Changing clinical characteristics of thyroid carcinoma at a single center from Turkey: before and after the Chernobyl disaster.

AIM: The aim of the study was to determine the possible role of Chernobyl disaster on changing clinical features of thyroid carcinoma (TC) in a moderately iodine deficient region. METHODS: We retrospectively reviewed demographical features, presenting symptoms, tumor size, histopathological diagnosis and distant metastates in 160 patients with TC diagnosed between 1990-2007. We compared our findings with the database of 118 TC patients diagnosed between 1970-1990 in the same center. RESULTS: There were 123 female (76.9%) and 37 (23.1%) male patients with a mean age of 44.89±14.84. Sex distribution and age at diagnosis were similar between 1970-1990 and 1990-2007 (P=0.77 and P=0.42, respectively). Histopathological diagnoses were papillary in 114 (73.1%), follicular in 22 (14.1%), medullary in 9 (5.8%), hurthle cell in 7 (4.5%) and anaplastic TC in 4 (2.6%) patients. We observed a marked increase in papillary TC (P<0.001) and marked decreases in follicular (P<0.001) and anaplastic TC (P=0.01) compared to the period between 1970-1990. Thyroid microcarcinomas accounted for 27.1% and 37.1% of carcinomas in 1970-1990 and 1990-2007, respectively (P<0.05). CONCLUSION: We showed that incidence of papillary TC increased and incidences of follicular and anaplastic TC decreased in a period that might be affected by Chernobyl fallout in a moderately iodine deficient area. Presenting symptoms of TC have changed and microcarcinomas are diagnosed more frequently compared to past. Further large scale trials are needed to find out whether Chernobyl disaster has role on changing characteristic of TC in countries that are not very near but also not very far from Chernobyl such as Turkey.

A possible cause of misinterpretation on radionuclide imaging: Chilaiditi's syndrome.

The authors of this work present two patients, diagnosed with lymphoma and prostate cancer, referred to nuclear medicine department for a gallium-67 scan and a bone scan, respectively. The abnormal accumulation of the radioactivity gave rise suspicion for possible other pathologies. Successive computed tomographic imaging revealed that the patients had had Chilaiditi's syndrome. The authors present these cases to draw attention for the possibility of misinterpretation of the scans due to distribution of radioactivity in this syndrome.

Association of tumor washout rates and accumulation of technetium-99m-MIBI with expression of P-glycoprotein in lung cancer.

UNLABELLED: In a prospective study, we correlated the washout rates of 99mTc-sestamibi (MIBI) and the degree of MIBI accumulation with the expression of P-glycoprotein (Pgp) in tumor tissues in a total of 46 patients with lung cancer. METHODS: All patients underwent early (30 min) and delayed (3 hr) MIBI imaging and bronchoscopic biopsy before initiation of chemo- or radiotherapy. The interval between biopsy and imaging varied between 2 and 10 days. All patients had radiologically detectable tumors. Immunohistochemical studies were performed on paraffin sections using a monoclonal antibody, JSB-1, developed against the internal epitope of Pgp. Normal tissue and tumor washout rates and tumor-to-background ratios were correlated with the level of Pgp expression. RESULTS: There was an inverse correlation between tumor-to-background ratios and the density of Pgp (p = 0.001), whereas there was no appreciable correlation between tumor washout rates of MIBI and the level of Pgp expression (p = 0.414). CONCLUSION: The current data strongly suggest that, although the reduced ability for the tumors to accumulate MIBI correlates well with the increased levels of Pgp expression, tumor washout rates of MIBI do not correlate with the density of Pgp in tumor tissues. Our results also warrant additional research for correlating immunohistological and imaging findings with messenger RNA levels determined by polymerase chain reaction and flow cytometry.

Clinical validation of the influence of P-glycoprotein on technetium-99m-sestamibi uptake in malignant tumors.

