Rare Hereditary Burden associated with a Hypercalcemic Small-Cell Carcinoma of Cervix in a Young Female Patient.

BACKGROUND: Oncological diseases have, in most cases, a multifactorial etiology, composed of a combination of external and internal environmental factors. Hereditary tumorous syndromes are mostly autosomal dominant diseases with incomplete but very high penetrance. OBSERVATION: The patient, an 18-year-old virgin female, consulted a gynecologist in June 2018 because of metrorrhagia. Magnetic resonance imaging revealed a cervical tumor with the dimensions 80 × 90 × 80 mm. Histological analysis confirmed the presence of a very rare hypercalcemic type of small-cell carcinoma of the cervix. Further investigation of the germinal exom of the patient showed pathological variations in genes PALB2 and BRCA2, presented with recommendation of detailed examination by medical genetics. CONCLUSION: Clinical experience with this type of tumor is very limited, but it still comes with some useful outcome. Small cell carcinomas of the gynecologic tract are very rare, aggressive diseases, with very poor prognosis, affecting mainly young women. Their origin is most often the ovaries, based on most clinical data, but these tumor also localize to the endometrium, cervix, vagina and vulva. It is an extremely rare type of cancer, for which clinical data is scant due to the extremely low number of reported cases. In this patient, the carcinoma had an unusual genetical mutation burden, which she inherited from her parents. In the light of these findings, we recommend that patients suspected of having a small-cell of the gynecologic tract provide a detailed family history, and that genetic testing be considered in similar cases. This work was supported by MH CR grant 16-33209A and research program of Charles University Progress Q40/06. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 10. 6. 2019 Accepted: 9. 9. 2019.

Impact of 18F-fluorodeoxyglucose positron emission tomography in the staging and treatment response assessment of extra-pulmonary small-cell cancer.

The aim of this study was to retrospectively evaluate the value of (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in extrapulmonary small-cell cancer (EPSCC). Patients with EPSCC who underwent PET for staging or response assessment between 1996 and 2007 were identified from a database. Patient records were reviewed. PET-based, and conventional staging and restaging results were compared. The binary staging classification of limited disease (LD) versus extensive disease (ED) was used. Patients with LD had tumours that could be encompassed within a tolerable radiation therapy (RT) volume. Of 33 eligible patients, 12 had staging PET scans, 11 had restaging scans and 10 had both. All known gross disease sites were FDG-avid. PET and conventional stage groupings were concordant in 21 of 22 cases. One patient was appropriately upstaged from LD to ED by PET. PET detected additional disease sites, without causing upstaging in three further patients. Restaging PET scans identified previously unrecognised persistent or progressive disease in 4 of 21 cases. In four further cases, persistent FDG uptake after treatment was either false positive (n = 2) or of uncertain (n = 2) aetiology. PPV was 100% for staging and 82% for restaging. In 8 of 43 imaging episodes (19%), PET appropriately influenced management in five cases by changing treatment intent from radical to palliative, and in three cases by altering the RT volume. PET has incremental value compared to conventional imaging for staging EPSCC, and may also be useful for restaging after therapy. PET influenced patient management in 19% of 43 imaging episodes.

Ensuring the right PET scan for the right patient.

Guidelines issued by the National Institute for Clinical Excellence (NICE) in the England and Wales recommend that rapid access to (18)F-deoxyglucose positron emission tomography (FDG-PET) is made available to all appropriate patients with non-small-cell lung cancer (NSCLC). The clinical evidence for the benefits of PET scanning in NSCLC is substantial, showing that PET has high accuracy, sensitivity and specificity for disease staging, as well as pre-therapeutic assessment in candidates for surgery and radical radiotherapy. Moreover, PET scanning can provide important information to assist in radiotherapy treatment planning, and has also been shown to correlate with responses to treatment and overall outcomes. If the government cancer waiting time targets are to be met, rapid referral from primary to secondary healthcare is essential, as is early diagnostic referral within secondary and tertiary care for techniques such as PET. Studies are also required to explore new areas in which PET may be of benefit, such as surveillance studies in high-risk patients to allow early diagnosis and optimal treatment, while PET scanning to identify treatment non-responders may help optimise therapy, with benefits both for patients and healthcare resource use. Further studies are needed into other forms of lung cancer, including small-cell lung cancer and mesothelioma. In conclusion, PET scanning has the potential to improve the diagnosis and management of lung cancer for many patients. Further studies and refinement of guidelines and procedures will maximise the benefit of this important technique.

