[¹8F-FDG PET-CT in cytomegalovirus-induced mononucleosis]. / ¹8F-FDG PET-TAC en mononucleosis por citomegalovirus.

The case of a 51 years-old woman with high fever, asthenia and weight loss of three weeks of evolution is presented. She had a personal history of breast cancer and liver metastases. The physical examination showed small painless enlarged lymph nodes in both latero-cervical chains. The blood analysis showed 9200 leukocytes with 69% of lymphocytes and elevated liver enzymes. Serological determinations as well as repeated blood and urine culture were negatives, only the anti-CMV IgM determination being positive. The CEA tumor marker was slightly elevated. PET/CT demonstrated hypermetabolic enlarged lymph nodes in the bilateral cervical chains and in celiac region, hepatosplenomegaly and diffusely increased ¹8F-FDG uptake in the spleen. These alterations were associated with CMV infection. Her evolution was favorable, and she was diagnosed of CMV mononucleosis. The appropriate clinical and immunological diagnosis of IM in patients aged over 40 years is important to avoid unnecessary diagnostic procedures.

[Treatment with (131)I of thyroid remnants in a patient with papillary thyroid carcinoma and end-stage chronic renal failure]. / Tratamiento con (131)I de restos tiroideos en paciente con carcinoma papilar de tiroides e insuficiencia renal crónica terminal.

The follow-up and treatment of thyroid cancer presents several aspects subject to discussion, such as its management in patients with End-Stage Renal Failure (ESRF). We present a patient with ESRF and papillary thyroid carcinoma, which had to be coordinated among different departments (Endocrinology, Nuclear Medicine, Nephrology and Physics and Radiation Protection). Both the diagnostic scintigraphy with (123)I and the ablative treatment with (131)I performed later were performed with the administration of rh TSH. The room in which the metabolic therapy was to be performed was prepared for the patient's periodic hemodialysis. The (131)I dose used was 80% of the usual dose. This made it possible to assure the therapeutic effect and that the patient's stay in hospital would only be for 5 days. Throughout the whole diagnostic and therapeutic process, no adverse effects attributable to rh TSH or radioiodine were observed. The coordination among the departments involved enabled an effective and safe process for the patient.

[Treatment of Graves-Basedow's disease with 131I. Assessment of a "modulated fixed activity" protocol]. / Tratamiento de la enfermedad de Graves-Basedow con I. Valoración de un protocolo de "actividades fijas moduladas".

PURPOSE: The purpose of this study was to retrospectively evaluate the hypothyroidism rate, persistence of hyperthyroidism and the complications after the administration of 131I in 3 cohorts defined according to the activity of 131I administered. METHODS: We consecutively treated 659 patients diagnosed with Graves-Basedow disease (GBD) with 131I. The activity was determined on the basis of a protocol that we called "modulated fixed activity". A total of 45 patients (Group 1) who had previously undergone surgery were given small 131I activities of between 111-185 MBq (3-5 mCi), 247 patients (Group 2) with normal or almost normal-sized thyroids were given activities of between 222-333 MBq (6-9 mCi) and the 367 patients with diffuse goiters (Group 3) activities of between 370-555 MBq (10-15 mCi). RESULTS: A total of 69.2 % of the patients presented hypothyroidism at the end of the follow-up period. By groups, the percentages of hypothyroidism at the end of the follow-up period were 69 %, 68.8 % and 69.6 % respectively. The average time for the patients to present hypothyroidism was 2.7 years with a maximum de 12.3 years and a minimum of 2 months. No severe precocious complications after the administration of 131I were noted. CONCLUSION: The choice of the modulated fixed doses of 131I for treatment of the GBD is a simple method and permit treatment in only one day.

[Scintimammography with 99mTC-MIBI in the clinical practice: repercussion on the clinical management of the patient]. / Gammagrafía de mama con 99mTc-MIBI en la práctica clínica. Repercusión en el manejo clínico del paciente.

