[Positive sentinel node risk in relation to oestrogen receptors in breast cancer in premenopausal and postmenopausal women]. / Relación entre el riesgo de metástasis en el ganglio centinela y los receptores estrogénicos en pacientes pre y posmenopáusicas con cáncer de mama.

OBJECTIVE: The influence of the relationship between pre- and post-menopausal stage of patients with breast cancer (BC) and the risk of sentinel lymph node (SLN) metastasis as well as the influence of oestrogen receptor (ER) status within each one of these groups were analyzed. METHODS: A BC database with 1,388 patients was analysed. Three age groups were studied: A, elderly postmenopausal, 200 patients, ≥ 70 years old; B, younger postmenopausal, 89 patients, 55-69 years old; C, premenopausal, 85 patients, <55 years old. In each group 2 subgroups were analyzed: positive ER and negative ER tumours. Data analysed: SLN-positive patients, non-sentinel node (NSN)-positive patients, non-surgical detections (NSD) and non disease-free (NDF) patients after a follow-up of 52 months. STATISTICAL ANALYSIS: chi-squared test, significance: P ≤ 0.05. RESULTS: SLN metastasis was significantly (P<0.025) more common in premenopausal than in postmenopausal patients, and within those, mainly in negative ER tumours. Positive-NSN increases slightly in premenopausal patients (exclusively in negative ER tumours). NDF patients are similar in the 3 groups and in all of them it is much more frequent in negative ER tumours. CONCLUSION: SLN metastasis varies significantly according to hormonal state and not according to age, being more frequent in premenopausal patients and mainly in ER negative tumours.

[Clinical utility of attenuation correction with X-rays in myocardial perfusion SPECT studies]. / Utilidad clínica de la corrección de atenuación con rayos X en los estudios SPECT de perfusión miocárdica.

OBJECTIVE: We have compared the uncorrected images of SPECT myocardial perfusion plus gated data with corrected images with X-rays in the management of coronary artery disease. METHODS: In 60 patients (p) a stress/rest-gated myocardial perfusion SPECT was performed with attenuation correction with a hybrid gammacamera. All patients underwent cardiac catheterization. 3 types of images were qualitatively evaluated: uncorrected stress/rest (NC), uncorrected stress/rest plus gated (NCG) and stress/rest corrected for attenuation with scatter correction (AC). McNemar's test was used to analyze the statistical differences in assessing the diagnostic accuracy of each type of images; p < 0.05 was considered statistically significant. RESULTS: Fourteen p did not have significant lesions in the coronary arteries (NSL), 46 p showed lesions in coronary arteries: 29 in anterior descending, 26 in right coronary and 18 in circumflex. In right coronary territory, diagnostic accuracy was significantly higher on AC than on NC images (p < 0.001) and on AC than on NCG images (p < 0.01). In NSL group there are significant differences between NC and AC (p < 0.02) and between NCG and AC (p < 0.05). CONCLUSIONS: Attenuation correction with X-rays significantly improves diagnostic accuracy of uncorrected images and uncorrected images plus gated.

[Influence of tumor location in patients with breast cancer on the sentinel node detection]. / Influencia de la localización del cáncer de mama en la detección del ganglio centinela.

OBJECTIVE: To evaluate the influence of tumour quadrant localization on the sentinel node (SN) detection and the visualisation of internal mammary chain (IM) drainage by radioisotopic techniques. 316 patients with breast cancer were studied. Mean age 57 years (range 29-88). All patients received 37-74 MBq of 99mTc-albumin nanocolloid in 2 ml by peritumoral injection. The breast cancer was located in the upper outer quadrant in 189 patients, in the upper inner in 57, in the lower outer in 57, in the lower inner in 55 and in the subareolar area in 18 patients. At two hours p.i., anterior and lateral chest lymphographies were obtained. The SN location was marked on the patient skin with permanent ink. SN was identified intraoperatively by the gamma probe. Histopatological analysis included imprints, delayed hematoxilin-eosin, inmunohistochemistry CAM 19-2 and PCR. RESULTS: The scintigraphy and surgical detection was in the upper outer quadrant of 90 % and 93 % respectively; in the lower outer quadrant of 91 % and 95 %, in the upper inner quadrant of 93 % and 95 %, in the lower inner quadrant 87 % and 95 % and in the subareolar area in 94 % and 83 %. The IM chain drainage was of 6 % in the UO, in the LO of 5 %, in the UI of 12 %, in the LI of 20 % and none in subareolar. CONCLUSIONS: Our data suggest that sentinel node location (quadrant) is not a influential factor in the scintigraphy and surgical detection. Tumours localised in internal quadrant show a higher rate of IM chain drainage.