The cost of lung cancer in Turkey.

The aim of this study was to evaluate the individual and societal burden of lung cancer in Turkey. A total of 103 cases with lung cancer attended our department between January 2002 and February 2003 were included in our study prospectively. The primary outcome measure was the cost of disease until death of the patients or the end of study. All the costs were expressed as United States dollars (USD) and were estimated regarding the effective exchange rate at the time of recording. Descriptive statistics, chi-square, Fisher's exact test, Kaplan-Meier analysis and non-parametric "Bootsraping" tests were performed to evaluate the data. The average survival was 6.8 months. The estimated total direct cost for the entire group was 564.490 USD, and the direct cost per patient was 5.480 +/- 4.088 USD. The total cost of lung cancer in the study group was 1.473.530 USD, with a per-patient cost of 14.306 +/- 17.705 USD. The average direct cost per life year was 18.058 +/- 25.775 USD. Age, gender and histopathology did not affect the cost, whereas direct medical costs were increased with increasing stage. With the low life expectancy and cure rates, lung cancer has been alerting for the cost minimization and disease control measures.

Computed tomography screening for lung cancer in Hodgkin's lymphoma survivors: decision analysis and cost-effectiveness analysis.

BACKGROUND: Hodgkin's lymphoma patients have an elevated risk of developing lung cancer and may be targeted for lung cancer screening. We used a decision-analytic model to estimate the potential clinical benefits and cost-effectiveness of computed tomography (CT) screening for lung cancer in Hodgkin's lymphoma survivors. MATERIALS AND METHODS: We developed a Markov decision-analytic model to compare annual low-dose CT screening versus no screening in a hypothetical cohort of patients diagnosed with stage IA-IIB Hodgkin's lymphoma at age 25, with screening starting 5 years after initial diagnosis. We derived model parameters from published studies and the Surveillance, Epidemiology and End Results (SEER) Program, and assumed that stage-shift produces a survival benefit. RESULTS: Annual CT screening increased survival by 0.64 years for smokers and 0.16 years for non-smokers. The corresponding benefits in quality-adjusted survival were 0.58 quality-adjusted life-years (QALYs) for smokers and 0.14 QALYs for non-smokers. The incremental cost-effectiveness ratios for annual CT screening compared with no screening were $34 100/QALY for smokers and $125 400/QALY for non-smokers. CONCLUSIONS: Our analysis suggests that if early promising results for lung cancer screening hold, CT screening for lung cancer may increase survival and quality-adjusted survival among Hodgkin's lymphoma survivors, with a benefit and incremental cost-effectiveness ratio for smokers comparable to that of other recommended cancer screening strategies.

Short communication: Semiquantitative assessment of 99mTc-EDDA/HYNIC-TOC scintigraphy in differentiation of solitary pulmonary nodules--a complementary role to visual analysis.

