A. Soriano Castrejón

Localización radioguiada de lesiones ocultas de mama (ROLL)

OBJECTIVE: To obtain correct location of occult breast lesions by radiopharmaceutical methods. MATERIAL AND METHODS: Sixty-one patients whose ages ranged from 32 to 83 years (average: 57), with non-palpable breast lesions detected by mammography were studied. Six of them had a background of previous breast cancer. Sixty-three lesions were found. The lesions were classified into 34 clusters of microcalcifications, 25 nodules and 4 others parenchymal distortions. All patients received one dose of 0.3-0.5 mCi (11.1-18.5 MBq) of macroaggregates of 99mTc-labelled human serum albumin (99mTc-MAA) into the lesion under stereotactic mammographic or ultrasonography guidance. Anterior and lateral scintigraphic images were acquired in order to verify the correct location of the radiopharmaceutical. Intraoperative location of the lesion was performed using a gammaprobe. In case of microcalcifications, the entire removal of the lesion was verified by X-ray of the specimen. RESULTS: Placement of the radiotracer was good in 60 of 63 (95.2%) cases. Sixty-one lesions were completely removed. Pathological examination revealed 29 (47.6%) breast cancers and 32 (52.4%) benign lesions. CONCLUSION: Radioguided occult breast lesion location by radiopharmaceutical methods is a simple, safe and well-tolerated method by patients.

La satisfacción del usuario como indicador de calidad en un servicio de Medicina Nuclear

Resumen Objetivo Valorar el grado de satisfaccion e insatisfaccion del paciente con el servicio de Medicina Nuclear. Material y metodos Se diseno un cuestionario compuesto por 9 preguntas cerradas, una de escala numerica y otra pregunta abierta que recogio comentarios y sugerencias. Las preguntas consideraron diferentes dimensiones de calidad del servicio relacionadas con el tiempo de espera en la realizacion de la exploracion, informacion, instalaciones, trato recibido por el personal del servicio y satisfaccion global (escala numerica 1-10). El grado de insatisfaccion se establecio mediante el analisis de quejas escritas recibidas en los ultimos 6 anos. Resultados Se obtuvieron 671 cuestionarios. El 58 % de los encuestados fueron mujeres. La edad media fue de 56,5 anos (DE: 16,26). La informacion suministrada fue correcta para el 81,7 % de los encuestados. El equipamiento y las instalaciones fueron satisfactorios para el 74,5 % de los pacientes. La lista de espera y el tiempo de espera fueron correctos para el 70 % y el 66,4 % respectivamente. El trato correcto fue el parametro mas favorablemente valorado (98,7 %). La satisfaccion global fue positiva (≥7 sobre 10) para el 82,8 % de los pacientes. Se recibieron un total de 29 quejas. La mayoria se baso en aspectos relacionados con la lista de espera (12) y disconformidad con la asistencia (9). Conclusiones El grado de satisfaccion fue alto en la mayoria de los pacientes. El tiempo de espera constituyo el parametro con menor satisfaccion y, por lo tanto, subsidiario de mejora. La principal queja espontanea referida por nuestros pacientes fue la lista de espera.

Análisis de costo-efectividad en el diagnóstico de fiebre de origen desconocido y el papel de la 18F-FDG PET-TC: propuesta de algoritmo diagnóstico

AIM To analyze the costs of Fever of Unknown Origin (FUO) prior to the PET-CT study. To determine the effectiveness of PET-CT in the diagnosis of FUO. A proposal of diagnostic algorithm. MATERIAL AND METHODS A retrospective study was performed that included 20 patients who had been studied between January 2007 and January 2011, with a mean age of 57.75 years and FUO diagnosis. All underwent a PET-CT study with (18)F-FDG. Individual and mean costs of FUO in these patients were assessed, including hospitalization days and complementary tests prior to the PET-CT study. The effectiveness of the PET-CT study in the diagnosis of FUO was analyzed. Costs of the FUO process were determined, including those of the PET-CT study, and if it had been done earlier in the diagnostic process. RESULTS Mean hospital stay per patient until the PET-CT study was 28 days. The cost per hospitalization day was 342 €. Average cost per patient in complementary tests was 1395 €. Total cost of the FUO process until the PET-CT study was around 11167 € per patient. The PET-CT study showed a 78% sensitivity, 83% specificity, 92% PPV and 62% NPV. If PET-CT had been performed earlier in the FUO process, assuming the same effectiveness, 5471 € per patient would have been saved. CONCLUSION The PET-CT study could be cost-effective in the FUO process if used at an early stage, helping to establish an early diagnosis, reducing hospitalization days due to diagnostic purposes and the repetition of unnecessary tests.

