC), positive (PPV) and negative predictive (NPV) values of (18)F-FDG-PET/CT with those of (99m)Tc-MIBI-scan and MPUS in detecting cancer. Univariate and multivariate analyses evaluated the association between each diagnostic tool and histopathology. RESULTS: On histopathology, 69 out of 87 nodules were found to be benign and 18 to be malignant. The SE, SP, AC, PPV and NPV of (18)F-FDG-PET/CT were 94, 58, 66, 37 and 98% respectively. The SE, AC and NPV of (18)F-FDG-PET/CT were significantly higher than those of MPUS and (99m)Tc-MIBI-scan. The association of both positive (18)F-FDG-PET/CT and MPUS (FDG+/MPUS+) showed significantly lower SE (61% vs 94%) and NPV (88% vs 98%) than (18)F-FDG-PET/CT alone, but significantly higher SP (77% vs 58%). On univariate analysis, (18)F-FDG-PET/CT and the combination of FDG+/MPUS+ and of FDG+/MIBI- were all significantly associated with histopathology. On multivariate analysis, only FDG+/MIBI- was significantly associated with histopathology. CONCLUSION: The AC of (18)F-FDG-PET /CT in detecting thyroid malignancy is higher than that of (99m)Tc-MIBI-scan and MPUS. A negative (18)F-FDG-PET/CT correctly predicts benign findings on histopathology. The association of FDG+/MPS+ is significantly more specific than (18)F-FDG-PET/CT alone in identifying differentiated thyroid cancer. A positive (18)F-FDG-PET/CT is significantly associated with malignancy when qualitative (99m)Tc-MIBI-scan is rated as negative.

Radioguided occult lesion localization of cervical recurrences from differentiated thyroid cancer: technical feasibility and clinical results.

AIM: We explored the feasibility of radioguided occult lesion localization (ROLL) for radioiodine-negative cervical recurrences from differentiated thyroid cancer (DTC). METHODS: The procedure was performed in 32 patients (3 patients being operated twice); 15/32 patients had had multiple prior lymph node dissections ("hostile" anatomy). 99mTc-albumin macro-aggregates (99mTc-MAA) were injected intra-lesionally under ultrasound guidance; 2 to 18 hours later, a hand-held gamma-probe helped to localize the lesions intraoperatively and to ascertain removal of the radiolabeled lesions. Mini-invasive excision of the radiolabelled lesions was performed in 12 cases (m-ROLL), while a modified radical neck dissection was performed in 23 cases after radioguided lymphadenectomy (d-ROLL). Fifty-nine lesions were radiolabelled (mean size 11±4.5 mm). RESULTS: Radioguidance allowed to identify/remove 56/59 lesions (95%). Some leakage of 99mTc-MAA in the surrounding tissues hampered detection of 3 lesions, which were removed anyway (100% overall localization). Histopathology confirmed metastatic involvement of the radiolabeled lesions and some additional metastases in other nodes. Neither nerve injury nor hypoparathyroidism occurred. After a median follow-up of 29 months, 19 patients were disease-free, 12 patients developed loco-regional recurrences, 1 patient had distant metastases and 1 patient had both loco-regional and distant metastases. Recurrences rates were 33% for m-ROLL and 40% for d-ROLL. CONCLUSIONS: The ROLL technique is feasible in selected patients with loco-regional recurrence from DTC, proving to be particularly useful also in patients already submitted to cervical dissections and/or with small lesions located in surgically difficult sites. It can therefore have a clinical role in the management of cervical DTC recurrences.

Role of low-cost thyroid follow-up in children treated with radiotherapy for primary tumors at high risk of developing a second thyroid tumor.

AIM: Differentiated thyroid cancer (DTC) is uncommon in childhood and data on its prevalence as a second malignant neoplasm (SNM) after radiotherapy (RT) for malignancies are limited. We evaluated: 1) the incidence DTC in pediatric-oncologic patients treated with RT; 2) the relationship between DTC, RT and the features of the first malignancy; 3) the usefulness of thyroid follow-up in irradiated oncological patients. METHODS: We have followed up 252 patients treated with RT out of 966 oncologic pediatric patients. Thyroid follow-up included TSH level evaluation and neck ultrasonography. In the presence of thyroid nodule/s ≥1 cm and/or with ultrasonography suspicious for malignancy, fine needle aspiration biopsy (FNAB) was performed. When papillary/follicular lesions were detected by cytology, thyroidectomy was performed. If DTC was confirmed, patients underwent radioactive iodine (RAI) treatment. RESULTS: At least one thyroid nodule was detected in 106 irradiated patients (42%): 45 patients underwent FNAB and 27 underwent thyroidectomy. Seventeen DTC (6.7%) were found on histology. A higher incidence of DTC was seen in patients with neuroblastoma (38%) or Wilms' tumor (18%). One third of DTC showed capsule invasion, and one fourth node involvement. Eleven patients, treated with a single RAI treatment, showed undetectable thyroglobulin levels after rh-TSH-stimulation. Five patients underwent at least two RAI treatments: four patients showed complete remission and one patient partial remission. CONCLUSION: A high rate of DTC, often with invasive features, was observed in children treated with RT for primary tumors. This finding underlines the usefulness of thorough low-cost thyroid follow-up in this high-risk population.