UNLABELLED: The aim of this study was the assessment of a value of a semiquantitative analysis of scintigrams obtained with (99m)Tc-EDDA/HYNIC-TOC as a radiopharmaceutical (RPH) in differential diagnosis of solitary pulmonary nodules (SPNs), as a method complementary to visual evaluation of scintigrams. MATERIAL AND METHODS: Scintigraphic images of 59 patients (33 males and 26 females between 34 and 78 years of age, mean value, 57) with SPN on chest radiographs (39 malignant and 20 benign) were retrospectively assessed semiquantitatively. Visual scintigram analysis was made earlier, prospectively. Nodule diameters ranged from 1 to 4 (mean 2.2) cm. A single photon emission computed tomography (SPECT) acquisition was performed at 2-4 hours after administration of 740 to 925 MBq of a RPH. Verification of scintigraphic results was based on a pathological examination of tumor samples (histopathology or cytology) and, in some cases, on bacteriological studies. As an additional criterion for tumor benignity, its stable size in a time interval not shorter than 3 years was accepted. A simple, semiquantitative method for assessment of radiopharmaceutical uptake in SPNs was used, based on "count sample" taken from tumor center (T) in relation to radiopharmaceutical concentration in the background (B) measured in the contralateral lung. A criterion for optimal differentiation between malignant and benign nodules (T/B ratio threshold value) was introduced, based on a receiver operating characteristic (ROC) curve. Additionally, a value of T/B ratio was searched for, excluding tumor benignity with high probability. RESULTS: Visual analysis of scintigrams revealed enhanced uptake of RPH at 36 of 39 (92%) sites, corresponding to locations of malignant nodules (including 34 of 35-97% cases of lung cancer). In 13 of 20 (65%) benign nodules, true negative results were obtained. Accuracy of the method equalled 83%. Optimal differentiation between malignant and benign nodules was found for a value of a T/B ratio amounting to 2. The semiquantitative method gave true positive results in 35 of 39 (90%) malignant nodules (as in visual method in 34 of 35-97% cases of lung cancer). True negative results were obtained in 17 of 20 (85%) benign cases. Accuracy of the method reached 88%. A T/B ratio exceeding 4 excluded tumor benignity with high probability. CONCLUSIONS: A simple method, of quantitatively assessing 99mTc-EDDA/HYNICTOC uptake in solitary pulmonary nodules by means of a T/B ratio can play a role that is complementary to the visual evaluation of scintigrams. It improves low specificity of the method in the detection of malignant nodules, without significant reduction of its sensitivity and provides a T/B ratio excluding tumor benignity with high probability.

CT screening for lung cancer: past and ongoing studies.

It has been widely recognized that the oft-quoted randomized clinical trials (RCTs) of lung cancer screening by chest radiography--studies that were interpreted as showing no benefit--were seriously flawed. We begin by describing the shortcomings of these trials and presenting an analysis of the problems typically encountered in performing RCTs in this area. Screening for lung cancer using computed tomography (CT) has shown that CT offers great superiority over chest radiography in diagnosing small lung cancers in the three studies that performed both CT and chest radiography on all patients. The Early Lung Cancer Action Project (ELCAP), showed that false-positive results can be kept reasonably low and are much less common on repeat screening, and that CT screening can be managed with no notable excess of percutaneous or surgical biopsies when following a well-defined regimen of screening. This regimen details the parameters of the initial CT, the definition of a positive result, and the subsequent work-up of positive results. Following the updated International (I)-ELCAP protocol, it has been further found that (1) the frequency of positive results is low: 15% for the baseline cycle of screening and 6% for the subsequent cycles. (2) The frequency of screen-diagnoses as compared with all diagnoses is 97% or higher. (3) The relative frequency of presurgical Stage I is well over 80%; the median diameter of the screen-diagnosed cases on repeat screening is 8 mm (versus 15 mm at baseline screening). (4) A high percentage of the screen-diagnosed cases were genuine cancers which led to death if not treated. (5) The estimated 8-year cure rate for resected baseline screen-diagnosed lung cancers without evidence of lymph node metastases is 95% and for resected annual repeat cancers is 98%. (6) CT screening appears to be highly cost-effective. These preliminary results of CT screening suggests that the cure rate of screen-diagnosed lung cancer, using the I-ELCAP regimen of screening, may be over 70% as compared with that of usual care of 10% and that of chest radiographic screening of 20%.

Limitations of screening for lung cancer with low-dose spiral computed tomography.

