Prognostic Value of Diaphragmatic Ultrasound in Patients Admitted for COVID-19 Pneumonia.

Introduction: COVID-19 pneumonia results in an impairment of the diaphragmatic musculature that influences the development of respiratory failure during the patient's hospitalization. Diaphragmatic ultrasound is a useful, non-invasive, and accessible tool for measuring the function of this muscle. Objective: Assessing the morphological and functional ultrasound status of the diaphragm in patients admitted within the first 24 h for COVID-related pneumonia and its association with hospital morbidity and mortality (NCT05805579). Material and methods: Observational, prospective cohort study that included 68 patients admitted for COVID-19 pneumonia with respiratory failure. Diaphragmatic ultrasound was performed within the first 24 h of admission to the pulmonology ward. Clinical, analytical, and ultrasound variables were collected: excursion, thickness, and diaphragmatic shortening fraction (DSF). DSF < 20% was used to define diaphragmatic dysfunction (DD). Patients who showed favorable progression and were managed on the ward (HCONV) were compared to those who required admission to the respiratory monitoring unit (RMU). Results: A total of 68 patients were included, of which 22 (32.35%) were admitted to the RMU. Diaphragmatic excursion at maximum volume was higher in the HCONV group compared to the RMU group (58.41 ± 17.83 vs. 50.03 ± 16.23; p = 0.123). Diaphragmatic dysfunction (DD) was observed in 21 (30.88%) patients, with a higher prevalence in the RMU group than in the HCONV group (15 (68.18%) vs. 6 (13.04%); p = 0.0001). In the multivariate analysis, age and DSF at admission were the best predictors of failure to discharge. Conclusions: Performing diaphragmatic ultrasound to assess mobility and DSF within the first 24 h of admission for COVID-19 pneumonia proves valuable in determining short-term progression and the need for admission to a respiratory monitoring unit.

Introducción: La neumonía por COVID-19 provoca un deterioro de la musculatura diafragmática que influye en la aparición de insuficiencia respiratoria durante la hospitalización del paciente. La ecografía diafragmática es una técnica no invasiva accesible y útil para medir la función de este músculo. Objetivo: Evaluar mediante ecografía el estado funcional y morfológico del diafragma en pacientes con neumonía por COVID durante las primeras 24 h de su ingreso y su asociación con la morbimortalidad intrahospitalaria (NCT05805579). Materiales y métodos: Se realizó un estudio prospectivo y observacional de una cohorte compuesta por 68 pacientes ingresados por neumonía por COVID-19 con insuficiencia respiratoria. La ecografía diafragmática se practicó durante las 24 h siguientes al ingreso en la planta de neumología. Se recopilaron variables clínicas, analíticas y ecográficas: desplazamiento, grosor y fracción de acortamiento diafragmático (FAD). Se utilizó una FAD < 20% como definición de disfunción diafragmática. Se comparó a los pacientes que evolucionaron favorablemente y recibieron tratamiento en planta (hospitalización convencional) con los pacientes que tuvieron que ser ingresados en la unidad de monitorización respiratoria (UMR). Resultados: Se incluyó en el estudio a un total de 68 pacientes, de los cuales 22 ingresaron en la UMR (el 32,35%). El desplazamiento diafragmático con el volumen máximo fue más alto en el grupo de hospitalización convencional que en el grupo ingresado en UMR (58,41 ± 17,83 frente a 50,03 ± 16,23; p = 0,123). Presentaron disfunción diafragmática 21 pacientes (30,88%) y la prevalencia fue más alta en el grupo ingresado en UMR que en el de hospitalización convencional: 15 pacientes (68,18%) frente a 6 (13,04%); p = 0,0001. En el análisis multivariable, la edad y la FAD al ingreso son los factores que mejor predicen la imposibilidad del alta. Conclusiones: La ecografía diafragmática para evaluar la movilidad y la FAD en las primeras 24 h del ingreso por neumonía por COVID-19 resulta valiosa para determinar la evolución a corto plazo y la necesidad de ingreso en una unidad de monitorización respiratoria.

Management and outcome of children with neuroendocrine tumors of the appendix in Spain: Is there room for improvement?

