Practical Overview of 123I-Ioflupane Imaging in Parkinsonian Syndromes.

Parkinsonian syndromes are a heterogeneous group of progressive neurodegenerative disorders involving the nigrostriatal dopaminergic pathway and are characterized by a wide spectrum of motor and nonmotor symptoms. These syndromes are quite common and can profoundly impact the lives of patients and their families. In addition to classic Parkinson disease, parkinsonian syndromes include multiple additional disorders known collectively as Parkinson-plus syndromes or atypical parkinsonism. These are characterized by the classic parkinsonian motor symptoms with additional distinguishing clinical features. Dopamine transporter SPECT has been developed as a diagnostic tool to assess the levels of dopamine transporters in the striatum. This imaging assessment, which uses iodine 123 (123I) ioflupane, can be useful to differentiate parkinsonian syndromes caused by nigrostriatal degeneration from other clinical mimics such as essential tremor or psychogenic tremor. Dopamine transporter imaging plays a crucial role in diagnosing parkinsonian syndromes, particularly in patients who do not clearly fulfill the clinical criteria for diagnosis. Diagnostic clarification can allow early treatment in appropriate patients and avoid misdiagnosis. At present, only the qualitative interpretation of dopamine transporter SPECT is approved by the U.S. Food and Drug Administration, but quantitative interpretation is often used to supplement qualitative interpretation. The authors provide an overview of patient preparation, common imaging findings, and potential pitfalls that radiologists and nuclear medicine physicians should know when performing and interpreting dopamine transporter examinations. Alternatives to 123I-ioflupane imaging for the evaluation of nigrostriatal degeneration are also briefly discussed. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Intenzo and Colarossi in this issue.

Effect of the Ductal Carcinoma In Situ Margin Consensus Guideline Implementation on Re-Excision Rates, Satisfaction, and Cost.

INTRODUCTION: The 2016 consensus guideline on margins for breast-conserving surgery (BCS) with whole-breast irradiation (WBI) for ductal carcinoma in situ (DCIS) recommended 2 mm margins to decrease local recurrence rates. We examined re-excision rates, cost, and patient satisfaction before and after guideline implementation. METHODS: From an Institutional Review Board-approved database, patients with DCIS who underwent BCS with over 1 year of follow-up at one academic institution and one community cancer center were evaluated. Two groups were compared based on when they received treatment, i.e. before (pre-consensus [PRE]) and after November 2016 (post consensus [POST]), with respect to outcome and cost parameters. RESULTS: After consensus guideline implementation, re-excision rate (32.1% vs. 20.0%) and mastectomy conversion (8.3% vs. 2.3%) significantly increased, although total resection volume, operative cost per patient, and satisfaction with breast scores did not differ. Not all patients with <2 mm margins were re-excised, although the re-excision rate among this subset significantly increased (62.4% vs. 31.3%). On multivariable analysis controlling for age, estrogen receptor status, WBI use, and margin status, surgery after consensus guideline publication was independently associated with a higher re-excision rate (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.08-3.59, p = 0.03) and a higher rate of conversion to mastectomy (OR 6.84, 95% CI 1.67-28.00, p = 0.007). CONCLUSIONS: Implementation of the 2016 margin consensus guideline for DCIS resulted in an increase in re-excisions and mastectomy conversions at two institutions. Research is needed for operative tools and strategies to decrease DCIS re-excision rates.

Correlating serum alpha-fetoprotein in hepatocellular carcinoma with response to Yttrium-90 transarterial radioembolization with glass microspheres (TheraSphere™).

BACKGROUND: Few studies have assessed the relationship between serum alpha-fetoprotein (AFP) and yttrium-90 (Y-90) radioembolization response in hepatocellular carcinoma (HCC). The objective of the study was to evaluate whether peri-procedural serum AFP was correlated with Y-90 therapy response in HCC. METHODS: Patients undergoing Y-90 radioembolization with glass microspheres (TheraSphere™) for HCC between 2006 and 2013 at a single center were evaluated. The relationship between AFP and 6-month radiographic improvement (complete or partial response by modified RECIST criteria), overall (OS), and disease-specific survival (DSS) were analyzed. RESULTS: Seventy-four patients underwent a total of 124 Y-90 infusions. Median age was 65 years, median AFP was 37 ng/mL (range: 2-112,593 ng/mL) and median model for end-stage liver disease score was 6.2 (range:1.8-11.2). Increased AFP was not associated with radiographic improvement (odds ratio (OR) = 0.99, 95% confidence interval (CI) = 0.75-1.30, p = 0.92). Median OS was 15.2 months and was increased in patients with low AFP compared to high AFP (30.8 months vs. 7.8 months, p < 0.001). On multivariable regression analysis, increased AFP was associated with worse OS (OR = 1.11, 95%CI = 1.01-1.22, p = 0.034) and DSS (OR = 1.13, 95%CI = 1.03-1.25, p = 0.018). CONCLUSION: Pre-infusion AFP independently predicted survival after Y-90 treatment for HCC, but not radiographic response, and can help guide treatment decisions.

