Utility of 99m Technetium Pertechnetate Thyroid Scan and Uptake in Thyrotoxic Patients: Jordanian Experience.

Objective The objective of this study was to assess our local experience with 99m Technitium thyroid uptake (TcTU) in thyrotoxicosis by examining mean and range of TcTU in both euthyroid patients and thyrotoxic patients. We also wanted to see how well TcTU performed as a substitute for radioiodine thyroid uptake in thyrotoxicosis. Methods The medical records of thyrotoxic patients were reviewed retrospectively. Inclusion criteria were: (1) thyrotoxicosis was proven biochemically, (2) the patient underwent TcTU at the time of thyrotoxicosis diagnosis, (3) at least 6 months of follow-up, and (4) the final diagnosis was documented. All TcTU of euthyroid patients were also reviewed to determine local normal TcTU mean and range. Patients were divided into three groups: Graves' disease, toxic nodular goiter, and subacute thyroiditis. Each patient group's TcTU mean and range were assessed separately. Results There were 209 patients in total (54 euthyroid, 112 Graves' disease, 26 toxic nodules, and 17 patients with subacute thyroiditis). TcTU mean±standard deviation and range for euthyroid patients were 1.5±1.1% and 0.17 to 4.8%, 10.6±10% and 0.43 to 40% for Graves' disease, 4.5±4% and 0.6 to 15% for toxic nodules, and 0.5±0.4% and 0.18 to 1% for subacute thyroiditis. Although one-third of thyrotoxic patients' TcTU values overlapped with the normal TcTU range, the diagnosis was made using qualitative image analysis. Subacute thyroiditis was characterized by poor thyroid visualization, whereas Graves'/toxic nodular goiter was well visualized. Conclusion The mean and range of our local normal TcTU were similar to those previously published. TcTU was a useful alternative to radioiodine in the evaluation of thyrotoxicosis. About two-thirds of the patients had accurate test results. The diagnosis was reached in the remaining one-third of patients by combining quantitative and qualitative image features. This method allowed us to stop giving radioiodine to our patients, resulting in a significant reduction in patient radiation exposure.

Morphometric study of foramina transversaria in Jordanian population using cross-sectional computed tomography.

Foramina transversaria are bilateral landmarks of human cervical vertebrae. Morphometric analysis of foramina transversaria is valuable in both clinical and academic fields. This study aims to build a novel normative database of the dimensions of foramina transversaria in Jordanian population and to correlate these data with gender and age. For this purpose, axial computer tomographic images of cervical vertebrae of 329 normal individuals were obtained from the Radiology Department at King Abdulla University Hospital. Cases were subdivided into adolescence, youth, and adulthood groups for both genders. Antero-posterior and transverse diameters were measured bilaterally at all cervical vertebral levels. Statistical analysis of measured dimensions was performed using Statistical Package of Social Sciences software. The results showed that the overall mean antero-posterior diameter of foramina transversaria was 6.09 ± 0.60mms and 5.94 ± 0.62mms on the left and on the right sides, respectively. The corresponding mean transverse diameter measured 4.76 ± 0.51mms and 4.62 ± 0.52mms on the left and the right sides, respectively. Foramina transversaria were significantly larger in males compared to females (p = 0.00). Age-related differences were statistically significant for both antero-posterior and transverse diameters in favor of adult age-group, irrespective of vertebral level. The relevance of these findings is discussed.

Ankylosing Spondylitis With Bilateral Symmetrical Uptake in the Greater Trochanters on Bone Scan.

Ankylosing spondylitis is a chronic inflammatory bone disease that commonly affects the spine and the sacroiliac joints. Ankylosing spondylitis can also cause enthesitis, or enthesopathy, which is an inflammation at the tendinous or ligamentous insertion sites on the bones. In this study, we present the case of a 37-year-old man with ankylosing spondylitis with a unique Tc-HDP bone scan finding of symmetrical increased uptake bilaterally in the greater trochanters.

Bone Marrow Metastasis Is an Early Stage of Bone Metastasis in Breast Cancer Detected Clinically by F18-FDG-PET/CT Imaging.

