Distribución de la FDG PET/TAC en la enfermedad de Castleman simulando Linfoma / FDG PET/CT appearance of multicentric Castleman's disease mimicking lymphoma

Se presenta un caso de enfermedad de Castleman multicéntrica con múltiples ganglios linfáticos que muestran una intensa captación de FDG, imitando el linfoma no-Hodgkin. El paciente presenta múltiples nódulos linfáticos cervicales, mediastínicos, hiliares, retroperitonealeses, así como nódulos linfáticos anormales en la ingle. La tomografía por emisión de positrones 18F fluorodeoxyglucosa/tomografía computarizada se realizó antes de obtener las muestras de tejido. La 18F FDG-PET mostró múltiples áreas de aumento de captación en ganglios linfáticos cervicaleses, mediastínicos, hiliares, retroperitoneales e inguinales, sugiriendo una enfermedad generalizada del sistema linfático, como el linfoma no-Hodgkin. El diagnóstico final se basó en los hallazgos histopatológicos obtenidos de la linfadenectomía cervical. El diagnóstico histológico fue el de enfermedad de Castleman multicéntrica variante de células plasmáticas. La 18F fluorodeoxyglucosa tomografía por emisión de positrones/tomografía computada ayudó a identificar la extensión corporal de la afectación ganglionar, pero no permitió un diagnóstico diferencial conel linfoma no Hodgkin. Se describen las conclusiones clínicas y los hallazgos de la PET/TAC(AU)

We report a case of a multicentric form of Castleman's disease with multiple lymph nodes showing intense FDG uptake on whole body scan mimicking non-Hodgkin's lymphoma. In this report, the patient had multiple cervical, mediastinal, hilar, retroperitoneal and abnormal lymph nodes in the groin. 18F-fluorodeoxyglucose positron emission tomography/computed tomography was performed before tissue sampling. 18F-FDG/PET demonstrated multiple areas of increased uptake in cervical, mediastinal, hilar, retroperitoneal and groin lymph nodes, suggesting a generalized disease of the lymphatic system including non-Hodgkin's lymphoma. The final diagnosis is based on the histopathological findings of the material obtained from the cervical lymphadenectomy. The histological diagnosis was multicentric plasma cell variant of Castleman's disease. 18F fluorodeoxyglucose positron emission tomography/computed tomography scan helped to identify the lymph nodes involved throughout the whole body, but did not help to differentiate non-Hodgkin's lymphoma. The clinical conclusions and PET/CT findings are described in this report(AU)

FDG PET/CT appearance of multicentric Castleman's disease mimicking lymphoma.

We report a case of a multicentric form of Castleman's disease with multiple lymph nodes showing intense FDG uptake on whole body scan mimicking non-Hodgkin's lymphoma. In this report, the patient had multiple cervical, mediastinal, hilar, retroperitoneal and abnormal lymph nodes in the groin. (18)F-fluorodeoxyglucose positron emission tomography/computed tomography was performed before tissue sampling. (18)F-FDG/PET demonstrated multiple areas of increased uptake in cervical, mediastinal, hilar, retroperitoneal and groin lymph nodes, suggesting a generalized disease of the lymphatic system including non-Hodgkin's lymphoma. The final diagnosis is based on the histopathological findings of the material obtained from the cervical lymphadenectomy. The histological diagnosis was multicentric plasma cell variant of Castleman's disease. (18)F fluorodeoxyglucose positron emission tomography/computed tomography scan helped to identify the lymph nodes involved throughout the whole body, but did not help to differentiate non-Hodgkin's lymphoma. The clinical conclusions and PET/CT findings are described in this report.

Hyperammonemic encephalopathy in a patient with primary hepatic neuroendocrine carcinoma.

A 53-year-old male patient was admitted to our hospital with abdominal pain in the right upper quadrant. There was no change in laboratory investigations other than a slight increase in serum levels of alkaline phosphatase (ALP), alanine aminotransferase (ALT), and gamma glutamyl transferase (GGT). Computed tomography (CT) of the abdomen showed multiple hepatic nodular lesions in the liver. Tru-cut biopsy of the lesions was reported as well-differentiated neuroendocrine carcinoma. The patient received sandostatin treatment. After a few days, the patient was hospitalized in the intensive care unit with disturbance of consciousness and clinical features suggestive of encephalopathy. Serum ammonia level was found highly elevated. After the treatment with L-ornithine-L-aspartate, a remarkable improvement in the level of patient's sensorium occurred as well as a reduction in serum ammonia level within a few days. Transarterial chemoembolization (TACE) was performed one week later. The patient's condition began to worsen along with increase in serum ammonia level and he died because of hyperammonemic encephalopathy. There are case reports of hyperammonemia with some malignancies such as multiple myeloma, plasma cell leukemia, and leiomyosarcoma, or in some patients who have received chemotherapy. This case may suggest an association between hyperammonemia and neuroendocrine tumors.