Past lung cancer screening trials in the United States with chest X-ray and sputum cytology were not able to show any decrease in lung cancer mortality; however, these trials are over 20 years old. Recent follow-up of the Mayo Lung Project showed a better survival from lung cancer in the screened arm, but no difference in overall mortality, suggesting an overdiagnosis of nonfatal cancers. Recent reports of low radiation dose spiral computed tomography (CT) chest screening for lung cancer have shown that CT screening detects cancers at a smaller size than chest X-rays. To date, there have been no randomized trials of CT versus observation or chest radiographs for screening purposes. All data available thus far on CT screening are from phase II proof-of-principle trials. The major limitations of CT screening, discussed here, include (a) a high rate of nodule detection: over 50% of participants will have at least one noncalcified nodule; (b) resulting follow-up CT scans, associated with increased costs; (c) cost and morbidity of biopsy or resection of benign noncalcified nodule (20-25% of such procedures in several trials); and (d) a small, but difficult to quantify, risk of cancer associated with multiple follow-up CT scans.

[Use of positron-emission tomography with F18-fluorodeoxyglucose for the assessment of lung lesions suspicious of malignancy]. / Uso de la tomografía de emisión de positrones PET con F18-FDG en la evaluación de lesiones pulmonares sospechosas de neoplasia.

Positron-emission tomography (PET) with F18-fluorodeoxyglucose (FDG) is very helpful in the evaluation and management of lung lesions. It is specially useful for the characterization of solitary nodules, for the staging, evaluation of recurrence and therapeutic response in non-small cell lung cancer, for the evaluation of small cell lung cancer and for the assessment of pulmonary metastases. This article is a literature review on PET with FDG in lung cancer. A preliminary analysis of PET results at the Military Hospital in Santiago, Chile, is also presented.

Endobronchial ultrasonography using a guide sheath increases the ability to diagnose peripheral pulmonary lesions endoscopically.

STUDY OBJECTIVE: To assess the ability of endobronchial ultrasonography (EBUS) using a guide sheath (EBUS-GS) to diagnose peripheral pulmonary lesions. METHOD: We devised a technique for EBUS-GS covering a miniature probe, and 150 lesions were evaluated in a prospective open study. In this procedure, the probe covered by a guide sheath is introduced into the lesion via the working channel of a bronchoscope. The probe is withdrawn, while the guide sheath is left in situ. A brush or biopsy forceps is introduced through the guide sheath into the lesion. RESULTS: One hundred sixteen of 150 EBUS-GS procedures (77%) were diagnostic. Cases in which the probe was located within the lesion had a significantly higher diagnostic yield (105 of 121 cases, 87%) than when the probe was located adjacent to it (8 of 19 cases, 42%) [p < 0.0001, chi(2)]. The diagnostic yield from EBUS-GS in lesions 10 to 15 to 20 to

Outcome in patients with lung cancer found on lung cancer mass screening roentgenograms, but who did not subsequently consult a doctor.

GOALS OF THE STUDY: To evaluate the outcome in patients with lung cancer found on lung cancer mass screening roentgenograms, but who did not subsequently consult a doctor. PATIENTS AND METHODS: This study enrolled 198 asymptomatic patients with lung cancer found by lung cancer mass screening during the 9-year period. Five-year survival rates in patients who did not consult a doctor or who stopped consulting a doctor in spite of abnormal shadows detected on last mass screening chest roentgenograms (n=45, delayed consultation group) and in patients who subsequently consulted a doctor when abnormal shadows were detected (n=153, control group) were evaluated by the method of Kaplan and Meier and clinical variables were examined as possible predictors of survival time by the Cox proportional-hazards model. RESULTS: There was a significant difference between the 5-year survival rates in the delayed consultation group and in the control group (21 vs. 51%, log rank: P=0.0003, Wilcoxon: P=0.0009). The risk of death increased 115.0% for the 1-year delay in consultation (hazard ratio: 2.150, 95% CI: 1.203-3.842, P=0.0097). With regard to the reason why they did not consult a doctor, many of them answered that they did not have any respiratory symptoms. CONCLUSION: The 1-year delay in consultation had a great significance in that these patients did not receive any treatment for lung cancer for 1 year, and the 1-year delay in treatment itself affected the outcome.