Evaluating the relationship between ductal carcinoma in situ, calcifications, and margin status in patients undergoing breast conserving surgery.

BACKGROUND: Microcalcifications associated with ductal carcinoma in situ (DCIS-AMC) close to lumpectomy margins could be used as a surrogate for margin involvement and aid in decreasing margin re-excision. We sought to evaluate the histologic factors of DCIS-AMC near lumpectomy margins. METHODS: Women with DCIS treated with breast-conserving surgery (BCS) who had DCIS-AMC on surgical specimens were identified. Pathology slides were reviewed to determine the distance of DCIS-AMC from each margin (six per specimen) and the distance of DCIS from each margin (ie, margin status). RESULTS: Of 35 patients (210 margins), 24 had close/positive margins (39 margins [18%]). DCIS-AMC≤10 mm from a margin was associated with a greater incidence of DCIS≤2 mm from the margin (31.7% DCIS-AMC≤10 mm vs 13.3% no DCIS-AMC≤10 mm, P = 0.003). On multivariable analysis, DCIS≤2 mm from the margin was independently associated with DCIS-AMC≤10 mm from the margin (odds ratio 2.95, 95% confidence interval 1.48-5.86, P = 0.002). CONCLUSIONS: DCIS-AMC≤10 mm from the inked margin is associated with DCIS at or close to the margin (≤2 mm). Using this knowledge, intraoperative techniques like specimen radiography could be utilized to detect microcalcifications≤10 mm from a margin and guide selective margin re-excision in BCS.

Diagnosis and Treatment of Cardiac Myxoma.

Cardiac myxoma is the most common primary cardiac neoplasm. It is a benign tumor that typically arises in the left atrium, specifically from the interatrial septum adjacent to the fossa ovalis. We present a case of a 71-year-old male presenting with hematuria that was incidentally found to have a left atrial myxoma on a CT urogram. Follow-up CT and MRI of the heart demonstrated findings compatible with myxoma. Cardiothoracic surgery was consulted, and the patient underwent resection of the left atrial mass, which was confirmed to be a myxoma on pathology.

Altered Biodistribution on 99m Tc-Dimercaptosuccinic Acid Renal Scan.

ABSTRACT: 99m Tc-dimercaptosuccinic acid ( 99m Tc-DMSA) scans are used to evaluate renal cortical defects typically related to parenchymal scarring or pyelonephritis, and ectopic renal parenchyma. 99m Tc-DMSA binds to metalloproteins in proximal tubular cells and typically localizes to the renal cortex, with minimal excretion. Planar and SPECT images are obtained 2 to 4 hours after IV administration of 99m Tc-DMSA. Altered 99m Tc-DMSA biodistribution has been reported in various conditions, including renal injury, technical issues, infiltrative processes, and hematologic disorders. Here, we present a case of altered biodistribution, with hepatic and splenic radiotracer uptake in the setting of hepatosplenomegaly and hematologic abnormalities concerning for a systemic hematologic disorder/lymphohistiocytosis.

Incidental Serous Cystadenoma Presenting as a Photopenic Pancreatic Defect on 18F-Fluciclovine PET/CT.

ABSTRACT: 18F-fluciclovine (Axumin) PET/CT has been widely used for the evaluation of biochemically recurrent prostate cancer following prior treatment. While lymph node and visceral organ metastases typically show increased radiotracer uptake, altered patterns of normal physiologic activity may also provide insight into other disease processes. We present a case of an incidental pancreatic head mass presenting as a photopenic defect on a staging 18F-fluciclovine PET/CT, which was subsequently confirmed to be a benign serous cystadenoma using multisequence MRI.

Identifying risk factor for development of perioperative venous thromboembolism in patients with gastrointestinal malignancy.

