A retrospective study with long term follow-up of Graves' disease patients treated with low activities of 131 Iodine.

BACKGROUND: Previous studies have shown that application of relatively low 131 I-Iodine activities can successfully be used to treat patients with Graves'disease (GD). We assessed treatment outcome in the long-term follow-up of our GD patients and influencing factors. METHODS: We evaluated 521 GD patients in this retrospective clinical single-center study. In all patients we performed scintigraphy and thyroid uptake measurement after 4 h and 24 h using 10 MBq 123 I and calculated administered activity using Marinellis' formula. Treatment was done according to national regulations. Minimal routine clinical evaluation of all patients was available after 6 weeks and after 3, 6 and 12 months. Success of treatment was defined as euthyroid state or hypothyroidism 6 months after therapy. RESULTS: We usually applied relatively low 131 I activities. 307 patients (58.9%) became hypothyroid within 21 years of follow-up. 139 patients (26.7%) became euthyroid and stayed euthyroid until the end of follow-up. We found a plateau after 7 years of initial therapy with only a few patients becoming hypothyroid after that time and identified 75 patients (14.4%) with persistent hyperthyroidism or recurrence. CONCLUSIONS: Treatment with relatively low 131 I activities produce favourable responses as shown in previous works. We found a high proportion of patients with long-term euthyroid state. Application of low activities reduces radiation burden of patients and, depending on radiation protection legislation, may lead to shortened hospital stay and reduced costs. Therefore, we feel that application of higher activities to treat GD patients as recommended in several current guidelines should be reconsidered.

Supernumerary brachioradialis - Anatomical variation with magnetic resonance imaging findings: A case report.

BACKGROUND: In this single case report study, we describe an anatomical variance of a brachioradialis muscle with two muscle bellies and two tendons with their common insertion on the suprastyloid crest of a distal radius. CASE SUMMARY: After a self-mutilating forearm injury of a borderline personality patient, we observed the anatomical variation of brachioradialis tendon. After tendon repair and aftercare the muscle function recovered completely. Five months after surgery the forearm magnetic resonance imaging was done revealing a supernumerary brachioradialis muscle. CONCLUSION: Anatomical variations of forearm muscles and tendons are not rare. The treating surgeons should be aware of their existence and anatomical relationships.

Pain reduction after lumbar epidural injections using particulate versus non-particulate steroids: intensity of the baseline pain matters.

OBJECTIVES: To compare pain relief after CT-guided lumbar epidural steroid injections (ESI) using particulate (triamcinolone) and non-particulate (dexamethasone) steroids, and to explore factors affecting the effectiveness of both steroid types. METHODS: This retrospective observational study included 806 patients with lumbar radiculopathy and corresponding MRI or CT abnormalities of the lumbar spine, who were matched using the propensity score method, yielding two cohorts of 209 patients each. Pain intensity was evaluated prior to the procedure using a pain numerical rating scale (NRS) with range 0-10. Reevaluation took place 1 day and 4 weeks post-injection. Logistic regression analysis and cubic splines applied to generalized additive models were implemented to assess the differences in pain reduction after ESI in the analyzed patient groups. RESULTS: Four weeks post-injection, the overall chance of ≥ 50% pain reduction was lower in the dexamethasone group than that in the triamcinolone group (odds ratio [OR] = 0.55; p < 0.012). In the dexamethasone cohort, the intensity of baseline pain and the presence of a herniated intervertebral disc in the infiltrated segment were both significant and independent predictors of ≥ 50% pain relief. Patients with baseline NRS score ≥ 7 points had markedly less chance of ≥ 50% pain relief than patients with NRS score < 7 (OR = 0.53; p < 0.032), whereas disc herniation increased the chances more than twofold (OR = 2.29; p < 0.044). There was no significant correlation between the effectiveness of triamcinolone and any analyzed concomitant variables. CONCLUSIONS: Triamcinolone was superior for lumbar radiculopathy of severe intensity. For mild to moderate pain, no benefit of using triamcinolone over dexamethasone was found. The effectiveness of dexamethasone was lower for stenotic spinal lesions than for disc herniation. KEY POINTS: • Triamcinolone is superior to dexamethasone for epidural treatment of severe lumbar radiculopathy. • For mild to moderate pain, dexamethasone could be equally effective. • Dexamethasone reduces pain caused by disc herniation much better than it does to pain caused by fixed stenotic spinal lesions.

Positron emission tomography/computed tomography for staging and restaging of head and neck cancer: comparison with positron emission tomography read together with contrast-enhanced computed tomography.