[F-18 fluorodeoxyglucose positron emission tomography in lung lesions]. / F-18-Fluorodeoxy-Glukose-Positronenemissionstomographie bei Lungenherden.

Positron emission tomography (PET) is used in an increasing number of patients for the evaluation of solitary pulmonary nodes as well as for staging and restaging of lung cancer. It adds metabolic information to the anatomical images of CT and may lead to significant cost savings as well in primary diagnostics as in restaging if patients are carefully selected.

Visualisation and assessment of the protein synthesis rate of lung cancer using carbon-11 tyrosine and positron emission tomography.

This study evaluated the potential role of L-(1-(11)C)-tyrosine positron emission tomography (TYR PET) for visualisation and quantification of protein metabolism in lung cancer. Dynamic TYR PET scans of the thorax were performed in 17 patients with lung cancer. Protein synthesis rate (PSR in micromol/min x l) and standardised uptake value (SUV, corrected for body measurements) of tumour tissue and contralateral normal tissue were calculated before and after chemotherapy or radiotherapy. All tumours [11 non-small cell lung carcinomas (NSCLCs), five small cell lung carcinomas (SCLCs), and one pleural mesothelioma] were visualised as a hot spot. The median PSR in tumour tissue was higher than that in corresponding contralateral normal lung tissue before [1.88 micromol/min x l (range 1.10-3.42) vs 0.40 micromol/min x l (range 0.12-0.86); P=0.003] and after treatment [1.33 micromol/min x l (range 0.45-2.21) vs 0.28 micromol/min x l (range 0.18-0.51); P<0.02]. In contrast to PSR of normal lung tissue, PSR of tumour tissue decreased significantly after therapy (P=0.03). Before therapy, no significant difference in PSR between NSCLCs and SCLCs was observed, but after therapy the PSR differed significantly between the subgroups [1.69 micromol/min x l (range 0.63-2.78) for NSCLC vs 0.67 micromol/min x l (range 0.45-0.92) for SCLC; P=0.03], irrespective of the treatment modality. The median SUV of tumour tissue was higher than that in corresponding contralateral normal lung both before and after therapy. Only a weak correlation between PSR and SUV was found when the latter was corrected for body surface area or lean body mass. Carbon-11 labelled tyrosine appears to be a good tracer for visualising lung cancer. PSR of tumour tissue can be used to quantify reduction in the metabolic rate of the tumour. Future studies need to be performed to determine whether TYR PET will supply additional clinical information with treatment implications in patients with lung cancer.

[Regional assessment of treatment in lung cancer using lung perfusion and ventilation images].

In 30 patients with lung cancer undergoing non-surgical treatment, we performed perfusion lung imaging using 99mTc-MAA and inhalation lung studies using Technegas before and after treatment and evaluated regional perfusion and ventilation status in the lung regions where bronchogenic carcinoma was located. Regional ventilation status was preserved rather than perfusion counterpart (V > P) in 18 patients (18/30 = 60.0%) before treatment, while the former was better than the latter in 27 patients (27/30 = 90.0%) after treatment, indicating that regional ventilation status improved more significantly than regional perfusion counterpart after treatment (p = 0.005). We also classified the therapeutic effect for regional perfusion and ventilation status as improved, unchanged, or worsened, respectively; improvement in regional perfusion status was observed in 17 patients (56.7%) and that in regional ventilation status in 24 patients (80.0%). There was a statistically significant correlation between improved regional perfusion and ventilation status (p = 0.0018) when therapeutic effect was recognized. The patients who showed improvement in regional perfusion status after treatment always showed improved regional ventilation status, but 7 patients showed either unchanged or worsened regional perfusion status after treatment, although regional ventilation status was improved. In conclusion the pulmonary vascular beds seem more vulnerable to bronchogenic carcinoma and improvement in regional perfusion status was revealed to be more difficult than that in regional ventilation status after treatment.

