PSMA Radioligand Therapy in Prostate Cancer: Where Are We and Where Are We Heading?

ABSTRACT: Diagnosis and treatment of prostate cancer are complex and very challenging, being a major health care burden. The efficacy of radioligand therapy with prostate-specific membrane antigen agents has been proven beneficial in certain clinical indications. In this review, we describe management of prostate cancer patients according to current guidelines, especially focusing on the available clinical evidence for prostate-specific membrane antigen radioligand therapy.

Suspicious amorphous microcalcifications detected on full-field digital mammography: correlation with histopathology.

OBJECTIVE: To evaluate suspicious amorphous calcifications diagnosed on full-field digital mammography (FFDM) and establish correlations with histopathology findings. MATERIALS AND METHODS: This was a retrospective study of 78 suspicious amorphous calcifications (all classified as BI-RADS® 4) detected on FFDM. Vacuum-assisted breast biopsy (VABB) was performed. The histopathological classification of VABB core samples was as follows: pB2 (benign); pB3 (uncertain malignant potential); pB4 (suspicion of malignancy); and pB5 (malignant). Treatment was recommended for pB5 lesions. To rule out malignancy, surgical excision was recommended for pB3 and pB4 lesions. Patients not submitted to surgery were followed for at least 6 months. RESULTS: Among the 78 amorphous calcifications evaluated, the histopathological analysis indicated that 8 (10.3%) were malignant/suspicious (6 classified as pB5 and 2 classified as pB4) and 36 (46.2%) were benign (classified as pB2). The remaining 34 lesions (43.6%) were classified as pB3: 33.3% were precursor lesions (atypical ductal hyperplasia, lobular neoplasia, or flat epithelial atypia) and 10.3% were high-risk lesions. For the pB3 lesions, the underestimation rate was zero. CONCLUSION: The diagnosis of precursor lesions (excluding atypical ductal hyperplasia, which can be pB4 depending on the severity and extent of the lesion) should not necessarily be considered indicative of underestimation of malignancy. Suspicious amorphous calcifications correlated more often with precursor lesions than with malignant lesions, at a ratio of 3:1.

OBJETIVO: Correlacionar o achado mamográfico de calcificações amorfas suspeitas diagnosticadas na mamografia digital com seus diagnósticos anatomopatológicos. MATERIAIS E MÉTODOS: Setenta e oito casos de calcificações amorfas suspeitas (todas classificadas como BI-RADS® 4) detectadas na mamografia digital e submetidas a biópsia percutânea assistida à vácuo foram retrospectivamente avaliados. A classificação anatomopatológica utilizada na biópsia foi: pB2 para lesão benigna, pB3 para lesão com potencial incerto de malignidade, pB4 para lesão suspeita, e pB5 para lesão considerada maligna. O tratamento foi recomendado para as lesões pB5, a exérese cirúrgica foi indicada para lesões pB3 e pB4, para descartar malignidade, e o seguimento evolutivo foi adotado para as demais pacientes. RESULTADOS: A histologia demonstrou 8 (10,3%) casos malignos (6 lesões pB5 e 2 lesões pB4) e 36 (46,2%) casos benignos (pB2). As demais 34 (43,6%) lesões foram classificadas como pB3 (33,3% foram lesões precursoras - hiperplasia ductal atípica, neoplasia lobular ou atipia epitelial plana - e 10,3% foram lesões de alto risco). A taxa de subestimação das lesões pB3 foi zero. CONCLUSÃO: O diagnóstico de lesões precursoras (excluindo hiperplasia ductal atípica, que pode corresponder a lesão pB4 dependendo da severidade e extensão dos achados) na biópsia percutânea assistida à vácuo por calcificações amorfas suspeitas não necessariamente representa lesão subestimada. Calcificações amorfas suspeitas se associaram a lesões precursoras numa proporção de 3:1 em relação às lesões malignas.

Serum interleukin measurement may help identify thyroid cancer patients with active disease.

BACKGROUND: Investigate the clinical utility of serum interleukin dosages of IL-2, IL-2R, IL-4, IL-6, IL-6R, IL-8, IL-10 and IL-12 in the diagnosis and characterization of patients with DTC. In particular, verify ILs utility in the identification of individuals who are evolving disease-free or with the active disease. METHODS: We evaluated 200 patients with malignant nodules (100 patients disease-free and 100 patients with recurrence/active disease); 60 benign nodules and 100 healthy controls, serum levels were assessed by ELISA. RESULTS: All ILs, but not IL-4, differentiated these three groups. We observed that IL-2, 2R and 10 serum concentrations were associated with thyroglobulin levels. Serum IL-2 was able to differentiate patients with active disease from the disease-free with a sensitivity of 98%, specificity of 58%, positive predictive value (PPV) of 70% and negative predictive value (NPV) of 97% (p=0.0007). IL-6R levels differentiated patients with active disease from the disease-free patients with 56% sensitivity, 63% specificity, PPV of 60% and NPV of 59% (p<0.0001). IL-8 values also distinguished patients with active disease from the disease-free ones with sensitivity of 50%, specificity of 76%, PPV of 68% and NPV of 60% (p=0.0025); using IL-12, we obtained a sensitivity value of 73%, specificity of 66%, PPV of 68% and NPV of 71% (p<0.0001). Furthermore, interleukin levels showed association with some tumor characteristics of aggressiveness. CONCLUSION: We suggest that the serum concentration of ILs may assist in the diagnosis and characterization of tumor malignancy helping identify patients with active disease who deserve closer medical attention.

