Spontaneous peeled ileal giant lipoma caused by lower gastrointestinal bleeding: A case report.

RATIONALE: Gastrointestinal subepithelial tumors (SETs) with endoscopic features such as ulceration, a red color change, a peeled mucosal layer, and spontaneous bleeding could have malignant potential. However, we encountered a case of a lipoma that presented features different from the generally known features of gastrointestinal SETs. Therefore, we report an interesting rare case of a terminal ileal giant lipoma with a unique feature of spontaneous peeled ulceration on the surface on endoscopy that caused gastrointestinal bleeding. PATIENT: An 82-year-old woman with a 1-week history of abdominal pain and hematochezia presented to our hospital. DIAGNOSES: Ileocolonoscopy revealed a SET with a peeled surface and erythematous and ulcerative mucosal changes as well as exposed a submucosal mass at the terminal ileum. Macroscopically, the lesion appeared as a yellowish pedunculated polypoid mass measuring 3 × 2 cm with a peeled mucosal ulceration. Histopathological findings revealed a submucosal lipoma of the terminal ileum. INTERVENTION: We thought that the endoscopic finding indicated malignant SETs or those with malignant potential rather than benign SETs. Therefore, the patient underwent an elective laparoscopic ileocecectomy. LESSONS: We encountered a lipoma that did not present with the typical features of gastrointestinal SETs. Our findings suggest that clinicians should consider that benign SETs in the terminal ileum may present with various endoscopic findings similar to those of malignant SETs, which can cause fatal symptoms and signs.

Correlation of Uptake Patterns on Single-Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) and Treatment Response in Patients with Knee Pain.

PURPOSE: To determine whether treatment response in patients with knee pain could be predicted using uptake patterns on single-photon emission computed tomography/computed tomography (SPECT/CT) images. METHODS: Ninety-five patients with knee pain who had undergone SPECT/CT were included in this retrospective study. Subjects were divided into three groups: increased focal uptake (FTU), increased irregular tracer uptake (ITU), and no tracer uptake (NTU). A numeric rating scale (NRS-11) assessed pain intensity. We analyzed the association between uptake patterns and treatment response using Pearson's chi-square test and Fisher's exact test. Uptake was quantified from SPECT/CT with region of interest (ROI) counting, and an intraclass correlation coefficient (ICC) calculated agreement. We used Student's t-test to calculate statistically significant differences of counts between groups and the Pearson correlation to measure the relationship between counts and initial NRS-1k1. Multivariate logistic regression analysis determined which variables were significantly associated with uptake. RESULTS: The FTU group included 32 patients; ITU, 39; and NTU, 24. With conservative management, 64 % of patients with increased tracer uptake (TU, both focal and irregular) and 36 % with NTU showed positive response. Conservative treatment response of FTU was better than NTU, but did not differ from that of ITU. Conservative treatment response of TU was significantly different from that of NTU (OR 3.1; p = 0.036). Moderate positive correlation was observed between ITU and initial NRS-11. Age and initial NRS-11 significantly predicted uptake. CONCLUSIONS: Patients with uptake in their knee(s) on SPECT/CT showed positive treatment response under conservative treatment.

Prognostic Value of Metabolic Tumor Volume Estimated by (18) F-FDG Positron Emission Tomography/Computed Tomography in Patients with Diffuse Large B-Cell Lymphoma of Stage II or III Disease.

PURPOSE: The purpose of this study was to evaluate the prognostic value of metabolic tumor volume (MTV) measured by (18)F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) in patients with diffuse large B-cell lymphoma (DLBCL) treated with rituximab-containing immunochemotherapy. METHODS: Patients with newly diagnosed DLBCL who underwent pre-treatment torso FDG-PET/CT scan taken within 10 days before treatment were included. MTV was defined as the volume of hypermetabolic tissue with a standardized uptake value (SUV) greater than a threshold value of 2.5 and calculated using volume viewer software. Association of MTV with patient characteristics and survival were compared. RESULTS: A total of 96 patients were evaluated. During a median follow-up period of 27.8 months, 3-year event-free survival (EFS) and overall survival was 69.5 % and 72.9 %, respectively. The Ann Arbor staging showed a limitation of prognosis because there was no difference of EFS between patients with Ann Arbor stage II and those with stage III. On the contrary, among patients with Ann Arbor stage II or III disease (n = 53), the higher MTV group showed significantly inferior EFS compared with the lower MTV group. CONCLUSIONS: In the current study, we identified the pre-treatment MTV measured by FDG-PET/CT as a potential predictor of survival in patients with DLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP), at least in Ann Arbor stage II and III disease.

Can Initial (18)F-FDG PET-CT Imaging Give Information on Metastasis in Patients with Primary Renal Cell Carcinoma?