Videotaped helical CT images for lung cancer screening.

PURPOSE: The goal of this work was to determine a radiologist's ability to detect solitary pulmonary nodules on helical CT using both video (cine) viewing and film-based viewing. METHOD: Sixty-five chest helical CT studies were reviewed. Six radiologists searched for 40 lung nodules on CT images presented in three formats. Film-based viewing of images at 10 and 5 mm increments was performed with a light box. Video viewing of the same examinations was performed in 5 mm increments at 2 frames/s. The area under the receiver operating characteristic curve (Az) measured the observer's ability to detect nodules. RESULTS: The Az was 0.948 for the video viewing, 0.844 for 5 mm increment film-based viewing, and 0.879 for 10 mm increment film-based viewing. There were no statistically significant differences. CONCLUSION: Lung nodules can be detected with similar detection rates when viewing conventional film or videotaped helical CT images. Videotaped images incur a lower cost, an important consideration in mass screening for lung cancer.

Small solitary pulmonary nodules: assessment of enhancement and enhancement patterns in benign and malignant tumours by high resolution computed tomography.

Our aim was to determine the accuracy of quantitative and qualitative findings of contrast-enhanced computed tomography (CT) by means of differential analysis of small uncalcified solitary pulmonary nodules and to compare the CT diagnosis with the results of transthoracic needle biopsies (TTNB). We assessed a consecutive series of 109 patients with 66 malignant or 45 benign pulmonary nodules before TTNB and surgery with contrast and high resolution computed tomography (HRCT). Pulmonary nodules were classified as small when equal to or smaller than 15 mm and large when larger than 15 mm. Diagnostic accuracy of CT qualitative evaluation was 95% for large nodules and 92% for small nodules. Specificity was 92% for small nodules, 80% for large nodules. Enhancing regular septa were observed in 28 hamartomas (80%) while except for two cases (3%), inner septa were absent or irregular in malignant tumours. TTNB accuracy was 70% for small nodules and 94% for large ones. Low-enhancing hamartomas are more frequent in Italy than in the US where the prevalence of high-enhancing granulomas in benign nodules reduces the specificity of quantitative CT analysis. We propose that certain geographic areas would benefit from enhanced-CT in place of TTNB in managing lung nodules equal to or less than 1.5 cm.

Vascularity index as a novel parameter for the in vivo assessment of angiogenesis in patients with cervical carcinoma.

BACKGROUND: The importance of angiogenesis now is well recognized. Conventionally, tumor angiogenesis is assessed by determination of microvessel density (MVD) in the surgical specimen. This study examines tumor angiogenesis using power Doppler ultrasound and a quantitative image processing system. The authors hope to develop an in vivo and noninvasive method for quantitating tumor angiogenesis. METHODS: Thirty-five patients with FIGO Stage IB-IIA cervical carcinoma exhibiting visible cervical tumors by transvaginal ultrasound were included in this study. All patients underwent radical abdominal hysterectomy and pelvic lymph node dissection. Transvaginal power Doppler ultrasound was performed before surgery to search for blood flow signals from the tumor. The intratumoral vascularity index (VI) and resistance index (RI) were calculated. The VI was defined as the number of colored pixels divided by the number of total pixels in the defined tumor section. Maximal VI and minimal RI of a certain tumor were used for analysis. Clinical and pathologic data also were recorded. The MVD of the excised tumor was assessed immunohistochemically using a monoclonal antibody against CD34. RESULTS: Significantly higher VI values were noted in Stage II tumors compared with Stage 1 tumors (19.01+/-10.90% vs. 9.09+/-6.59%; P = 0.008), tumors invad-ing+/-50% of the cervical stroma compared with tumors invading < 50% of the cervical stroma (13.20+/-8.20% vs. 5.72+/-5.00%; P = 0.003), tumors with lymphovascular emboli compared with tumors without lymphovascular emboli (17.28+/-8.26% vs. 6.98 +/- 5.09%; P = 0.001), and tumors with pelvic lymph node metastases compared with tumors without pelvic lymph node metastases (26.16+/-7.88% vs. 8.00+/-4.95%; P = 0.021). None of the variables mentioned earlier showed a significant difference in terms of the RI values. No correlation was noted between intratumoral RI and VI in respective tumors (P = 0.53). Analysis of VI revealed linear regression with regard to tumor size (P < 0.001, correlation coefficient [r] = 0.586) and depth of stromal invasion (P = 0.002, r = 0.497). In addition, the MVD exhibited a linear relation with VI (P = 0.006, r = 0.454), tumor size (P = 0.005, r = 0.465), and depth of stromal invasion (P = 0.009, r = 0.436) using simple regression analysis. No correlation could be found between MVD and RI. CONCLUSIONS: In cervical carcinoma, intratumoral VI assessment by power Doppler ultrasound and quantitative image processing system showed better correlation with tumor stage, tumor size, and pathologic findings including depth of stromal invasion, lymphovascular emboli, and pelvic lymph node metastases than intratumoral RI. The in vivo indicator of angiogenic activity (VI) is well correlated with the conventional indicator of tumor angiogenic activity (MVD). Thus, VI could be a useful parameter for the in vivo assessment of global tumor angiogenesis.