UNLABELLED: We prospectively studied 48 patients with either breast cancer (30 patients) or lung cancer (18 patients) to ascertain the relationship between the degree of accumulation of 99mTc-sestamibi and the expression of p-glycoprotein in tumor tissues. METHODS: During initial presentation (37 patients) or post-therapy evaluation (11 patients), the patients underwent contemporaneous 99mTc-sestamibi imaging and biopsy (30 patients) or surgery (18 patients). The interval between surgery/biopsy and imaging varied between 3 and 15 days. All patients had radiologically detectable tumors. Immunohistochemical studies were performed on paraffin sections using a monoclonal antibody, JSB-1, developed against the internal epitope of p-glycoprotein. Tumor-to-background ratios were correlated with the level of p-glycoprotein expression determined by immunohistochemical studies. RESULTS: Our results showed an inverse correlation between the tumor-to-background ratios of 99mTc-sestamibi and the density of p-glycoprotein expression in tumor tissues. The values for the tumor-to-background ratios were significantly lower for those tumors expressing p-glycoprotein at high levels than those with scattered and no expression (p < 0.01 and p < 0.001, respectively). CONCLUSION: Although our results warrant further studies at the molecular level using PCR techniques after the extraction of mRNA, our data strongly suggest that 99mTc-sestamibi imaging is useful to noninvasively determine the presence of multidrug resistance in patients with malignant tumors.

P-glycoprotein expression by technetium-99m-MIBI scintigraphy in hematologic malignancy.

UNLABELLED: Our aim was to ascertain the relationship between the degree of 99mTc-MIBI uptake and the level of p-glycoprotein (Pgp) expression determined by flow cytometry and reverse transcription-polymerase chain reaction (RT-PCR) techniques in patients with hematologic malignancy. METHODS: A total of 21 samples (19 patients) were evaluated. Two patients had repeat studies after therapy. Thirteen samples were studied at the time of initial diagnosis and 8 during relapse after therapy. After MIBI imaging, either bone marrow aspiration or peripheral blood was obtained for flow cytometric and RT-PCR analyses. Flow cytometry was performed using two different antibodies. After the injection of 555 MBq MIBI, whole-body and pelvic spot images were acquired using a dual-head gamma camera. The uptake in the bone marrow was evaluated against the background (adjacent soft tissue) by both qualitative (scoring system) and quantitative (tm/bkg ratios) analyses. RESULTS: For flow cytometry, the limit for Pgp overexpression was set at >15% Pgp-positive mononuclear bone marrow or peripheral blood cells. There was an inverse correlation between the levels of Pgp and MIBI imaging using both the qualitative (scoring system) and quantitative (tm/bkg ratios) analyses (p = 0.022). Mean values were statistically different between Pgp+ and Pgp- groups for both qualitative and quantitative analyses (p = 0.009 and 0.024, respectively). For RT-PCR, there was statistical support toward a difference in the mean values between Pgp+ and Pgp- groups by qualitative analysis (p = 0.061); however, no statistical difference was found between these two groups by quantitative analysis (p = 0.179). CONCLUSION: Based on the strong correlation between the imaging and flow cytometry and a statistical support toward the correlation between the imaging and RT-PCR, MIBI imaging may be used for the in vivo detection of Pgp in patients with hematologic malignancy.

Scintigraphic diagnosis of a right to left shunt in end-stage lung disease.

PURPOSE: The presence of a right to left shunt influences the surgical approach to lung transplantation in patients with end-stage pulmonary disease. The purposes of this study included comparing contemporaneous lung scintigraphy with cardiac catheterization in the detection of intracardiac shunts in patients with end-stage lung disease and the point prevalence of right to left shunting was determined in patients with several different types of end-stage lung disease. METHODS: Hundred and twenty six patients with end-stage lung disease who were candidates for lung transplantation underwent perfusion images of the lungs with Tc-99m-labeled macro-aggregated albumin (MAA). Planar scans of the brain and the kidneys were performed contemporaneously. Statistical analyses included correlation ofthe clinical, laboratory and scintigraphic variables. Group means were compared with the students t-test (two-tailed P-value). RESULTS: There were 21 patients with primary pulmonary hypertension (PPH), 72 with emphysematous lung disease (COPD), 22 with pulmonary fibrotic disease (PF) and 11 with congenital heart disease (CHD) leading to pulmonary hypertension. Only 13 patients (10.3%) were found to have a right to left shunt. Of these, 4 had PPH, 2 had PF, and 7 had CHD. No shunts were found in patients with emphysema. All the positive studies had abnormally increased activity in both the brain and the kidneys. However, there were 25 cases with renal activity and none of these patients had brain activity or clinical evidence of a shunt. Increased pulmonary artery pressure was associated with scintigraphic presence of a shunt. There were no cases of a right to left shunt with a mean pulmonary artery pressure less than 50 mm Hg. In the subset of patients with a pulmonary pressure greater than 50 mm Hg, approximately 40% of the patients had a right to a left shunt. There were no measurable differences in the spirometry results, right ventricular ejection fraction (RVEF) or left ventricular ejection fraction (LVEF) in the subgroup of patients with PPH and right to left shunt in comparison with patients with PPH but without a right to left shunt. CONCLUSIONS: The findings indicate that images of the brain, but not the kidneys, are an effective way to diagnose extrapulmonary right to left shunts in patients with end-stage pulmonary disease. The problem of a right to left shunt is uncommon in patients with emphysematous lung disease and relatively common in patients with primary pulmonary hypertension.