PURPOSE: The aim of this study was to investigate the relationship between the maximum standardized uptake values (SUVmax) of primary renal cancers with and without metastatic lesions, if any. We also studied the relationship between the size of primary renal cancers and their SUVmax, and tried to find a clinical value of (18)F-FDG PET-CT for the initial evaluation of renal cell carcinoma (RCC). METHODS: The cases of 23 patients, 16 men and 7 women, who underwent PET-CT examination before operation were retrospectively reviewed. We measured the SUVmax of the primary renal cancers and those of any existing metastatic lesions, and the size of the primary renal cancers. We compared the SUVmax of primary RCCs with metastases and those without metastases, SUVmax of primary RCC and those of metastases, and studied the correlation between the size and SUVmax of primary RCCs. RESULTS: The SUVmax of primary RCC of the 16 patients without metastasis ranged from 1.1 to 5.6 with a median value of 2.6. Those of the patients with metastasis ranged from 2.9 to 7.6 with a median of 5.0. The size of the all 23 primary renal cancers ranged from 1.7 cm to 13.5 cm, with a median of 4.5 cm, and their SUVmax ranged from 1.1 to 7.6, with a median of 2.9. There was a statistically significant difference between the SUVmax of the primary RCC with metastasis (5.3 ± 1.7) and those without metastasis (2.9 ± 1.0). There was a moderate positive correlation between the sizes and SUVmax of all 23 primary RCCs. However, there was no statistically significant correlation between the sizes and SUVmax of primary RCCs with metastatic lesions and the same for RCCs without metastasis. The cutoff value of SUVmax for predicting extra-renal lesion was 4.4 and that for size was 5.8 cm according to the receiver operating characteristic curves. CONCLUSIONS: Those who have primary RCC with high SUVmax are suggested to have a likelihood of metastasis. Also, there was a moderate trend of increasing value of SUVmax of primary RCC as their size increases. Physicians should beware of missing extra-renal lesions elsewhere.

Usefulness of (18)F-FDG PET/CT for the Evaluation of Bone Marrow Involvement in Patients with High-Grade Non-Hodgkin's Lymphoma.

PURPOSE: To assess the usefulness of (18)F-fluorodeoxyglucose PET/CT in the detection of bone marrow (BM) involvement of high-grade non-Hodgkin's lymphoma (NHL). METHODS: One hundred twenty patients with newly diagnosed diffuse large B-cell lymphoma or peripheral T-cell lymphoma between January 2007 and June 2011, who received BM trephine biopsy and (18)F-FDG PET/CT before chemotherapy, were included in this retrospective study. We reviewed their (18)F-FDG PET/CT images and bone marrow biopsy (BMB) results. After reviewing the images, we reviewed the medical records and radiological findings of interesting patients. RESULTS: There were 23 (18)F-FDG PET/CT scans in which the marrow was considered to be abnormal (either positive or equivocal), and 97 (18)F-FDG PET/CT scans were regarded as having negative FDG uptake. Of 120 patients, 100 (83.3 %) had a concordant result of BM interpretation between (18)F-FDG PET/CT and BMB, and the remaining 20 patients had discordant results. Among 23 patients with either positive or equivocal (18)F-FDG PET/CT scans, 1 of 12 patients with 'positive' (18)F-FDG PET/CT had a lymphomatous involvement on BMB. In contrast, 10 of 11 patients with 'equivocal' BM hypermetabolism were reported as having positive involvement by BMB. Patients with abnormal (18)F-FDG PET/CT had significantly higher mSUVhighest than those with normal FDG-PET/CT. CONCLUSIONS: (18)F-FDG PET/CT and BMB are complementary techniques in assessing the presence of BM involvement in patients with high-grade NHL. The increasing availability of (18)F-FDG PET/CT will raise the need for additional biopsy for FDG-avid lesions, especially in patients with negative standard BMBs. (18)F-FDG PET/CT can be useful as a decision-making tool for determining whether to perform a standard BMB or targeted biopsy to the FDG-avid lesion as an initial staging procedure. A direct bone biopsy for FDGpositive bone lesions should be included in staging guidelines in future. In (18)F-FDG PET/CT-negative cases, BMB is still a powerful procedure, but BMB alone is insufficient for full evaluation of BM.

Role of FDG-PET/CT in detecting lymphomatous bone marrow involvement in patients with newly diagnosed diffuse large B-cell lymphoma.