OBJECTIVE: To determine the value of 18F-FDG PET/CT in detection of bone marrow (BM) metastasis in breast cancer which is considered an early stage of bone metastasis. PATIENTS AND METHODS: Retrospectively, breast cancer patients with bone metastasis were included. BM metastasis was considered if the lesion was PET positive/CT occult while bone metastasis was considered if the lesion was PET positive/ CT positive. BM metastases were observed sequentially on F18-FDG PET/CT. RESULTS: We included 35 patients. Eighteen patients (51%) had BM metastases in addition to other bone metastases. BM metastases comprised 24% of all lesions. Posttreatment scan was performed on 26/35 patients. Twenty-three percent of BM metastases had resolved completely without causing bone destruction after treatment. Sixty-five percent of BM metastases had converted into bone metastases after treatment. Twelve percent of BM metastases had persisted after treatment. CONCLUSION: This retrospective study showed clinically by 18F-FDG PET/CT imaging that BM metastasis is an early stage of bone metastasis in breast cancer. Interestingly, 18F-FDG-PET/CT showed that early eradication of individual BM metastasis by systemic treatment precluded development of bone metastasis. However, more research is needed to study the impact of an early diagnosis of BM metastases on treatment outcome.

Effectiveness of 18F-FDG-PET/CT vs Bone Scintigraphy in Treatment Response Assessment of Bone Metastases in Breast Cancer.

The aim of the study was to examine the effectiveness of fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) versus bone scintigraphy (BS) in treatment response assessment of bone metastases in breast cancer.The medical records of breast cancer patients with metastatic bone disease were reviewed retrospectively in our hospital from the period of January 2003 until April 2014. We included in our study patients evaluated by BS and/or 18F-FDG-PET/CT. Group 1 included patients who underwent pre- and post-treatment BS. Group 2 included patients who underwent pre- and post-treatment 18F-FDG-PET/CT scans. Group 3 included patients who underwent pretreatment BS and post-treatment both modalities. Functional and structural bone changes were monitored on pre- and post-treatment scans.Group 1 included 71 patients, average age of 49.5 y (range 28-73 y). Post-treatment results were as follows: 34% stable disease, 43% progressed disease, 19% improved disease, 3% resolved disease, and 2% relapsed disease. Group 2 included 32 patients, average age 53.2 y (ranges between 37 and 78 y). Post-treatment results were as follows: 3% stable disease, 15% progressed disease, 15% improved disease, 53% resolved disease, and 14% relapsed disease. After treatment, the total symptomatic/imaging concordance rate was 51% in BS and 83% in 18F-FDG-PET/CT. Structurally, most patients with newly diagnosed metastatic bone disease had predominantly osteolytic lesions, which became mixed or osteoblastic after treatment as noted on CT images of responders. Group 3 included 8 patients, average age 48.9 y (ranges 32-64 y). Five patients had stable disease according to BS. 18F-FDG-PET/CT was concordant in 3/5 patients and discordant in 2/5 patients. Three patients had progressed disease on BS with concordant findings on 18F-FDG-PET/CT.18F-FDG-PET/CT was found a powerful tool in treatment response assessment of bone metastases in breast cancer and consistent with clinical status of the patients as it reflects tumor activity. BS is insufficient for response assessment of bone metastases as it reflects osteoblastic reaction of the bone against metastatic disease which increases as the disease responds to treatment.

Clinical relevance of 18F-FDG-negative osteoblastic metastatic bone lesions noted on PET/CT in breast cancer patients.

