Adjuvant Hysterectomy in Patients After Radiation for Locally Advanced Cervical Cancer: A Single-Center Prospective Longitudinal Study.

Introduction: Residual or recurrent cervical cancer post-CCRT is a challenging clinical issue, even though there has been much effort in recent decades to increase patient survival after radiation. There is a paucity of literature regarding the role of hysterectomy in recurrent/residual disease after radiation in LACC patients. Such a procedure is controversial and not routinely performed because of difficulties in obtaining tumor-free margins and the high rate of associated morbidity. Aims and Objectives: Evaluate outcomes and morbidities in patients who had undergone hysterectomy for residual or recurrent disease after radiation in LACC patients. Material and Methods: This is a prospective observational study on radiotherapy-treated LACC patients (IIB-III) with residual disease or recurrent disease who have undergone adjuvant hysterectomy. This study has been conducted at AHPGIC, Cuttack, with a sample size of 30 patients. Results: 18/30 patients underwent extrafascial hysterectomy, and rest 12 patients had radical hysterectomy. No significant difference in complications, achieving tumor free margins or recurrences post adjuvant hysterectomy based on the radicality of surgery was observed. 5 cases of recurrences post-adjuvant hysterectomy were detected. Some of the factors which had significant association with recurrences post adjuvant hysterectomy were non squamous histology, no preoperative brachytherapy, deep stromal invasion and positive surgical margins. Median follow-up time was 14 months (12-27 months). Conclusion: This study shows that adjuvant hysterectomy is feasible with good outcome and acceptable morbidity after chemoradiotherapy in cervical cancer patients "If selection of patients for adjuvant hysterectomy is appropriate."

Validation of renal output efficiency as an objective quantitative parameter in the evaluation of upper urinary tract obstruction.

This is a preliminary study of the parameter, renal output efficiency (ROE), for the quantitation of furosemide (frusemide) response in diuresis renography. This is calculated by a technique independent of variations in uptake rate by the kidneys. Eleven healthy volunteers and 34 patients suspected of upper urinary obstruction were subjected to gamma camera studies using 99mTc-MAG3 and a standard protocol. Furosemide was given at 18 min after the study was started. The ROE was calculated in each kidney and the results were correlated with final diagnosis. The range of ROE in healthy individuals varied between 82% and 98% (mean = 91.6%); while obstructed kidneys showed significantly reduced values (p < 0.001) ranging between 30% and 76% (mean = 56%). In the diagnosis of urinary obstruction, the ROE has a sensitivity of 91%, specificity of 94% and accuracy of 94%. ROE complements conventional diuresis renography and provides better diagnostic yield in patients with impaired renal function.

Captopril renal scintigraphy in patients with hypertension and chronic renal failure.

UNLABELLED: The aim of this prospective study was to determine the ability of the captopril renogram to reveal the presence of angiotensin II-dependent renovascular disorder in hypertensive patients with chronic renal failure and to assess the possibility of predicting beneficial effect of angiotensin-converting enzyme (ACE) inhibitors on renal function. METHODS: Forty-one patients were evaluated. Baseline renal scintigraphy was performed with 80 MBq of 99mTc-mercaptoacetyltriglycine (MAG3) injected intravenously. Scintigraphy was repeated within a week with 25 mg of oral captopril given 60 min prior to the test. Using the measurements outlined by the Working Party on Diagnostic Criteria of Renovascular Hypertension with Captopril Renography, the patients were categorized into high (7 patients), indeterminate (19 patients) and low (15 patients) probability for renal artery stenosis (RAS). RESULTS: In five of the seven patients with high probability, the presence of RAS was confirmed angiographically and corrective surgical procedure performed in two. In patients with GFR of 10 ml/min/1.73 m2 and/or split renal function of 10% or less, all qualitative and semiquantitative scintigraphic parameters were nonspecific. Mean parenchymal transit time of tracer was a useful parameter to predict the beneficial effect of ACE inhibition therapy in 23 patients (14 low and 9 indeterminate probability of RAS). CONCLUSION: In hypertensive patients with renal failure, captopril renal scintigraphy can be utilized to identify the presence of angiotensin II-dependent renal dysfunction and possibly help to predict the beneficial effect of ACE inhibitor therapy.

Is (99m)Tc-sestamibi scintimammography complementary to conventional mammography for detecting breast cancer in patients with palpable masses?

