The role of 18 F-FDG-PET/CT in the management of differentiated thyroid cancer.

INTRODUCTION: In previous literature, 18 F-FDG-PET/ CT imaging significantly impacted differentiated thyroid cancer (DTC) therapy. Low thyroglobulin (Tg) levels and negative Iodine-131 (131I) whole-body scan (WBS), along with negative 18 F-FDG-PET/ CT, suggested a lesser likelihood of active illness. Positive 18 F-FDG-PET/CT findings, however, were associated with a variety of signs of local recurrence and regional or distant metastases in patients with suspected WBS. We aim to evaluate the utility of 18 F-FDG-PET/CT in managing DTC patients with negative 131I post-therapy WBS and elevated Tg. MATERIAL AND METHODS: We retrospectively reviewed 55 patients with DTC (76% papillary and 24% follicular). Patients underwent total thyroidectomy or several radioactive iodine (RAI) treatments or both. WBS was performed 5-7 days after RAI treatment. Inclusion criteria were elevated serum Tg, negative anti-Tg auto-antibodies (AbTg) during long-term follow-up, presence of 18F-FDG-PET/CT images, and negative or suspicious WBS. RESULTS: 54% of 18 F-FDG-PET/CTs detected at least one lesion, mainly, cervical lymph nodes (49.9%), mediastinal lymph nodes (40.4%), local recurrence (34%), and bone or tissue metastasis (36.2%). The three major sites of metastasis were lung, bone, and liver. 18 F-FDG-PET/CT identified recurrence or metastasis in 45% of patients with high serum Tg and negative WBS, modifying therapeutic management in half the patients for suitable treatment modality (surgery vs. tyrosine kinase inhibitor). CONCLUSION: The findings redemonstrate that elevated Tg with negative or suspicious WBS necessitates 18 F-FDG-PET/CT for localization of recurrence. 18 F-FDG-PET/CT is useful in managing locally recurrent or metastatic DTC with high Tg levels. It influences treatment and accurately assesses disease severity.

Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas.

Background: This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications. Methods: The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study. Results: Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively. Conclusion: The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.

The multiple roles of LDH in cancer.

High serum lactate dehydrogenase (LDH) levels are typically associated with a poor prognosis in many cancer types. Even the most effective drugs, which have radically improved outcomes in patients with melanoma over the past decade, provide only marginal benefit to those with high serum LDH levels. When viewed separately from the oncological, biochemical, biological and immunological perspectives, serum LDH is often interpreted in very different ways. Oncologists usually see high serum LDH only as a robust biomarker of a poor prognosis, and biochemists are aware of the complexity of the various LDH isoforms and of their key roles in cancer metabolism, whereas LDH is typically considered to be oncogenic and/or immunosuppressive by cancer biologists and immunologists. Integrating these various viewpoints shows that the regulation of the five LDH isoforms, and their enzymatic and non-enzymatic functions is closely related to key oncological processes. In this Review, we highlight that serum LDH is far more than a simple indicator of tumour burden; it is a complex biomarker associated with the activation of several oncogenic signalling pathways as well as with the metabolic activity, invasiveness and immunogenicity of many tumours, and constitutes an extremely attractive target for cancer therapy.

From Spot Sign to Bleeding on the Spot: Classic and Original Signs of Expanding Primary Spontaneous Intracerebral Hematoma.

Expansion of a primary spontaneous intracranial hemorrhage (PSICH) has become lately of increasing interest, especially after the emergence of its early predictors. However, these signs lacked sensitivity and specificity. The flood phenomenon, defined as a drastic increase in the size of a PSICH during the same magnetic resonance study, was first described in this paper based on the data of a university medical center in Lebanon. Moreover, further review of this data resulted in 205 studies with presumed diagnosis of primary spontaneous intracranial hemorrhage within the last 10 years, of which 29 exams showed typical predictors of hematoma expansion on computed tomography. The intended benefit of this observation is to draw the radiologists' attention towards minimal variations in the volume of the hematoma between the two extreme sequences of the same MRI study, in order to detect inconspicuous flood phenomena-a direct sign of hematoma expansion.

Single-Institution Experience with Selective Internal Radiation Therapy (SIRT) for the Treatment of Primary and Secondary Hepatic Tumors.

PURPOSE: We aim to provide results of the real-world experience of a single center in Lebanon on the use of radioembolization to treat liver-only or liver-dominant tumors.  Methods: This retrospective review included patients who were evaluated for radioembolization between January 2015 and June 2017 and who had a lung shunt fraction of 20% or less. Tumor responses were determined using the response evaluation criteria in solid tumors (RECIST). RESULTS: Of the 23 Arab patients with a median age of 64 years (range, 36-87 years), eight had hepatocellular carcinoma, four had cholangiocarcinoma, and 11 had liver-only or liver-dominant metastases from other primary cancers. Most (n=17) had multifocal lesions, and 13 had a history of branched (n=8) or main (n=5) portal vein thrombosis. When appropriate, the gastroduodenal artery and middle hepatic artery were embolized for consolidation of radiotherapy; 18 patients required arterial coil occlusion, two had their cystic artery occluded, and one developed cholecystitis, which was successfully treated with antibiotics and supportive care. Another patient developed a post-radioembolization complication-a peptic ulcer unrelated to arterial reflux of microspheres because both the gastroduodenal and right gastric arteries were occluded. The median time to progression was seven months (range, 3-36 months), and median overall survival from radioembolization was 12 months (range, 3-40 months). Tumor responses included five complete responses, 13 partial responses, one stable disease, and four cases of progressive disease.  Conclusion: Performing radioembolization in a non-referral, private center in Lebanon resulted in good patient outcomes with few complications.