OBJECTIVE: Establish the usefulness of scintimammography (SM) in day-to-day clinical practice. MATERIAL AND METHODS: We have evaluated 308 SM consecutively performed in our Department. The diagnosis was established by way of biopsy or clinical and mammography follow-up (minimum 18 months). In all cases we evaluated the kind of lesions (palpable or non-palpable) and their degree of suspicion of malignancy in the mammography (BIRADS). We determined the number of fine-needle aspiration cytology (FNAC) or biopsies performed in dependence of kind of lesions, mammography and SM results. RESULTS: Final diagnosis was cancer in 18 % of the patients, and 71 % of the lesions were non palpable. Negative predictive value (NPV) of SM was 96 %. Pathological diagnosis was performed in 100 % of lesions with SM+ and 16 % of lesions with SM-. According to the kind of lesion, FNAC and/or biopsy was performed in 62 % of palpable lesions and in 20 % of non-palpable lesions; and according to the mammography in 21 % of lesions BIRADS I-II, 14 % in BIRADS III, 70 % in BIRADS IV and 100 % in BIRADS V. The number of FNAC and/or biopsies performed is significantly higher in all cases when SM is positive (p > 0,001), excepting in BIRADS V lesions. CONCLUSIONS: In day-to-day clinical practice SM is generally performed in low prevalence of breast cancer population, in the evaluation of non-palpable lesions with a low suspicion of malignancy. SM has a high NPV, increase the diagnostic accuracy of the mammography and has repercussion on patient management, except in BIRADS V lesions.

In-111 DTPA octreotide scintigraphy and intraoperative gamma probe detection in the diagnosis and treatment of residual lymph node metastases of a rectal carcinoid tumor.

PURPOSE: We report a case of a rectal carcinoid tumor that was treated using endoscopic resection. This case highlights the usefulness of using somatostatin receptor scintigraphy in the postresection endoscopy of the tumor and the intraoperative use of a gamma probe detector for the surgical resection of metastatic adenopathy that had not been detected using computed tomography (CT) scanning. METHODS: The patient was studied using CT scanning, somatostatin receptor scintigraphy (SRS), and rectal endoscopic ultrasonography (EUS). A gamma probe detector was scheduled for use during the subsequent surgical intervention. RESULTS: The SRS demonstrated a pelvic metastatic lymphatic node that had not been detected on CT scanning. Additional EUS did not show regional metastatic lymph nodes. Histopathology following removal of retroperitoneal and presacral lymphatic nodes confirmed the diagnosis of metastatic carcinoid tumor. At follow up at 6 months, SRS and rectoscopy were normal. CONCLUSION: Somatostatin receptor scintigraphy is very useful in identifying the presence of lymph node metastases, even with a small rectal carcinoid tumor. This is of considerable importance when scheduling surgery and the CT and EUS are normal. The use of an intraoperative gamma-probe detector assists in the surgical excision of the metastatic lymphatic nodes, especially because they had been detected only using SRS, and when their exact location is uncertain.

[Treatment of bone metastatic pain with Sm153-EDTMP. Evaluation of the analgesic response and the existence of differences according to the primary tumor and the metastatic pattern]. / Tratamiento del dolor óseo metastásico con Sm153-EDTMP. Valoración de la respuesta analgésica y de la existencia de diferencias según el tipo de tumor y el patrón metastásico.