UNLABELLED: The aim of this trial was to evaluate in developing countries from different regions the diagnostic performance of (99m)Tc-sestamibi scintimammography (SM) in palpable breast lesions and to verify the clinical usefulness of a joint evaluation with mammography and SM. METHODS: From 10 countries, a total of 238 patients with palpable breast masses (n = 245) were included in this prospective multicenter trial. Prone SM was performed 10 min and 60-90 min (157 patients) after injection using an isotime acquisition of 10 min. Mammography was assessed by the same dedicated imaging radiologist according to breast imaging reporting and data system (BI-RADS) categories for malignancy and breast density. Masked SM findings and mammography findings were checked for a correlation with histopathology findings for excisional biopsy samples. Diagnostic values for breast cancer detection were calculated per lesion. RESULTS: Histopathology revealed 189 cancerous lesions and 56 benign lesions. The sensitivity and specificity of SM were 0.83 and 0.77, respectively. SM diagnostic values did not depend on the incidence of breast cancer in the country of origin or on the timing of imaging (early vs. delayed scans). On mammography, the technique yielded a sensitivity and specificity of 0.85 and 0.66, with 27 mammograms classified as BI-RADS category 1, 33 as category 2, 5 as category 3, 56 as category 4, and 124 as category 5. Thirty-seven lesions were considered to show increased radiologic density. No significant difference was found in SM diagnostic values among different BI-RADS categories or between the groups with low and high breast density. A sensitivity of 96% was calculated when SM and mammography results were combined, with 75% of all false-negative mammography findings classified as true-positive results by SM. CONCLUSION: SM complements mammography in patients with palpable masses and negative mammography findings.

Technetium-99m-HMPAO SPECT cerebral blood flow study in children with craniosynostosis.

UNLABELLED: Premature closure of cranial sutures (primary craniosynostosis) in children leads to characteristic skull deformities and prevents the constricted brain from growing normally. Although the cause remains unknown, several etiological factors have been cited. Recently, hypovascularity has been reported as a possible cause of craniosynostosis. METHODS: In a prospective study regional cerebral blood flow studies were carried out with 99mTc-HMPAO SPECT in seven children with craniosynostoses. Five preoperative and six postoperative studies were conducted and the results correlated with radiological and surgical findings. RESULTS: Preoperative studies revealed regional hypovascularity in the underlying cerebral hemisphere, corresponding to the fused sutures. Postoperative studies revealed disappearance of these perfusion defects in most cases, indicating normalization of perfusion following surgical decompression. CONCLUSION: This study establishes the presence of cerebral hypovascularity in craniosynostoses and suggests that early surgery and release of craniostenosis is essential to achieve optimum perfusion and brain development.

Imaging bacterial infection with (99m)Tc-ciprofloxacin (Infecton).

AIMS: The diagnosis of deep seated bacterial infections, such as intra-abdominal abscesses, endocarditis, and osteomyelitis, can be difficult and delayed, thereby compromising effective treatment. This study assessed the efficacy of a new radioimaging agent, Tc-99m ciprofloxacin (Infecton), in accurately detecting sites of bacterial infection. METHODS: Eight hundred and seventy nine patients with suspected bacterial infection underwent Infecton imaging and microbiological evaluation. The sensitivity and specificity of Infecton in detecting sites of bacterial infection were determined with respect to Centres of Disease Control, World Health Organisation, and Dukes's criteria. RESULTS: Five hundred and seventy four positive and 295 negative images were produced. These included 528 true positives, 46 false positives, 205 true negatives and 90 false negatives, giving an overall sensitivity of 85.4% and a specificity of 81.7% for detecting infective foci. Sensitivity was higher (87.6%) in microbiologically confirmed infections. CONCLUSIONS: Infecton is a sensitive technique, which aids in the earlier detection and treatment of a wide variety of deep seated bacterial infections. The ability to localise infective foci accurately is also important for surgical intervention, such as drainage of abscesses. In addition, serial imaging with Infecton might be useful in monitoring clinical response and optimising the duration of antimicrobial treatment.

Masked polycythaemia vera in a patient with extrahepatic portal venous obstruction.

Myeloproliferative disorder (MPD) is an important cause of thrombosis of the hepatic and portal venous system. The diagnosis in many of these patients is missed as they have an atypical clinical presentation and may have a normal haematological profile at presentation. We report a 30-year-old patient with features of portal hypertension due to extrahepatic portal venous obstruction. She had a normal haemoglobin level and haematocrit at presentation, but the red cell mass was found to be elevated even in the presence of low serum iron levels. A diagnosis of polycythaemia vera as the underlying disease was made.