To evaluate the role of FDG-PET/CT in detecting bone marrow (BM) involvement, pre-treatment bilateral bone marrow biopsies (BMBs) and FDG-PET/CT scans of 89 patients with diffuse large B-cell lymphoma (DLBCL) treated with rituximab-CHOP were reviewed and analyzed. Fourteen patients (15.7%) had lymphomatous involvement based on BMB (BMB+), and 17 patients (19.1%) had the possibility of BM involvement on FDG-PET/CT (FDG-PET/CT+). Seventy-two patients (80.8%) had concordant results between BMB and FDG-PET/CT (seven patients were positive for both, and 65 patients were negative for both), but 17 patients (19.2%) had a discordant interpretation (seven patients were BMB+ and FDG-PET/CT-, and ten were BMB- and FDG-PET/CT+). Although BMB+ patients had an inferior 2-year EFS (37.0% vs. 79.8%, p < 0.001) and OS (36.3% vs. 81.0%, p < 0.001) compared to BMB- patients, no differences in EFS (62.6% vs. 72.7%, p = 0.185) and OS (59.4% vs. 78.0%, p = 0.146) were shown between FDG-PET/CT+ and FDG-PET/CT- patients. Whereas six of seven patients with diffuse hypermetabolism were BMB+, only one of ten patients with focal hypermetabolism was BMB+. The results suggest that FDG-PET/CT had a limited value to detect BM involvement in patients with DLBCL. Focal hypermetabolism of hematopoietic BM in FDG-PET/CT had no impact on survival.

Quantitative measurement of serum hepatitis B surface antigen using an immunoradiometric assay in chronic hepatitis B.

PURPOSE: Measurement of serum hepatitis B virus surface antigen (HBsAg) levels is important for the management of chronic hepatitis B patients in terms of monitoring response to antiviral therapy. This study aimed to evaluate the diagnostic performance of a new diagnostic kit, which quantitatively measures serum HBsAg level using an immunoradiometric assay (IRMA)-based method. Measurements were compared with those obtained using a chemiluminescent microparticle immunoassay (CMIA)-based method. METHODS: The blood samples of 96 patients with chronic hepatitis B were used in this study. Copy numbers of serum hepatitis B virus (HBV) DNA were determined in 23 of these samples. The correlation between and the concordance of IRMA and CMIA results were determined using Pearson's correlation coefficients. P values of 0.05 were considered to be statistically significant throughout. RESULTS: Laboratory diagnoses based on IRMA were wholly in agreement with those based on CMIA. Furthermore, serum HBsAg levels by IRMA were found to be highly correlated with those determined by CMIA (correlation coefficient R (2) = 0.838, p < 0.001). Serum HBsAg level and serum HBV DNA copies were found to be linearly related by both methods (R (2) = 0.067, p = 0.316 by IRMA, and R (2) = 0.101, p = 0.215 by CMIA). CONCLUSION: The diagnostic performance of the investigated IRMA method of determining HBsAg levels was found to be comparable with that of a CMIA-based method in chronic hepatitis B patients.

Total Thyroidectomy in the Mouse: the Feasibility Study in the Non-thyroidal Tumor Model Expressing Human Sodium/Iodide Symporter Gene.

PURPOSE: This study sought to probe the feasibility of performing total thyroidectomy in the mouse using a non-thyroidal hNIS expressing tumor model. MATERIALS AND METHODS: Our thyroidectomy protocol included thorough excision of both lobes and the isthmus. For evaluating the completeness of thyroidectomy, we compared the (99m)Tc-pertechnetate scans taken before and after thyroidectomy. The prostate cancer cell line was subcutaneously inoculated 2 weeks after the thyroidectomy. When the tumor reached 5-10 mm in diameter, Ad5/35-E4PSESE1a-hNIS was injected intratumorally, and (131)I scans were performed. The radioiodine uptakes of the neck and the tumor were compared with those of the other regions. RESULTS: Total thyroidectomy was performed in 13 mice. Although 38.5% died during or just after thyroidectomy, the others survived in good health for 2 months. Thyroid tissue was completely eliminated using our protocol; the residual uptake of (99m)Tc-pertechnetate was minimal in the neck area. The neck/background uptake ratio after thyroidectomy was significantly lower than that before thyroidectomy (p < 0.05). Non-thyroidal tumor models were successfully established in all the surviving mice. Radioiodine accumulation in the tumors was visualized on (131)I scans, and the neck uptakes were minimal. CONCLUSION: Using our total thyroidectomy protocol, we successfully established a hNIS-transfected prostate cancer model with a minimal accumulation of radioiodine in the neck. The relatively high mortality after surgery can be a problem, and this might be reduced by minimizing the surgical stress.

Diagnostic performance of three-phase bone scan for complex regional pain syndrome type 1 with optimally modified image criteria.

