Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD).

PURPOSE: Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques. METHODS: This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status. RESULTS: A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35-65%) in the study group and 62% (24/39, 95% CI: 46-75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status. CONCLUSION: DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03984734.

[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.

One-day protocol versus two-day protocol in acquisition of scintigraphy with "in vitro" labelled white blood cells for diagnosis of osteoarticular infection. / Protocolo de un día vs protocolo de dos días de adquisición mediante gammagrafía con leucocitos marcados in vitro para el diagnóstico de infección osteoarticular.

INTRODUCTION: It is difficult to determine osteoarticular infection and differentiate inflammation from infection with laboratory and imaging procedures (CT, MRI, US). Labelled white-blood-cell scintigraphy (WBCS) is the nuclear medicine test of choice but it takes two days, sometimes finds it difficult to differentiate soft tissue from bone infection and therefore causes interobserver variability, which decreases its specificity. OBJECTIVE: To demonstrate the usefulness of the one-day protocol with time decay-corrected acquisition in WBCS to diagnose osteoarticular infection and to reduce interobserver variability. The role of SPECT/CT in WBCS in locating the infected focus was also evaluated. METHODS: 110 patients with suspected osteoarticular infection were studied prospectively. Planar images were obtained with time decay-corrected acquisition at 30min, 4h, 8h and 24h. WBCS planar images were grouped in two protocols: One-day protocol: experts evaluated 30min, 4h and 8h images. Two-day protocol: experts evaluated 30min, 4h and 24h images. Both protocols were classified as: SPECT/CT was performed in 72 patients. Kappa index was calculated to evaluate interobserver variability. RESULTS: Infection was confirmed in 34 cases. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were 97.1%, 97.4%, 94.3%, 98.7%, and 97.3% for the one-day protocol and 94.1%, 97.4%, 94.1%, 97.4%, and 96.4% for two-days-protocol. SPECT/CT contributed to diagnosis in 45/50 patients with planar WBCS positive. Kappa index: 0.8 for one-day protocol and 0.79 for two-day protocol, respectively. CONCLUSION: One-day protocol with time decay-corrected acquisition WBCS and SPECT/CT enables early and accurate diagnosis of osteoarticular infection.

[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.

[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.

[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.

[Selective biopsy of the sentinel lymph node in patients with breast cancer and previous excisional biopsy: is there a change in the reliability of the technique according to time from surgery?]. / Biopsia selectiva del ganglio centinela en pacientes con cáncer de mama y biopsia escisional previa: ¿cambia la fiabilidad de la técnica según el tiempo transcurrido desde la cirugía?

AIM: To assess the influence of time on the reliability of sentinel lymph node biopsy (SLNB) in breast cancer patients with previous excisional biopsy (EB), analyzing both the sentinel lymph node detection and the lymph node recurrence rate. MATERIAL AND METHODS: Thirty-six patients with cT1/T2 N0 breast cancer and previous EB of the lesion underwent a lymphoscintigraphy after subdermal periareolar administration of radiocolloid, the day before SLNB. Patients were classified into two groups, one including 12 patients with up to 29 days elapsed between EB and SLNB (group A), and another with the remaining 24 in which time between both procedures was of 30 days or more (group B). Scintigraphic and surgical detection of the sentinel lymph node, histological status of the sentinel lymph node and of the axillary lymph node dissection, if performed, and lymphatic recurrences during follow-up, were analyzed. RESULTS: Sentinel lymph node visualization at the lymphoscintigraphy and surgical detection were 100% in both groups. Histologically, three patients showed macrometastasis in the sentinel lymph node, one from group A and two from group B. None of the patients, not even those with malignancy of the sentinel lymph node, relapsed after a medium follow-up of 49.5 months (24-75). CONCLUSION: Time elapsed between EB and SLNB does not influence the reliability of this latter technique as long as a superficial injection of the radiopharmaceutical is performed, proving a very high detection rate of the sentinel lymph node without evidence of lymphatic relapse during follow-up.

Effect of a diagnostic dose of 185 MBq 131I on postsurgical thyroid remnants.

UNLABELLED: Stunning of thyroid remnants after diagnostic scanning with 131I may limit 131I therapy. The follow-up scans and serum thyroglobulin levels of such patients have been studied. METHODS: Three-hundred seventy-eight patients who underwent thyroidectomy for differentiated thyroid carcinoma were studied. Diagnostic scans were obtained with 185 MBq 131I; 7.2 wk afterward, the patients received 489 ablative treatments with 4 GBq 131I. A total of 1575 scans were obtained (pre- and posttreatment scans and 615 follow-up scans). The evolution of serum thyroglobulin levels was determined. RESULTS: In all patients, the thyroid-stimulating hormone level was more than 30 microIU/mL. Posttherapy scans showed less uptake than did diagnostic scans or even showed negative findings in 99 patients (21%). In these patients, the mean time between diagnostic scanning and therapy was 7.9 wk. In 61 of these 99 patients (61.6%), follow-up scans have shown negative findings, serum thyroglobulin was less than 3 ng/mL, and antithyroglobulin antibodies were not present. Twenty-three patients (23.2%) have not undergone follow-up scanning yet. In 8 patients (8.1%), follow-up scans showed negative findings but serum thyroglobulin was more than 3 ng/mL. In 7 patients (7.1%), follow-up scans showed less uptake than posttherapy scans, but the findings were not yet negative and thyroglobulin was less than 3 ng/mL. CONCLUSION: Our data suggest that a stunning effect does not exist for doses of 185 MBq 131I for diagnostic scans. However, a therapeutic effect may exist.