Diagnostic value of ischaemia-modified albumin for predicting myocardial ischaemia during myocardial perfusion scintigraphy.

During acute ischaemia the N-terminal site of albumin is altered, reducing its binding capacity; the modified protein is termed ischaemia-modified albumin (IMA). IMA is a sensitive marker of acute myocardial ischaemia but its diagnostic value in chronic angina pectoris patients is unclear. We investigated changes in blood levels of IMA during myocardial perfusion scintigraphy in patients with chronic angina pectoris in a study including 26 male and 20 female patients, with mean age 60 years. Technetium 99m perfusion imaging detected myocardial ischaemia in 26 patients. Coronary angiography was carried out in these 26 ischaemic patients. Mean IMA values at rest and peak exercise were significantly higher in the ischaemic than the nonischaemic group. All IMA values were considered negative for cardiac ischaemia. Peak exercise IMA was significantly lower than the pre-exercise level only in the non-ischaemic group. IMA measurements during myocardial perfusion scintigraphy are not helpful in the diagnosis of myocardial ischaemia in patients with stable angina pectoris.

Effect of Helicobacter pylori infection and eradication therapy on interleukin-6 levels in patients with Familial Mediterranean Fever.

It is being questioned if Helicobacter pylori infection, which causes a chronic inflammatory response, can increase the frequency and severity of attacks in patients with Familial Mediterranean Fever (FMF) and if the impact of inflammatory response can be diminished by eradication of the infection. To evaluate if there is difference in interleukin (IL)-6 levels of H. pylori-positive and -negative patients both before and during FMF attacks; if there is a change in IL-6 levels following successful eradication treatment; and if MEFV gene mutations have an effect on IL-6 levels. IL-6 levels were evaluated in 47 FMF patients before and during FMF attacks. Genetic testing to determine M694V, M694I, E148Q, V726V, M680I mutations was also performed in all patients. IL-6 levels were also determined after successful eradication of the infection in H. pylori-positive patients. IL-6 levels were compared in H. pylori-positive and -negative patients, and before and after eradication treatment in patients who cleared the infection. Number of patients in tested mutation groups was not enough to compare IL-6 levels in these groups. Thirty-four patients (73.9%) were H. pylori-positive. Before FMF attack there was no statistically significant difference in IL-6 levels of H. pylori-positive and -negative groups. IL-6 levels were significantly higher in both groups during the attacks than before the attacks (p < 0.05). There was a statistically significant decline in IL-6 levels both before and during FMF attacks, following eradication therapy in patients who cleared the infection (p < 0.05). In patients with homozygous M694V mutation, IL-6 levels before and during the FMF attacks were not significantly different in H. pylori-positive and -negative groups, despite a much lower level found in H. pylori-negative group (p > 0.05). Comparisons were not performed in other mutation groups because of small number of patients in each group. C-reactive protein (CRP) and fibrinogen levels were not significantly different between the groups (p > 0.05). We believe that the observation of IL-6 levels are lower both before and during FMF attacks both in H. pylori-negative patients and in patients who cleared the infection after eradication therapy is very important in the determination of the role of eradication of H. pylori on decreasing the frequency and severity of FMF attacks. As for today, the correlation between H. pylori infection and FMF seems unlikely; however, studies evaluating the interaction of cytokines in both diseases and their relations and roles will be needed to reach better conclusions.

Lesion detectability and clinical effectiveness of dual-head coincidence gamma camera imaging in comparison with dedicated PET systems in tumour patients.

The lesion detection capability and clinical effectiveness of dual-head coincidence gamma camera imaging (c-PET) were compared with those of dedicated positron emission tomography (d-PET) in 37 cancer patients who underwent whole-body c-PET and d-PET imaging after administration of 370 - 540 MBq (18)F-fluorodeoxyglucose. Eighty-nine lesions were detected on c-PET whereas 133 lesions were seen with d-PET imaging. The relative sensitivity of c-PET compared with d-PET was 62% and 73% for lesions < 15 and > or = 15 mm, respectively, and the relative concordance rate was 84% when the patients were restaged. Since the lesion detection rate of c-PET imaging was lower than that of d-PET, the detection of small lesions, therefore, requires care. The clinical effectiveness of c-PET, however, was similar to that of d-PET and, therefore, it is concluded that c-PET can be used as an alternative to d-PET, particularly considering the high cost and limited availability of d-PET cameras.

Is the remarkable contradiction between histology and 14C urea breath test in the detection of Helicobacter pylori due to false-negative histology or false-positive 14C urea breath test?