Effect of inhalation of salbutamol, beclomethasone dipropionate & ipratropium bromide on mucociliary clearance in some patients with chronic stable bronchial asthma.

BACKGROUND & OBJECTIVES: Asthma is now regarded as an inflammatory disease and bronchial inflammation may disrupt mucociliary function. Inhaled drugs may act by improving mucociliary function. The aim of the study was to investigate the effect of salbutamol, ipratropium bromide and beclomethasone on mucociliary clearance in patients with chronic stable asthma and to compare the efficacy of these drugs on mucociliary clearance. METHODS: Ten patients with chronic stable asthma were enrolled in the study, but two patients did not complete the study. Patients with bronchial asthma were chosen on clinical grounds. (99m)Tc phytate radioaerosol generated through a nebulizer, was given to each patient on four days. After each administration the radioactivity over the thorax was constantly measured in sequential frame mode for 120 min. Radioactivity in the thorax was also measured after 24 h. A base-line pulmonary function test with reversibility was obtained. Salbutamol, ipratropium bromide, beclomethasone dipropionate and placebo inhalation were given randomly to each patient on four days. RESULTS: The mean age of patients (n = 8) was 36 +/- 9.3 yr and mean duration of symptoms was 5 +/- 6.6 yr. There was no visual impression that mucociliary clearance was enhanced with any of the drugs. The time activity curves did not show any visually recognisable change in slope. In only one patient the curve tended to show a steeper slope with ipratropium inhalation. In the rest of the patients the curves showed no difference at all with medication when compared with placebo. All the quantitative indices analyzed by two-way ANOVA at the end of one and two hours were comparable for the three test drugs and placebo. None of the three test drugs demonstrated statistically significant mucociliary clearance effect compared with placebo. However, the temporal difference in airways clearance efficiency (ACE) was significant with beclomethasone and ipratropium bromide. INTERPRETATION & CONCLUSION: Inhalation of any of the three drugs tested did not produce any immediate improvement in mucociliary clearance as compared to placebo in patients with stable bronchial asthma suggesting the need for further studies using higher doses of drugs for longer duration in a large sample.

Significance of transplant perfusion index in the diagnosis of acute rejection in live related renal allograft recipients.

The study was undertaken to assess the usefulness of transplant perfusion index (TPI) in the differential diagnosis of renal allograft dysfunction with special reference to acute rejection. It was observed that the TPI has a sensitivity of 100 per cent and specificity of 98.1 per cent in the diagnosis of acute rejection. It was also observed that the serial values of TPI provided valuable clues and guide in the management of transplant dysfunction and helped in the immediate and long term follow-up of patients with renal allografts.

Clinical features of differentiated thyroid carcinoma in children and adolescents from a sub-Himalayan iodine-deficient endemic zone.

Northern India is an identified sub-Himalayan iodine-deficient endemic zone. We retrospectively analysed the case files of children with differentiated thyroid carcinoma from this endemic zone and attempted to define the disease in terms of its presentation, clinical course and outcome of radioiodine therapy. Between 1967 and June 2000, 1135 patients with thyroid cancer were treated in our centre and 80 (7%) were less than 20 years of age. There were 45 females and 35 males. Histologically, 85% of patients had papillary carcinoma and the rest follicular carcinoma. Cervical lymph node involvement was seen in 66% of patients, and distant metastasis, mainly pulmonary, in 29%. In children less than 10 years of age, 75% of patients had distant metastasis at the time of presentation. The post-surgery 48 h radioiodine neck uptake was 12.2+/-9.6%. Ninety-six per cent of the residual thyroid, 90% of nodal metastases and 57% of pulmonary metastases were ablated. Although nine patients had nodal recurrence between surgery and radioiodine treatment, no recurrence was observed thereafter, and three disease-related deaths (all in children less than 10 years of age) were seen in the mean follow-up of 6 years. We conclude that, except for the relatively higher incidence of follicular thyroid cancer and the higher mortality in the less than 10 year age group, the course and outcome of differentiated thyroid carcinoma in children from iodine-deficient areas is no different from that in children in iodine-sufficient areas.

Effect of Lugol's iodine on the vascularity of thyroid gland in hyperthyroidism.