AIMS: To evaluate the response to Sm153-EDTMP treatment in patients with metastatic bone pain and the existence of differences in the response according to the scintigraphic pattern (99mTc-MDP) and the primary tumor. MATERIAL AND METHODS: We have evaluated the response to Sm153-EDTMP treatment in 32 patients (17 male and 15 female) who received 38 doses (1 mCi/kg). The primary tumor was prostate cancer in 15 patients, breast in 13, lung in 2, intestinal carcinoid in one and unknown in one. Two types of response were considered: a) effective and b) non-effective. Patients were classified into 3 groups according to the metastatic pattern: 1) Superscan (SS), 2) Generalized metastases (GM) and 3) Regional metastases (RM). RESULTS: There was effective response in 24 doses (63.15%) and non-effective in 14 (36.84%). The mean duration of the response was 12.08 weeks. Patients with GM pattern showed 16 effective responses (76.19%) and 5 non-effective (23.8%). In SS pattern there were 6 effective responses (60%) and 4 non-effective (40%) and 2 effective (28.57%) and 5 non-effective (71.53%) in RM pattern. These differences did not reach statistical significance (p > 0.05). We did not find differences in the response between prostate cancer (12 effective and 6 non-effective) and breast cancer (10 effective and 6 non-effective) (p = 0.79968). CONCLUSIONS: Sm153-EDTMP treatment is efficacious in patients with metastatic bone pain with effective response in 63.15% of the treatments. The response percentage was lower in patients with RM pattern but the differences did not reach statistical significance. There were no differences in the response between prostate and breast cancer patients.

Mammography and 99mTc-MIBI scintimammography in suspected breast cancer.

UNLABELLED: The aim of this work has been to evaluate whether a diagnostic protocol based on the joint use of mammography and 99mTc-methoxyisobutyl isonitrile (MIBI) scintimammography is capable of reducing the number of biopsies required in patients with suspected breast cancer. METHODS: We performed prone scintimammography in 90 patients with suspected breast cancer, involving 97 lesions. In all patients, the diagnosis was established by way of biopsy. On mammography, we evaluated the degree of suspicion of malignancy and the size of the lesion (smaller or larger than 1 cm in diameter). RESULTS: The results of only 41 of the biopsies indicated malignancy. On mammography, 20 lesions (of which 1 was breast cancer) were considered to be of low suspicion of malignancy, 31 (of which 4 were breast cancer) as indeterminate and 46 (of which 36 were breast cancer) as high. Fourteen lesions (2 low probability, 2 indeterminate and 10 high) were smaller than 1 cm, whereas 83 (18 low probability, 29 indeterminate and 36 high) were larger. The sensitivity, specificity, positive predictive value and negative predictive value of scintimammography were 85%, 79%, 74% and 88%, respectively. Scintimammography was positive in all cases of breast cancer that initially had a low or indeterminate suspicion of malignancy according to mammography, as well as in 30 cases of breast cancer that initially were highly suspicious. Six false-negative scintimammography studies were obtained in lesions with a high suspicion of malignancy. CONCLUSION: We propose a diagnostic protocol with a biopsy performed on lesions that have a high suspicion of malignancy as well as those with low or indeterminate suspicion that are smaller than 1 cm or with positive scintimammography results. This would have reduced the total number of biopsies performed by 34%. More importantly, there would have been a 65% reduction in number of biopsies performed in the low and indeterminate mammographic suspicion groups. All 41 cases of breast cancer would have been detected.

[131I-treatment of the autonomous toxic nodule. Assessment of a fixed dose protocol]. / Tratamiento con 131I del nódulo autónomo tóxico. Valoración de un protocolo de dosis fijas.

Ninety six patients diagnosed of toxic thyroid adenomas received fixed doses of 131I (555MBq) for treatment of hyperthyroidism. The inclusion and exclusion criteria, the patient's characteristics and the advantages of the fixed doses are described. The hypothyroidism rate found at the end of the mean follow-up period (2.46 +/- 1.72 years) which was 27.08% significantly lower to that observed in patients treated for Graves-Basedow disease, is pointed out. No differences were found in the hypothyroidism rate when the patients were differentiated by sex or when this situation was related to pretreatment with the antithyroid drugs. The extensive differences in the hypothyroidism rates observed between the different series that have been published and the variability in the doses administered leads us to think that factors other than the dose of 131I may be responsible for this post-therapeutic hypothyroidism.

[Treatment with (131)I of toxic multinodular goiter. Assessment of a fixed dose protocol]. / Tratamiento con (131)I del bocio multinodular tóxico. Valoración de un protocolo de dosis fijas.