This retrospective study aimed to describe the differences between image readings done with combined positron emission tomography/computed tomography (PET/CT) and PET read together with contrast-enhanced CT (ceCT) in patients with squamous cell carcinoma of the head and neck. In 46 patients, no differences were found between the two readings for assessing infiltration of adjacent structures (P=.63), transgression of the midline (P=.67), lymph node involvement (P=.32), and T- and N stage. PET/CT and PET read together with ceCT have comparable diagnostic yield.

Dual-source computed tomography coronary angiography: influence of obesity, calcium load, and heart rate on diagnostic accuracy.

AIMS: To prospectively investigate the diagnostic accuracy of dual-source computed tomography coronary angiography (CTCA) to diagnose coronary stenoses in relation to body mass index (BMI), Agatston score (AS), and heart rate (HR) as compared with catheter coronary angiography (CCA). METHODS AND RESULTS: Hundred and fifty consecutive patients (47 female, mean age 62.9 +/- 12.1 years) underwent dual-source CTCA without HR control. Patients were divided into subgroups depending on the median of their BMI (26.0 kg/m2), AS (194), and HR (66 b.p.m.). CCA was considered the standard of reference. Mean BMI was 26.5 +/- 4.2 kg/m2 (range 18.3-39.1 kg/m2), mean AS was 309 +/- 408 (range 0-4387), and HR was 68.5 +/- 12.6 b.p.m. (range 35-102 b.p.m.). Diagnostic image quality was found in 98.1% of all segments (2020/2059). Considering not-evaluative segments at CTCA as false-positive, overall per-patient sensitivity, specificity, positive, and negative predictive value were 96.6%, 86.8%, 82.6%, and 97.5%, respectively. High HR did not deteriorate diagnostic accuracy of CTCA. High BMI and AS were associated with a decrease in per-patient specificity to 84.1% and 77.8%, respectively, while sensitivity and negative predictive value remained high. CONCLUSION: Dual-source CTCA provides high diagnostic accuracy irrespective of the HR and serves as a modality to rule-out coronary artery stenoses even in patients with high BMI and AS.

[18FDG] PET-CT-based intensity-modulated radiotherapy treatment planning of head and neck cancer.

PURPOSE: To define the best threshold for tumor volume delineation of the (18) fluoro-2-deoxy-glucose positron emission tomography ((18)FDG-PET) signal for radiotherapy treatment planning of intensity-modulated radiotherapy (IMRT) in head and neck cancer. METHODS AND MATERIALS: In 25 patients with head-and-neck cancer, CT-based gross tumor volume (GTV(CT)) was delineated. After PET-CT image fusion, window level (L) was adapted to best fit the GTV(CT), and GTV(PET) was delineated. Tumor maximum (S) and background uptake (B) were measured, and the threshold of the background-subtracted tumor maximum uptake (THR) was used for PET signal segmentation. Gross tumor volumes were expanded to planning target volumes (PTVs) and analyzed. RESULTS: The mean value of S was 40 kBq/mL, S/B ratio was 16, and THR was 26%. The THR correlated with S (r = -0.752), but no correlation between THR and the S/B ratio was seen (r = -0.382). In 77% of cases, S was >30 kBq/mL, and in 23% it was 30% +/- 1.6% kBq/mL and 40% in tumors with S

FDG PET and PET/CT for the detection of the primary tumour in patients with cervical non-squamous cell carcinoma metastasis of an unknown primary.

In patients with a neck metastasis from an unknown primary with non-squamous cell cancer (non-SCC) histology, the primary is often located outside the head and neck area. We retrospectively evaluated 326 patient records and found 14 patients with non-SCC neck lymph node metastasis from an unknown primary undergoing whole body F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) with or without coregistered computed tomography (PET/CT). The PET or PET/CT findings were verified by pathological work-up, additional imaging tests, and clinical follow-up. PET detected pathological FDG uptake suspicious for the primary in eight patients. PET or PET/CT findings were true positive in seven patients, true negative in 4, false positive in 1, and false negative in two patients. In one patient PET/CT revealed a synchronous ovarian carcinoma. The results suggest that whole body imaging with FDG PET and PET/CT can be useful to identify unknown primaries of non-SCC origin. However, the work-up of patients undergoing PET or PET/CT in our study was very heterogeneous and the primary was more likely found in patients without extensive imaging before PET scanning. Further studies should evaluate if the histology of a neck nodal metastasis should influence the choice of the imaging method and the role of PET and PET/CT imaging for the work up of patients with a non-SCC neck lymph node metastasis of an unknown primary.