Fluorodeoxyglucose-positron emission tomography staging can replace bone marrow biopsy in Hodgkin's lymphoma. Results from Brazilian Hodgkin's Lymphoma Study Group.

OBJECTIVE: To investigate, in a large prospective multicenter study, whether 2-[18F]-fluoro-2-deoxy-d-glucose-positron emission tomography is sufficiently accurate to identify clinically important bone marrow involvement by Hodgkin's lymphoma to replace routine bone marrow biopsy in a developing tropical country. METHODS: Patients newly diagnosed with Hodgkin's lymphoma were recruited from six cancer centers in Brazil. All were staged by the results of positron emission tomography/computed tomography that were centrally reviewed and by iliac crest bone marrow biopsy. Patients were classified as having marrow disease if they had lymphoma identified by marrow biopsy histology or had focal 2-[18F]-fluoro-2-deoxy-d-glucose marrow uptake that resolved following chemotherapy. RESULTS: A total of 246 participants were recruited from six different centers and 62 (25.2%) were judged to have Hodgkin's lymphoma in the bone marrow. Positron emission tomography and biopsies were concordant in 206 patients (83%). Positron emission tomography correctly identified marrow disease in 59/62 patients (95.1%) and marrow biopsy in 25/62 patients (40.3%). In 22/62 (35.4%) patients, the two techniques were concordant in the diagnosis of marrow involvement. Of the forty discordant results, positron emission tomography found bone marrow involvement in 37 patients, upstaging 22 to stage IV and having an impact on therapeutic decision in nine cases given their reallocation from early to advanced stage. Three false negative positron emission tomography results were obtained with bone marrow biopsy giving positive findings. All three cases were classified as stage IV regardless of bone marrow findings implying no modification in the clinical management. The sensitivity, specificity and accuracy of positron emission tomography for detecting bone marrow disease were 95%, 100% and 98% and for bone marrow biopsy they were 40%, 100% and 84%, respectively. CONCLUSION: We conclude that positron emission tomography can replace marrow biopsy in Brazilian patients with Hodgkin's lymphoma without compromising clinical management.

Low sensitivity of three-phase bone scintigraphy for the diagnosis of repetitive strain injury.

CONTEXT AND OBJECTIVE: The diagnosis of repetitive strain injury (RSI) is subjective and solely based on clinical signs and physical examination. The aim of this paper was to assess the usefulness of three-phase bone scintigraphy (TPBS) in diagnosing RSI. DESIGN AND SETTING: Prospective study at the Division of Nuclear Medicine, Department of Radiology, School of Medical Sciences, Universidade Estadual de Campinas (UNICAMP). METHODS: Seventy-three patients (mean age 31.2 years; 47 males) with clinical suspicion of RSI in the upper limbs were studied. A total of 127 joints with suspicion of RSI were studied. The shoulders, elbows and wrists were analyzed semi-quantitatively, using the shafts of the humeri and ulnae as references. The results were compared with a control group of 40 normal individuals. The patients signs and symptoms were used as the "gold standard" for calculating the probabilities. RESULTS: From visual analysis, abnormalities were observed in the flow phase for four joints, in the blood pool phase for 11 joints and in the delayed images for 26 joints. Visual analysis of the joints of the control group did not show any abnormalities. Semi-quantitative analysis showed that most of the patients joint ratios were normal. The exceptions were the wrists of patients with left-sided RSI (p = 0.0216). However, the sensitivity (9%) and accuracy (41%) were very low. CONCLUSION: TPBS with semi-quantitative analysis has very low sensitivity and accuracy in the detection of RSI abnormalities in the upper limbs.

Statistical voxel-wise analysis of ictal SPECT reveals pattern of abnormal perfusion in patients with temporal lobe epilepsy.

OBJECTIVE: To investigate the pattern of perfusion abnormalities in ictal and interictal brain perfusion SPECT images (BSI) from patients with temporal lobe epilepsy (TLE). METHOD: It was acquired interictal and ictal BSI from 24 patients with refractory TLE. BSIs were analyzed by visual inspection and statistical parametric mapping (SPM2). Statistical analysis compared the patients group to a control group of 50 volunteers. The images from patients with left-TLE were left-right flipped. RESULTS: It was not observed significant perfusional differences in interictal scans with SPM. Ictal BSI in SPM analysis revealed hyperperfusion within ipsilateral temporal lobe (epileptogenic focus) and also contralateral parieto-occipital region, ipsilateral posterior cingulate gyrus, occipital lobes and ipsilateral basal ganglia. Ictal BSI also showed areas of hypoperfusion. CONCLUSION: In a group analysis of ictal BSI of patients with TLE, voxel-wise analysis detects a network of distant regions of perfusional alteration which may play active role in seizure genesis and propagation.