OBJECTIVE: Present the results of treatment with 131I in a cohort of 119 patients diagnosed of toxic multinodular goiter (TMG) from a specific geographic area who had been treated with fixed doses of isotopes (555 MBq). The indication for the administration of the 131I was hyperthyroidism correction in all of the cases. MATERIAL AND METHODS: 111 of the 119 patients treated were women (93%) and 8 were men (7%) and their ages ranged from 38 to 88 years. The follow-up periods were always greater than one year (1.78 +/- 1.05 years). Treatment with thyroid medication was discontinued in all of the patients at least 7 days prior to the administration of the isotope. RESULTS: 93 (78.1%) of the 119 patients remained euthyroidic, 10 (8.4%) presented hypothyroidism, 11 (9.2%) hyperthyroidism and 5 (4.2%) had sub-clinical levels of hyperthyroidism at the end of the follow-up period. No statistically significant relationship were found between hypothyroidism, gender and previous administration of thyroid medication. CONCLUSIONS: The use of 131I is an alternative to the treatment of TMG produced hyperthyroidism. The fixed doses of 555 Mbq that we propose are comfortable, make it unnecessary for the patients to travel in extensive geographic areas and produce a low rate of hypothyroidism. In our opinion, the differences in the iodine content of the diets that continue to exist are one of the factors that could influence in the differences in results observed in the different series, although other factors, such as the size of the goiter and the heterogeneity of the radioisotope uptake can contribute to the variations found in our patients.

[Bronchial carcinoid tumor and scintigraphy of somatostatin receptors: detection of bone metastasis]. / Tumor carcinoide bronquial y gammagrafía de receptores de somatostatina: detección de metástasis óseas.

UNLABELLED: Surgery is the treatment of choice for bronchial carcinoid tumor (BCT), whenever the staging is adequate. There is little information about the capability of the somatostatin receptor scintigraphy (SRS) to detect bone metastases in the carcinoid tumor. AIM: This work has aimed to evaluate retrospectively the diagnostic accuracy of the SRS in the detection of bone metastases in BCT. MATERIALS AND METHODS: Based on their clinical indication, the patients were classified into two different groups: Group A (n = 4), staging of a known BCT; and Group B (n = 6), treatment control. The SRS results could be correlated with the CT results in all 4 patients from the group A, and in one patient from the group B, and the SRS results were compared with the clinical follow up during at least one year in the other 5 patients. RESULTS: The SRS scan detected the 4 BCT from the group A; in 2 of them the patient staging was superior when the SRS was used than with the CT, whereas the scan overestimated the tumor stage (BCT + sarcoidosis) in another patient. During the clinical course, one of these patients developed bone and liver metastases. The SRS was normal in 5 asymptomatic patients from group B, whereas the scan showed disseminated metastatic disease (liver, bone, spleen and lymph nodes) in another patient. In the 2 patients with bone metastases, the total number of bone metastases detected by the bone scan was 12, and by the SRS 8. The four lesions that were not detected by SRS were located in the ribs (n = 3) and 12-D (n = 1). CONCLUSIONS: The capability of the SRS to detect bone metastases makes it more useful in BCT staging. Over the next few years, the role of the bone scan and SRS in the detection of bone metastases in carcinoid tumors needs to be established.

[Diabetes mellitus and pancreatic tumor]. / Diabetes mellitus y tumor pancreático.

