Optimal timing of SPECT/CT to demonstrate parathyroid adenomas in 99mTc-sestamibi scintigraphy.

BACKGROUND: Accurate preoperative localisation of the parathyroid adenoma is essential to achieve a minimally invasive parathyroidectomy. The purpose of this study was to validate and improve our single-isotope dual-phase parathyroid imaging protocol utilising 99mTechnetium-Sestamibi ([99mTc]MIBI). There has been no accepted gold standard evidence-based protocol regarding timing of single-photon emission computed tomography/computed tomography (SPECT/CT) acquisition in parathyroid imaging with resultant variation between centres. We sought to determine the optimum timing of SPECT/CT post administration of [99mTc]MIBI in the identification of parathyroid adenomas. We aimed to evaluate the efficacy of early and late SPECT/CT and to establish whether SPECT/CT demonstrates increased sensitivity over planar imaging. MATERIAL AND METHODS: A sample of 36 patients with primary hyperparathyroidism underwent planar and SPECT/CT acquisition 15 minutes (early) and two hours (late) post [99mTc]MIBI administration. Two radionuclide radiologists reviewed the images and Fisher's exact Chi-squared statistic was used to evaluate the diagnostic performances of early versus late SPECT/CT acquisition and SPECT/CT versus planar imaging. RESULTS: Twenty-one likely parathyroid adenomas were identified with a statistically superior diagnosis rate in the late SPECT/CT acquisition compared with both early SPECT/CT and planar imaging (p < 0.05). All adenomas diagnosed on early SPECT/CT acquisition were also identified on late SPECT/CT images. CONCLUSIONS: Single late phase SPECT/CT is significantly superior to early SPECT/CT in the identification of parathyroid adenomas. Late SPECT/CT improves diagnostic accuracy over planar acquisition. Imaging protocols should be revised to include late SPECT/CT acquisition. Early SPECT/CT acquisition can be eliminated from scan protocols with associated implications regarding reduced scan time and increased patient throughput.

Imaging features of atypical adrenocortical adenomas: a radiological-pathological correlation.

OBJECTIVE: Adrenal adenomas are frequently picked up incidentally on cross-sectional imaging and are known to have a classic imaging appearance on CT and MRI. However, not all adrenal adenomas have this typical radiologic appearance. Our aim is to present the radiological features of atypical adrenocortical adenomas with pathological correlation. METHODS: All the imaging from the pathologically proven adrenal adenoma cases in our hospital (Tallaght University Hospital, Dublin, Ireland) database (from 2004 to 2019) was reviewed. 8 out of 48 cases (16%) had an atypical radiological appearance and were selected for presentation. RESULTS: Eight cases demonstrated atypical radiological features including heterogeneous density, incomplete washout on post-contrast imaging, the presence of macroscopic fat and calcification. Lipomatous metaplasia was present in two of the cases pathologically. CONCLUSION: Adrenocortical adenomas are the most common adrenal mass encountered on CT, however, may not always have classic imaging features. Radiologists should be familiar with both the typical and atypical imaging manifestations of these benign adrenal lesions. ADVANCES IN KNOWLEDGE: This paper comprehensively describes the atypical features of adrenocortical adenomas with case examples and radiologic-pathologic correlation. Guidelines and an approach to the work-up of adrenal lesions with atypical appearances are also provided.

Radium-223 in combination with enzalutamide in metastatic castration-resistant prostate cancer: a multi-centre, phase II open-label study.