Thyroid uptake and scintigraphy using 99mTc pertechnetate: standardization in normal individuals.

CONTEXT: Thyroid uptake and scintigraphy using 99mTc-pertechnetate has proven to be more advantageous than with 131I-iodide, since the images have better quality, the procedure is faster and the patient is submitted to a lower radiation dose. OBJECTIVE: The purpose of this study was to standardize a simple and fast methodology for performing thyroid uptake and scintigraphy and to determine the normal values for 99mTc- pertechnetate uptake. TYPE OF STUDY: Prospective, non-randomized. SETTING: Division of Nuclear Medicine, Department of Radiology, School of Medical Sciences, Campinas State University. PARTICIPANTS: The study consisted of 47 normal individuals, 30 women and 17 men, with ages ranging from 19 to 61 years (mean of 33 years). PROCEDURES: The laboratory assessment of thyroid function consisted of serum dosages of ultra-sensitive thyroxin and thyrotrophin. Twenty minutes after an intravenous injection of 10 mCi (370 MBq) of 99mTc-pertechnetate, the images were obtained on a computerized scintillation camera equipped with a low-energy high-resolution parallel hole collimator. RESULTS: All the individuals were euthyroid both on clinical and laboratory evaluation. The baseline thyroid 99mTc-pertechnetate uptake ranged from 0.4 to 1.7%. The uptake values obtained in these normal individuals showed that 95% presented a thyroid uptake that ranged from 0.4 to 1.5% of the injected dose. CONCLUSION: The assessment of thyroid structure and function using 99mTc-pertechnetate is a simple, fast and efficient method, which could easily become a part of the routine studies in nuclear medicine laboratories.

Treatment of bone pain secondary to metastases using samarium-153-EDTMP.

CONTEXT: More than 50% of patients with prostate, breast or lung cancer will develop painful bone metastases. The purpose of treating bone metastases is to relieve pain, reduce the use of steroids and to maintain motion. OBJECTIVE: To evaluate the use of samarium-153-EDTMP (153Sm-EDTMP) for the treatment of bone pain secondary to metastases that is refractory to clinical management. TYPE OF STUDY: Retrospective. SETTING: Division of Nuclear Medicine, Universidade Estadual de Campinas (Unicamp). METHODS: Fifty-eight patients were studied (34 males) with mean age 62 years; 31 patients had prostate cancer, 20 had breast cancer, three had lung cancer, one had lung hemangioendothelioma, one had parathyroid adenocarcinoma, one had osteosarcoma and one had an unknown primary tumor. All patients had multiple bone metastases demonstrated by bone scintigraphy using 99mTc-MDP,and were treated with 153Sm-EDTMP. Response to treatment was graded as good (pain reduction of 50-100%), intermediate (25-49%) and poor (0-24%). RESULTS: All patients showed good uptake of 153Sm-EDTMP by bone metastases. Among the patients with prostate cancer, intermediate or good response to therapy occurred in 80.6% (25 patients) and poor response in 19.4% (6). Among the patients with breast cancer, 85% (17) showed intermediate or good response to therapy while 15% (3) showed poor response. All three patients with lung cancer showed poor response to treatment. The lung hemangioendothelioma and unknown primary lesion patients showed intermediate response to treatment; the osteosarcoma and parathyroid adenocarcinoma patients showed good response to treatment. No significant myelotoxicity occurred. DISCUSSION: Pain control is important for improving the quality of life of patients with advanced cancers. The mechanism by which pain is relieved with the use of radionuclides is still not yet completely understood, however, the treatment is simple and provides a low risk of mielotoxicity. CONCLUSION: Treatment with 153Sm-EDTMP can control the pain secondary to bone metastases effectively in most patients with breast and prostate cancer without significant side effects.

99mTc-DISIDA uptake in liver lesion and pulmonary metastases shown on SPECT/CT in a patient with hepatocellular carcinoma.

A 43-year-old man, previously submitted to right hepatectomy, right hepatic artery chemoembolization, and surgical resection of liver lesions, with well-differentiated and moderately differentiated hepatocellular carcinoma (HCC) confirmed by histopathology, underwent cholescintigraphy with Tc diisopropyliminodiacetic acid (Tc-DISIDA) due to recurrent cholangitis. The scintigraphic images and the coregistered CT images showed radiotracer uptake in an area of biliary ectasia near the hepatic surface (which may be associated with recurrent cholangitis), in a hepatic nodule, and in multiple pulmonary metastases.

68Ga-DOTATATE PET/CT, 99mTc-HYNIC-octreotide SPECT/CT, and whole-body MR imaging in detection of neuroendocrine tumors: a prospective trial.