A 68 year old Ecuadorian man was investigated for polyuria, polydipsia and weight loss of 3 kg during the previous two months. Insulin dependent diabetes mellitus was diagnosed 10 year before admission and treated with appropriate diet and insulin (35 U/d). 18 months before was diagnosed in El Ecuador of "multiple liver nodes non-suggestive of malignancy". Physical examination showed a large multinodular petrous hepatomegaly. There was no evidence of skin lesions. Results of laboratory studies included a basal plasma glucose level that ranged between 275-367 mg/dl (N=60-100), glycosylated haemoglobin of 8.9% (N<5) and a serum albumin of 2.8 gr./dl (N=3.4-4.8). At admission non-other laboratory alterations were detected. Computed tomography showed a mass on the head of the pancreas with loco-regional lymph nodes and liver metastases. Tumor markers were normal. Fine-needle aspiration cytology of the liver masses revealed the presence of liver metastases of a non-differentiated malignant tumor. A 111In-DTPAOC scintigraphy revealed the presence of somatostatin receptors in the liver metastases, also detecting the presence of multiple bone metastases in the axial and appendicular skeleton. Plasma glucagon level was 678 pg/ml (N<250). A diagnosis of metastatic glucagonoma was established and therapy with streptozocin, 5-FU, insulin and synthetic somatostatin analogs was initiated. Three months after the therapy initiation the patient was symptom free. Some weeks after the patient suffered from left hip pain, and a control 111In-DTPA scintigraphy showed progression of his bone metastases. In conclusion, glucagonoma must be suspected in all diabetic patients with metastatic liver, even in absence of necrotic migratory erythema. In these circumstances, plasmatic glucagon level and somatostatin receptors scintigraphy will be a useful tool for establishing the final diagnosis.

[Frostbite of the upper and lower limbs in an expert mountain climber: the value of bone scan in the prediction of amputation level]. / Congelaciones de manos y pies en un montañero de elite: utilidad de la gammagrafía ósea para predecir el nivel de amputación.

A 38 year old man was admitted to our hospital 10 days after suffering a frostbite injury in hands and feet while practicing mountain climbing, at 8,100 meters of altitude, while he was trying to reach the top of the K2 mountain. A 99mTc-MDP bone scan performed in aseptic conditions showed: in hands: absence of bone uptake in the 3rd phalanx and distal portion of 2nd phalanx of the 5th finger of the left hand, and multiple areas of increased uptake in the distal portion of both hands. In feet: uptake decreases in the 2nd phalanx of the first toe of the left foot, and absence of bone uptake in the 3rd phalanx of the 2nd toe of the left foot, and in 2nd phalanx of the 1st toe and 3rd phalanx of the 2nd, 3rd and 4th toes of the right foot. As in the hands, there were multiple areas of increased uptake in the distal portion of both feet. The phalanges with absence of bone uptake had to be amputated, while those that presented increased uptake recovered with conservative treatment. Bone scan is indicated in the evaluation of frostbite injuries and helps to establish the prognosis early.

[The scintigraphy of somatostatin receptors in the carcinoid tumor]. / La gammagrafía de receptores de somatostatina en el tumor carcinoide.

UNLABELLED: This study aimed to evaluate the diagnostic utility of 111In-DTPA-D-Phe1-octreotide scintigraphy in the different situations that can be present when an examination is requested during the clinical course of the carcinoid tumor (CT). MATERIALS AND METHODS: We have performed 41 scintigraphies with 111In-octreotide (145-185 MBq) in 35 patients (19 females and 16 males) with clinically suspected or confirmed CT. The patients were classified into five groups: Group A: Indolent symptoms of CT (n=9); B: CT staging located in lung (n=4), stomach (n=2), cecum (n=1), thymus (n=1) and pancreas (n=1); C: Carcinoid syndrome (n=1); D: CT staging after surgery located in pancreas (n=1), ovary (n=1), cecum (n=1), stomach (n=1), appendix (n=1) and ileum (n=1); and E: Post-treatment follow-up (n=13), with CT located in bronchial tree (n=5), small intestine (n=3), appendix (n=2), thymus (n=1), ovary (n=1) and unknown primary tumor (n=1). Three patients of this group had one scintigraphic study before the treatment. Head and neck, thorax and abdomen images were obtained at 4 and 24 h in all of the patients and SPECT images of the abdomen (n=14), thorax (n=10), and brain (n=1) were obtained at 24 h in 25 patients. RESULTS: Group A: In the 3 patients with a positive scintigraphy, the definitive diagnosis was meningioma, Hurtle cell's carcinoma and lung adenocarcinoma. The clinical follow-up in the six other patients, at least during one year, did not show any evidence of CT. Group B: Six of the 9 CT were detected with the scintigraphy. In 2 cases of bronchial CT, the scan showed sarcoidotic regional lymph node involvement and CT hepatic and bone metastases, respectively. Group C: The scintigraphy detected hepatic metastases from an unknown primary tumor. Group D: The scintigraphy was positive in 3 cases (hepatic or/and abdominal metastases) and was normal in the other 3. The scintigraphy was negative in one patient with peritoneal metastases. Group E: The scintigraphy was normal in 7 patients in concordance with the clinical follow-up. In 3 patients with a scintigraphy performed prior to treatment, the scintigraphy detected recurrence (thymic CT), progression of the metastatic disease (ovarian CT) and partial regression of the hepatic metastases (carcinoid syndrome). In the three other patients, the scintigraphy showed metastases located in liver in one patient and hepatic and extra-hepatic metastases in the two other patients. The sensitivity and specificity of 111In-Octreotide in the detection of the primary tumor and metastases were 72% and 84% respectively. CONCLUSIONS: The 111In-Octreotide scintigraphy has a low diagnostic utility in patients with indolent symptoms of CT. However, it is the first line of diagnosis for the staging of the CT and to evaluate the follow up after therapy.