Prediction of restenosis after successful percutaneous coronary angioplasty by dobutamine thallium-201 scintigraphy.

We evaluated the accuracy of dobutamine thallium-201 myocardial perfusion scintigraphy in predicting restenosis after successful percutaneous coronary angioplasty. Restenosis is one of the most important problems in patients who have undergone percutaneous coronary angioplasty. Exercise thallium-201 myocardial perfusion scintigraphy has been a well accepted non-invasive method to predict the restenosis of the dilated vessel after percutaneous coronary angioplasty, however, the role of thallium-201 myocardial perfusion using dobutamine, as a substitute for exercise in patients unable to exercise, in predicting restenosis is not well known. Therefore, 34 consecutive patients underwent dobutamine tomographic (single photon emission computed tomography) thallium-201 myocardial perfusion scintigraphy following a total of 37 successful angioplasties. No serious side effects during dobutamine infusion occured. The interval between percutaneous coronary angioplasty and scintigraphy ranged between 8 weeks to 2 years. All patients underwent control angiography within one month following myocardial perfusion scintigraphy. Sensitivity, specificity and accuracy of dobutamine myocardial imaging for predicting restenosis were 76%, 79% and 77%, respectively. Sensitivity and specificity related to the vascular territories were: left anterior descending artery 66-69%, left circumflex artery 75-100%, right coronary artery 83-66%, respectively. In conclusion, our findings demonstrating high accuracy of dobutamine myocardial single photon emission tomography for angiographic restenosis suggest its usefulness as a non-invasive tool in the follow-up of percutaneous coronary angioplasty patients.

Hereditary intraosseous vascular malformation of the craniofacial region: imaging findings.

Benign vascular lesions can be classified into two categories depending on clinical behaviour and endothelial cell characteristics: neoplasms (haemangiomas) and vascular malformations. However, intraosseous vascular anomaly, previously called intraosseous haemangioma, is a very rare malformation. In our previous study, we described the first hereditary form of intraosseous vascular malformation of the craniofacial region, vascular malformation osseous (VMOS). Characteristic findings are autosomal recessive inheritance, severe and diffuse intraosseous vascular malformation in all craniofacial bones without soft tissue involvement and associated mid-line abnormalities such as umbilical hernia and supra-umbilical raphe. In this paper, we discuss the imaging findings of this new disorder in detail.

Correlation of flow cytometric parameters and transferrin receptors with gallium-67 scintigraphic images in lymphoma patients.

The purpose of this study was to determine the correlation of flow cytometric parameters and transferrin receptors with gallium-67 scintigraphic imaging results in Hodgkin's and non-Hodgkin's lymphoma patients. DNA content and cell cycle analyses were performed using flow cytometry and transferrin receptor analysis was carried out by the immunohistochemistry technique in 24 patients aged between 16 and 62 years. All patients underwent gallium-67 scintigraphy, and tumour to background ratios were calculated. The findings were correlated with computed tomography and/or magnetic resonance imaging. A strong relationship was observed between flow cytometry and transferrin receptor expression with gallium-67 tumour scintigraphy [P = 0.005, r = 0.054 and P = 0.038, r = 0.54 (Spearman test), respectively]. The results of this study show that there is a close correlation between each of these modalities and, as they reflect the biological activity of the tumour, together they have a major role in treatment and follow-up.

