SPECT/CT Lymphoscintigraphy Accurately Localizes Clipped and Sentinel Nodes After Neoadjuvant Chemotherapy in Node-Positive Breast Cancer.

PURPOSE: The aim of this study was to evaluate the impact of SPECT/CT lymphoscintigraphy on targeted axillary dissection (TAD) in node-positive breast cancer (BC) patients who had undergone neoadjuvant chemotherapy (NAC). METHODS: Sixty-two female BC patients with biopsy-confirmed axillary nodal metastases underwent NAC, followed by breast surgery with TAD. A metallic clip was placed in the sampled LN before NAC. On the day of surgery, a periareolar intradermal 99m Tc-nanocolloid injection was administered, followed by SPECT/CT lymphoscintigraphy. The clipped nodes were localized on CT images, assessed for 99m Tc uptake before surgery, and confirmed during the procedure. RESULTS: T1-4, N1-2 patients were enrolled in the study. All patients underwent sentinel lymph node (SLN) biopsy. The clipped node was the SLN in 54 (88.5%) patients. In 3 patients (4.9%), a clip was found in a nonsentinel lymph node. In 4 patients, the clips were not visible on SPECT/CT images, and lymph nodes were not found during the procedure. SPECT/CT correctly localized the clipped lymph node in all patients. The overall false-negative rate for TAD was 3.33%. The mean follow-up duration was 29 months, and there were no axillary recurrences. CONCLUSIONS: SPECT/CT lymphoscintigraphy can accurately localize clipped nodes and SLNs after NAC in patients with node-positive BC.

Nivolumab for relapsed or refractory Hodgkin lymphoma: real-life experience.

Classical Hodgkin lymphoma (cHL) is considered a curable disease; however, in approximately one-third of the responding patients, the disease relapses following completion of therapy. One of the drugs that have been approved for the treatment of relapsed/refractory cHL is nivolumab, an immune check point inhibitor that shows its effects by blocking the programmed death 1 (PD-1) receptor. In this study, we present a retrospective "real-life" analysis of the usage of nivolumab in patients with relapsed/refractory cHL that have joined the named patient program (NPP) for nivolumab, reflecting 4 years of experience in the treatment of relapsed/refractory cHL. We present a retrospective analysis of 87 patients (median age, 30) that participated in the NPP in 24 different centers, who had relapsed/refractory cHL and were consequently treated with nivolumab. The median follow-up was 29 months, and the median number of previous treatments was 5 (2-11). In this study, the best overall response rate was 70% (CR, 36%; PR, 34%). Twenty-eight of the responding patients underwent subsequent stem cell transplantation (SCT). Among 15 patients receiving allogeneic stem cell transplantation, 9 patients underwent transplantation with objective response, of which 8 of them are currently alive with ongoing response. At the time of analysis, 23 patients remained on nivolumab treatment and the rest discontinued therapy. The main reason for discontinuing nivolumab was disease progression (n = 23). The safety profile was acceptable, with only nine patients requiring cessation of nivolumab due to serious adverse events. The 24-month progression-free and overall survival rates were 58.5% (95% CI, 0.47-0.68) and 78.7% (95% CI, 0.68-0.86), respectively. Eighteen patients died during the follow-up and only one of these was regarded to be treatment-related. With its efficacy and its safety profile, PD-1 blockers became an important treatment option in the heavily pretreated cHL patients.

Use of fluorodeoxyglucose positron emission tomography for diagnosis of bleomycin-induced pneumonitis in Hodgkin lymphoma.

Bleomycin is an antineoplastic agent causing fatal pulmonary toxicity. Early diagnosis of bleomycin-induced pneumonitis is crucial to prevent irreversible damage. Pulmonary function tests are unreliable for identifying risk of bleomycin toxicity. Fluorodeoxyglucose PET/CT scanning can reveal inflammation secondary to pneumonitis but is not sufficiently specific for diagnosis. We retrospectively analyzed scans from 77 patients with Hodgkin lymphoma (median age 41 years, mean bleomycin dose 134 mg) to evaluate bleomycin-induced pneumonitis. We identified 13 patients with abnormal lung uptake of fluorodeoxyglucose. Tracer activity was predominantly diffuse, bilateral, in the lower lobes and subpleural areas. Interim scanning during treatment revealed pneumonitis in eight of 13 patients (asymptomatic in six). One asymptomatic patient died of bleomycin toxicity. For remaining 12 patients, bleomycin was discontinued and methylprednisolone given, all showed resolution of the pneumonitis. These findings suggest that routine interim or end-of-treatment FDG-PET/CT scanning could be beneficial for alerting clinicians to asymptomatic bleomycin-induced toxicity.

