Cirugía radioguiada de las lesiones no palpables de mama (ROLL): ¿cómo lo hacemos? / No disponible

El objetivo de este trabajo es describir la técnica ROLL tal como nosotros la venimos aplicando, aprendida durante estancias realizadas en el Instituto Europeo de Oncología de Milán. S e describen los aspectos más importantes que tenemos en cuenta en las distintas fases: diagnóstica, pre-quirúrgica, quirúrgica y de cuidados postoperatorios. El procedimiento ROLL es una técnica multidisciplinar sencilla y reproducible que permite conseguir resultados óptimos y una tasa baja de reintervenciones, así como un buen resultado estético cuando se adquiere la suficiente experiencia(AU)

The aim of this paper is to describe the ROLL technique as we perform after having it learned during stays at the European Institute of Oncology in Milan. We describe the most important aspects that we consider in the different phases such as diagnostic, pre-surgical, surgical and postoperative care. The ROLL procedure is a multidisciplinary technique, simple and reproducible, that allows optimum results with a low rate of reintervention and a good cosmetic result when sufficient experience is gained(AU)

Displasia fibrosa en el síndrome de McCune-Albright / Fibrous dysplasia in McCune-Albright-syndrome

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Lipomatosis intraósea: positividad de la gammagrafía ósea con 99mTc-HDP / Intraosseous lipomatosis: positivity in bone scintigraphy with 99mTc-HDP

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Evaluation of renal graft haemodynamia by 51Cr-EDTA and o-[131I]iodohippurate: its use in the early diagnosis of glomerular hyperfiltration.

Chronic rejection is the most important cause of renal graft dysfunction. Non-immunological mechanisms have been suggested as a probable origin of chronic graft rejection, provoking a decrease in renal mass function, followed by glomerular hyperfiltration in the remnant nephrons, which could cause progressive glomerulosclerosis and functional loss. Early, or preclinical, identification of patients with glomerular hyperfiltration, defined as an increase in glomerular filtration fraction (GFF) and in glomerular capillary pressure (GCP), could prolong graft life. The objective of this study was to evaluate, non-invasively, stable renal graft haemodynamia and early glomerular hyperfiltration. We studied 116 renal transplant patients with stable renal function and five healthy living kidney donors with normal renal function. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were determined using 51Cr-EDTA and o-[131I]iodohippurate, respectively. GFF was obtained from the relation between GFR and ERPF, and GCP from a mathematical model (Hall-Gomez' formula). A simultaneous analysis of renal function was performed. In transplant patients, the GFR and ERPF were significantly lower than in healthy, living, kidney donors (P<0.02). The same trend was observed for GCP (P<0.01), while GFF was not significantly different. Twelve patients (10.3%) had criteria of glomerular hyperfiltration. In patients without criteria of glomerular hyperfiltration, plasma level and clearance of creatinine were 128+/-33 micromol.l-1 and 56+/-15 ml.min-1, respectively; and in those patients with glomerular hyperfiltration criteria were 108+/-18 micromol.l-1 (P=NS) and 83+/-24 ml.min-1 (P=0.002) respectively. It is concluded that determinations of GFR, ERPF, GFF and GCP allow non-invasive evaluation of renal graft haemodynamia and can be useful in the early detection of glomerular hyperfiltration.

Captación de 99mTc-HDP por tejidos blandos secundaria a hipercalcemia / 99mTc-HDP uptake by soft tissue secondary to hypercalcemia