PURPOSE: Our study aims to assess the clinical relevance of fluorine-18 fluorodeoxyglucose (F-FDG) negative osteoblastic metastatic bone lesions noted on PET/computed tomography (CT) in breast cancer patients. PATIENTS AND METHODS: The medical records of breast cancer patients were reviewed retrospectively from January 2012 until April 2015. We included the patients who had metastatic bone disease evaluated by F-FDG-PET/CT. Group 1 included patients with newly diagnosed metastatic bone disease at the time of imaging and group 2 included patients with a history of treated metastatic bone disease at the time of imaging. Functional and structural bone abnormality was monitored on F-FDG-PET/CT scans. RESULTS: Fifty-three patients, median age 47.1 years (range 27-80 years), were included. Group 1 included 35 patients. Of those, 88% had predominantly F-FDG-avid osteolytic and mixed lesions (destructive pattern). Complete response was noted in 65% of the patients after treatment, evidenced by disappearance of bony focal activity with partial or total ossification of most osteolytic lesions converting into mixed and 'secondary' osteoblastic lesions. In addition, more ossified lesions were noted in some patients whose lesions were left untreated for long time (aged lesions). The remaining 12% of group 1 patients had pure 'primary' osteoblastic lesions (nondestructive pattern), which started small and expanded with time and tend to be F-FDG-negative. Group 2 included 18 patients who had predominantly mixed and 'secondary' osteoblastic lesions. CONCLUSION: We described two types of osteoblastic metastatic bone lesions in breast cancer patients: 'primary' and 'secondary'. 'Secondary' lesions (88%) are totally ossified (healed) osteolytic lesions and are almost always F-FDG-negative on PET/CT. These lesions are of no clinical importance. Healing is potentially seen after treatment or if the lesions are left untreated for a long time (aged lesions). 'Primary' lesions (12%) are seen without previous bone destruction and tend to be F-FDG-negative, although they contain tumor cells. Hence, sequential CT is more helpful than sequential FDG-PET in following 'primary' lesions.

Osteoblastoma is a metabolically active benign bone tumor on 18F-FDG PET imaging.

We describe a case of a 9-y-old girl who on (18)F-FDG PET imaging was found to have a highly metabolically active sacral tumor with an average standarized uptake value of 6.2. The tumor was proven to be osteoblastoma by pathologic examination. Osteoblastoma is a relatively rare benign primary bone tumor and occurs predominantly in patients younger than 20 y. The most common area of involvement is the spine. Osteoblastoma has been reported to be metabolically active on (18)F-FDG PET imaging, with an average standarized uptake value of 3.2, which renders (18)F-FDG PET imaging unable to differentiate benign from malignant primary bone tumors. To our knowledge, only 5 cases of osteoblastoma evaluated by (18)F-FDG PET imaging have been reported in the literature; all were metabolically active on (18)F-FDG PET imaging. The objective of this case report is to show that a metabolically active primary bone tumor on (18)F-FDG PET imaging might be benign and not necessarily malignant.

Value of baseline and follow-up whole-body bone scans in detecting bone metastasis in high-risk breast cancer patients.

OBJECTIVE: The aim of the study was to test the value of routine baseline and follow-up bone scans in societies with a prevalence of high-risk breast cancer features. PATIENTS AND METHODS: The medical records of 261 Jordanian breast cancer patients were reviewed. Patients who had (a) breast cancer proven by pathology, (b) had undergone a baseline bone scan, and (c) had undergone follow-up bone scan(s) for at least 12 months were included in the study. The patients were divided into three groups. Group 1 included 171 patients who had negative bone scans; group 2 included 52 patients who had negative baseline bone scans but developed bone metastasis on follow-up; and group 3 included 38 patients who had bone metastasis at presentation. RESULTS: Patients' ages ranged between 21 and 85 years with mean ± SD of 49.7 (± 11.3) years. About 55% of our patients were younger than 50 years. Clinicopathological stages were as follows: 14% of patients were in stage I, 42% were in stage II, 30% were in stage III, and 14% were in stage IV. A significant proportion of our patients have high-risk features. Fourteen percent of the patients already had bone metastasis at diagnosis and 20% developed bone metastasis on follow-up. Sixty percent of group 2 patients developed bone metastasis within 2 years after diagnosis and the rest (40%) developed bone metastasis 2 years after diagnosis (≤ 13 years). CONCLUSION: Within the limitations of this retrospective study, in a country like Jordan with greater prevalence of high-risk breast cancer features, a routine baseline whole-body bone scan might be justifiable. Follow-up whole-body bone scans might result in better quality of life and lower skeletal-related morbidity. Further prospective work is suggested.