BACKGROUND: Radium-223 and enzalutamide are approved agents for patients with metastatic castration-resistant prostate cancer (mCRPC). Combining radium-223 and enzalutamide to improve outcomes is of clinical interest due to their differing modes of action and non-overlapping toxicity profiles. METHODS: This phase II study enrolled patients with mCRPC and bone metastases. Patients received six cycles of radium-223 in combination with enzalutamide, followed by enzalutamide alone. The primary endpoint was safety for the combination; secondary endpoints included radiographic/clinical progression-free survival (PFS), PSA PFS, overall survival (OS), change in alkaline phosphatase, patient-reported pain outcomes and skeletal related events. RESULTS: Forty-five patients received the combination treatment: 42 patients (93.3%) received all six cycles. Fourteen patients (31.1%) developed grade 3 or 4 toxicities, most commonly fatigue and neutropaenia. Fractures during the combination period occurred in four patients (8.9%). A further 13 patients (28.9%) developed fractures after completing combination treatment, giving a total of 17 patients (37.8%) who developed a fracture at any time on study. The median time to fracture was greater than 17.2 months [95% confidence interval (CI), 17.2-not estimable]. The median time to PSA progression was 18.1 months (95% CI, 12.68-22.60) and the median time to radiological/clinical progression was 28.0 months (95% CI, 22.54-not reached). At the primary analysis, 19 (42.2%) out of 45 patients had died with a median OS not reached (mean 34.8 months, standard error 1.4). CONCLUSION: In men with progressive mCRPC and bone metastases, the combination of radium-223 and enzalutamide was tolerable with the majority of patients completing the combination treatment. Bone fractures during the combination period were uncommon; however, we did identify a higher incidence of fractures occurring in patients after completing combination treatment. Bone health agents should be administered and bone health should be closely monitored following treatment with radium-223 and enzalutamide.

Imaging of genetically-mediated pancreatitis.

OBJECTIVES: To review the imaging of patients with Genetically-Mediated Pancreatitis (GMP), identify common imaging findings in this cohort and assess phenotypical characteristics of specific genotypes. MATERIALS AND METHODS: Retrospective review of the databases of the Irish National Surgical Centre for Pancreatic Cancer (NSCPC) and Cystic Fibrosis (CF) from November 2010 to January 2018. Retrospective imaging and chart review for the patients with positive genetics for GMP. RESULTS: The NSCPC database contained 699 patients; the CF database included 352 patients. Of these 1051, 14 were identified as having GMP (age range: 20-65, M:F ratio of 1:1). 14 of 1051 patients from the database had positive genetics for GMP. 10 had imaging to support a diagnosis of hereditary pancreatitis or familial recurrent pancreatitis (1.3%) and 4 had imaging to support a diagnosis of CF-related pancreatitis. Imaging findings were considered in 3 categories, determined by genotype - PRSS1 hereditary pancreatitis, SPINK 1 autosomal recessive pancreatitis and those for CFTR - cystic fibrosis related pancreatitis. Imaging findings in PRSS1 hereditary pancreatitis patients included: pancreatic atrophy, calcification and main pancreatic duct (MPD) dilatation, referred to as the PRSS1 imaging triad. Patients with the SPINK1 gene mutation had less severe imaging manifestations (pancreatic atrophy 33%, MPD dilatation 33%, pancreatic calcification 33%). CFTR patients with imaging findings had pancreatic atrophy (100%). CONCLUSION: GMP should be suspected when the features of 'chronic pancreatitis' are seen in young adults with no history of excess alcohol intake. Genetic testing, endocrinology review and long-term imaging follow-up for pancreatic carcinoma are indicated.

Comorbidity polypharmacy score and its clinical utility: A pragmatic practitioner's perspective.

Modern medical management of comorbid conditions has resulted in escalating use of multiple medications and the emergence of the twin phenomena of multimorbidity and polypharmacy. Current understanding of how the polypharmacy in conjunction with multimorbidity influences trauma outcomes is limited, although it is known that trauma patients are at increased risk for medication-related adverse events. The comorbidity-polypharmacy score (CPS) is a simple clinical tool that quantifies the overall severity of comorbidities using the polypharmacy as a surrogate for the "intensity" of treatment necessary to adequately control chronic medical conditions. Easy to calculate, CPS is derived by counting all known pre-injury comorbid conditions and medications. CPS has been independently associated with mortality, increased risk for complications, lower functional outcomes, readmissions, and longer hospital stays. In addition, CPS may help identify older trauma patients at risk of post-emergency department undertriage. The goal of this article was to review and refine the rationale for CPS and to provide an evidence-based outline of its potential clinical applications.

18F-fluorodeoxyglucose positron emission tomography in the staging and prognosis of T cell lymphoma.