18F-FDG semi-quantitative parameters and biological prognostic factors in locally advanced breast cancer

AIM To analyse the correlation between (18)F-FDG uptake assessed by PET/CT in locally advanced breast tumours and histopathological and immunohistochemical prognostic factors. MATERIAL AND METHODS Thirty-six women with breast cancer were prospectively evaluated. PET/CT was requested in the initial staging previous to adjuvant chemotherapy (multicentric study). All the patients underwent an (18)F-FDG PET/CT with a dual-time-point acquisition. Both examinations were evaluated qualitatively and semiquantitatively with calculation of SUVmax values in PET-1 (SUV-1) and in PET-2 (SUV-2) and the percentage variation of the standard uptake values (retention index) between PET-1 and PET-2. Clinical and metabolic stages were assessed according to TNM classification. The biological prognostic parameters, such as the steroid receptor status, p53 and c-erbB-2 expression, proliferation rate (Ki-67), and grading were determined from tissue of the primary tumour. Metabolic and biological parameters were correlated. RESULTS A positive relationship was found between semiquantitative metabolic parameters and biological parameters. SUV-1 and SUV-2 values did not show significant statistical correlation (p<.05) except for the clinical tumour size. About the biological parameters, retention index showed the best results with positive and significant relation (p<.05) with estrogen and progesterone receptor status and Ki-67. Isolated SUV values did not show significant relation to these parameters. CONCLUSION Retention index showed the best relation with biological parameters compared to isolated SUVmax values. These data suggest that SUV change over time is a prognostic marker.

PET-TAC con contraste intravenoso en la valoración de pacientes con linfoma. Aproximación hacia las indicaciones diagnósticas

AIM To define the utility of intravenous contrast administration in the PET-CT (PET-CTc) in patients with lymphoma in order to determine its possible indications. MATERIAL AND METHODS 78 patients with lymphoma were prospectively evaluated. All underwent simultaneous PET-CTc scans in a hybrid system for staging (8), evaluation of response to treatment (29), suspicion of recurrence (9) and complete remission control (48). The PET scan was acquired by a conventional method and the diagnostic CT scan was performed according to radiological protocol. Both examinations were evaluated blinded and independently, analyzing 28 anatomical locations in order to determine the degree of agreement. Final diagnosis was established by the clinician based on the histological study, results of other diagnostic techniques or clinical follow-up. RESULTS The final result of both techniques were concordant in 87/94 studies (92.5%). A total of 158 (36 FP) pathological locations were detected with PET-CT and 189 (71 FP) with CTc, with 72 locations being discordant between both techniques. Global sensitivity, specificity, PPV and NPV were 93%, 98%, 77% and 99%; and 94%, 97%, 62% and 99%, respectively. CONCLUSIONS Administration of intravenous contrast does not seem to provide any advantage in the determination of nodal and extranodal disease in lymphoma patients. The low prevalence of disease probably accounts for the limited PPV of both techniques. An increase of our sample size, with a greater homogeneity of the groups, should offer more reliable results.

Utilidad de la imagen de transportadores de dopamina (SPECT cerebral con ioflupano I-123) en la valoración de los trastornos del movimiento

Resumen Objetivo El objetivo de nuestro trabajo fue valorar la precision diagnostica de la imagen de transportadores de dopamina con Ioflupano I-123 en los pacientes con temblor y algun otro signo anadido de parkinsonismo en cuanto a su catalogacion en parkinsonismos con afectacion/indemnidad de neuronas dopaminergicas presinapticas asi como para establecer un diagnostico diferencial entre temblor esencial (TE) y parkinsonismo degenerativo. Material y metodos Incluimos 105 pacientes, 45 en los que era necesario establecer un diagnostico diferencial entre parkinsonismo degenerativo y TE, 52 para determinar cual era el origen de su parkinsonismo (degenerativo versus secundario) y 8 con un diagnostico definitivo, 5 de enfermedad de Parkinson (EP) y 3 de TE. Se administro una dosis de 185 MBq de Ioflupano I-123 y se adquirio el estudio tomografico a las 5 horas. Tras la reconstruccion, se valoraron los cortes transaxiales por tres observadores. En todos los pacientes se establecio el diagnostico por un neurologo especializado en trastornos del movimiento, segun la clinica, evolucion, respuesta al tratamiento y resultado del Ioflupano I-123. Resultados 42 pacientes fueron diagnosticados de parkinsonismo degenerativo (EP o parkinsonismo plus) y 63 de TE o parkinsonismos secundarios. Obtuvimos unos valores de sensibilidad, especificidad, VPP, VPN y precision diagnostica del 93 %, 100 %, 100 %, 97 % y 97 % respectivamente. En el 18 % de los pacientes el Ioflupano I-123 indujo un cambio en el manejo terapeutico. Conclusiones El SPECT con Ioflupano I-123 se muestra como un test de gran valor diagnostico para establecer diagnostico diferencial entre parkinsonismo degenerativo versus TE y parkinsonismo secundario versus degenerativo.