UNLABELLED: There are different metabolic imaging methods, various tracers, and emerging anatomic modalities to stage neuroendocrine tumor (NET). We aimed to compare NET lesion detectability among (99m)Tc-hydrazinonicotinamide (HYNIC)-octreotide (somatostatin receptor scintigraphy [SSRS]) SPECT/CT, (68)Ga-DOTATATE PET/CT, and whole-body diffusion-weighted MR imaging (WB DWI). METHODS: Nineteen consecutive patients (34-77 y old; mean, 54.3 ± 10.4 y old; 10 men and 9 women) underwent SSRS SPECT/CT, (68)Ga-DOTATATE PET/CT, and WB DWI. Images were acquired with a maximum interval of 3 mo between them and were analyzed with masking by separate teams. Planar whole-body imaging and SPECT/CT were performed from thorax to pelvis using a double-head 16-slice SPECT/CT scanner 4 h after injection of 111-185 MBq of (99m)Tc-HYNIC-octreotide. (68)Ga-DOTATATE PET/CT was performed from head to feet using a 16-slice PET/CT scanner 45 min after injection of 185 MBq of tracer. WB DWI was performed in the coronal plane using a 1.5-T scanner and a body coil. The standard method of reference for evaluation of image performance was undertaken: consensus among investigators at the end of the study, clinical and imaging follow-up, and biopsy of suggestive lesions. RESULTS: McNemar testing was applied to evaluate the detectability of lesions using (68)Ga-DOTATATE PET/CT in comparison to SSRS SPECT/CT and WB DWI: a significant difference in detectability was noted for pancreas (P = 0.0455 and P = 0.0455, respectively), gastrointestinal tract (P = 0.0455 and P = 0.0455), and bones (P = 0.0082 and P = 0.0082). Two unknown primary lesions were identified solely by (68)Ga-DOTATATE PET/CT. (68)Ga-DOTATATE PET/CT, SSRS SPECT/CT, and WB DWI demonstrated, respectively, sensitivities of 0.96, 0.60, and 0.72; specificities of 0.97, 0.99, and 1.00; positive predictive values of 0.94, 0.96, and 1.00; negative predictive values of 0.98, 0.83, and 0.88; and accuracies of 0.97, 0.86, and 0.91. CONCLUSION: (68)Ga PET/CT seems to be more sensitive for detection of well-differentiated NET lesions, especially for bone and unknown primary lesions. NET can be staged with (68)Ga-DOTATATE PET/CT. WB DWI is an efficient new method with high accuracy and without ionizing radiation exposure. SSRS SPECT/CT should be used only when (68)Ga-DOTATATE PET/CT and WB DWI are not available.

Suspicious amorphous microcalcifications detected on full-field digital mammography: correlation with histopathology / Microcalcificações amorfas suspeitas detectadas na mamografia digital: correlação histológica

Abstract Objective: To evaluate suspicious amorphous calcifications diagnosed on full-field digital mammography (FFDM) and establish correlations with histopathology findings. Materials and Methods: This was a retrospective study of 78 suspicious amorphous calcifications (all classified as BI-RADS® 4) detected on FFDM. Vacuum-assisted breast biopsy (VABB) was performed. The histopathological classification of VABB core samples was as follows: pB2 (benign); pB3 (uncertain malignant potential); pB4 (suspicion of malignancy); and pB5 (malignant). Treatment was recommended for pB5 lesions. To rule out malignancy, surgical excision was recommended for pB3 and pB4 lesions. Patients not submitted to surgery were followed for at least 6 months. Results: Among the 78 amorphous calcifications evaluated, the histopathological analysis indicated that 8 (10.3%) were malignant/suspicious (6 classified as pB5 and 2 classified as pB4) and 36 (46.2%) were benign (classified as pB2). The remaining 34 lesions (43.6%) were classified as pB3: 33.3% were precursor lesions (atypical ductal hyperplasia, lobular neoplasia, or flat epithelial atypia) and 10.3% were high-risk lesions. For the pB3 lesions, the underestimation rate was zero. Conclusion: The diagnosis of precursor lesions (excluding atypical ductal hyperplasia, which can be pB4 depending on the severity and extent of the lesion) should not necessarily be considered indicative of underestimation of malignancy. Suspicious amorphous calcifications correlated more often with precursor lesions than with malignant lesions, at a ratio of 3:1.