PURPOSE: Neuroendocrine tumors (NETs) are, after lymphomas, the most frequent gastrointestinal tumors in children, mainly located in the appendix. Best management remains unclear, given the absence of pediatric guidelines. We present the first Spanish series of pediatric patients with NETs. PATIENTS AND METHODS: Retrospective study of all pediatric patients (<18 years) with NET treated in four oncology reference institutions in Spain between 1994 and 2015. RESULTS: Seventeen patients were included. All patients presented with acute abdomen. TNM stage was T1a (82%) and T1b (12%). Extension study was heterogenous, with only 4 patients undergoing an OctreoScan. Four patients met criteria for second surgery (affected surgical margins or mesoappendix invasion), but it was only performed in two. Despite the diverse management, none of the patients relapsed during follow-up. CONCLUSIONS: The disparity in diagnostic tests, second surgery criteria and follow-up shown in this study highlights the need for specific pediatric guidelines.

[Treatment protocols and follow-up of differentiated thyroid carcinoma: results of a questionnaire sent to the Spanish Metabolic Therapy Units]. / Los protocolos de tratamiento y seguimiento del carcinoma diferenciado de tiroides: resultados de un cuestionario enviado a las Unidades de Terapia Metabólica españolas.

OBJECTIVE: To know the treatment and follow-up protocols of differentiated thyroid carcinoma patients in Spanish Metabolic Therapy Units, the clinical variability between them and the adaptation to the consensus guidelines. MATERIALS AND METHODS: Analysis of the results obtained from the questionnaire submitted by E-mail to the Spanish Society of Nuclear Medicine (SEMNIM) members on the treatment and follow-up of differentiated thyroid carcinoma patients. A descriptive study was made of the qualitative variables (frequency, percentage) and quantitative variables (mean, standard deviation). RESULTS: Twenty Radiometabolic Therapy Units responded to the questionnaire. In spite of the varied origin of the patients, the Units receive sufficient clinical information and have specialized surgeons. There is variability in the surgical protocols and indication for ablation in patients with intermediate and low risk of recurrence. The Units agree on the use of (131)I doses for ablation and therapy, but show great variability regarding the preparation protocols (previous (131)I-whole body scan or other imaging techniques, (131)I-whole body scan dose, diet and radioiodine contrast prohibition, total dose per patient). Nuclear Medicine physicians perceive radioiodine adverse effects and prevention methods are used. The post-ablation follow-up protocol differs between Units. CONCLUSIONS: Treatment and follow-up protocols of differentiated thyroid carcinoma patients in the Spanish Radiometabolic Therapy Units show variability in aspects such as surgery and ablation indications, patient preparation for radioiodine therapy and follow-up. Our clinical practice differs in several aspects from the recent consensus guideline recommendations.

[Indication for bone scans in early breast cancer staging]. / Indicación del rastreo óseo en la estadificación del cáncer de mama de inicio.

OBJECTIVE: Evaluate the indication for bone scanning during staging of early breast cancer in the light of scientific evidence to assess the need to modify practices with scant effectiveness. MATERIAL AND METHODS: The bone scans carried out in our Nuclear Medicine Department in 2007 on patients with primary breast cancer were reviewed retrospectively. Results were analyzed in relation to the clinical and histopathologic findings for each tumor. Bone scan results of tumors >2 cm y 3 cm, and pre-treatment clinical stage. RESULTS: Out of 245 bone scans of patients with breast cancer, 237 (97%) were negative for metastatic disease and 8 (3%) were positive. Lesions <2 cm (Tis and T1) were diagnosed in 131 patients (53.5%), none of which had bone metastasis at time of diagnosis. Lesions >2 cm and 3 cm. The bone scan findings did not modify staging in any of the 66 patients with T2 tumors stage IIA, but it did modify staging in 2 of 12 patients with stage IIB tumors. Twenty percent of 15 patients with T3 tumors and 13% of patients with T4 tumors had bone metastasis at time of diagnosis. CONCLUSIONS: Ineffective practices should be modified and bone scanning should not be indicated in patients with early breast cancer Tis, T1 and T2 with tumor

[67Ga SPECT/low-dose CT. A case report of spondylodiscitis and Schmorl's node]. / SPECT-TAC de baja dosis con 67Ga en un caso de espondilodiscitis y hernia de Schmorl.