Radiofrequency ablation of osteoid osteoma using tissue impedance as a parameter of osteonecrosis.

INTRODUCTION: The aim of this study is to assess the safety and the efficacy of radiofrequency ablation (RFA) of osteoid osteoma with Soloist monopolar electrode using tissue impedance, rather than temperature, as an indicator of osteonecrosis. METHODS: The medical records and imaging studies of 30 patients (males 18, females 12) who underwent RFA of osteoid osteoma at our institution were reviewed. The mean age of the patients was 15.3 years (range 5-34 years) and the mean duration of follow up was 26.9 months (range 3-52 months). The lesions were located in the femur (n=6, 53%), tibia (n = 8, 27%), hand (n = 3, 10%), foot (n = 2, 6%) and humerus (n = 1, 3%). The procedure was performed with general anaesthesia under CT guidance. The nidus was accessed with 11-gauge bone biopsy needle and then the stylet was removed and replaced by monopolar 16.5G radiofrequency probe with a 9-mm active tip through the coaxial axis. Power delivery via the radiofrequency generator was started at 2 W and increased gradually until the end point of 450-500 Ω reached and 'Roll-Off' achieved indicating coagulation necrosis of the target lesion. RESULTS: The procedure was technically successful in all patients. The mean procedure time was 72 min and the mean RFA time was 12.7 min. The clinical success rate was 93%. In one patient, the procedure was abandoned due to immature Roll-Off despite all measures. In one patient (3%), recurrence occurred 39 months after the procedure. No major complications were encountered. Two minor skin burns occurred that were resolved with conservative measures. CONCLUSION: RFA of osteoid osteoma using Soloist monopolar electrode is a safe and effective treatment. Tissue impedance could be used as an alternative to temperature to indicate osteonecrosis of osteoid osteoma during RFA.

Patterns of thyroid radioiodine uptake: Jordanian experience.

UNLABELLED: This study aimed to determine the reference range of 24-h radioiodine uptake in euthyroid Jordanians, as well as the reference ranges for patients with diffuse and nodular hyperthyroidism. In addition, radioiodine uptake ranges were determined for those patients with Hashimoto's thyroiditis and early-phase subacute thyroiditis. METHODS: The medical records of 285 Jordanian patients referred for (131)I thyroid scintiscans and 24-h radioiodine uptake tests were reviewed. The patients were referred because of a presumed-certain thyroid disorder. The patients included those who were euthyroid or who had Graves' disease, toxic nodules, Hashimoto's thyroiditis, or subacute thyroiditis. Mean radioiodine uptake and the 95% confidence interval were determined in each group. A comparison was made between groups. RESULTS: Mean uptake (+/-SD) for the euthyroid group, toxic-nodule group, and Hashimoto's thyroiditis group was 15% +/- 7%, 19% +/- 9%, and 19% +/- 15%, respectively, and these values were not significantly different from each other (P > 0.05). Mean uptake for the subacute thyroiditis group and Graves' disease group was 3% +/- 4% and 40% +/- 14%, respectively, and both values were significantly different from other groups (P < 0.05). CONCLUSION: The reference range of radioiodine uptake in Jordan is comparable to that reported in North America and Europe because Jordanians likely have a sufficient daily intake of stable iodine. Radioiodine uptake discriminates between euthyroid patients, subacute thyroiditis patients, and Graves' disease patients. Radioiodine uptake in toxic-nodule patients is diagnostic only if combined with image findings. Mean radioiodine uptake in Hashimoto's thyroiditis is higher than the euthyroid mean but has a wide range.

Gallbladder ejection fraction measured by fatty meal cholescintigraphy: is it affected by extended gallbladder emptying data acquisition time?