Resumo Objetivo: Correlacionar o achado mamográfico de calcificações amorfas suspeitas diagnosticadas na mamografia digital com seus diagnósticos anatomopatológicos. Materiais e Métodos: Setenta e oito casos de calcificações amorfas suspeitas (todas classificadas como BI-RADS® 4) detectadas na mamografia digital e submetidas a biópsia percutânea assistida à vácuo foram retrospectivamente avaliados. A classificação anatomopatológica utilizada na biópsia foi: pB2 para lesão benigna, pB3 para lesão com potencial incerto de malignidade, pB4 para lesão suspeita, e pB5 para lesão considerada maligna. O tratamento foi recomendado para as lesões pB5, a exérese cirúrgica foi indicada para lesões pB3 e pB4, para descartar malignidade, e o seguimento evolutivo foi adotado para as demais pacientes. Resultados: A histologia demonstrou 8 (10,3%) casos malignos (6 lesões pB5 e 2 lesões pB4) e 36 (46,2%) casos benignos (pB2). As demais 34 (43,6%) lesões foram classificadas como pB3 (33,3% foram lesões precursoras - hiperplasia ductal atípica, neoplasia lobular ou atipia epitelial plana - e 10,3% foram lesões de alto risco). A taxa de subestimação das lesões pB3 foi zero. Conclusão: O diagnóstico de lesões precursoras (excluindo hiperplasia ductal atípica, que pode corresponder a lesão pB4 dependendo da severidade e extensão dos achados) na biópsia percutânea assistida à vácuo por calcificações amorfas suspeitas não necessariamente representa lesão subestimada. Calcificações amorfas suspeitas se associaram a lesões precursoras numa proporção de 3:1 em relação às lesões malignas.

Fluorodeoxyglucose-positron emission tomography staging can replace bone marrow biopsy in Hodgkin's lymphoma. Results from Brazilian Hodgkin's Lymphoma Study Group

ABSTRACT Objective: To investigate, in a large prospective multicenter study, whether 2-[18F]-fluoro-2-deoxy-D-glucose-positron emission tomography is sufficiently accurate to identify clinically important bone marrow involvement by Hodgkin's lymphoma to replace routine bone marrow biopsy in a developing tropical country. Methods: Patients newly diagnosed with Hodgkin's lymphoma were recruited from six cancer centers in Brazil. All were staged by the results of positron emission tomography/computed tomography that were centrally reviewed and by iliac crest bone marrow biopsy. Patients were classified as having marrow disease if they had lymphoma identified by marrow biopsy histology or had focal 2-[18F]-fluoro-2-deoxy-D-glucose marrow uptake that resolved following chemotherapy. Results: A total of 246 participants were recruited from six different centers and 62 (25.2%) were judged to have Hodgkin's lymphoma in the bone marrow. Positron emission tomography and biopsies were concordant in 206 patients (83%). Positron emission tomography correctly identified marrow disease in 59/62 patients (95.1%) and marrow biopsy in 25/62 patients (40.3%). In 22/62 (35.4%) patients, the two techniques were concordant in the diagnosis of marrow involvement. Of the forty discordant results, positron emission tomography found bone marrow involvement in 37 patients, upstaging 22 to stage IV and having an impact on therapeutic decision in nine cases given their reallocation from early to advanced stage. Three false negative positron emission tomography results were obtained with bone marrow biopsy giving positive findings. All three cases were classified as stage IV regardless of bone marrow findings implying no modification in the clinical management. The sensitivity, specificity and accuracy of positron emission tomography for detecting bone marrow disease were 95%, 100% and 98% and for bone marrow biopsy they were 40%, 100% and 84%, respectively. Conclusion: We conclude that positron emission tomography can replace marrow biopsy in Brazilian patients with Hodgkin's lymphoma without compromising clinical management.

Brain hypoperfusion in adolescents dependent of multiple drugs.

UNLABELLED: Brain SPECT imaging (BSI) with statistical parametric mapping (SPM) offers a clear and accurate vision of perfusion changes. OBJECTIVE: To study brain perfusion abnormalities in adolescents' dependent of multiple drugs. METHOD: Sixteen male patients (15.1 + or - 2.1 years) were submitted to (99m)Tc-HMPAO BSI with SPM. RESULTS: Cortical hypoperfusion occurred in 7/16 patients (44%). There was a significant inverse correlation between the number of hypoperfused regions and the patient's age (p= -0.6737; p=0.004) and with the age when the drug dependence began (p= -0.5616; p=0.023). There was also a tendency towards an inverse correlation between regions of hypoperfusion and the duration of the drug dependence. CONCLUSION: BSI with SPM can help detect hypoperfusion in adolescents dependent on multiple drugs. The younger the patients, the more regions of hypoperfusion are noted. Probably, the neuronal plasticity has an important role in this phenomenon because the highest neural activity occurs in childhood.

Brain SPECT in mesial temporal lobe epilepsy: comparison between visual analysis and SPM.

OBJECTIVE: To compare the accuracy of SPM and visual analysis of brain SPECT in patients with mesial temporal lobe epilepsy (MTLE). METHOD: Interictal and ictal SPECTs of 22 patients with MTLE were performed. Visual analysis were performed in interictal (VISUAL(inter)) and ictal (VISUAL(ictal/inter)) studies. SPM analysis consisted of comparing interictal (SPM(inter)) and ictal SPECTs (SPM(ictal)) of each patient to control group and by comparing perfusion of temporal lobes in ictal and interictal studies among themselves (SPM(ictal/inter)). RESULTS: For detection of the epileptogenic focus, the sensitivities were as follows: VISUAL(inter)=68%; VISUAL(ictal/inter)=100%; SPM(inter)=45%; SPM(ictal)=64% and SPM(ictal/inter)=77%. SPM was able to detect more areas of hyperperfusion and hypoperfusion. CONCLUSION: SPM did not improve the sensitivity to detect epileptogenic focus. However, SPM detected different regions of hypoperfusion and hyperperfusion and is therefore a helpful tool for better understand pathophysiology of seizures in MTLE.