Vascularity of the thyroid gland was measured in twenty thyrotoxic patients (including Graves and multinodular goitres) and eight normal subjects by a new objective parameter--'Thyroid Vascularity Index' (TVI). The TVI was calculated by comparing the areas under the normalized thyroid and carotid artery curves up to the time of peak of the arterial curve caused by the first passage of a radioactive bolus. Compared to normal thyroid, all the toxic goitres had increased TVI (p less than 0.001); it being maximum in Graves disease (p less than 0.05). TVI in Graves disease was not affected by carbimazole therapy but decreased dramatically in eight out of ten patients (p less than 0.01) two weeks after Lugol's iodine was added. There was a sustained fall in TVI in all the ten patients (p less than 0.001) with chronic iodine therapy up to six weeks without any hormonal escape. TVI in multinodular goitres showed no significance change with carbimazole or iodine therapy.

Scintigraphic patterns of lymphocele in post-renal transplant.

Lymphocele is a common cause of fluid collection in post-renal transplant patients. Most of these patients are routinely followed up with 99mTc diethylenetriaminepentaacetate renal dynamic scintigraphy. The present study retrospectively reviews the range of findings with renal dynamic scintigraphy in documented lymphoceles. A lymphocele was diagnosed when there was a pelvic collection on ultrasonography with a similar biochemical composition to plasma. Four types of scintigraphy patterns were noted in lymphocele in a total of 13 patients. In nine patients there was an initial photopenic area, which progressively filled up with tracer activity equal to that of the background level in delayed images. In two other patients, the activity in the initial photopenic area exceeded the background activity in delayed images. A persistently photopenic area was seen in early and delayed images in the two remaining patients. In addition, a rim of increased tracer activity was noted surrounding the photopenic area in four patients in the early images. In conclusion, an initial photopenic area (with or without a surrounding rim of increased tracer activity), which fills up with tracer in delayed images seems to be the most common pattern seen in lymphoceles in scintigraphic studies of renal transplants. The presence of a rim sign may add confidence to the reporting of a collection as a lymphocele.

Individual kidney glomerular filtration rate in the interpretation of non-diagnostic curves on captopril renography.

Captopril renography is known to have low sensitivity in the detection of renovascular disease in patients with bilateral renovascular disease and in patients with unilateral renovascular disease with a small kidney. In these groups of patients, we have tried to make the standard captopril renogram more objective by simultaneously estimating the individual kidney glomerular filtration rate (IKGFR). Twenty-five patients (10 bilateral, 15 unilateral) with angiographically proven renal artery stenosis (RAS) were studied. Ten renal units in five hypertensive patients with normal renal arteries were used as controls. A fall of more than 10% in IKGFR post-captopril was considered a positive result. The sensitivities of renogram and IKGFR in patients with bilateral RAS were 52.9% and 88.2% respectively. In patients with unilateral RAS, the sensitivities of renogram and IKGFR were 30% and 80% respectively. A significant fall in IKGFR was noted in eight of the 15 'normal' renal units of the unilateral RAS group. In conclusion, individual kidney GFR estimation in combination with captopril renography improved significantly the sensitivity in patients with symmetrical bilateral RAS and unilateral RAS with a small, poorly functioning kidney. A fall in GFR in the normal counterpart of a unilateral RAS kidney may be indicative of ongoing damage in the non-involved kidney.

Radioiodine kinetics and thyroid function following the universal salt iodization policy.

BACKGROUND: Universal salt iodization was introduced in Delhi in 1989. The present study quantifies the change in iodine kinetics as a result of this. The previous values were reported 10-30 years earlier, when Delhi was iodine deficient. METHODS: Thirty subjects (18 men and 12 women, 17-48 years of age) who were residents of Delhi and had no thyroid disorder, were recruited from our outpatient clinic in 1999. The 24-hour urinary excretion of iodine and the iodine content of salt consumed at home by these subjects were estimated. Kinetic studies of iodine using radiotracer 131I were done to determine thyroid iodine clearance, renal iodine clearance, percentage uptake and absolute iodine uptake by the thyroid gland, and plasma inorganic iodine. RESULTS: The median 24-hour urinary iodine excretion was 341.3 micrograms. The mean (SD) thyroid uptake of radioactive iodine was 4.9 (2.3)% at 2 hours and 19.1 (8.0)% at 24 hours. The median calculated plasma inorganic iodine was 1.36 micrograms/dl, absolute iodine intake 6.5 micrograms/hour and thyroid iodine clearance was 4.8 ml/minute (geometric means 1.68 micrograms/dl, 8.5 micrograms/hour and 8.1 ml/minute, respectively). The serum thyroid hormones and thyroid stimulating hormone were within normal limits. CONCLUSION: Compared to the values reported 10-30 years ago when the population was iodine deficient, the present urinary iodine excretion, plasma inorganic iodine and absolute iodine intake have increased, while the percentage thyroid uptake of iodine ingested and thyroid clearance have decreased. The lack of change in the serum thyroid hormone levels after 10 years of universal salt iodization indicates that iodine consumption has had no adverse effect on thyroid function in these normal individuals. These changes are consistent with the increase in iodine consumption. Since the iodine ingestion in a community may change with time, assessment of iodine kinetics should be done periodically in different regions of the country.