[Clinical utility of fused 67Ga SPECT/CT scan images in patients with lymphoma]. / Utilidad clínica de las imágenes de fusión 67Ga SPECT/TC en pacientes con linfoma.

AIM: The aim of this work is to show the clinical utility of the fused SPECT 67Ga/CT images in patients with lymphoma. MATERIAL AND METHOD: 44 patients (22 male) with lymphoma have been studied. 22 with Hodgkin's disease and 22 with non Hodgkin lymphoma. 59 studies were performed (33 thorax-cervical [T], 24 abdomen [A] and 2 skull-cervical area [SC]) with an hybrid gammacamera Millenium VG. We acquire consecutively a whole body scan, a SPECT and a CT, for its fusion with the SPECT, of the affects areas. The images were evaluated by two experts blinded, who classify the contribution of the fusion of images respect to the SPECT like: non changes, it improves the location or changes the extension of the injuries and it changes the staging. Final lesion location was confirmed by a high resolution CT performed within one month. RESULTS: 32/59 studies did not change the location or extension of the injuries (20T, 12A), 23/59 studies changed the location or extension of the injuries (12T, 9A and 2 SC) and on 4/59 the change of location induced a change of staging respect to showed by the SPECT. CONCLUSION: To make fused SPECT 67Ga/CT images in patients with lymphoma allows improving the diagnostic precision in a 46% of the cases, mainly in the abdominal, bone and of the diaphragmatic area studies.

[Lymphoscintigraphy and sentinel node biopsy in non-palpable breast cancer]. / Linfogammagrafía y biopsia del ganglio centinela en el carcinoma no palpable de mama.

OBJECTIVE: The aim of the study was to evaluate the efficacy of lymphatic mapping and sentinel node biopsy in non-palpable breast cancer (NPBC) patients in comparison with palpable breast cancer (PBC) patients. MATERIAL AND METHODS: 199 breast cancer patients were studied. Patients were classified into two groups: NPBC and PBC. Following sentinel node biopsy all patients underwent axillary lymphadenectomy. Surgery was performed at 4-24 h after peritumoral injection of 111MBq 99mTc-nanocolloid. Histological sentinel node analysis was performed by cytological imprinting and delayed study. The following parameters were analyzed in both groups: scintigraphic and surgical detection rates, true positives (TP), true negatives (TN), sensitivity (S), predictive negative value (PNV), false negative rate (FNR) and global precision (GP) of the technique. RESULTS: No significant differences were observed (p > 0.05) in either the lymphoscintigraphy or surgical sentinel node detection, or drainage to internal mammary chain (p = 0.211) in both groups. Metastatic axillary prevalence was lower in NPBC group (p = 0.019). Similar S, NPV and GP values (>90 %) and FNR (< or = 6 %) were found in both groups. CONCLUSIONS: The reliability of the technique is similar in both groups. Drainage is predominantly axilar. Drainage to internal mammary chain was more frequently seen in medial tumours and in NPBC. Metastatic axillary prevalence was lower in the NPBC group.

[Simultaneous location of non-palpable breast neoplasms and sentinel node (SN) study by radioisotopic techniques]. / Localización simultánea de neoplasias de mama no palpables y estudio del ganglio centinela (GC) mediante técnicas radioisotópicas.