Paciente varón de 49 años con antecedentes de enolismo y tabaquismo importantes, que es diagnosticado de doble carcinoma escamoso en orofaringe y seno piriforme. Al diagnóstico, correspondían a un estadio T3N2cM0 de seno piriforme y un estadio T2N0M0 de orofaringe. Se considera candidato a quimioterapia de inducción (que consiguió una reducción tumoral de más del 50 per cent) y posteriormente se realiza radioterapia previa a una posible cirugía. El paciente presenta un empeoramiento progresivo con aparición de metástasis pulmonares. Se decide ingreso hospitalario para estudio y valoración de quimioterapia paliativa, realizándose una gammagrafía ósea para despistaje de metástasis óseas (fig. 1) donde se encuentra importante captación de 99mTcHDP por parte de tejidos blandos. Entre las posibles causas de esta hipercaptación, la más probable se consideró una hipercalcemia maligna secundaria a la neoplasia. En el momento de la realización de la gammagrafía ósea la calcemia era de 5,14 mmol/l (N = 2,15-2,55 mmol/l) (AU)

Osteosarcoma de mama / Breast osteosarcoma

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Concordance between rest MIBG and exercise tetrofosmin defects: possible use of rest MIBG imaging as a marker of reversible ischaemia.

Perfusion imaging combined with pharmacological stress is the study of choice in patients with ischaemic heart disease who are incapable of exercising. Some medical conditions, however, can preclude the use of pharmacological stress. In these particular situations, availability of a diagnostic test which allows for the assessment of ischaemic territory at rest would be desirable. With the purpose of providing a marker of reversible ischaemia, we evaluated myocardial iodine-123 metaiodobenzylguanidine (MIBG) uptake in regions with fixed and reversible defects defined by exercise/rest perfusion study. Fifty-four male patients with ischaemic heart disease and previous myocardial infarction were studied by means of exercise/rest tetrofosmin and MIBG single-photon emission tomography (SPET). Regional tracer uptake was quantified and expressed as a percentage of maximum peak activity. Areas with denervated but perfused myocardium and areas with ischaemic myocardium were calculated. Regions with<75% of peak activity in the exercise perfusion study were divided into two groups according to whether the increase in peak activity in the respective rest study was >10% (reversible regional defect) or <10% (fixed regional defect). These percentages were compared with the percentages of the innervation study. The area of the innervation defect was significantly larger when the perfusion defect was reversible than when it was fixed. In regions with reversible perfusion defects, the size of the area of denervated but perfused myocardium was similar to the size of the area of ischaemic myocardium. In regions with reversible defects, the percentage of myocardial MIBG uptake was not significantly different from the percentage of tetrofosmin uptake at exercise, while it was significantly lower than the percentage of tetrofosmin uptake at rest. In regions with fixed defects, the percentage of myocardial MIBG uptake was significantly lower than the percentage of tetrofosmin uptake at exercise and at rest. In patients who developed angina during exercise test, the area of denervated but perfused myocardium was significantly larger than in patients without angina (4.1+/-2.4 vs 3.4+/-2.5, P=0.02). The same trend was observed with regard to the size of the innervation defect (8.6+/-2.4 vs 5.7+/-2.2, P=0.02). It is concluded that when the use of pharmacological stress is not possible in patients incapable of exercising, rest studies with MIBG combined with rest myocardial perfusion studies may be useful as a marker of reversible ischaemia.

[67 Ga-citrate scintigraphy as a determiner in the diagnosis of a subacute thyroiditis]. / Gammagrafía con 67Ga-citrato determinante en el diagnóstico de una tiroiditis subaguda.

We present the case of a 41-year-old man admitted to the hospital with fever and toxic syndrome possibly having an oncological or infectious origin. A whole body scan with 67Ga-citrate showed an intense and diffuse radiotracer accumulation in the thyroid gland. The patient was re-evaluated and studied with other diagnostic tests including a thyroid 99mTc-pertechnetate scintigraphy and a thyroidal radioiodine uptake. A correct final diagnosis of painless subacute thyroiditis was made.