Cintilografia de perfusão miocárdica na detecção da isquemia silenciosa em pacientes diabéticos assintomáticos / Myocardial perfusion scintigraphy in the detection of silent ischemia in asymptomatic diabetic patients

OBJECTIVE: This study was aimed to evaluate myocardial perfusion in asymptomatic patients with type 1 (DM1) and type 2 diabetes mellitus (DM2) without previous diagnoses of coronary artery disease (CAD) or cerebral infarction. MATERIALS AND METHODS: Fifty-nine consecutive asymptomatic patients (16 DM1, 43 DM2) underwent myocardial perfusion scintigraphy with 99mTc-sestamibi (MPS). They were evaluated for body mass index, metabolic control of DM, type of therapy, systemic arterial hypertension, dyslipidemia, nephropathy, retinopathy, peripheral neuropathy, smoking, and familial history of CAD. RESULTS: MPS was abnormal in 15 patients (25.4%): 12 (20.3%) with perfusion abnormalities, and 3 with isolated left ventricular dysfunction. The strongest predictors for abnormal myocardial perfusion were: age 60 years and above (p = 0.017; odds ratio [OR] = 6.0), peripheral neuropathy (p = 0.028; OR = 6.1), nephropathy (p = 0.031; OR = 5.6), and stress ECG positive for ischemia (p = 0.049; OR = 4.08). CONCLUSION: Silent myocardial ischemia occurs in more than one in five asymptomatic diabetic patients. The strongest predictors of ischemia in this study were: patient age, peripheral neuropathy, nephropathy, retinopathy and a stress ECG positive for ischemia.

OBJETIVO: Este estudo teve por finalidade avaliar a perfusão miocárdica de pacientes com diabetes mellitus tipo 1 (DM1) e tipo 2 (DM2) assintomáticos, sem diagnóstico prévio de doença arterial coronariana (DAC) ou acidente vascular cerebral. MATERIAIS E MÉTODOS: Cinquenta e nove pacientes consecutivos (16 DM1, 43 DM2) foram submetidos a cintilografia de perfusão miocárdica com sestamibi-99mTc (CPM). Foram avaliados quanto ao índice de massa corpórea, controle metabólico do diabetes, dislipidemia, terapia para o diabetes, hipertensão arterial sistêmica, nefropatia, retinopatia, neuropatia periférica, tabagismo e história familiar de DAC. RESULTADOS: CPM foi anormal em 25,4%: 12 (20,3%) com alterações de perfusão e 3 com disfunção ventricular esquerda isolada. Os mais fortes preditores de perfusão miocárdica anormal foram: idade igual ou maior a 60 anos (p = 0,017, odds ratio [OR] = 6,0), neuropatia periférica (p = 0,028, OR = 6,1), nefropatia (p = 0,031, OR = 5,6) e ECG de esforço positivo para isquemia (p = 0,049, OR = 4,08). CONCLUSÃO: A isquemia miocárdica silenciosa ocorre em mais de um em cada cinco diabéticos assintomáticos. Os mais fortes preditores de isquemia foram: idade avançada, neuropatia periférica, nefropatia, retinopatia e ECG de esforço positivo para isquemia.

Fusion of magnetic resonance and scintimammography images for breast cancer evaluation: a pilot study.

BACKGROUND: To achieve a more specific method to estimate the real size of breast cancer, we have developed a method to fuse magnetic resonance imaging (MRI) and scintimammography (SM) images. The aim of this study was to assess the feasibility of this method and to evaluate its accuracy to measure the size of breast cancer compared with MRI alone, mammography, and clinical examination, employing pathologic size as the gold standard. METHODS: Twenty consecutive breast cancer women at stages IIA-IIIA, scheduled for mastectomies, underwent SM with (99m)Tc-sestamibi and MRI with gadolinium 2-10 days before surgery. All patients had had recent mammographies and were examined clinically. Software was developed in visual language to perform the fusion between MRI and SM images and tumor measurements (MRI/SM). The tumor size, in 3 diameters (anteroposterior, longitudinal, and transverse), for each examination was correlated with pathological measurements using linear regression. RESULTS: The MRI/SM technique was successfully performed in all patients, and the principal tumor was measured by this method. The MRI/SM cancer measurements correlated better with pathology than MRI, mammography, and clinical exam in all diameters analyzed (r = 0.88, 0.81, 0.81; SE = 0.11, 0.14, 0.11 in anteroposterior, longitudinal, and transverse diameters, respectively). CONCLUSIONS: The MRI/SM is a feasible technique and appears to be more accurate than other examinations (MRI alone, mammography, and clinical exam) to measure breast cancer size.