OBJECTIVE: The main objective of this study was to determine the effect of gallbladder emptying acquisition time on gallbladder ejection fraction (GBEF) measurement obtained by fatty meal cholescintigraphy (CS). METHODS: During fatty meal cholescintigraphy (CS), GBEF1 and GBEF2 were calculated 20 and 45 min, respectively, post meal ingestion on 50 healthy volunteers, 37 patients with chronic acalculous cholecystitis (CAC) and 20 non-CAC patients. GBEF1/GBEF2 was calculated and represented the percentage of GBEF occurred during 20 min after meal ingestion. The gallbladder was classified as ended pattern if it terminated contraction before the end of data acquisition or classified as continuous pattern if it continued to contract before the end of data acquisition. Mean GBEF in continuous pattern was compared with mean GBEF in ended pattern in each group. RESULTS: Gallbladder emptying had two phases; early rapid phase and late slow phase. About two-thirds of ejected volume occurred within the rapid phase. About half of gallbladders in each group were classified as ended pattern while the other half was classified as continuous pattern. There was no significant difference in mean GBEF values between both patterns in each group. CONCLUSION: GBEF measurement obtained by CS is not affected by further extension of gallbladder emptying data acquisition beyond the standard 45-60 min acquisition time.

Reproducibility of gallbladder ejection fraction measured by Fatty meal cholescintigraphy.

PURPOSE: There are conflicting data in the literature regarding the reproducibility of the gallbladder ejection fraction (GBEF) measured by fatty meal cholescintigraphy (CS). We aimed to test the reproducibility of GBEF measured by fatty meal CS. METHODS: Thirty-five subjects (25 healthy volunteers and 10 patients with chronic abdominal pain) underwent fatty meal CS twice in order to measure GBEF1 and GBEF2. The healthy volunteers underwent a repeat scan within 1-13 months from the first scan. The patients underwent a repeat scan within 1-4 years from the first scan and were not found to have chronic acalculous cholecystitis (CAC). Our standard fatty meal was composed of a 60-g Snickers chocolate bar and 200 ml full-fat yogurt. RESULTS: The mean ± SD values for GBEF1 and GBEF2 were 52 ± 17% and 52 ± 16%, respectively. There was a direct linear correlation between the values of GBEF1 and GBEF2 for the subjects, with a correlation coefficient of 0.509 (p = 0.002). Subgroup data analysis of the volunteer group showed that there was significant linear correlation between volunteer values of GBEF1 and GBEF2, with a correlation coefficient of 0.473 (p = 0.017). Subgroup data analysis of the non-CAC patient group showed no significant correlation between patient values of GBEF1 and GBEF2, likely due to limited sample size. CONCLUSIONS: This study showed that fatty meal CS is a reliable test in gallbladder motility evaluation and that GBEF measured by fatty meal CS is reproducible.

Diagnostic value of gallbladder emptying variables in chronic acalculous cholecystitis as assessed by fatty meal cholescintigraphy.

OBJECTIVE: The main purpose of this study was to determine the diagnostic value of gallbladder emptying variables in chronic acalculous cholecystitis (CAC). The variables investigated were latent period, gallbladder ejection fraction (GBEF) and patterns of gallbladder emptying. In addition, two other biliary system motility variables were investigated including the onset of gallbladder filling and biliary-to-bowel transit time. METHODS: Thirty-nine healthy volunteers underwent fatty meal cholescintigraphy (CS) prospectively to determine the normal values of these variables. Retrospectively, fatty meal CS studies of 88 patients suspected of having CAC were retrieved and reprocessed to obtain corresponding values of these variables, which then compared with normal values. RESULTS: The mean onset of gallbladder filling for patient groups was not significantly different from volunteer group mean. The mean+/-SD GBEF value for CAC group (29+/-20%) was significantly lower than volunteer group value (54+/-23%), whereas for non-CAC group (60+/-21%) it was not significantly different. The latent period was found invariable and not significant in CAC diagnosis. Two patterns of gallbladder emptying were noted: ended and continuous. The pattern of gallbladder emptying did not affect the mean GBEF and was found insignificant in the diagnosis of CAC. There was no significant difference in the number of cases with late biliary-to-bowel transit time between the groups. CONCLUSION: The single most important gallbladder emptying variable in diagnosing CAC is the GBEF. The latent period and the pattern of gallbladder emptying as well as the onset of gallbladder filling and biliary-to-bowel transit time are of no significant diagnostic value in CAC.