Semi-quantitative assessment of 99Tcm-sestamibi uptake in lung cancer: relationship with clinical response to chemotherapy.

The objectives of this study were to measure semi-quantitatively uptake of 99Tcm-sestamibi (99Tcm-MIBI) by tumour tissue in patients with lung cancer and to investigate its relationship with clinical response to chemotherapy. 99Tcm-MIBI single photon emission tomography was performed at the time of diagnosis in 31 patients with biopsy-proven lung cancer (19 small cell carcinomas, 12 non-small cell carcinomas), all of whom were undergoing chemotherapy. Fifteen patients were also investigated 2 weeks after the first and third cycles of chemotherapy. To quantify 99Tcm-MIBI uptake, a tumour/lung (T/L) ratio was calculated for the tomographic slices. The response to chemotherapy was rated as complete remission, partial remission or no remission using dimensional criteria. The results were expressed as the median and inter-quartile range; non-parametric statistical analyses were used. Forty one neoplastic localizations (31 primary tumours and 10 hilar or mediastinal lymph node masses) were assessed. The median T/L ratio of the primary tumours was 1.85 (range 1.7-2.4). Patients with a different response to chemotherapy had a significantly different median T/L ratio before chemotherapy: complete remission (n = 8), T/L ratio = 2.95 (range 2.20-3.25); partial remission (n = 10), 2.15 (range 1.77-2.40); no remission (n = 13), 1.70 (range 1.47-1.75) (Kruskal-Wallis, P < 0.0001). A T/L ratio of 1.80 gave sensitivity of 83%, specificity of 85% and accuracy of 84% in the prediction of the response to chemotherapy. The patients with small cell carcinomas demonstrated greater 99Tcm-MIBI uptake than those with non-small cell carcinomas: T/L ratio, median 2.30 (range 1.76-3.00) vs 1.70 (range 1.50-1.78) (Mann-Whitney U-test, P = 0.001). No significant difference in 99Tcm-MIBI uptake was observed between the 10 lymph node metastases and the corresponding primary tumours: T/L ratio, median 2.30 (range 1.75-2.50) vs 2.15 (1.77-3.00) (Wilcoxon's paired samples rank test, N.S.). Of the 15 patients who were monitored with scintigraphy during chemotherapy, 10 showed complete or partial remission and a parallel reduction in their T/L ratio. The other five patients showed no response to chemotherapy and their T/L ratio was either unaffected or increased. We conclude that the semi-quantitative assessment of 99Tcm-MIBI uptake may have a significant role to play in the management of lung cancer, providing an effective means of predicting the efficacy of chemotherapy and of selecting subgroups of patients requiring radiotherapy or combined protocols before the start of treatment. 99Tcm-MIBI imaging may also be of use in monitoring clinical response to chemotherapy.