F-18 FDG whole-body PET for the assessment of disease activity in patients with rheumatoid arthritis.

UNLABELLED: PURPOSE OF REPORT: F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) can be used to image synovitis in patients with rheumatoid arthritis (RA). The aim of this study was to evaluate if a simple scoring system based on visual assessment of FDG joint uptake correlates with the clinical assessment of patients with RA undergoing antiinflammatory treatment. MATERIALS AND METHODS: Seven patients with active RA underwent whole-body FDG PET and clinical assessment before and after treatment with the antitumor necrosis factor alpha antibody (infliximab). A PET total joint score, ie, the sum of all scores based on FDG uptake intensity between zero and 4 in 28 joints, was correlated with a total joint score based on the clinical disease activity in the same joints using a Spearman rank correlation. RESULTS: The PET based total joint score was similarly high before onset as was the clinical total joint score. The decrease of FDG joint uptake in the follow-up PET scans correlated significantly with the clinical assessment. Additionally, synovial FDG uptake was found in extraarticular sites such as tendon sheaths and bursae. CONCLUSIONS: Visual assessment of FDG uptake shows a significant correlation with clinical evaluation of disease activity in patients with RA undergoing antiinflammatory treatment.

In-line (18)F-fluorodeoxyglucose positron emission tomography with computed tomography (PET/CT) in patients with carcinoma of the sinus/nasal area and orbit.

BACKGROUND: Contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) are the standard imaging techniques to evaluate patients with carcinoma in the sinus/nasal area and orbit. The use of positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) in such patients is as yet less well established. PURPOSE: The aim of this study was to assess the clinical impact of PET co-registered with CT (PET/CT). PATIENTS: Evaluation of 21 consecutive patients. METHODS: A retrospective analysis of the whole body PET/CT studies was done. Images were assessed visually without knowing the results of the other imaging technique. Histology and clinical follow-up served to verify lesions. The clinical impact on therapy was assessed together with the physician in charge. RESULTS: All patients underwent PET/CT and CT or MRI for staging (n=9 scans) and restaging (n=17 scans) without treatment between the examinations. PET/CT changed the treatment protocol in 2 patients at staging and in 7 at re-staging. Distant metastases were found in 5 and a secondary tumour in 1 patient. CONCLUSIONS: Whole body PET/CT adds clinically important information to CT or MRI, thus, influencing treatment.

Bone invasion in patients with oral cavity cancer: comparison of conventional CT with PET/CT and SPECT/CT.

PURPOSE: To prospectively compare the accuracy of helical contrast material-enhanced computed tomography (CT) with that of CT and positron emission tomography (PET) combined and CT and single photon emission CT (SPECT) combined in the detection of bone invasion in patients scheduled to undergo surgery for clinically suspected oral cavity carcinoma with possible bone invasion, with surgical results as the reference standard. MATERIALS AND METHODS: This study had local ethical committee approval, and all patients gave written informed consent. Thirty-four consecutive patients (17 men, 17 women; mean age, 64.2 years; age range, 46.0-84.6 years) who were clinically suspected of having bone invasion from oral cavity carcinoma prospectively underwent helical contrast-enhanced CT, coregistered PET/CT, and coregistered SPECT/CT. Two radiologists assessed the contrast-enhanced CT images and two nuclear medicine physicians separately assessed the PET/CT and SPECT/CT images in consensus and without knowledge of the results of other imaging tests. The presence of bone involvement as suggested with an imaging modality was compared with histologic findings in the surgical specimen. RESULTS: With histologic findings as the standard of reference, the accuracy of SPECT/CT (88% [30 of 34 patients]) was lower than that of PET/CT and contrast-enhanced CT (94% [32 of 34 patients] and 97% [33 of 34 patients], respectively). Sensitivity was highest with PET/CT (100% [12 of 12 patients]), and specificity was highest with contrast-enhanced CT (100% [22 of 22 patients]). Fluorine 18 fluorodeoxyglucose (FDG) uptake seen on two sides of the same cortical bone was not a helpful imaging pattern for better identifying bone invasion in patients without evident cortical erosion on CT scans. CONCLUSION: The assessment of cortical erosion with contrast-enhanced CT and the CT information from PET/CT are the most reliable methods for detecting bone invasion in patients with oral cavity carcinoma. FDG uptake seen on PET/CT images does not improve identification of bone infiltration.

Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness.