We assessed the diagnostic value of the 14C urea breath test (UBT) in the detection of Helicobacter pylori compared with histology and the rapid urease test (RUT). The study included 68 patients (22 men and 46 women) with dyspeptic symptoms. H. pylori status was evaluated by 14C UBT, RUT and histology. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were determined for 14C UBT and for RUT. Histology revealed dense yeast-like micro-organisms in the biopsy specimens in all patients with false-positive results by 14C UBT (n = 8), a significantly higher proportion than in patients with negative 14C UBT (five of 31). The low specificity of the H. pylori 14C UBT should not be neglected by accepting histology results as false-negative. Gastric mucosal colonization by yeast-like micro-organisms with urease activity can account for the high frequency of false-positive results for 14C UBT.

Low parathormone levels and hypercalcaemia in patients with pulmonary tuberculosis: relation to radiological extent of disease and tuberculin skin test.

AIM: We hypothesised that serum calcium (Ca) and parathormone (PTH) levels correlate with radiological extent and that there may also be a relationship between the tuberculin skin test (TST), serum Ca and PTH levels in patients with pulmonary tuberculosis (PTB). MATERIALS AND METHODS: Forty-four patients with active PTB and 33 healthy subjects were enrolled in the study. Serum Ca, PTH, magnesium and phosphate levels were measured in patients and controls and compared. Correlations were also investigated for TST values, erythrocyte sedimentation rate (ESR), the degree of radiological involvement, serum PTH and corrected Ca levels. RESULTS: There was a significant difference between the two groups for mean serum PTH and corrected Ca levels. Significant correlations were detected between radiological extent of disease and serum PTH levels, between TST values and serum PTH levels and between ESR and serum PTH levels. We suggest that abnormal Ca metabolism in PTB patients is related to the radiological extent of disease. Factors determining the radiological extent of disease, predominantly the patient's immune status, may have an important role in modulating Ca metabolism in PTB patients.

Gastric carcinoma and thyroid status.

Gastric carcinoma is reported to be more frequent in geographical areas where diets are either iodine-deficient or iodine-excessive. Reports have also shown an association between thyroid diseases and some of the risk factors for gastric carcinoma. We investigated the frequency of thyroid disorders in 61 patients with gastric carcinoma compared with 55 healthy control subjects. Thyroid health was evaluated by physical examination and by measuring the serum levels of thyroid hormones and thyroid autoantibodies. More patients with gastric cancer had goitre compared with healthy controls (49.1% versus 20%, respectively). Significantly more patients with gastric cancer had non-toxic goitre compared with control subjects. There was also a significant difference in the incidence of autoimmune thyroid disease--27.8% of patients with gastric cancer versus 10.9% of control subjects were affected. These results indicate that there is a significant association between gastric cancer and thyroid disorders.

Use of CA15-3, CEA and prolactin for the primary diagnosis of breast cancer and correlation with the prognostic factors at the time of initial diagnosis.

The main goals of the clinical use of tumor markers are to evaluate the adequacy of the treatment, monitor recurrence and follow up response to the treatment applied. For this purpose a baseline level for the commonly used tumor marker must be known at the time of initial diagnosis, before any therapy, in order to compare with the tumor marker levels which will be obtained after the treatment and during the clinical follow-up. The aim of this study was to investigate the correlation, if there is any, of the baseline levels of CA15-3, CEA and prolactin (PRL) in patients with breast cancer with the most commonly used prognostic factors, i) the presence of distant metastasis, ii) the presence of axillary lymphatic invasion, iii) the number of invaded axillary lymph nodes, iv) tumor size and v) stage of the disease, for breast cancer. Baseline serum CA15-3, CEA and PRL levels of 172 patients with breast masses were determined prior to biopsy. The sensitivity and specificity of baseline CA15-3, CEA and PRL were; 23.2% and 95.3%, 17.41% and 83.7%, 5.8% and 97.6%, respectively. At least one of the three tumor markers was high in 36% (31/86) of the breast cancer patients. Baseline CA15-3 levels were frequently higher than CEA in patients with bone metastasis (60% vs. 20%) and axillary lymphatic invasion (31.8% vs. 25%), and showed a better correlation with the stage of disease. Baseline tumor marker levels showed no statistically significant correlation with either the number of invaded axillary lymph nodes or tumor size. In conclusion, sensitivities and negative predictive values for baseline CA15-3, CEA and PRL were not satisfactory for primary diagnosis of breast cancer. Correlation of baseline CA15-3 was found superior to CEA and PRL in terms of stage of disease, presence of axillary invasion and distant metastasis.

The comparison of dual phase Tc-99m MIBI and tc-99m MDP scintimammography in the evaluation of breast masses: preliminary report.