OBJECTIVE: To obtain correct location of non-palpable breast lesions, with high suspicion of malignancy and detection of SN by radiosotopic techniques. MATERIAL AND METHODS: Thirty-one patients whose ages ranged from 35 to 79 years, with non-palpable breast lesions detected by mammography and/or ultrasonography were studied. All the patients were diagnosed of breast cancer and treated with primary chemotherapy. All the patients underwent total axillary dissection. At 24 hours of the intervention, all patients received one dose of 37 MBq (1 mCi) of 99mTc labeled macroaggregated albumin (MAA) in the center of the lesion by ultrasonographic guide. Scintigraphic images were performed in anterior and lateral projections (in prone decubitus with hanging breast) to verify the correct location of the radiopharmaceutical. After, a study of the SN was performed by subdermal administration of an 18 MBq (0.5 mCi) dose of 99mTc labeled nanocolloid. The SN site was labeled on the skin with indelible ink. The intrasurgical site of the breast lesion and SN was performed using a gamma detector probe. Correct placement of the intralesional radiopharmaceutical, existence of disease free borders and histological study of SN were performed by the pathologist in the surgical act. The differed pathology study was performed with hematoxilin-eosin and immunohistochemistry. RESULT: In 29 of the 31 lesion sites, there was good placement of the radiotracer (93.5 %). There was 1 case of contamination of the needle pathway and another that did not coincide with the lesion, due to poor placement. Location of the SN was 96 % in the axilla and 4 % in axilla and internal mammary chain. The SN was located in surgery in 28/31 patients (90 %). CONCLUSION: Simultaneous radioguided location of the hidden breast lesions and sentinel node is a simple method, which is well tolerated by the patients and can be done in a single operation act.

[First diagnostic choice in patients with high clinical suspicion of pulmonary thromboembolism: helical CT or ventilation/perfusion pulmonary scintigraphy?]. / Primera elección diagnóstica en pacientes con alta sospecha clínica de tromboembolismo pulmonar: gammagrafía de ventilación/perfusión pulmonar o tomografía computarizada helicoidal?

AIM: Comparative analysis about helical CT (ThC) vs ventilation-perfusion pulmonary scintigraphy (V/P Sc) diagnosis effectiveness, as a first diagnosis technique in patients with high clinical suspicion of pulmonary thromboembolism (PT). MATERIALS AND METHODS: Prospective study of 30 patients with high clinical suspicion and high Dimer-D levels (> 250 microg/l). The diagnosis was defined as anticoagulant therapeutic prescription and posterior clinical evolution. V/P Sc were performed to each patient within the next 48 h (an average of 14.8 h) after TCh, without anticoagulant treatment. We classified the scintigrams according to the PIOPED criteria and hTC images as positive, negative and indeterminated. RESULTS: In sixteen patients final diagnosis was PT: in 9 both techniques were positive; in 5 scintigraphy was positive with normal hTC and in 1, hTC was normal with negative scintigraphy. The last case was an indeterminated hTC with negative scintigraphy. In fourteen patients, final diagnosis was non-PT: in 6 both techniques were negative; in 7 scintigraphy was negative with positive hTC and in 1, both results were indeterminated. The sensitivity, specificity, positive predictive value, negative predictive value and efficiency were respectively 87.5, 100, 100, 87.5 and 93 % for V/P Sc and 62, 50, 58.8, 53.8 and 53 % for TCh. CONCLUSION: V/P Sc has better PT diagnosis reliability. It is recommended to do V/P Sc in all patients with high clinical suspicion of PT.

Renogram deconvolution in the management of diabetic nephropathy: utility of the measurement of initial tracer uptake.

Our objective was to assess mean transit time (MTT) and initial uptake, both parameters derived from the renal retention function (RRF), in the study of renal function in patients with diabetic nephropathy. We studied 25 patients, 7 with type I diabetes mellitus and 18 with type II diabetes mellitus, all of whom fulfilled the criteria for diabetic nephropathy with proteinuria and/or retinopathy. We found a statistically significant correlation between initial uptake and the other biochemical and renographic parameters studied except proteinuria: serum creatinine (r = 0.66, P < 0.002), creatinine clearance (r = 0.61, P < 0.003), glomerular filtration rate (r = 0.74, P < 0.003) and effective renal plasma flow (r = 0.66, P < 0.003). The other renographic parameters studied (maximal activity of the conventional renogram and MTT of the deconvoluted renogram) did not show any correlation. Initial uptake is a semi-quantitative renographic parameter that can provide complementary information to biochemical data and it may be useful in the management of diabetic nephropathy, especially in patients with high serum creatinine or creatinine clearance.

Gamma probe sentinel node localization and biopsy in breast cancer patients treated with a neoadjuvant chemotherapy scheme.