OBJECTIVE: We sought to determine the impact of positron emission tomography/computed tomography (PET/CT) on the management of presumed resectable pancreatic cancer and to assess the cost of this new staging procedure. SUMMARY BACKGROUND DATA: PET using 18F-fluorodeoxyglucose (FDG) is increasingly used for the staging of pancreatic cancer, but anatomic information is limited. Integrated PET/CT enables optimal anatomic delineation of PET findings and identification of FDG-negative lesions on computed tomography (CT) images and might improve preoperative staging. MATERIAL AND METHODS: Patients with suspected pancreatic cancer who had a PET/CT between June 2001 to April 2004 were entered into a prospective database. Routine staging included abdominal CT, chest x-ray, and CA 19-9 measurement. FDG-PET/CT was conducted according to a standardized protocol, and findings were confirmed by histology. Cost benefit analysis was performed based on charged cost of PET/CT and pancreatic resection and included the time frame of staging and surgery. RESULTS: Fifty-nine patients with a median age of 61 years (range, 40-80 years) were included in this analysis. Fifty-one patients had lesions in the head and 8 in the tail of the pancreas. The positive and negative predictive values for pancreatic cancer were 91% and 64%, respectively. PET/CT detected additional distant metastases in 5 and synchronous rectal cancer in 2 patients. PET/CT findings changed the management in 16% of patients with pancreatic cancer deemed resectable after routine staging (P = 0.031) and was cost saving. CONCLUSIONS: PET/CT represents an important staging procedure prior to pancreatic resection for cancer, since it significantly improves patient selection and is cost-effective.

Fluorocholine PET/CT in patients with prostate cancer: initial experience.

Institutional review board approval and written informed consent were obtained. Patients with newly diagnosed prostate cancer and patients suspected of having recurrent prostate cancer were prospectively evaluated with fluorine 18 fluorocholine (FCH) combined in-line positron emission tomography (PET) and computed tomography (CT). In 19 patients (mean age, 67 years +/- 8; range, 57-85 years), standardized uptake values of FCH in 17 different tissues were determined by using volumes of interest. In nine patients evaluated at initial staging, histologic findings of the resected prostate were compared to FCH uptake. Only small variations of physiologic tracer accumulation were measured in all organs but the kidneys. Differentiation of benign hyperplasia from cancerous prostate lesions was not possible with FCH PET/CT. However, in patients with recurrent prostate cancer, FCH PET/CT is a promising imaging modality for detecting local recurrence and lymph node metastases.

Non-Hodgkin lymphoma and Hodgkin disease: coregistered FDG PET and CT at staging and restaging--do we need contrast-enhanced CT?

PURPOSE: To retrospectively compare diagnostic value of coregistered fluorine 18 fluorodeoxyglucose positron emission tomographic (PET) and computed tomographic (CT) scans obtained with low-dose nonenhanced CT (PET/CT) with those routinely obtained with contrast material-enhanced CT for staging and restaging of disease in patients with Hodgkin disease or high-grade non-Hodgkin lymphoma. MATERIALS AND METHODS: Sixty patients (mean age, 39.6 years +/- 17.1 [standard deviation]) with Hodgkin disease (n = 42) or high-grade non-Hodgkin lymphoma (n = 18) were included in this retrospective study. All patients underwent PET/CT and contrast-enhanced CT within a maximum of 24 days (mean, 9.1 days +/- 7.0) of each other for staging (n = 19) or first follow-up examination (n = 41). Findings were extracted from original written reports (PET/CT, contrast-enhanced CT) and compared with findings of reference standard, which included biopsy or follow-up with clinical, laboratory, or other imaging findings. For statistical analysis, sensitivity and specificity were calculated with findings of the reference standard. Agreement of both methods was determined with Cohen kappa and McNemar tests on a per-patient basis. RESULTS: For evaluation of lymph node involvement, sensitivity of PET/CT and contrast-enhanced CT was 94% and 88%, and specificity was 100% and 86%, respectively. For evaluation of organ involvement, sensitivity of PET/CT and contrast-enhanced CT was 88% and 50%, and specificity was 100% and 90%, respectively. Agreement of both methods was excellent (kappa = 0.84) for assignment of lymph node involvement but only fair (kappa = 0.50) for extranodal disease. A difference with P <.05 (McNemar test) was considered significant in regard to exclusion of disease with PET/CT, compared with contrast-enhanced CT. CONCLUSION: PET/CT performed with nonenhanced CT is more sensitive and specific than is contrast-enhanced CT for evaluation of lymph node and organ involvement, especially regarding exclusion of disease, in patients with Hodgkin disease and high-grade non-Hodgkin lymphoma.