We previously reported that (18)F-fluorodeoxyglucose positron emission tomography scan (FDG-PET) is almost universally positive in patients with T cell lymphoma. In the present analysis we examined the impact of FDG-PET on the initial staging of peripheral T cell lymphomas (PTCLs), and the prognostic value of interim FDG-PET. This retrospective analysis identified patients with mature T or natural killer (NK) lymphomas who had PET scans as part of initial staging or staging at relapse [(n = 95) (staging cohort)] in the PTCL database at Memorial Sloan-Kettering Cancer Center. A subset of these patients had repeat PET for interim restaging during initial therapy with curative intent [(n = 50) (interim restaging cohort)]. The frequency of specific T cell histologies included in this analysis were: PTCL not otherwise specified (NOS) (n = 35); angioimmunoblastic T cell lymphoma (AITL) (n = 17); anaplastic large cell lymphoma (ALCL), ALK-1+ (n = 11) and ALK-1- (n = 12); adult T cell lymphoma/leukemia (ATLL) (n = 7); NK/T cell lymphoma (NKTCL) (n = 10); and enteropathy-associated T cell lymphoma (EATL) (n = 3). In the staging cohort, 77 patients were newly diagnosed, and 18 had relapsed disease. Pretreatment FDG-PET was positive in 96% of patients. PET identified additional disease sites in 47/95 patients (50%) when added to conventional staging. Most frequently identified additional sites were: other nodal (n = 24); bone (n = 10); skin (n = 8); nasopharynx (n = 4); spleen (n = 3); and lung (n = 2). However, FDG-PET modified computed tomography (CT)-based staging in only 5/95 patients (5.2%): two patients were upstaged and three patients were downstaged. FDG-PET-based staging did not alter planned treatment for any patient. Interim restaging with PET was performed after a median of 4 cycles of chemotherapy. In this cohort, treatment regimens included cyclophosphamide, doxorubicin, vincristine and prednisone CHOP (n = 19); CHOP/ifosfamide, carboplatin and etoposide (ICE) (n = 26); and other (n = 7). Subsequently, 29 patients were consolidated with either autologous (n = 22) or allogeneic (n = 7) stem cell transplant. After a median follow-up of 3.4 years for surviving patients, those with negative interim PET had superior progression-free survival (PFS) compared to patients with positive interim PET (p = 0.03). There were no differences in overall survival (OS). In PTCL, FDG-PET commonly identifies additional sites of disease but infrequently impacts CT-based staging and does not influence therapy. Interim FDG-PET may predict for PFS. FDG-PET should be integrated into prospective trials to confirm these findings.

Compression garments: no enhancement of high-intensity exercise in hot radiant conditions.

PURPOSE: To establish the thermal and performance effects of wearing a lower-body graduated compression garment (GCG) in a hot environment (35.2°C ± 0.1°C) with a representative radiant heat load (~800 W/m²) in contrast to a control (running shorts) and sham condition (a compression garment 1 size larger than that recommended by the manufacturer), with the latter included to establish any placebo effect. METHOD: Eight participants (mean ± SD; age 21 ± 2 y, height 1.77 ± 0.06 m, mass 72.8 ± 7.1 kg, surface area, 1.89 ± 0.10 m²) completed 3 treadmill tests at a fixed speed for 15 min followed by a self-paced 5-km time trial. Performance (completion time) and pacing (split time), thermal responses (aural, skin, and mean body temperature, cardiac frequency), and perceptual responses (rating of perceived exertion [RPE], thermal sensation, thermal comfort) were measured. RESULTS: Performance in the compression group was not different than in either sham or control at any stage (P > .05); completion time 26.08 ± 4.08, 26.05 ± 3.27, and 25.18 ± 3.15 min, respectively. At the end of the 5-km time trial, RPE was not different; it was 19 ± 1 across conditions. In general, thermal and perceptual responses were not different, although the radiant heat load increased site-specific skin temperature (quadriceps) in the garment conditions. CONCLUSION: GCG did not enhance performance in a hot environment with a representative radiant heat load. The sham treatment did not benefit perception. GCG provided no evidence of performance enhancement.

Characterization of T-cell lymphomas by FDG PET/CT.