The aim of this study was to analyse the accuracy of scintigraphic and gamma probe sentinel node (SN) localization in breast cancer patients who have been submitted to neoadjuvant chemotherapy (NC). Seventy-six patients with single breast cancer were included in the study, and were classified into two groups. Group 1 consisted of 40 women who had received NC, and Group 2 consisted of 36 women who did not receive NC. All patients received 111 MBq (3 mCi) of 99Tcm-nanocolloid in 3 ml, by peritumoural injection. Anterior and lateral thoracic scans were obtained 2 h post-injection. The following day (18-24 h post-injection) the patients underwent surgery and sentinel nodes were localized by using a gamma probe. Complete axillary lymph node dissection was performed in all patients. Histological analysis included haematoxylin-eosin in all cases and immunohistochemistry in 10 cases. In Group 1, SNs were localized in 36/40 patients, histological analysis was performed in 34 and there were four false negatives (22%). In Group 2, SNs were localized in 32/36 patients, histological analysis was performed in 29 and there were two false negatives (9%). Predictive negative values were 78% and 90% in Groups 1 and 2, respectively. In summary, sentinel node localization in breast cancer patients submitted to previous neoadjuvant chemotherapy is less accurate than in patients who do not receive this therapy. The procedure is not sufficiently accurate to localize the sentinel node, thus it cannot be recommended in these patients.

Simultaneous administration of 99Tcm-HMPAO-labelled autologous leukocytes and 111In-labelled non-specific polyclonal human immunoglobulin G in bone and joint infections.

The aim of this study was to investigate the ability of 111In-labelled human polyclonal immunoglobulin G (111In-IgG) to localize bone and joint infections compared with 99Tcm-HMAPO-labelled leukocytes (99Tcm-WBC). Thirty-four patients routinely referred for investigation of bone and joint infections were studied. In all patients, a bone scan using 99Tcm-MDP was initially obtained. Subsequently, 99Tcm-WBC and 111In-IgG were simultaneously injected and images obtained at 30 min, 4 h and 24 h post-injection. Diagnostic accuracy was established by bacteriology of specimens obtained by needle aspiration and/or surgery, other imaging methods and clinical follow-up. The images were read by three experienced observers blinded to any other information; the clinical suspicion of infection and the diagnosis were established when two observers agreed. Infection was confirmed in 11 patients. The 99Tcm-WBC scans gave 8 true-positive, 5 false-positive, 18 true-negative and 3 false-negative results. With 111In-IgG, the figures were 7, 6, 17 and 4, respectively. The sensitivity, specificity and accuracy were 72.7%, 78.2% and 76.4% respectively for the labelled leukocytes and 63.6%, 73.9% and 70.6% respectively for 111In-IgG. There was greater agreement between the observers with 99Tcm-WBC than 111In-IgG. In this study, 111In-IgG was less sensitive and less specific than 99Tcm-WBC scintigraphy for the diagnosis of chronic infections, but these differences were not significant. Both tracers appear to be useful in the diagnosis of bone and joint infections. However, our results were less reliable for the diagnosis of an infected prosthesis.

[Nonmetastatic accumulations in bone radionuclide scans in a patient with breast neoplasm]. / Acúmulos no metastásicos en la gammagrafía ósea de una paciente con neoplasia de mama.

A 51 year old woman with breast cancer four years ago was studied by bone scintigraphy. At the moment of the study she had bone pain. The bone scintigraphy showed uptake in humerus and femur and no more uptake in other zones of axial skeleton. Then, we made others radiological procedures (X-Ray and MRI) with the aim to make an accurate diagnosis. Then a diagnosis of benign bone tumours; enchondroma was made. It means something obvious but very interesting. In case of doubt we ever have to compare the bone scintigraphy with other diagnostic. examinations.

[Radioisotopic localization of the sentinel lymph node in breast cancer. Preliminary results]. / Localiazación radioisotópica del ganglio centinela en el carcinoma de mama. Resultados preliminares.