Diagnostic contribution of (18)F-FDG-PET/CT in fever of unknown origin.

OBJECTIVES: Fever of unknown origin (FUO) remains one of the most compelling diagnostic issues in medicine. We aimed to evaluate the potential clinical contribution of 18-fluoro-2-deoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) in the identification of the underlying cause of FUO. METHODS: Fifty consecutive patients (27 men and 23 women; age range 16-88 years) with FUO based on the revised definition criteria were included in the study. A diagnostic protocol including biochemistry, histopathology, and microbiological tests was performed and the patients were followed up. FDG-PET was performed in 25 of the 50 patients (12 males and 13 females; age range 16-88 years) in order to determine the etiology of the patient's fever. PET-CT images were obtained with the Gemini Philips TF (18)F-FDG-PET/CT camera after a 60-min 'standard uptake' period following an injection of a mean 330 MBq (range 290-370 MBq) intravenous (18)F-FDG. RESULTS: A total of 21 patients were available for analysis of the diagnostic contribution of PET/CT (two patients were undiagnosed and two had non-contributory PET/CT findings). (18)F-FDG-PET/CT was able to precisely detect the cause of fever in 60% of the cases (n=15). The accuracy, sensitivity, and specificity of this imaging modality were 90.5%, 93.8%, and 80%, respectively. Among the cases with a true-positive (18)F-FDG-PET/CT finding (i.e., 15 cases), the identified underlying causes of FUO included localized infection (n=7), non-infective inflammatory process (n=5), and malignancy (n=3). CONCLUSIONS: Further studies to confirm the high diagnostic yield of (18)F-FDG-PET/CT observed in the present study would lend support to the inclusion of this imaging modality in the initial diagnostic work-up of patients with suspected FUO.

Excision efficiency of radioguided occult lesion localization in reoperative thyroid and parathyroid surgery.

BACKGROUND: The purpose of this study was to investigate the efficiency of a radioguided occult lesion localization technique in reoperative thyroid and parathyroid procedures in patients who had undergone previous neck exploration for thyroid or parathyroid disease. METHODS: Twenty-one consecutive patients who were scheduled for reoperative thyroid or parathyroid surgery were studied. The indication for reoperation was recurrent papillary thyroid cancer (PTC) in eight patients, completion thyroidectomy for PTC in eight patients who had previously undergone a bilateral subtotal thyroidectomy, recurrent goiter in two patients, primary hyperparathyroidism in two patients, and recurrent parathyroid cancer in one patient. Ninety minutes before surgery, 0.1 mL of Technetium-99m (0.2 mCi)-labeled macroaggregated albumin was injected directly into the lesion under ultrasonographic guidance. During surgery, a handheld gamma probe was used to localize and excise the lesions. The background and postexcisional site radioactivities were compared to confirm the completeness of each procedure. The radiation dose in the operating room environment, duration of surgery, and postoperative complication rates were evaluated in all patients. In patients with PTC, the change in serum thyroglobulin (Tg) following surgery was noted. RESULTS: Thirty lesions were marked and excised. The postexcisional bed gamma counts (610 ± 141) were markedly decreased compared with the pre-excisional site counts (21,415.8 ± 4993.4; p = 0.0001). The ratio of the postexcisional and background counts (4.6 ± 4.3) was significantly lower than the ratio of the pre-excisional and background counts (173.7 ± 156.4; p = 0.0001). The mean operation duration was 53.3 ± 7.5 minutes. The dose absorbed by the hands of the surgeon was estimated as 0.07 ± 0.02 and 0.15 ± 0.05 millisievert/h when one or three lesions were marked, respectively. One patient developed postoperative transient hypoparathyroidism. After surgery, serum Tg levels dropped to <2 ng/mL in 86% (6/7) of the patients with PTC whose preoperative serum Tg was elevated. CONCLUSIONS: The radioguided occult lesion localization technique was efficient in the perioperative identification of thyroid and parathyroid tumors in patients who were undergoing reoperation for PTC and hyperparathyroidism.