A distance-assisted training program for nuclear medicine technologists.

We have developed training materials for nuclear medicine technologists to be used in distance-assisted training programs. We have completed our first pilot project in Asia and report that there will be nearly 500 students around the world, in Asia, Africa, Central America and South America, using our materials during the coming year.

Hepatobiliary scintigraphy in congenital cystic dilatation of biliary tract.

Six preoperative and five postoperative hepatobiliary scans in children having cystic dilatation of the biliary tract were analyzed. The preoperative hepatobiliary scans revealed three distinct patterns. The type 1 pattern showed, in early scans, good hepatic uptake of radioactivity, and photon deficient area(s) around the porta hepatis or in the subhepatic region. These area(s) showed progressive accumulation of radio activity in the delayed scans. The type 2 pattern revealed poor hepatic uptake, nonvisualization of major biliary channels, and photon deficient area(s) in the porta hepatis or subhepatic region which persisted throughout the study. Preoperatively, it was possible to diagnose cystic dilatation of biliary tract in cases that showed type 1 and type 2 patterns. No preoperative diagnosis was possible when the scans showed a type 3 pattern. Analysis of results revealed a correct pre-operative diagnostic rate of 83.3% for the cystic dilatation of biliary tract. It was also possible to provide correct functional information regarding the patency of the bile outflow tract in all 11 cases, both pre- and postoperatively, with a diagnostic rate of 100%. On the basis of the overall accuracy of results obtained in this series, hepatobiliary scintigraphy is strongly advocated in suspected cases of cystic dilatation of the biliary tract for the initial diagnosis and for the assessment of the status of the bilioenteric bypass postoperatively.

Spontaneous perforation of the common bile duct in infancy: role of Tc-99m mebrofenin hepatobiliary imaging.

A 2-month-old infant had jaundice that began 3 days after birth. The clinical features were suggestive of biliary obstruction. Tc-99m mebrofenin hepatobiliary imaging confirmed the diagnosis of spontaneous perforation of the common bile duct, and surgical intervention resulted in progressive recovery.

Serendipity in technetium-99m DTPA renal dynamic study.

A nine-year-old child was referred for a routine renal dynamic study to detect a renal and/or renovascular cause for hypertension. Tc-99m DTPA renography accidentally discovered and correctly localized a pheochromocytoma.

"Insular" carcinoma of thyroid. A subset of anaplastic thyroid malignancy with a less aggressive clinical course.

Insular carcinoma of the thyroid appears to represent an entity situated morphologically and biologically in an intermediate position between the well-differentiated and undifferentiated (anaplastic) tumors. The retention of I-131 concentrating ability by this variant, unlike anaplastic, is very encouraging and amenable to detection and therapy by radioiodine after initial aggressive surgery. A 46-year-old man with a histologic label of anaplastic thyroid carcinoma has had an unusually prolonged disease-free survival and histopathologic review confirmed insular carcinoma. Postoperative radioiodine evaluation revealed avid concentration of tracer in the thyroid bed. Thus, it is possible to ablate with radioiodine. The insular carcinoma should be considered as a distinct clinicopathologic entity and widespread awareness of this variant of tumor may help pathologists, surgeons, and nuclear medicine practitioners to aggressively treat the condition after initial diagnosis.

Reflex sympathetic dystrophy of the patello-femoral joint. Diagnosis and relevance.

A 30-year-old man had severe left anterior knee pain after a trivial injury. A three-phase bone scan diagnosed this condition to be reflex sympathetic dystrophy, which was subsequently confirmed by sympathetic blockade.