OBJECTIVE: The purpose of this article is to describe the utility of FDG PET/CT in documenting sites of disease in patients with T-cell lymphomas, to quantify the degree of FDG avidity in the various subtypes of this heterogeneous group of disorders, and to highlight the pattern of imaging findings associated with specific disease subtypes. MATERIALS AND METHODS: A retrospective review of patients with T-cell lymphomas who underwent PET/CT examination for initial disease staging or at disease relapse over a 5-year period was undertaken by correlation between a patient database and a PACS radiology information system. Disease subtypes were grouped according to World Health Organization categorization of mature natural killer cell-T-cell neoplasms. Sites of disease involvement were documented according to cutaneous or extranodal, nodal, and visceral locations. The maximum standardized uptake value (SUV) was recorded for each patient. RESULTS: One hundred thirty-five patients with T-cell lymphoma were included, and sites of disease were documented by use of FDG PET/CT in 122 (90%) patients. Of those 122 patients, 55 (45%) had cutaneous involvement, 95 (78%) had FDG-avid lymphadenopathy, and 54 (44%) had FDG-avid extranodal disease other than cutaneous involvement. A significant difference in maximum SUV was observed in cases of mycosis fungoides and mycosis fungoides with large cell transformation (SUV, 11.3 vs 3.8; p < 0.05). CONCLUSION: We found high rates of FDG positivity in T-cell lymphoma. Given the propensity for disease involvement outside the normal scan range of diagnostic CT, we recommend that patients with T-cell lymphoma be scanned from vertex to feet by use of PET/CT.

Integrated positron emission tomography/computed tomography may render bone scintigraphy unnecessary to investigate suspected metastatic breast cancer.

PURPOSE: Although the accurate detection of osseous metastases in the evaluation of patients with suspected metastatic breast cancer (MBC) has significant prognostic and therapeutic implications, the ideal diagnostic approach is uncertain. In this retrospective, single-institution study, we compare the diagnostic performance of integrated positron emission tomography/computed tomography (PET/CT) and bone scintigraphy (BSc) in women with suspected MBC. PATIENTS AND METHODS: Women with suspected MBC evaluated with PET/CT and BSc (within 30 days) between January 1, 2003 and June 30, 2008, were identified through institutional databases. Electronic medical records were reviewed, and radiology reports were classified as positive/negative/equivocal for osseous metastases. A nuclear medicine radiologist (blinded to correlative and clinical end points) reviewed all equivocal PET/CT and BSc images and reclassified some reports. Final PET/CT and BSc classifications were compared. Baseline patient/tumor characteristics and bone pathology were recorded and compared to the final imaging results. RESULTS: We identified 163 women who had a median age of 52 years (range, 30 to 90 years); 32% had locally advanced breast cancer, 42% had been diagnosed with breast cancer less than 12 weeks before identification. Twenty studies were originally deemed equivocal (five with PET/CT, and 15 with BSc), and 13 (65%) of these studies were reclassified after radiology review. Overall, PET/CT and BSc were highly concordant for reporting osseous metastases with 132 paired studies (81%); 32 (20%) were positive, and 100 (61%) were negative. Thirty-one occurrences (19%) were discordant. Twelve of these (39%) had pathology confirming osseous metastases: nine (of 18) were PET/CT positive and BSc negative; one (of three) was PET/CT positive and BSc equivocal; and two (of two) were PET/CT equivocal and BSc negative. CONCLUSION: This study supports the use of PET/CT in detecting osseous metastases for suspected MBC. Whether PET/CT may supplant BSc in this setting is unknown.

Mounier-Kuhn syndrome in an older patient.

Respiratory problems in older adults are frequently labelled as being due to chronic obstructive airways disease (COAD). However where the presentation may be suggestive of another pathology due to the clinical history or type of pathogen isolated from the sputum, then consideration should be given to appropriate imaging. We describe a case of an older lady labelled for many years as COAD but who was a lifelong non-smoker and had Pseudomonas in her sputum. A CT of thorax for suspected bronchiectasis revealed tracheobroncomegaly (Mounier-Kuhn syndrome). This is the oldest case of Mounier-Kuhn syndrome at presentation and highlights the importance of appropriate history taking and investigation of older people.