Gammagrafía con 67Ga-citrato determinante en el diagnóstico de una tiroiditis subaguda / 67 Ga-citrate scintigraphy as a determiner in the diagnosis of a subacute thyroiditis

Presentamos el caso de un paciente varón de 41 años de edad que ingresó en nuestro hospital para estudio de fiebre y síndrome tóxico de posible etiología neoplásica o infecciosa. La prueba que condujo al diagnóstico definitivo fue un rastreo corporal total con citrato de 67Ga que mostró la existencia de hipercaptación difusa a nivel de glándula tiroides. Tras una nueva valoración del proceso y practicadas otras exploraciones complementarias, que incluyeron gammagrafía de tiroides con 99mTc- pertecnetato y captaciones con 131I, se llegó al diagnóstico definitivo de tiroiditis subaguda silente (AU)

Myocardial sympathetic innervation in the athlete's sinus bradycardia: is there selective inferior myocardial wall denervation?

BACKGROUND: Sinus bradycardia in trained athletes is predominantly a manifestation of increased vagal tone, but it is not known whether an alteration in the cardiac sympathetic system can contribute to blunted chronotropic response. This study assessed the integrity of the sympathetic system in trained athletes with sinus bradycardia by means of the iodine-123-metaiodobenzylguanidine (123I-MIBG) procedure. METHODS AND RESULTS: Fourteen athletes with sinus bradycardia and 8 athletes with a normal heart rate were explored by means of planar and single photon emission computed tomography MIBG studies. The heart/mediastinum ratio, regional myocardial distribution, and percent of regional myocardial MIBG uptake were evaluated. The heart/mediastinum ratio in athletes with sinus bradycardia was 1.87+/-0.10, and in athletes with a normal heart rate, the heart/mediastinum ratio was 1.86+/-0.16 (P = not significant). In athletes with sinus bradycardia, the regional distribution of MIBG showed an inferior and apical uptake defect in 8 athletes, an inferior, apical, and septal defect in 3 athletes, an inferior defect in 1 athlete, and normal distribution in 2 athletes (14%). In athletes with a normal heart rate, the regional distribution of MIBG showed an apical uptake defect in 3 athletes and normal distribution in 5 athletes (63%). The percent of regional MIBG uptake in the inferior region was significantly reduced in athletes with sinus bradycardia (44%+/-13% vs. 72%+/-11%, P<.01). CONCLUSION: These results show severely reduced myocardial MIBG distribution in the inferior region in athletes with sinus bradycardia, suggesting selective inferior myocardial wall sympathetic denervation, which may be related to increased vagal tone.

Influence of exercise rehabilitation on myocardial perfusion and sympathetic heart innervation in ischaemic heart disease.

Exercise rehabilitation improves the clinical status in ischaemic heart disease. The purpose of this study was to assess the influence of exercise rehabilitation on myocardial perfusion and sympathetic heart innervation. Sixteen patients with ischaemic heart disease and previous myocardial infarction were investigated by means of exercise/rest tetrofosmin and metaiodobenzylguanidine (MIBG) exercise/rest single-photon emission tomography (SPET) studies, before and 6 months after starting an exercise rehabilitation programme. Tomograms were divided into 15 segments, and these were grouped into five myocardial anatomical regions. Regional uptake of both tracers was quantified and expressed as a percentage of maximum peak activity. The percentage < or =55% was chosen to evaluate defect size, and the results were expressed as a percentage of left ventricular mass. Areas with perfused and denervated myocardium and areas with ischaemic myocardium were calculated. In addition, regions with <75% of peak activity in the exercise perfusion study at baseline were divided into two groups according to whether there was an increase in peak activity of >10% (representing reversible regional defects) or an increase of <10% (representing fixed regional defects) in the rest study. These percentages were compared with the percentages obtained in the innervation study, and with the percentages obtained in exercise/rest perfusion and innervation studies performed 6 months after starting rehabilitation. Myocardial perfusion defects were significantly smaller than myocardial innervation defects before and 6 months after starting exercise rehabilitation. The area of ischaemia 6 months after starting exercise rehabilitation was significantly smaller than that before rehabilitation (0.31%+/-1.4% vs 1.4%+/-1.6%, P<0.01). The size of innervation defects and the area of perfused and denervated myocardium did not show significant differences between the two studies performed before and 6 months after starting exercise rehabilitation. In reversible regional defects the percentage of peak activity was significantly increased 6 months after starting exercise rehabilitation in exercise and rest studies (P<0.001), while in fixed regional defects it was significantly increased only in exercise studies (P<0.001). There was no significant change in the regional MIBG percentages. We conclude that in ischaemic heart disease, exercise rehabilitation over a period of 6 months improves myocardial perfusion, but does not cause changes in sympathetic myocardial innervation.