The aim of this prospective study was to determine the diagnostic value of Tc-99m MDP scintimammography (SMG) for the detection of breast cancer in patients with breast masses and to compare the results with Tc-99m MIBI scintimammography. Twenty patients, categorized as suspicious, positive or benign for breast cancer according to the mammographic findings were included in the study. Dual phase Tc-99m MIBI and Tc-99m MDP SMG were performed in the prone lateral position within 5 days of each other. Although early and late Tc-99m MIBI SMG showed equal (90.4%) sensitivity, the specificity of late Tc-99m MIBI (87.5%) was found superior to early (62.5%) imaging. The overall sensitivity and specificity of early Tc-99m MDP SMG were 71.4% and 62.5%, respectively. Although late Tc-99m MDP imaging showed 100% specificity, its sensitivity was only 23.8%. In the patients with palpable masses, both early Tc-99m MDP and Tc-99m MIBI showed equal sensitivity (100%), but the sensitivity of early Tc-99m MIBI (37.5%) was found slightly higher than Tc-99m MDP (25.0%) for nonpalpable breast lesions. The sensitivity of Tc-99m MIBI and Tc-99m MDP SMG in detecting metastatic axillary involvement was 66.6% and 50%, respectively. High sensitivity and specificity together with its low cost, easy availability and the possibility of detecting bone metastases seems to make Tc-99m MDP a contributive agent in the evaluation of breast lesions as an alternative to Tc-99m MIBI.

The effect of trimebutine maleate on gastric emptying in patients with non-ulcer dyspepsia.

The study was designed to investigate the effect of trimebutine maleate, a drug used in both hyperkinetic and hypokinetic motility disorders, on gastric emptying in patients with non-ulcer dyspepsia having prolonged gastric emptying rates and to compare the parameters used for the determination of the lag period observed during the emptying of solid foods from the stomach. Gastric emptying was measured by the radionuclide technique. Twenty normal volunteers and 43 patients with non-ulcer dyspepsia participated in the study. Radionuclide imaging was performed by using a solid meal labeled with 99mTc-tin colloid. Of the patients with non-ulcer dyspepsia, 20 had prolonged gastric emptying. They were given three weeks of oral treatment with trimebutine maleate and had their radionuclide gastric emptying study repeated. Treatment with trimebutine maleate resulted in reduction in duration of the lag period and less retention of food at 100 minutes (p < 0.0005). After treatment with trimebutine maleate, no significant difference has been observed in the mean symptom score of patients with prolonged gastric emptying. Among the parameters used for the determination of the lag period, lag period determined by a mathematical equation (TLAG) has been found to be longer than the lag period determined by visual inspection of the images (VLAG) and there was correlation between the two parameters when the lag time was short.

Measurement of bone mineral density by dual energy X-ray absorptiometry in preterm infants fed human milk or formula.

UNLABELLED: Bone mineralization of healthy preterm infants fed human milk were compared with that of similar fed preterm formula. Bone mineralization was studied by dual energy X-ray absorptiometry in 43 preterm infants divided into two groups; 21 preterm infants were fed with maternal breast milk and 22 preterm infants with a preterm formula containing 70 mg calcium and 35 mg phosphorus per decilitre. CONCLUSION: Preterm infants fed breast milk had lower bone mineral density than the preterm formula-fed group. Fortifying preterm human milk with calcium and phosphorus will improve bone mineralization in preterm infants.

A case of thyrotropin-secreting pituitary microadenoma with normal thyrotropin alpha-subunit level.

We present a 32-year-old male with a thyrotropin (TSH)-secreting pituitary microadenoma with normal alpha-subunit (SU) and/or alpha-SU/TSH molar ratio. An interesting feature of this patient is that the size of the pituitary tumor remained unchanged during a 6-year follow-up without treatment. The tumor was clearly visualized with somatostatin receptor imaging, indicating that it was somatostatin receptor-positive. Subcutaneous injection of 100 microg octreotide acetate three times daily resulted in significant reduction of TSH and free thyroid hormones 6 weeks after initiation of treatment. However, tumor size was not changed 3 months after initiation of octreotide therapy and thyroid hormones, but not TSH level, eventually increased in spite of increasing the octreotide dosage up to 600 microg/day. This led to discontinuation of treatment. The patient responded only temporarily to octreotide in spite of somatostatin receptors. This case further demonstrates that a normal alpha-SU and/or alpha-SU/TSH molar ratio cannot exclude the possibility of a TSH-secreting pituitary adenoma.

The visualization of granulomatous disease with somatostatin receptor scintigraphy.

In-111 labeled pentetreotide scintigraphy was applied to three patients with proven granulomatous disease (two with sarcoidosis, one with tuberculosis). All revealed accumulation of In-111 labeled pentetreotide in the granulomatous lesions, which was considered to be due to the presence of activated lymphocytes in these regions. This method may be of value in assessing the activity and extent of sarcoidosis and tuberculosis.