A 61-year-old male patient with microbiological diagnosis of L3-L4 spondylodiscitis and persist pain underwent a (67)Ga scintigraphic study to assess the antibiotic treatment response. Pathological uptake foci in vertebral bodies of L2 and L4 were observed in the (67)Ga planar scintigraphy. A SPECT low-dose CT of the lumbar spine was performed as part of anatomical correlated protocol, detecting an active spondylodiscitis in L3-L4 and a second uptake foci in L2 that was identify as a Schmorl's node. In this case the SPECT-CT hybrid image allowed us to avoid a false positive diagnosis to by locate and characterize an image with abnormal uptake of (67)Ga, improving the test specificity and avoiding a wrong diagnosis.

[Scintimammography with 99mTC-MIBI in the clinical practice: repercussion on the clinical management of the patient]. / Gammagrafía de mama con 99mTc-MIBI en la práctica clínica. Repercusión en el manejo clínico del paciente.

OBJECTIVE: Establish the usefulness of scintimammography (SM) in day-to-day clinical practice. MATERIAL AND METHODS: We have evaluated 308 SM consecutively performed in our Department. The diagnosis was established by way of biopsy or clinical and mammography follow-up (minimum 18 months). In all cases we evaluated the kind of lesions (palpable or non-palpable) and their degree of suspicion of malignancy in the mammography (BIRADS). We determined the number of fine-needle aspiration cytology (FNAC) or biopsies performed in dependence of kind of lesions, mammography and SM results. RESULTS: Final diagnosis was cancer in 18 % of the patients, and 71 % of the lesions were non palpable. Negative predictive value (NPV) of SM was 96 %. Pathological diagnosis was performed in 100 % of lesions with SM+ and 16 % of lesions with SM-. According to the kind of lesion, FNAC and/or biopsy was performed in 62 % of palpable lesions and in 20 % of non-palpable lesions; and according to the mammography in 21 % of lesions BIRADS I-II, 14 % in BIRADS III, 70 % in BIRADS IV and 100 % in BIRADS V. The number of FNAC and/or biopsies performed is significantly higher in all cases when SM is positive (p > 0,001), excepting in BIRADS V lesions. CONCLUSIONS: In day-to-day clinical practice SM is generally performed in low prevalence of breast cancer population, in the evaluation of non-palpable lesions with a low suspicion of malignancy. SM has a high NPV, increase the diagnostic accuracy of the mammography and has repercussion on patient management, except in BIRADS V lesions.

[Treatment of bone metastatic pain with Sm153-EDTMP. Evaluation of the analgesic response and the existence of differences according to the primary tumor and the metastatic pattern]. / Tratamiento del dolor óseo metastásico con Sm153-EDTMP. Valoración de la respuesta analgésica y de la existencia de diferencias según el tipo de tumor y el patrón metastásico.

AIMS: To evaluate the response to Sm153-EDTMP treatment in patients with metastatic bone pain and the existence of differences in the response according to the scintigraphic pattern (99mTc-MDP) and the primary tumor. MATERIAL AND METHODS: We have evaluated the response to Sm153-EDTMP treatment in 32 patients (17 male and 15 female) who received 38 doses (1 mCi/kg). The primary tumor was prostate cancer in 15 patients, breast in 13, lung in 2, intestinal carcinoid in one and unknown in one. Two types of response were considered: a) effective and b) non-effective. Patients were classified into 3 groups according to the metastatic pattern: 1) Superscan (SS), 2) Generalized metastases (GM) and 3) Regional metastases (RM). RESULTS: There was effective response in 24 doses (63.15%) and non-effective in 14 (36.84%). The mean duration of the response was 12.08 weeks. Patients with GM pattern showed 16 effective responses (76.19%) and 5 non-effective (23.8%). In SS pattern there were 6 effective responses (60%) and 4 non-effective (40%) and 2 effective (28.57%) and 5 non-effective (71.53%) in RM pattern. These differences did not reach statistical significance (p > 0.05). We did not find differences in the response between prostate cancer (12 effective and 6 non-effective) and breast cancer (10 effective and 6 non-effective) (p = 0.79968). CONCLUSIONS: Sm153-EDTMP treatment is efficacious in patients with metastatic bone pain with effective response in 63.15% of the treatments. The response percentage was lower in patients with RM pattern but the differences did not reach statistical significance. There were no differences in the response between prostate and breast cancer patients.