Scintigraphic imaging of uveal melanoma with 99Tcm-glutathione.

A prospective study with a new tumour-seeking agent, 99Tcm-glutathione (GSH), was performed on 17 patients with choroidal melanoma. Planar and SPECT images using 99Tcm-GSH clearly demonstrated melanotic melanoma but failed to show amelonotic melanomas. Following confirmation of our results by concurrent ultrasonography and magnetic resonance imaging or computed tomography, patients were managed by either 125I plaque brachytherapy, diode laser transpupillary thermotherapy or enucleation depending on the site and location. In combination with other diagnostic tests, 99Tcm-GSH scintigraphy may play a role in the detection of uveal melanoma and its possible distant metastases.

Laurence-Moon-Biedl syndrome: scintigraphic appearance of kidneys.

We report a 7-year-old child with Laurence-Moon-Biedl syndrome, an autosomal recessive syndrome, with impaired renal function detected by means of technetium-99m diethylenetriamine-pentaacetic acid (Tc-99m DTPA), technetium-99m dimercaptosuccinic acid (Tc-99m DMSA) scintigraphy, and ultrasonography. The altered renal morphology and decreased renal functions are documented.

Visualization of orbital retinoblastoma with technetium-99m (V) dimercaptosuccinic acid.

The potential contributions of technetium-99m (V) dimercaptosuccinic acid scintigraphy in the evaluation of orbital retinoblastoma, its local extensions and metastases were assessed in this study. Both planar and SPECT images clearly demonstrated the primary tumor and metastatic sites. Following confirmation of our results by contemporaneous ultrasonography, MRI and a subsequent incisional biopsy, the patient was treated with external beam radiotherapy and chemotherapy. This preliminary study showed that in combination with other diagnostic tests, Tc-99m (V) DMSA scintigraphy may play a role in the detection and follow-up of the local tumor extensions and metastases in patients with retinoblastoma.

Tc-99m dextran scintigraphy in the diagnosis of protein losing enteropathy.

Tc-99m dextran scintigraphy was performed on a 16-year-old male patient with protein losing enteropathy. Abnormal leakage of the radiotracer was observed in the right upper lumbar area that moved over time and excreted in the stool which was suggestive of protein loss. It is concluded that Tc-99m dextran is useful in the detection of protein losing enteropathy which is not detected by extensive radiological and endoscopic examination.

Visualization of uveal amelanotic melanoma with technetium-99m(V) dimercaptosuccinic acid.

The possibility of using technetium-99m(V) dimercaptosuccinic acid, Tc-99m DMSA, in the evaluation of uveal amelanotic melanoma was assessed in this study. Both planar and SPECT images clearly demonstrated the tumor. Following confirmation of our results by contemporaneous ultrasonography and MRI the patient was treated with Iodine-125 brachytherapy. In combination with other diagnostic tests, Tc-99m(V) DMSA scintigraphy may play a role in the detection of uveal melanoma and its possible systemic metastases.

Superiority of tc-99m MAG3 to tc-99m DTPA in treating a patient with mild renal artery stenosis.

A 22-year-old female patient with severe hypertension underwent both Technetium-99m diethylenetriaminepentaacetate and Technetium-99m mercaptoacetyltriglycine basal and captopril renal scintigraphy. While no significant change was seen with Tc-99m DTPA, there was left sided parenchymal retention of captopril Tc-99m MAG3 suggesting renal artery stenosis which was confirmed by angiography.

Technetium-99m pertechnetate uptake in ectopic parathyroid adenoma.

A 37-year-old male with a persistent increased parathyroid hormone level, after subtotal thyroidectomy and parathyroidectomy, was referred for scintigraphic localization of a possible ectopic parathyroid adenoma. Tc-99m pertechnetate and Tc-99m MIBI scintigraphy were performed on separate days. There was marked uptake of both tracers in the mediastinum, which at surgery was confirmed to be an extrathyroidal parathyroid adenoma. Hypervascularity was suggested as a possible explanation for rare cases of pertechnetate avid parathyroid adenomas. And Tc-99m MIBI scintigraphy proved to be a successful imaging procedure for ectopic parathyroid tissue.