PURPOSE: Although the three-phase bone scan (TBPS) is one of the widely used imaging studies for diagnosing complex regional pain syndrome type I (CRPS-1), there is some controversy regarding the TPBS image criteria for CRPS-1. In this study, we modified the image criteria using image pattern and quantitative analysis in the patients diagnosed using the most recent consensus clinical diagnostic criteria. MATERIALS AND METHODS: The study included 140 patients with suspected CRPS-1 (CRPS-1, n = 79; non-CRPS, n = 61; mean age 39 ± 15 years) who underwent TPBS. The clinical diagnostic criteria for CRPS-1 revised by the Budapest consensus group were used for confirmative diagnosis. Patients were classified according to flow/pool and delayed uptake (DU) image patterns, and the time interval between the initiating event and TPBS (TIevent-scan). Quantitative analysis for lesion-to-contralateral ratio (LCR) was performed. Modified TPBS image criteria were created and evaluated for optimal diagnostic performance. RESULTS: Both increased and decreased periarticular DU were significant image findings for CRPS-1 (CRPS-1 positive-rate = 73% in the increased DU group, 75% in the decreased DU group). The TIevent-scan did not differ significantly between the different image pattern groups. Quantitative analysis revealed an LCR of 1.43 was the optimal cutoff value for CRPS-1 and diagnostic performance was significantly improved in the increased DU group (area under the curve = 0.732). Given the modified image criteria, the sensitivity and specificity of TPBS for diagnosing CRPS-1 were 80% and 72%, respectively. CONCLUSIONS: Optimally modified TPBS image criteria for CRPS-1 were suggested using image pattern and quantitative analysis. With the criteria, TPBS is an effective imaging study for CRPS-1 even with the most recent consensus clinical diagnostic criteria.

Use of granulocyte colony-stimulating factor for fluorine-18-fluorodeoxyglucose labeling in human leukocytes.

OBJECTIVE: Insufficient labeling efficiency and poor retention of radioactivity are the considerable shortcomings of fluorine-18-fluorodeoxyglucose (¹8F-FDG) labeling in human leukocytes. This study was conducted to evaluate the feasibility of using granulocyte colony-stimulating factor (G-CSF) to improve ¹8F-FDG labeling in human leukocytes. METHODS: Leukocyte separation was performed using methods reported earlier. Separated leukocytes were preincubated with G-CSF or insulin at 37°C for 1 h. After preincubation, labeling was performed with ¹8F-FDG (37-74 MBq) at 37°C for 30 min. Retained radioactivity was assessed at 1-4 h after labeling by the same method described in earlier reports. The viability of labeled leukocytes was assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay. RESULTS: Labeling efficiency of leukocytes preincubated with G-CSF, G-CSF with insulin, insulin, and control leukocytes was 52.1±8.9%, 49.9±10.5%, 40.3±7.7%, and 40.3±6.0%, respectively. G-CSF significantly increased the labeling efficiency compared with insulin (P=0.005) and control (P=0.004). In leukocytes preincubated with G-CSF, 77.0±1.2%, and 59.0±1.8% of radioactivity was retained at 1 and 3 h after labeling. There was no significant difference in retained radioactivity compared with that of leukocytes with different treatment at all time points. Furthermore, no significant difference in viabilities among leukocytes with different treatments was observed. CONCLUSION: Use of G-CSF significantly improved ¹8F-FDG labeling efficiency without a significant effect on cell viability and retention of radioactivity.

Behavior and awareness of thyroid cancer patients in Korea having non-hospitalized low-dose radioiodine treatment with regard to radiation safety.

PURPOSE: With the recent increase in incidence of thyroid cancer, non-hospitalized low-dose (NH-LD) radioiodine treatment (RIT) has also increased rapidly. The radioactivity limit that is allowed to be administered without hospitalization depends on individual calculation, based partly on patients' behavior. In this study, Korean patients' behavior in relation to radiation safety in NHLD RIT was surveyed. METHODS: A total of 218 patients who underwent NH-LD RIT of 1.1 GBq (131)I in a single center were surveyed. The patients underwent RIT with a standard protocol and the survey was performed by interview when they visited subsequently for a whole-body scan. The survey questionnaire included three parts of questions: general information, behavior relating to isolation during RIT, and awareness of radiation safety. RESULTS: After administration of radioiodine, 40% of patients who returned home used mass transportation, and another 47% went home by taxi or in car driven by another person. Isolation at home was generally sufficient. However, 7% of patients did not stay in a separate room. Among the 218 patients, 34% did not go home and chose self-isolation away from home, mostly due to concerns about radiation safety of family members. However, the places were mostly public places, including hotels, resorts, and hospitals. About half of the patients replied that access to radiation safety information was not easy and their awareness of radiation safety was not satisfactory. As a result, 45% of patients wanted hospitalized RIT. CONCLUSIONS: In many countries, including Korea, RIT is continuously increasing. Considering the radiation safety of patients' family members or the public and the convenience of patients, the pretreatment education of patients should be enhanced. In addition, the hospitalization of patients having low-dose therapy is recommended to be seriously considered and expanded, with the expansion of dedicated treatment facilities.