In-111 DTPA octreotide scintigraphy and intraoperative gamma probe detection in the diagnosis and treatment of residual lymph node metastases of a rectal carcinoid tumor.

PURPOSE: We report a case of a rectal carcinoid tumor that was treated using endoscopic resection. This case highlights the usefulness of using somatostatin receptor scintigraphy in the postresection endoscopy of the tumor and the intraoperative use of a gamma probe detector for the surgical resection of metastatic adenopathy that had not been detected using computed tomography (CT) scanning. METHODS: The patient was studied using CT scanning, somatostatin receptor scintigraphy (SRS), and rectal endoscopic ultrasonography (EUS). A gamma probe detector was scheduled for use during the subsequent surgical intervention. RESULTS: The SRS demonstrated a pelvic metastatic lymphatic node that had not been detected on CT scanning. Additional EUS did not show regional metastatic lymph nodes. Histopathology following removal of retroperitoneal and presacral lymphatic nodes confirmed the diagnosis of metastatic carcinoid tumor. At follow up at 6 months, SRS and rectoscopy were normal. CONCLUSION: Somatostatin receptor scintigraphy is very useful in identifying the presence of lymph node metastases, even with a small rectal carcinoid tumor. This is of considerable importance when scheduling surgery and the CT and EUS are normal. The use of an intraoperative gamma-probe detector assists in the surgical excision of the metastatic lymphatic nodes, especially because they had been detected only using SRS, and when their exact location is uncertain.

[Carcinoid tumor and bone metastases: diagnosis by somatostatin receptor scintigraphy]. / Tumor carcinoide y metástasis óseas: diagnóstico mediante gammagrafía de receptores de somatostatina.

OBJECTIVE: The aim of this study has been to retrospectively assess the usefulness of 111In-DTPAOC scintigraphy in the detection of bone metastases (BM) in patients diagnosed of carcinoid tumour (CaT). MATERIALS AND METHODS: Between June 1995 and April 2003 78 111In-DTPAOC studies were consecutively performed in 58 patients, 31 females and 27 males, 28 to 73 years old, with a histological diagnosis of CaT. Moreover, whole body bone scans (BS) using 99mTc-MDP were performed in 13 of these patients. The patients were classified into three groups: Group A: Initial CaT staging (n = 23); Group B: CaT staging after surgery (n = 14); and Group C: Post-treatment CaT re-staging (n = 29). In this last group, 6 patients of group A and 2 patients of group B were included. In only 2 patients the diagnoses of bone metastases were established before the 111In-DTPAOC scan. RESULTS: Twenty six (44.8 %9 of the 58 patients with CaT had metastatic disease: 15 patients with hepatic metastases, associated with BM in 4 of them, 10 patients with hepatic and extra-hepatic metastases, abdominal and/or thoracic, associated with BM in 4 and in one patient, the BMs were the only metastases detected. The global incidence of BM in patients diagnosed with CaT was 15.5 % (9/58), whereas the incidence of BM in patients with metastasic disease was 34.6 % (9/26). Significant differences (p = 0.0035) were found on the incidence of BM in patients with or without hepatic metastases. In 4 patients, BMs were detected during the initial staging (group A), whereas in 5 patients, BMs were detected during the post-treatment re-staging (group C). During diagnosis, 4 of the 9 patients with BM had bone pain. BM were multiples in 8 patients, affecting axial skeleton in 4 and axial and appendicular skeleton in 4. One patient had a diffuse infiltration of bone marrow. BS was positive in 8 of the 9 patients with BM. In these 8 patients with abnormal BS, 111In-DTPAOC scintigraphy provides similar information to the BS in one patient, shows a greater number of bone lesions in 3, whereas BS was superior in 5 patients. Four of the patients with BM died between 6 and 47 months after diagnosis (mean: 29.7 months). CONCLUSIONS: BMs are preferably located on axial skeleton, can be asymptomatic and are associated with hepatic metastases. Although the 111In-DTPAOC scintigraphy is able to detect some BM earlier than BS, the information provided by both studies is complementary. In patients with CaT, any invasive therapy on the hepatic metastases make it necessary to exclude extrahepatic metastases, including bone ones, and the somatostatin receptor scintigraphy is the diagnostic method of choice.