Scintigraphic evaluation of tumors metastatic to the choroid using technetium-99m(V)-dimercaptosuccinic acid.

Technetium-99m(V)-dimercaptosuccinic acid scintigraphy was used to evaluate three patients with intraocular tumors who had metastatic breast, lung, and rectal carcinomas, respectively. At the time of initial examination, two patients had no known systemic cancer, but the scintigraphy results in one patient revealed the primary site and were highly suggestive of disseminated carcinomatosis in the other patient. In the third patient, scintigraphy was successful to confirm very small bilateral intraocular tumors and also other systemic lesions. Technetium-99m(V)-dimercaptosuccinic acid scintigraphy can be reliably employed in a very select group of patients with intraocular tumors where metastatic carcinoma is a serious diagnostic possibility against a primary intraocular malignancy. This safe and promising tumor-imaging agent has the ability to demonstrate the ocular lesions and other systemic foci simultaneously, information that would prove to be crucial in both the diagnosis and the management of the patient.

Neonatal hypothyroid disease: absent salivary gland evident on technetium-99m pertechnetate scan.

PURPOSE: Technetium-99m pertechnetate scintigraphy is a well-established technique for diagnosing congenital hypothyroid disease. However, the biodistribution of pertechnetate (TcO4-) in neonates and young infants is not well documented. The purpose of this study was to analyze and document the biodistribution of TcO4- in young infants. MATERIALS AND METHODS: Scintigraphic studies of 31 patients being examined for hypothyroid disease were analyzed. All patients had elevated levels of thyroid-stimulating hormone. Dyshormonogenesis was diagnosed in 7 patients, ectopic thyroid glands in 19, and agenesis in 5. RESULTS: Images of the neck, chest, and abdomen taken in the anterior and left lateral positions using a low-energy, all-purpose collimator were reviewed. Twenty-six of the patients had no accumulation of the isotope in the salivary glands and 11 had no gastric uptake on either view. CONCLUSIONS: Based on the absence of salivary gland activity in the patients examined, this study suggests that this is a normal finding in infants younger than 3 months. A lateral view of the neck with markers is sufficient to localize the thyroid gland, because any activity in the neck region would belong to the thyroid. Furthermore, poor and variable uptake of the isotope in the stomach may lead to false-negative results, so caution is urged in the use of this tracer in Meckel's scintigraphy in young infants, particularly if the study findings are within normal limits.

Impaired Tc-99m MIBI uptake in the thyroid and parathyroid glands during early phase imaging in hemodialysis patients.

The purpose of this study is to evaluate the possible reasons of an observation of diminished uptake of Tc-99m MIBI in the early phase of parathyroid scintigraphy in the thyroid and parathyroid glands in patients with chronic renal failure who are being evaluated for hyperparathyroidism. Fourteen patients with secondary hyperparathyroidism all on hemodialysis with supplement therapy consisting of mainly vitamin D and calcium carbonate were studied. Neck and mediastinum images obtained at early and late phases were evaluated both visually and semiquantitatively. Patients with high PTH levels on hemodialysis showed diminished accumulation of radioactivity in the thyroid glands in the early phase compared to the soft tissue with a ratio of 1.54 +/- 0.39 (mean +/- std). A control group consisting of 10 patients with osteoporosis and Rickets' disease on vitamin D therapy was taken as control group A, as well as 11 patients with no problems other than cardiac who were not on any medication as control group B and 8 patients on hemodialysis only with normal PTH levels as control group C. Patients in control group A and C showed diminished accumulation of radioactivity in the thyroid glands in the early phase compared to the soft tissue with a ratio of 1.57 +/- 0.43 and 1.34 +/- 0.13, respectively, while patients in control group B showed good uptake 3.18 +/- 0.43. None of the studies showed parathyroid pathology. The results of this study show that patients with chronic renal failure under hemodialysis treatment are prone to show decreased uptake of the radioactivity. Another finding is that vitamin D supplements can cause diminished uptake of Tc-99m MIBI. A possible explanation is mentioned in the literature by an increase in PGP level and multi-drug resistance, so we suggest that it may play a role in impaired Tc-99m MIBI uptake in the thyroid phase and recommend cessation of vitamin D3 metabolites before performing parathyroid scintigraphy.