Somatostatin receptor scintigraphy predicts impending cardiac allograft rejection before endomyocardial biopsy.

The invasive nature of endomyocardial biopsy has led to a search for alternative diagnostic modalities for the detection of cardiac allograft rejection. To date, no non-invasive test meets all the requirements for the detection of acute and chronic rejection. The rejection process usually presents with lymphocyte infiltration with or without myocyte necrosis, which indicates the severity of cardiac allograft rejection and the necessity of treatment. Activated lymphocytes express somatostatin receptors; thus somatostatin receptor imaging could be used to target them. The aim of this study was to assess the feasibility of using somatostatin receptor imaging to target activated lymphocytes in the process of cardiac allograft rejection. Thirteen somatostatin receptor imaging studies were performed on ten cardiac allograft recipients 12-4,745 days after transplantation, simultaneously with endomyocardial biopsy, to assess the imaging of activated lymphocytes in comparison with histological findings. Somatostatin receptor imaging was performed 4 h after the injection of 110 MBq of the somatostatin analogue indium-111 pentetreotide. 111In-pentetreotide uptake was visually scored and semi-quantitatively estimated by the calculation of a heart-to-lung ratio (HLR). The visual score correlated with the HLR. Intense/moderate uptake on visual assessment and an HLR >1.6 was observed in eight studies. In three of these studies there was significant rejection in the simultaneous endomyocardial biopsy [International Society of Heart and Lung Transplantation (ISHLT) rejection grade 3A/4]. Intense/moderate uptake was associated with mild or no rejection in the remaining five patients, and in four of them the next endomyocardial biopsy performed 1 week later demonstrated significant rejection requiring treatment. Two patients with low uptake and an HLR <1.6 had no evidence of rejection either in the simultaneous endomyocardial biopsy or in the endomyocardial biopsy performed the following week. These preliminary results indicate the feasibility of targeting activated lymphocytes with somatostatin receptor imaging in the detection of cardiac allograft rejection. Somatostatin receptor imaging may predict impending rejection at least 1 week before the endomyocardial biopsy becomes positive. The late appearance of diagnostic endomyocardial biopsy probably reflects a lag-time between lymphocytic activation and induction of myocyte damage. Furthermore, somatostatin receptor imaging at 4 h may in any case allow earlier intervention in the event of rejection, given the time required for histological processing of endomyocardial biopsy.

Thymic carcinoid and parathyroid hyperplasia detection with 99mTc-MIBI men type 1.

We report a case of a 35-year-old male, with a history of diarrhea, renal lithiasis with frequent expulsions of calculus and hypercalcemia during the last 2 years. The patient was studied and diagnosed with a multiple endocrine neoplasia type I (MEN I), familiar (mother with MEN I). A scintigraphic study with 99mTc-MIBI was performed in order to localize hyperfunctioning parathyroid glands because of biochemical diagnosis of primary hyperparathyroidism. Double phase 99mTc-MIBI scan detected one hyperfunctioning parathyroid gland and a large anterior mediastinal mass. Subsequent, plain radiograph and CT of the chest showed a soft-tissue mass in that localization. Punch biopsy of the lesion guided by CT revealed malignant cells of neuroendocrine tumor. The tumor was removed and histologically confirmed as a carcinoid within a thymus in a MEN type I syndrome. MEN I patients can benefit from the examination with this agent which can potentially localize not only parathyroid endocrine pathology but also unknown associated tumors.