MAG3 renogram deconvolution in kidney transplantation: utility of the measurement of initial tracer uptake.

UNLABELLED: The study of renal retention function by deconvolution analysis of renographic curves is useful to calculate quantitative parameters in renal studies. The aim of the work is to evaluate the usefulness of 99mTc-MAG3 renogram deconvolution in renal function monitoring of kidney graft recipients. METHODS: Forty-three kidney grafts and 112 renograms were studied: 41 were diagnosed as functioning graft, 35 as acute tubular necrosis, 24 as acute rejection, 8 as obstruction and 4 as cyclosporin toxicity. The parameters calculated were mean transit time (MTT), time at 20% of renal retention function (T20) and initial uptake (IU). RESULTS: MTT and T20 were significantly longer in obstructives than in functioning grafts (p < 0.001). Initial uptake was significantly lower in acute tubular necrosis (ATN) and acute rejection (p < 0.001) and in obstructives (p < 0.05) than in functioning grafts. The joint evaluation of MTT and IU allowed to diagnose cases with graft function severely impaired. CONCLUSION: Initial uptake is useful in evaluating post-transplantation complications and in combination with MTT and T20 reflects renal dysfunction severity.

99Tcm-MAG3 renogram deconvolution in normal subjects and in normal functioning kidney grafts.

This study provides values of transit times obtained by 99Tcm- mercaptoacetyl triglycine (99Tcm-MAG3) renogram deconvolution for both normal subjects and kidney graft recipients. The analysis included 50 healthy kidney units from 25 volunteers and 28 normal functioning kidney grafts. The parameters calculated for the whole kidney (WK) and for the renal parenchyma (P) were: mean transit time (MTT) and times at 20% (T20) and 80% (T80) of renal retention function initial height. For healthy kidneys the WK MTT was 174 +/- 27 s and P MTT 148 +/- 22 s. The WK T20 values were 230 +/- 33 s and P T20 231 +/- 34 s. The WK T80 was 108 +/- 19 s and P T80 106 +/- 12 s. Whole kidney and parenchymal values of transit times for normal functioning kidney grafts do not present significant differences with respect to healthy kidneys.

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.

[Classification of kidney grafts by renographic parameters]. / Clasificación de injertos renales mediante parámetros renográficos.

The aim of this work was to analyze the use of some renographic parameters derived from the 99mTc-MAG3 renogram to classify post-transplantion studies in two groups: Normal functioning grafts (NFG) and delayed grafts function (DGF) which included Acute Tubular Necrosis (ATN) and Acute Rejection (AR). The analysis included data from 38 NFG, 33 ATN and 23 AR. The parameters calculated were: mean transit time (MTT), the Initial Uptake (IU) and the maximum activity (MA) of the renogram. The results obtained from this analysis show that ln(IU) is the best parameter to classify individuals in either group and that the use of MA or the MTT does not improve the results. Using a cutoff point of ln(IU) = 0.28 and a prevalence of 25% for DGF, the estimated predictive values were 92% for DGF and 99% for NFG.

[Study of renal transplant by deconvoluted renogram with 99m Tc-mercaptoacetyltriglycine (Mag3)]. / Estudio de la evolución del trasplante renal mediante la deconvolución del renograma con 99m Tc-mercapto-acetil-triglicina (Mag-3).

AIM: To evaluate the usefulness of the 99mTc-MAG3 renogram deconvolution and its derived parameters in kidney graft function monitoring. MATERIAL AND METHOD: 221 renograms were studied: 64 were diagnosed as functioning graft (FG), 37 as functioning graft with elevated serum creatinine (FG2), 59 as acute tubular necrosis (ATN), 30 as acute rejection (AR), 20 as urinary tract obstruction (OBS) and 11 as cyclosporine nephrotoxicity (TNX). The parameters evaluated were: maximal activity of conventional renogram and mean transit time (MTT), time to reach 20% (T20) and 80% (T80) of the height of the RRF and initial uptake (IU) from the deconvoluted renal retention function (RRF). RESULTS: MTT and T20 were significantly longer and IU significantly lower in non-functioning grafts. However, MTT and T20 became shorter than in FG when graft function is severely impaired. CONCLUSION: IU, MTT and T20 are more useful than maxim activity of renogram in monitoring kidney graft function and in evaluating renal dysfunction severity. IU is a very sensitive and early parameter.

[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.