Uncommon association of germline mutations of RET proto-oncogene and CDKN2A gene.

INTRODUCTION: Calcitonin measurement is advised in the diagnosis of thyroid nodules, as it is an accurate marker of medullary thyroid carcinoma (MTC). C-cell hyperplasia (CCH)-induced hypercalcitoninemia cannot be distinguished from that induced by MTC, unless surgery is performed. CASE: We report the clinical and biological features of a patient with a family history of cancer, including melanoma and pancreatic cancer, who had previously undergone surgery for melanoma. He presented the unusual association of papillary thyroid carcinoma (PTC), normocalcemic hyperparathyroidism, and hypercalcitoninemia with a pathological response to pentagastrin, which was histologically deemed secondary to CCH. Multiple endocrine neoplasia (MEN) 2A was diagnosed. RET gene analysis showed a p.V804M missense mutation in exon 14, a low- but variably penetrant defect found in both sporadic and MEN2A-associated MTC/CCH, and a p.G691S polymorphism in exon 11. Furthermore, the germline P48T mutation was found in the CDKN2A gene exon 1, which is known to be associated with melanoma and pancreatic cancer. The patient showed the uncommon coexistence of a germline mutation in two suppressor genes, RET and CDKN2A; this finding, deemed to be a mere coincidence, did not modify the phenotype expected by each single mutation. CCH associated with V804M RET mutation is a precancerous condition and surgery is recommended. In order to exclude MTC, surgery is advised in patients with a pathological calcitonin response to pentagastrin, in the absence of thyroid autoimmunity. CCH-induced hypercalcitoninemia can be associated with thyroid cancers other than MTC (e.g., PTC). Family history is important in scheduling specific genetic screening in high-risk patients and their relatives.

[Role of echography in the diagnosis of visceral ischemic syndrome]. / Ruolo dell'ecografia nella diagnosi della sindrome ischemica viscerale.

Personal experience of the current possibilities of ultrasonography in the diagnosis of visceral ischaemic syndrome is reported.

[Intramural diverticulosis of the gallbladder]. / Le diverticolosi intramurali della colecisti.

The authors report on 9 cases of acalculous adenomyomatosis of the gallbladder, selected to Arianoff's classification. The clinical, anatomopathological and radiological data are considered: there isn't difference concerning the clinical symptoms between adenomyomatosis and cholelithiasis; only radiological study may clarify the nature and character of these lesions. The authors conclude stressing the importance of surgical therapy because the medical therapy is only symptomatic and does not modify the natural evolution of the disease and its complications.

[Acute abdomen caused by retroperitoneal hemangiopericytoma (indications of a clinical case)]. / Addome acuto da emangiopericitoma retroperitoneale (segnalazione di un caso clinico).

The authors describe a case of acute abdomen due to retroperitoneal hemorrhage in a patient suffering from perirenal hemangiopericytoma. They emphasize the rareness of such clinical picture and the difficulties involved in the radical surgical extirpation.

[Atypical cutaneous leishmaniasis. Report of a personal case]. / Leishmaniosi cutanea atipica. A proposito di una osservazione personale.

A cause of cutaneou leishmaniosis is reported in which the similarities with ordinary dermatoses made differential diagnosis rather difficult. The patient's provenance from a endemic area and the exposed location of the lesions indicated leishmaniosis but conclusive diagnosis was only confirmed when the parasite was found in the lesion.

[Delayed intestinal cannulation in the postoperative period]. / I ritardi della canalizzazione intestinale nel post-operatorio.

550 patients given abdominal or extra-abdominal surgery in the first six months of 1980 were examined to provide data on the incidence of delayed postoperative canalisation. Both general (sex, age, physical constitution) and surgical (extent of surgery, whether the peritoneal sac was opened) factors were considered. The data collected provide information on the prophylaxis and therapy of delayed postoperative canalisation.

[Bleeding Meckel's diverticulum. Apropos of a case diagnosed by scintigraphy]. / Diverticolo di Meckel sanguinante. A proposito di un caso diagnosticato mediante scintigrafia.

Abdominal imaging after intravenous injection of 99m Tc pertechnetate is a simple diagnostic procedure to show ectopic gastric mucosa. A case of Meckel's diverticulum show by Technectium scanning is described. It is concluded that abdominal imaging is useful in the preoperative investigations for rectal bleeding.