BACKGROUND: Current data suggests that decreasing VTE incidence may require focus on other factors. This study aimed to identify perioperative risk factors for VTE in patients undergoing surgery for gastrointestinal (GI) malignancy. METHODS: Patients undergoing surgery for GI malignancy from 2013 to 2016 were grouped according to whether or not they developed a postoperative VTE, and groups were compared along demographic, perioperative, and outcome variables. RESULTS: Patients who developed VTE were more likely to be older (67 ±â€¯11 VTE vs. 61 ±â€¯10 no VTE, p = 0.04), male (92% vs. 59%, p = 0.02), and have a history of atrial fibrillation (39% vs. 11%, p = 0.01). They also experienced higher intraoperative blood loss (328 ±â€¯724 mL no VTE vs. 918 ±â€¯1885 mL VTE, p = 0.01). On multivariable analysis, history of atrial fibrillation was independently associated with development of postoperative VTE (odds ratio = 3.83, 95% confidence interval = 1.13-13.05, p = 0.03). CONCLUSION: A prior history of atrial fibrillation independently predicts increased risk of developing VTE after surgery for GI malignancy. Improving understanding of the underlying VTE pathophysiology in these patients can help guide effective prevention strategies.

Evaluating the Effect of Margin Consensus Guideline Publication on Operative Patterns and Financial Impact of Breast Cancer Operation.

BACKGROUND: This study sought to evaluate re-excision rates, patient satisfaction with their breasts, and healthcare costs before and after publication of 2014 Society of Surgical Oncology/American Society of Radiation Oncology consensus guideline on margins for breast conserving operation with whole-breast irradiation for stage I and II breast cancer at an academic institution. STUDY DESIGN: Patients with stage I and II invasive carcinomas who underwent partial mastectomy were divided into 2 groups based on whether they were treated before (PRE) or after (POST) guideline publication in March 2014. Groups were compared with respect to re-excision rates, conversion to mastectomy, specimen volumes, mean cost per patient of surgical care, and prospectively collected patient post-procedure quality of life. RESULTS: A total of 237 patients who underwent partial mastectomy were examined (n = 126 in the PRE group and n = 111 in the POST group). Patients in the POST group were less likely to require re-excision (9% POST vs 37% PRE; p < 0.001) and were less likely to undergo conversion to mastectomy (5% POST vs 14% PRE; p = 0.02). After consensus guideline publication, mean operative cost per patient decreased ($4,874 POST vs $5,772 PRE; p < 0.001), and patients had improved breast quality of life scores (77 out of 100 POST vs 61 out of 100 PRE; p = 0.03). On multivariable analysis, publication of the consensus statement was an independent predictor of decreased re-excision rates (odds ratio 0.17; 95% CI 0.08 to 0.38; p < 0.001) and operative cost per patient (odds ratio 0.14; 95% CI 0.78 to 0.30; p < 0.001). CONCLUSIONS: Widespread implementation of the consensus guideline on margins for breast conserving operation will likely lead to the intended improvements in operative and financial outcomes, as well as patient satisfaction with breast conserving operation.

The impact of enhanced recovery pathways on cost of care and perioperative outcomes in patients undergoing gastroesophageal and hepatopancreatobiliary surgery.

INTRODUCTION: Enhanced recovery after surgery protocols have been increasingly adopted to standardize patient care and decrease overall costs. This study evaluated the impact of a prospectively implemented enhanced recovery after surgery protocol for patients undergoing surgery for gastroesophageal and hepatopancreatobiliary disease at an academic institution. METHODS: Patients undergoing either hepatopancreatobiliary or gastroesophageal procedures between January 2013 and May 2017 were classified according to whether or not they were placed on an enhanced recovery after surgery protocol. Groups were compared along demographic, perioperative, outcomes, and financial variables. RESULTS: Of a total of 377 patients, 149 were placed on an enhanced recovery after surgery protocol. There was a significant association between enhanced recovery after surgery protocol use and increased perioperative antibiotic use (98.0% enhanced recovery after surgery vs. 87.3% non-enhanced recovery after surgery, P < .001), decreased intraoperative crystalloid use (1,155 ± 705 mL enhanced recovery after surgery vs. 1,576 ± 826 non-enhanced recovery after surgery, P < .001), decreased requirement for intensive care unit stay (20.1% enhanced recovery after surgery vs. 36.4% non-enhanced recovery after surgery, P < .001), and decreased total hospital costs ($10,688.38 ± 10,518.22 vs. $15,439.22 ± 14,201.24, P < .001). On multivariable analysis, enhanced recovery after surgery protocol use was independently associated with decreased rate of intensive care unit admission (odds ratio 0.39, 95% confidence interval 0.23-0.66, P < .001). CONCLUSION: Enhanced recovery after surgery pathways can be safely implemented in patients undergoing hepatopancreatobiliary and gastroesophageal procedures and can help standardize perioperative practices, decrease requirement for intensive care unit admission, and decrease total hospital costs.