The aim of this preliminary work is to show the results of the radioisotopic localization of the sentinel node in breast cancer and the surgical resection using a gamma probe. We studied 10 patients with breast cancer without primary chemotherapy and 3 patients with primary chemotherapy before surgery. A lymphoscintigraphy was made after injection of 111 MBq of Tc99m-nanocolloid in a volume of 3 ml. The scans were performed after 30 minutes, 2 hours, 4 hours and 24 hours after injection. We detected the node and then a skin mark was made. The next day, surgical resection of this node was performed, guided by a gamma probe. We detected all sentinel nodes but one: 12 sentinel nodes and 7 second echelon nodes. The mean time for a surgical detection was about 16 minutes. In our experience this technique allows an accurate localization of the sentinel node in patients with breast cancer. We are able to localize the node in the surgical room guided with gamma probe. The peroperatory evaluation by anatomopathological techniques shown the status of this node. All this, does not delay the surgical time.

[Isotopic renal study in diabetic nephropathy]. / Estudio isotópico renal en la nefropatía diabética.

UNLABELLED: This study aimed to evaluate the prognostic value of the kidney split function (KSF), the effective renal plasma flow (ERPF) and glomerular filtration rate (GF) in the evolution of diabetic nephropathy. MATERIAL AND METHODS: 125 patients (IDDM:10, NIDDM:115), including 62 men, ages 18-84 years, were studied. In all cases GF (Cr 51 EDTA), ERPF (131I-hippuran), kidney split function (obtained from the 99mTc-MAG3 renogram) and basal serum creatinine (SC) were evaluated at the beginning of the study and patients were clinically followed up for 5 years by SC. Ultrasound and/or intravenous digital angiography were performed in 120 patients. RESULTS: In patients with decreased ERPF (76 patients) the SC increased progresively during the 5 years, in both those with elevated PC (N = 54) as well as in those with normal baseline SC (n = 22). In patients with normal ERPF the SC did not change significantly during the study. An asymethric split function (KSF < 40% in one kidney) was found in the renogram of 42 patients; in 32 of them the ERPF was decreased. Of these, ulttrasonography was normal in 9, and vascular and/or obstructive pathology was demonstrated by ultrasonography or digital angiography in only 6 patients. CONCLUSION: The ERPF becomes altered earlier than serum creatinine in patients with diabetic nephropaty. ERPF and split function calculation, and FG seems to have higher prognostic value than ultrasounds in the management of diabetic nephropathy. Radionuclides seems to be an accurate test than the ultrasonography to detect renal function abnormalities in patients with diabetic and thus can be an examination of choice in these patients.

[Radionuclide scan with TC-99m-tin colloid in the evaluation of orthopedic implant infections]. / Gammagrafía con 99mTc-coloide de estaño en la valoración de la infección de los implantes ortopédicos.

We have studied 26 patients (32-77 years old, 16 females) with suspicion of joint arthroplasty infection: 11 total hip replacements, 12 total knee replacements and 3 osteosinthesys. A bone scintigraphy with MDP-99mTc, a scintigraphy with HMPAO-WBC and a scintigraphy with 99mTc-stannous colloid were made in all patients. The final diagnostic was based in joint cultures and clinic and radiologic evolution of the patients. The earliest phase of the bone scintigraphy was positive in 18 patients. The later phase was positive in all them. The WBC was positive in 20 out of 26 patients. The bone marrow scintigraphy showed a congruent pattern with WBC in 18 patients (17 infected and 1 without infection). The other ones (8 patients) showed an incongruent pattern (7 with infection and 1 without it). The results show that the bone marrow scintigraphy with 99mTc-stannous colloid improves the accuracy of the diagnostic of bone prosthesis infection and should be included into the diagnosis protocol of this disease.

[Sentinel lymph node (SN) detection in patients with breast cancer. Influence of tumor size and age of the patient]. / Localización del ganglio centinela en el carcinoma de mama. Influencia del tamaño tumoral y edad de la paciente.