[Carcinoid tumor and bone metastases: diagnosis by somatostatin receptor scintigraphy]. / Tumor carcinoide y metástasis óseas: diagnóstico mediante gammagrafía de receptores de somatostatina.

OBJECTIVE: The aim of this study has been to retrospectively assess the usefulness of 111In-DTPAOC scintigraphy in the detection of bone metastases (BM) in patients diagnosed of carcinoid tumour (CaT). MATERIALS AND METHODS: Between June 1995 and April 2003 78 111In-DTPAOC studies were consecutively performed in 58 patients, 31 females and 27 males, 28 to 73 years old, with a histological diagnosis of CaT. Moreover, whole body bone scans (BS) using 99mTc-MDP were performed in 13 of these patients. The patients were classified into three groups: Group A: Initial CaT staging (n = 23); Group B: CaT staging after surgery (n = 14); and Group C: Post-treatment CaT re-staging (n = 29). In this last group, 6 patients of group A and 2 patients of group B were included. In only 2 patients the diagnoses of bone metastases were established before the 111In-DTPAOC scan. RESULTS: Twenty six (44.8 %9 of the 58 patients with CaT had metastatic disease: 15 patients with hepatic metastases, associated with BM in 4 of them, 10 patients with hepatic and extra-hepatic metastases, abdominal and/or thoracic, associated with BM in 4 and in one patient, the BMs were the only metastases detected. The global incidence of BM in patients diagnosed with CaT was 15.5 % (9/58), whereas the incidence of BM in patients with metastasic disease was 34.6 % (9/26). Significant differences (p = 0.0035) were found on the incidence of BM in patients with or without hepatic metastases. In 4 patients, BMs were detected during the initial staging (group A), whereas in 5 patients, BMs were detected during the post-treatment re-staging (group C). During diagnosis, 4 of the 9 patients with BM had bone pain. BM were multiples in 8 patients, affecting axial skeleton in 4 and axial and appendicular skeleton in 4. One patient had a diffuse infiltration of bone marrow. BS was positive in 8 of the 9 patients with BM. In these 8 patients with abnormal BS, 111In-DTPAOC scintigraphy provides similar information to the BS in one patient, shows a greater number of bone lesions in 3, whereas BS was superior in 5 patients. Four of the patients with BM died between 6 and 47 months after diagnosis (mean: 29.7 months). CONCLUSIONS: BMs are preferably located on axial skeleton, can be asymptomatic and are associated with hepatic metastases. Although the 111In-DTPAOC scintigraphy is able to detect some BM earlier than BS, the information provided by both studies is complementary. In patients with CaT, any invasive therapy on the hepatic metastases make it necessary to exclude extrahepatic metastases, including bone ones, and the somatostatin receptor scintigraphy is the diagnostic method of choice.