Dual time point 2-deoxy-2-[18F]fluoro-D-glucose PET/CT: nodal staging in locally advanced breast cancer.

AIM To assess dual time point 2-deoxy-2-[(18)F]fluoro-D-glucose (18)(F)FDG PET-CT accuracy in nodal staging and in detection of extra-axillary involvement. MATERIAL AND METHODS Dual time point [(18)F] FDG PET/CT scan was performed in 75 patients. Visual and semiquantitative assessment of lymph nodes was performed. Semiquantitative measurement of SUV and ROC-analysis were carried out to calculate SUV(max) cut-off value with the best diagnostic performance. Axillary and extra-axillary lymph node chains were evaluated. RESULTS Sensitivity and specificity of visual assessment was 87.3% and 75%, respectively. SUV(max) values with the best sensitivity were 0.90 and 0.95 for early and delayed PET, respectively. SUV(max) values with the best specificity were 1.95 and 2.75, respectively. Extra-axillary lymph node involvement was detected in 26.7%. CONCLUSION FDG PET/CT detected extra-axillary lymph node involvement in one-fourth of the patients. Semiquantitative lymph node analysis did not show any advantage over the visual evaluation.

Implantación de un sistema de gestión de calidad según norma UNE-UN-ISO 9001:2008 en un servicio de medicina nuclear

OBJECTIVE To describe the process of implementing a quality management system according to UNE-EN-ISO 9001:2008 standard in a Nuclear Medicine Department. MATERIAL AND METHOD In February 2008, the committee on internal quality of the Department was established, naming a responsible physician. The general operating plan was drawn up, following the requirements established by the ISO 9001:2008 standard. It defined the scope of the standard, defining, preparing and transcribing the various activities of our Department. Four training sessions were carried out. RESULTS A total of nine general and two specific procedures were documented in which all the activities performed in our Department were included. Personnel records of each worker were created, including their profiles and training plan. A record of the equipment and service providers was created, as well as issues with the latter. Satisfaction surveys were obtained from external (patients) and internal customers (faculty applicants). Targets for improvement and activity markers were established. Two audits were performed to complete the process, one internal and one external. The Department was accredited in April 2010. CONCLUSION The quality accreditation process is a tool that requires reflection on how we do things and how they can be improved. It makes it possible to measure what we do, to analyze and introduce improvement measures, and therefore, to achieve a higher level of quality in the service we provide our customers. The involvement of the Department workers with a commitment to team performance was essential.OBJECTIVE To describe the process of implementing a quality management system according to UNE-EN-ISO 9001:2008 standard in a Nuclear Medicine Department. MATERIAL AND METHOD In February 2008, the committee on internal quality of the Department was established, naming a responsible physician. The general operating plan was drawn up, following the requirements established by the ISO 9001:2008 standard. It defined the scope of the standard, defining, preparing and transcribing the various activities of our Department. Four training sessions were carried out. RESULTS A total of nine general and two specific procedures were documented in which all the activities performed in our Department were included. Personnel records of each worker were created, including their profiles and training plan. A record of the equipment and service providers was created, as well as issues with the latter. Satisfaction surveys were obtained from external (patients) and internal customers (faculty applicants). Targets for improvement and activity markers were established. Two audits were performed to complete the process, one internal and one external. The Department was accredited in April 2010. CONCLUSION The quality accreditation process is a tool that requires reflection on how we do things and how they can be improved. It makes it possible to measure what we do, to analyze and introduce improvement measures, and therefore, to achieve a higher level of quality in the service we provide our customers. The involvement of the Department workers with a commitment to team performance was essential.