OBJECTIVE: The objective of this study is to analyze the influence of tumor size and age of the patient in the detection of the SN in breast neoplasms. MATERIAL AND METHODS: A total of 190 patients affected of breast cancer with a mean age of 57 years (range from 28 to 87 years) were studied. According to age, the following were distinguished: under 40 years, 23 patients; between 40 and 60 years, 102 patients and over 60 years, 65 patients. The lesions were classified based on size (in mm) into: less than 10 in 27 patients, between 10 and 20 in 61 patients, between 20 and 30 in 64 patients, and greater than 30 in 38 patients. In all the cases, a scintigraphy was performed at 2 hr. post-injection of 3 mCi of 99mTc-nanocoloide, in the peritumoral area. After lymphoscintigraphy detection of the SN, cutaneous labeling was performed and it was detected surgically by a gamma detector probe. A complete lymphadenectomy was performed in all the patients. The histopathology was performed with hematoxylin-eosin and immunohistochemistry techniques and the state of the SN was compared with the remaining lymph nodes of the lymphadenectomy. RESULTS: The SN was located in 169 of the 190 cases (89%). In 164 cases, it was found in the axilla. The greatest percentage of those not detected was observed in tumors over 30 mm (32%) and patients older than 60 years (30%). No false negative were observed in tumors under 10 mm or in patients under 40 years, but the false negative rate increased with the patient's age and the tumor size. CONCLUSIONS: The patient's age and tumor size seem to influence SN detection rates. The FN rates seem to be superior in patients over 60 years. Patients under 40 years with tumors less than 10 mm are those who benefit most from this technique.

[Tomographic studies of myocardial perfusion normality with 99m Tc-Tetrofosmin. Spanish multicenter study]. / Estudios tomográficos de normalidad de perfusión miocárdica con 99mTc-Tetrofosmina. Estudio multicéntrico español (I). Aspectos técnicos: diseño del estudio y control de calidad.

As a first phase in a nationwide multicenter study to obtain myocardial perfusion normality patterns, this work presents the study design and quality control methodology used to guarantee that the gammacameras fulfilled some minimum quality requirements. The following aspects were considered in the study design in order to guarantee the homogeneity and interchangeability of the results: creation and structure of the work group, data interchange system, data selection and acquisition, centralized archiving and processing, assessment system, study acceptance criteria and distribution of the results. To carry out the instrumental quality control, three phantom studies were established, one to control the rotation center, another to verify tomographic uniformity and a third to simulate the shape and orientation of the left ventricle. The three phantoms circulated through all of the 18 participating centers in this project, which corresponded to 19 gammacameras. Very strict guidelines had to be followed in the acquisition and processing of these phantom studies. If any camera and/or center did not fulfill the criteria established, it was advised of the problem detected in order to correct it. Once the defect was repaired, all the phantoms were sent again for verification. Uniformity of the rotation center was quantified by means of the eccentricity of a 360 degrees orbit, admitting up to a maximum of 10%. Tomographic uniformity was visually assessed, taking in account the number of slices with rings and their contrast and finally no artifacts could be present in the reconstructed study of the ventricle. The center of rotation was within limits in all the cameras except one case while the tomographic uniformity was incorrect in 6 cases. All the departments, except one, corrected the defects detected, and passed the acceptance test. The results made it possible to guarantee adequate homogeneity and instrumental quality in this multicenter study.

[Tomographic studies of myocardial perfusion normality with 99m Tc-Tetrofosmin. Spanish multicenter study]. / Estudios tomográficos de normalidad de perfusión miocárdica con 99mTc-Tetrofosmina. Estudio multicéntrico español (II). Aspectos clínicos.

This objective of this study was to obtain a pool of Myocardial Perfusion SPECTs with a 99mTetrofosmin stress/rest one day protocol in normal volunteers having a less than or equal to 5% likelihood of coronary artery disease that represents normalcy in the Spanish population. A total of 169 volunteers from 15 hospitals were studied. The volunteers were divided into 5 groups: Groups 1, 2 or 3 corresponding to men < 30 years (n = 33), men between 30 and 50 years (n = 32), or men > 50 years (n = 31); Groups 4 or 5: premenopausal (n = 38) or postmenopausal women (n = 35). A clinical history, physical examination, clinical laboratory parameters, echocardiography and a symptom limited exercise stress test were performed in all of them and had to be normal. The mean likelihood of coronary artery disease was 1.15 +/- 1.07%.Twenty-four segments were analyzed in each study and were classified into 5 grades of uptake (1 = normal, 2, 3, 4 = mild, moderate or severe defect and 5 = no uptake). Defects were then analyzed according to sex and location. Considering the stress and rest studies separately (8,112 segments), only 19 moderate and 75 mild defects were found, these corresponding to 16 volunteers, with more inferior defects in men and anterior defects in women. These data validate the normalcy of our population. A pool of Myocardial Perfusion SPECTs with a 99mTetrofosmin stress/rest one day protocol in normal volunteers that represents Spanish normal values was obtained.