Why most PET of lung and head-and-neck cancer will be PET/CT.

Experience in our and other institutions with PET/CT imaging of lung and head and neck cancers has shown that this new modality has higher specificity and sensitivity than PET alone and in certain settings even when compared to PET and CT viewed side by side. The largest experience exists with non-small cell lung cancer (NSCLC), in which it has been demonstrated that PET/CT is superior to PET and CT in T and in N staging. Superiority in M staging has yet to be demonstrated. CT contrast media enhancement is probably only necessary when a substantial mediastinal tumor component is present. In such cases, delineation of tumor from vascular structures is relevant. In ENT tumors, PET/CT also appears to be superior to PET, and probably also to PET and CT viewed side by side. Early information suggests that contrast media enhancement for staging may not be required, but the data available is still limited. In both settings, it is interesting to note that in a number of patients, second metachronous tumors are discovered with PET/CT, mainly localized in the GI tract.

Positron emission tomography in the early follow-up of advanced head and neck cancer.

OBJECTIVE: To assess the clinical effect of an early follow-up positron emission tomography (PET) examination at the time of the first routine clinical control in patients with advanced-stage head and neck squamous cell carcinoma (HNSCC). DESIGN: Prospective, nonrandomized, case-control study. SETTING: Single referral center. PATIENTS AND INTERVENTION: A total of 26 patients (mean age, 56 years) with histologically confirmed stage III-IV HNSCC underwent PET before and approximately 6 weeks after the end of a combined treatment with radiation and chemotherapy with curative intent. The PET findings were confirmed by histologic analysis and a 6-month clinical follow-up. MAIN OUTCOME MEASURES: The presence of distant metastases, secondary synchronous cancers, and residual locoregional tissue was confirmed, and the effect on further clinical management was assessed. RESULTS: Using PET, we correctly identified residual tumor tissue, distant metastases, or a second primary tumor in 10 patients, 5 of whom had no clinical evidence of such findings. Results were true negative in 14 cases; false positive in 1; and false negative in 1. Sensitivity and specificity for follow-up PET scans were 90.9% and 93.3%, respectively. All patients with positive findings were evaluated for further treatment such as salvage surgery. CONCLUSIONS: Whole-body PET scanning approximately 6 weeks after completion of a combined treatment regimen with radiation and chemotherapy can reliably identify locoregional residual cancer and distant metastases or secondary tumors in patients with advanced-stage HNSCC and has a direct influence on management decisions.

Increased 18F-FDG uptake mimicking thyroid cancer in a patient with Hashimoto's thyroiditis.

We report the case of a 68-year-old patient with a known paravertebral malignant schwannoma, sent to us for postoperative staging. A combined whole-body PET/CT scan showed only poor (18)F-fluorodeoxyglucose uptake in the region of the primary tumor but distinct increased fluorodeoxyglucose uptake in the left and right thyroid gland. Thyroid sonography showed two hypoechogenic nodules. Ultrasound-guided fine-needle aspiration biopsy of one nodule showed oxyphil transformed cells, compatible with malignancy. Based on these findings, the patient underwent a subtotal thyroidectomy. Histopathology of the specimen revealed a chronic follicular Hashimoto's thyroiditis. This case demonstrates that Hashimoto's thyroiditis can mimic thyroid cancer in PET but also in sonography and fine-needle aspiration biopsy.

Follow-up of women with breast cancer: comparison between MRI and FDG PET.

The aim of this study was to compare MRI of the breast with (18)F-fluoro-deoxy-glucose (FDG) positron emission tomography (PET) in patients with suspected local or regional breast cancer recurrence or suspected contralateral breast cancer. Thirty-two patients (mean age 57.2 years, age range 32-76 years) with suspected loco-regional recurrence ( n=19), chest wall recurrence ( n=5), and suspected secondary tumor of the contralateral breast ( n=8) underwent MRI of the breast and FDG PET of the whole body and breast region. Cytology/histology ( n=17) or a clinical follow-up examination ( n=15) with additional imaging served as the standard of reference. A McNemar test was performed to compare PET and MRI, and kappa was determined to quantify agreement of both methods. Sensitivity was 79 and 100%, specificity was 94 and 72%, and accuracy was 88 and 84% for MRI and PET, respectively. Additional metastases outside the field of view of MRI were found in PET in 5 patients. In this study both imaging methods had comparable accuracy. The detection of distant metastases with whole-body PET imaging can influence patient management.