Impacto diagnóstico y terapéutico de la 18F-FDG-PET/TAC en pacientes con sospecha de recidiva de cáncer de mama

Breast cancer is a tumor with high prevalence in our environment. Thus, it is essential to make an early diagnosis in both the primary disease and its recurrence, given the high mortality of the cases with the advanced disease. Our study has aimed to evaluate the impact of (18)F-FDG-PET/CT in patients with suspected breast cancer recurrence and their therapeutic management. This study analyzed the PET/CT of 70 patients with a background of breast cancer and suspicion of recurrence, either because of elevation of tumor markers (n=28), doubtful findings on other imaging techniques (n=56) and/or suspicious symptoms (n=1). All the patients underwent a standard FDG-PET study acquired in combination with low-dose CT. The studies were considered pathological in 34 of the 70 patients, with 29 true positive, 32 true negative, 5 false positive and 4 false negative results. The final diagnosis was established either by histopathologic confirmation (n=17), other imaging techniques (n=26) and/or clinical radiological follow-up (n=27, mean 12.7 months). The sensitivity, specificity, positive predictive value and negative predictive values obtained were 87.8%, 86.4%, 85.2% and 88.8%, respectively. Therapeutic management was modified in 41% of the patients. In conclusion, PET/CT is a technique with high diagnostic yield in patients with suspected breast cancer recurrence.

PET-TAC con 18F-FDG en el seguimiento de pacientes con linfoma, detección de recidivas asintomáticas

AIM To assess the diagnostic accuracy of (18)F-FDG-PET/CT in detecting asymptomatic recurrences in patients with lymphoma. To define uptake patterns of recurrence indicative of recurrence. MATERIAL AND METHODS Those patients with lymphoma who fulfilled the following inclusion criteria of clinical complete remission and negative PET/CT study were included retrospectively and longitudinally. Conventional surveillance of these patients was performed only by (18)F-FDG PET/CT following a standardized procedure. Pathologic locations (supra- and infradiaphragmatic) and their character (single or multiple) were analyzed in order to determine reliable metabolic patterns of recurrence. The final diagnosis was established by histopathological analysis or clinical follow-up greater than 8 months. RESULTS A total of 199 explorations belonging to 106 patients with lymphoma were included. Of these patients, 59 had Hodgkins lymphoma and 47 non-Hodgkins lymphoma. There was suspicion of relapse from the metabolic point of view in 27 of the PET/CT scans. Of these, 14 (10 patients) were false positive (FP), and 13 (8 patients) true positive. The remaining studies were true negative, no false negatives being detected. The pattern most frequently related to recurrence was infradiaphragmatic lymph node involvement while most of the FP had isolated supradiaphragmatic involvement. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of PET/CT parameters for the study were 100%, 92%, 48%, 100% and 93%, respectively. CONCLUSION (18)F-FDG-PET/CT is a sensitive technique in the detection of asymptomatic recurrences in patients with lymphoma during their follow-up. Multiple character and infradiaphragmatic locations were the patterns that best correlated to the diagnosis of recurrence.AIM To assess the diagnostic accuracy of (18)F-FDG-PET/CT in detecting asymptomatic recurrences in patients with lymphoma. To define uptake patterns of recurrence indicative of recurrence. MATERIAL AND METHODS Those patients with lymphoma who fulfilled the following inclusion criteria of clinical complete remission and negative PET/CT study were included retrospectively and longitudinally. Conventional surveillance of these patients was performed only by (18)F-FDG PET/CT following a standardized procedure. Pathologic locations (supra- and infradiaphragmatic) and their character (single or multiple) were analyzed in order to determine reliable metabolic patterns of recurrence. The final diagnosis was established by histopathological analysis or clinical follow-up greater than 8 months. RESULTS A total of 199 explorations belonging to 106 patients with lymphoma were included. Of these patients, 59 had Hodgkins lymphoma and 47 non-Hodgkins lymphoma. There was suspicion of relapse from the metabolic point of view in 27 of the PET/CT scans. Of these, 14 (10 patients) were false positive (FP), and 13 (8 patients) true positive. The remaining studies were true negative, no false negatives being detected. The pattern most frequently related to recurrence was infradiaphragmatic lymph node involvement while most of the FP had isolated supradiaphragmatic involvement. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of PET/CT parameters for the study were 100%, 92%, 48%, 100% and 93%, respectively. CONCLUSION (18)F-FDG-PET/CT is a sensitive technique in the detection of asymptomatic recurrences in patients with lymphoma during their follow-up. Multiple character and infradiaphragmatic locations were the patterns that best correlated to the diagnosis of recurrence.