Brain hypoperfusion in adolescents dependent of multiple drugs / Hipoperfusão cerebral em adolescentes dependentes de múltiplas drogas

Brain SPECT imaging (BSI) with statistical parametric mapping (SPM) offers a clear and accurate vision of perfusion changes. OBJECTIVE: To study brain perfusion abnormalities in adolescents' dependent of multiple drugs. METHOD: Sixteen male patients (15.1±2.1 years) were submitted to 99mTc-HMPAO BSI with SPM. RESULTS: Cortical hypoperfusion occurred in 7/16 patients (44 percent). There was a significant inverse correlation between the number of hypoperfused regions and the patient's age (p= -0.6737; p=0.004) and with the age when the drug dependence began (p= -0.5616; p=0.023). There was also a tendency towards an inverse correlation between regions of hypoperfusion and the duration of the drug dependence. CONCLUSION: BSI with SPM can help detect hypoperfusion in adolescents dependent on multiple drugs. The younger the patients, the more regions of hypoperfusion are noted. Probably, the neuronal plasticity has an important role in this phenomenon because the highest neural activity occurs in childhood.

SPECT cerebral (SC) com statistical parametric mapping (SPM) oferece uma visão clara e acurada de alterações perfusionais. OBJETIVO: Avaliar anormalidades perfusionais cerebrais em adolescentes usuários de múltiplas drogas. MÉTODO: Dezesseis pacientes masculinos (15,1±2,1 anos) foram submetidos a SC com SPM utilizando-se HMPAO-99mTc. RESULTADOS: Hipoperfusão cortical ocorreu em 7/16 pacientes (44 por cento). Houve uma significativa correlação inversa entre o número de áreas hipoperfundidas e a idade dos pacientes (p= -0,6737; p=0,004) e com a idade quando iniciaram o abuso das drogas (p= -0,5616; p=0,023). Também houve uma tendência para uma correlação inversa entre as áreas de hipoperfusão e a duração do abuso de drogas. CONCLUSÃO: SC com SPM pode auxiliar na detecção de hipoperfusão cortical em adolescentes dependentes de múltiplas drogas. Quanto menor a idade, mais áreas de hipoperfusão são identificadas. Provavelmente a plasticidade neuronal tem importante papel neste fenômeno, pois a maior atividade neuronal ocorre na infância.

Brain SPECT in mesial temporal lobe epilepsy: comparison between visual analysis and SPM / SPECT cerebral na epilepsia de lobo temporal mesial: comparação entre análise visual e SPM

OBJECTIVE: To compare the accuracy of SPM and visual analysis of brain SPECT in patients with mesial temporal lobe epilepsy (MTLE). METHOD: Interictal and ictal SPECTs of 22 patients with MTLE were performed. Visual analysis were performed in interictal (VISUAL(inter)) and ictal (VISUAL(ictal/inter)) studies. SPM analysis consisted of comparing interictal (SPM(inter)) and ictal SPECTs (SPM(ictal)) of each patient to control group and by comparing perfusion of temporal lobes in ictal and interictal studies among themselves (SPM(ictal/inter)). RESULTS: For detection of the epileptogenic focus, the sensitivities were as follows: VISUAL(inter)=68 percent; VISUAL(ictal/inter)=100 percent; SPM(inter)=45 percent; SPM(ictal)=64 percent and SPM(ictal/inter)=77 percent. SPM was able to detect more areas of hyperperfusion and hypoperfusion. CONCLUSION: SPM did not improve the sensitivity to detect epileptogenic focus. However, SPM detected different regions of hypoperfusion and hyperperfusion and is therefore a helpful tool for better understand pathophysiology of seizures in MTLE.

OBJETIVO: Comparar a acurácia do SPM com a análise visual na detecção do foco epileptogênico e alterações perfusionais à distância no SPECT cerebral. MÉTODO: Foram realizados os SPECTs ictal e interictal de 22 pacientes com epilepsia de lobo temporal mesial (ELTM). A análise visual foi realizada nos estudos interictal (VISUAL(inter)) e ictal (VISUAL(ictal/inter)). Na análise com SPM foi comparado o estudo interictal (SPM(inter)) e ictal (SPM(ictal)) de cada paciente com o grupo controle e comparou-se a perfusão dos lobos temporais entre os estudos ictal e interictal (SPM(ictal/inter)). RESULTADOS: Para a detecção do foco epileptogênico, as sensibilidades foram as seguintes: VISUAL(inter)=68 por cento; VISUAL(ictal/inter)=100 por cento; SPM(inter)=45 por cento; SPM(ictal)=64 por cento and SPM(ictal/inter)=77 por cento. O SPM foi capaz de detectar mais áreas de hiperperfusão e hipoperfusão. CONCLUSÃO: O SPM não aumentou a sensibilidade na detecção do foco epileptogênico. Entretanto, o SPM detectou diferentes regiões de hipoperfusão e hiperperfusão e portanto, ele pode ser uma ferramenta de ajuda para se melhor entender a patofisiologia das crises na ELTM.