Current Status of Cancer-Related Pain and Opioid use in South Lebanon: A Pilot Study.

OBJECTIVE: This study aimed to evaluate the patients and health providers' (doctors and nurses) knowledge and understanding of the disease-related pain, and the perception of pain drugs (opioids) in South Lebanon. PATIENTS AND METHODS: This was a pilot study conducted at different hospitals in South Lebanon among patients with confirmed cancer diagnosis and providers. Data was collected using patients' and providers' questionnaires. RESULTS: 43 patients and 42 providers were included. 22 (52%) patients were male. Nine (21%) patients were aware of their diagnosis and only 60% talked about their pain to their oncologist. Pain was not optimally controlled with 25 (58%) patients having uncontrolled pain and 18 (42%) patients having continuous pain. Morphine was negatively perceived with 55.8% of patients believing that morphine causes addiction and 59% taking pain medications only when the pain is maximal. This led to a 58% short duration control of intermittent pain. 60% of the providers were certain that cancer pain cannot be relieved by morphine while only 33% believed that morphine can cause complete relief. Addiction seemed to be the main obstacle for morphine use with 37 (89%) thinking that narcotics causes addiction and 51% considering morphine withdrawal if side effects appear. Finally, 30% suggested to discontinue morphine in the terminal stages of cancer. DISCUSSION AND CONCLUSION: Major misconceptions in cancer patients are observed in the approach to antalgic treatment in our population. With good education, better knowledge and optimal palliative care units, misconceptions about opioids can be corrected with best management of cancer pain.

18F-fluoro-2-deoxyglucose positron emission-computed tomography in a rare cutaneous form of Rosai-Dorfman disease: A case report.

Rosai-Dorfman disease (RDD), or sinus histiocytosis with massive lymphadenopathy, commonly involves the lymph nodes but may secondarily involve the skin. Purely cutaneous disease without lymphatics or internal organ involvement occurs rarely. The present report detailed a rare case of 18F-fluoro-2-deoxyglucose positron emission-computed tomography (18FDG PET-CT) performed in a 33-year-old male soldier with a purely cutaneous form of RDD. Staging with 18FDG PET-CT was ordered prior to excisional biopsies of the aforedescribed masses and pathology reported RDD. The case demonstrated accurate localization of increased radioglucose metabolism. The present case was also discussed in light of literature data in terms of clinical features, etiologies, histology, medical imaging, therapy planning and prognosis.

Secondary ion mass spectrometry as a tool for investigating radiopharmaceutical distribution at the cellular level: the example of I-BZA and (14)C-I-BZA.

UNLABELLED: Further development of nuclear medicine for imaging and internal radiotherapy demands a precise knowledge of the tissue and cellular distribution of radiopharmaceuticals. Ion microscopy (secondary ion mass spectrometry [SIMS]) may be particularly useful in this respect. We used SIMS to study the biodistribution of the melanoma-targeting molecule N-(2-diethylaminoethyl)-4-iodobenzamide (I-BZA), both in its native state and radiolabeled with (14)C. METHODS: C57BL6/J1/co mice bearing pulmonary colonies of B16 melanoma cells were injected with I-BZA or (14)C-I-BZA. Appropriate tissues were fixed and included in epoxy embedding resin for SIMS studies. The distribution of unlabeled I-BZA was studied by detecting its stable iodine atom ((127)I). (14)C-I-BZA distribution was studied by dual detection of (127)I and (14)C. The time course of I-BZA concentrations at sites of tissue fixation was studied by measuring the signal ratio of (14)C and the naturally occurring isotope (13)C. RESULTS: SIMS showed that I-BZA concentrated in the cytoplasm of tumoral melanocytes (melanoma cells) and in the cytoplasm of tumor-infiltrating macrophages (melanophages). I-BZA was also detected in the cytoplasm of normal melanocytes in the pigmented structures of skin and eye. Interpretation of I-BZA distribution by using electron micrographs of adjacent sections showed that the intracytoplasmic melanin-rich organelles (melanosomes) were responsible for I-BZA retention. The distributions of (127)I and (14)C after (14)C-I-BZA injection were identical, even when I-BZA was separately labeled with (14)C at 2 different positions, indicating the stability of the amide bond of I-BZA. The time course of the (14)C/(13)C ratio in the melanosomes of melanoma cells suggested a retention half-life of about 38 h. CONCLUSION: Contrary to previous suggestions that I-BZA fixes principally to sigma-1 membrane receptors, our results strongly indicate that I-BZA associates with intracytoplasmic melanin pigments. Early I-BZA accumulation, in both melanocytes and melanophages, suggests that this compound fixes to preformed melanin rather than being incorporated during de novo melanin synthesis. These quantitative and qualitative data obtained with I-BZA illustrate the excellent potential of SIMS for studying the biologic fate of radiopharmaceuticals.