[Diabetes mellitus and pancreatic tumor]. / Diabetes mellitus y tumor pancreático.

A 68 year old Ecuadorian man was investigated for polyuria, polydipsia and weight loss of 3 kg during the previous two months. Insulin dependent diabetes mellitus was diagnosed 10 year before admission and treated with appropriate diet and insulin (35 U/d). 18 months before was diagnosed in El Ecuador of "multiple liver nodes non-suggestive of malignancy". Physical examination showed a large multinodular petrous hepatomegaly. There was no evidence of skin lesions. Results of laboratory studies included a basal plasma glucose level that ranged between 275-367 mg/dl (N=60-100), glycosylated haemoglobin of 8.9% (N<5) and a serum albumin of 2.8 gr./dl (N=3.4-4.8). At admission non-other laboratory alterations were detected. Computed tomography showed a mass on the head of the pancreas with loco-regional lymph nodes and liver metastases. Tumor markers were normal. Fine-needle aspiration cytology of the liver masses revealed the presence of liver metastases of a non-differentiated malignant tumor. A 111In-DTPAOC scintigraphy revealed the presence of somatostatin receptors in the liver metastases, also detecting the presence of multiple bone metastases in the axial and appendicular skeleton. Plasma glucagon level was 678 pg/ml (N<250). A diagnosis of metastatic glucagonoma was established and therapy with streptozocin, 5-FU, insulin and synthetic somatostatin analogs was initiated. Three months after the therapy initiation the patient was symptom free. Some weeks after the patient suffered from left hip pain, and a control 111In-DTPA scintigraphy showed progression of his bone metastases. In conclusion, glucagonoma must be suspected in all diabetic patients with metastatic liver, even in absence of necrotic migratory erythema. In these circumstances, plasmatic glucagon level and somatostatin receptors scintigraphy will be a useful tool for establishing the final diagnosis.

[Somatostatin receptor scintigraphy. When would a SPECT study be performed?]. / Gammagrafía de receptores de somatostatina. Cuándo hacer una SPECT?

UNLABELLED: Somatostatin receptor scintigraphy has become an essential tool in the treatment planning of patients with carcinoid tumor (CaT) and pancreatic neuroendocrine tumors (PNET). However, the contribution of SPECT images in the diagnosis and staging of these tumors has not been well established. OBJECTIVE: 1) To find out if SPECT improves the sensitivity of planar imaging and adds any value to tumor diagnosis, and 2) To determine under which circumstances SPECT images must be obtained. MATERIAL AND METHODS: We have evaluated 49 patients, 26 females and 23 males, using both planar and SPECT 111In-DTPAOC images. The patients were classified into three groups according to their clinical indication: Group A: Indolent symptoms of CaT or PNET (n = 9); Group B: Known or functioning CaT or PNET tumors (n = 22); Group C: Post-surgical follow-up (n = 18). The total number of SPECT studies were 51 (37 abdomen, 13 thorax and 1 brain). In all cases SPECT was performed 24 hours after 111In-DTPAOC injection. Scintigraphic images were compared with surgical findings in 17 patients and with a synthesis of biochemical, clinical and CT findings in the other patients. RESULTS: 16 primary lesions were detected with planar images whereas SPECT detected 18. The two tumors detected only by SPECT were a bronchial CaT and an insulinoma located in the pancreatic tail. Planar and SPECT image sensitivities were 66.6% and 75% respectively. Twenty one patients developed metastatic disease. Sensitivities of planar and SPECT images for metastases were 76.1% and 90.4% respectively. Furthermore, SPECT helps planar images in the evaluation of six patients with uncertain images (lesions with low receptor density or with an uncertain scintigraphic localization). Therefore, in 15.6% of patients with primary or metastatic tumors, planar images were normal whereas SPECT was abnormal and SPECT provided an added value in 21.8% of the studies with abnormal planar images. CONCLUSIONS: We recommend the use of SPECT images in: 1) Patients with specific functional clinical syndrome or with a known CaT or PNET and normal planar images. 2) When planar images are abnormal only in primary tumor. 3) In order to confirm the absence of other metastases in patients with known liver metastases. 4) In order to enhance the detection of lesions with low receptor density and uncertain planar images and 5) In order to determine exactly the anatomic location of some lesions