Systemic Radionuclide Therapy of Painful Prostate Cancer Bone Metastases With Samarium-153-edtmp

Most patients with prostate cancer (PC) will develop painful bone metastases, which alters their quality of life. Objective: This study aimed to evaluate the efficacy and toxic hematological profile of samarium for the treatment of PC metastases’ bone pain. Methods: Twenty-nine PC patients (median age: 69 years, range: 46-84; Gleason score equal to or higher than 7 in 66.7% and under 7 in 33.3% of patients presenting multiple painful bone metastases were treated with intravenous injection of 153Sm-EDTMP. Response to treatment was defined as either a reduction of at least 25% in patient’s pain score, using a 0 to 10 scale (score 0: no pain, score 10: maximum pain), or in daily analgesic dosage. Complete blood counts were performed before 153Sm–EDTMP administration and 4 and 8 weeks after treatment with the purpose of evaluating hematological side effects of the agent. Results: Twenty-five patients (86.2%) responded to treatment (median time: 1.5 month, range: 1.0 to 2.0 months). A reduction equal to or higher than 25% in post-treatment values compared to baseline values was seen in hemoglobin (Hb) of 3 (12.0%) patients, in leukocytes (Lo) of 16 (64.0%) patients, and in platelets (Pl) of 19 (76.0%) patients. Hb under 10g/dl, Lo under 2.0x103/ul, and Pl under than 50.0x103/ul were seen in 7 (28.0%), 3 (12.0%) and 2 (8.0%) out of 25 patients analyzed after 153Sm–EDTMP, respectively. No infectious or bleeding episodes were seen in any patient during the study. Conclusion: 153Sm-EDTMP is effective for acute control of PC patients’ bone pain. However, additional studies with bone marrow assessment before and after 153Sm–EDTMP are necessary to clarify the origin of cytopenias found in our cases.

Avaliação pré-cirúrgica de epilepsia neocortical de lobo temporal com utilização de FDG-18F SPECT: relato de caso / Surgical planning with 18F-FDG SPECT in refractory neocortical temporal lobe epilepsy: case report

INTRODUÇÃO: Muitos portadores de epilepsias parciais não apresentam foco epileptogênico facilmente identificado na investigação com EEG de superfície e ressonância magnética (RM). Nestes casos o uso de técnicas de neuroimagem funcional como a tomografia por emissão de pósitrons (PET) interictal e a tomografia por emissão de fóton único (SPECT) ictal devem ser considerados, visando evitar a colocação de eletrodos profundos em alguns casos ou guiar o posicionamento destes em outros. O exame de PET, no entanto, não é disponível em grande parte dos centros de epilepsia, principalmente por seu alto custo. OBJETIVO: O nosso objetivo é demonstrar que a utilização de FDG-18F SPECT interictal pode ser uma boa alternativa ao uso do PET na localização do foco e planejamento cirúrgico. MATERIAIS E MÉTODOS: Relato de uma paciente com epilepsia parcial de lobo temporal neocortical, refratária a tratamento clínico, com RM normal e EEG ictal sem localização definida do foco epileptogênico. RESULTADOS: Após a extensa investigação pré cirúrgica sem resultados satisfatórios optou-se pela realização de exame de medicina nuclear FDG-18F SPECT interictal. O exame demonstrou hipometabolismo na região anterior das porções mesial e lateral do lobo temporal direito. A paciente foi, então, submetida à ressecção destas áreas e permanece com excelente controle de crises (Engel IB) 24 meses após a cirurgia. CONCLUSÃO: O FDG-18F SPECT pode tornar-se um substituto do PET nos locais onde esta tecnologia não é disponível.

INTRODUCTION: Several patients with partial epilepsies do not present an easily identified epileptogenic focus on scalp EEG or visible lesion on MRI. There are some useful functional neuroimaging techniques that could be considered in these cases, such as interictal positron emission tomography (PET) scan and ictal single-photon emission computed tomography (SPECT). These techniques can guide the placement of deep electrodes or even prevent their use in some situations. Unfortunately, PET scanners are not easily available in a great number of epilepsy centers because of its cost. OBJECTIVE: To demonstrate that 18F-FDG SPECT could be a good alternative replacing PET scan on localization of epileptic focus and surgical planning in places where this technology is not available. MATERIALS AND METHODS: Case report of a patient with refractory neocortical temporal lobe epilepsy, with normal MRI and nuclear EEG localization. RESULTS: The patient was submitted to interictal 18F-FDG SPECT scan, that showed hypometabolism in the anterior, mesial and lateral parts of the right temporal lobe. These areas were surgically resected and the patient outcome after 24 moths has been very good (Engel IB). CONCLUSION: We suggest that in some situations an interictal 18F-FDG SPECT scan could replace 18F-FDG PET scan where this technique is not available.