Cuneyt Turkmen

The additional value of FDG PET imaging for distinguishing N0 or N1 from N2 stage in preoperative staging of non-small cell lung cancer in region where the prevalence of inflammatory lung disease is high.

Purpose: The aim of this study was to evaluate the efficacy of PET imaging and compare it with the performance of CT in mediastinal and hilar lymph node staging in potentially operable non-small cell lung cancer (NSCLC). Methods: Fifty-nine patients with potentially resectable NSCLC who underwent preoperative PET and CT imaging were enrolled into this prospective study. All patients underwent surgical evaluation by means of mediastinoscopy with mediastinal lymph node sampling (14 patients) or thoracotomy (45 patients). Results: The prevalence of lymph node metastases was 53%. Overall, the sensitivity, specificity, accuracy, PPV, and NPV of PET were 79%, 76%, 78%, 86%, and 76% for N0 and N1 lymph nodes and 76%, 79%, 80%, 67%, and 83% for N2 lymph nodes, while those values for CT were 66%, 43%, 58%, 68%, and 43% for N0 and N1 stations and 43%, 66%, 54%, 41%, and 66% for N2 lymph nodes, respectively. PET correctly differentiated cases with mediastinal lymph node involvement (N2) from those without such involvement (N0 or N1) in 76% of cases. Statistical analysis of the diagnostic accuracy of nodal involvement showed that PET improves diagnostic accuracy significantly in the detection of both N0 or N1 and N2 status in the individual patient based on analysis, compared with CT (P < 0.01 and P < 0.01, respectively). When preoperative nodal staging was compared with postoperative histopathological staging, 38 (65%) patients were correctly staged, 9 (15%) were overstaged, and 12 (20%) were understaged by PET, while 29 patients (49%) were correctly staged, 13 (22%) were overstaged, and 17 (29%) were understaged by CT. Conclusion: It has been clearly shown that PET is more accurate than CT for the differentiation of N0 or N1 from N2 disease in patients with NSCLC. However, PET imaging alone does not appear to be sufficient to replace mediastinoscopy for mediastinal staging in patients with lung cancer, especially in geographic regions with high granulomatous or inflammatory mediastinal disease prevalence.

Comparison of different injection sites of radionuclide for sentinel lymph node detection in breast cancer: single institution experience.

Background: There are still ongoing controversies about several aspects of lymphatic mapping and sentinel lymph node biopsy for breast cancer, including injection site of radioisotope and blue dye. This study aims to evaluate the success rate of different radiocolloid injection techniques in the detection of sentinel lymph nodes (SLN) in early breast cancer. Study Design: One hundred ninety-two women with early breast cancer were included. For SLN mapping with lymphoscintigraphy (LSG), 5 different injections were used. Group A (36 patients) had 4 peritumoral (PT), group B (n = 36) had 1 subdermal (SD) injection of Tc-99m rhenium sulfide colloid over the tumor quadrant. Group C (59 patients) had 1 PT and 1 SD combined injections. In group D (56 patients), lymphatic mapping was performed with 2 intradermal periareolar (ID-PA) injections. In group E (n = 41), 2 ID-PA and 1 PT combined injections were performed. Early dynamic and delayed images were obtained. A surgical gamma probe was used to explore the SLNs. Surgical specimens were evaluated histopathologically. The SLN identification rate, false negative rate, and comparison of groups were evaluated by statistical methods. Results: The SLN identification rate by LSG in groups A, B, C, D, and E were 72%; 92%, 93.2%, 98%, and 95%, respectively. The highest detection rates for the axilla (98%) and mammary internal (MI) drainage (22%) were obtained with ID-PA injections and a peritumoral injection, respectively. Seventy of 192 patients (36.4%) had positive axillary lymph nodes. The only statistically significant difference was between the PT and SD injection groups in axillary SLN identification rate by LSG (P = 0.016). Conclusion: The success rate was superior with intradermal periareolar injection compared with PT and SD injection to visualize the axillary SLN. However, PT deep injection combined with ID-PA injections may be more favorable to demonstrate the primary internal mammary (IM) lymphatic drainage.

Effect of intracoronary streptokinase administered immediately after primary percutaneous coronary intervention on long-term left ventricular infarct size, volumes, and function.

OBJECTIVES The purpose of this study was to investigate the reflections of the improvement in microvascular perfusion provided by adjuvant intracoronary streptokinase (ICSK) on late-phase infarct size and left ventricular volumes and functions. BACKGROUND It has been shown that ICSK given immediately after primary percutaneous coronary intervention (PCI) improves myocardial perfusion in the early days of ST-segment elevation acute myocardial infarction. METHODS Ninety-five patients undergoing primary PCI were randomized to ICSK 250 kU (n = 51) or no additional therapy (n = 44). Two days later, coronary hemodynamic indexes were measured to evaluate tissue-level perfusion. After 6 months, angiography, echocardiography, and technetium-99m single-photon emission computed tomography (SPECT) were performed. RESULTS At 2 days, all indexes of microvascular function were significantly better in the ICSK group than in the control group, including coronary flow reserve (2.5 vs. 1.7, p < 0.001) and index of microvascular resistance (20.2 vs. 34.2, p < 0.001). At 6 months, infarct size (22.7% vs. 32.9%; p = 0.003) and left ventricular end-systolic (41.1 ml vs. 60.9 ml; p = 0.009) and end-diastolic volumes (95.5 ml vs. 118.3 ml; p = 0.006) were significantly smaller, and the ejection fraction was significantly higher (57.2% vs. 51.8%; p = 0.018) in the ICSK group compared with the control group. CONCLUSIONS In this study, it has been demonstrated that low-dose ICSK given immediately after primary PCI significantly limits long-term infarct size and preserves left ventricular volumes and functions. (Effect of Complementary Intracoronary Streptokinase Administration Immediately After Primary Percutaneous Coronary Intervention on Microvascular Perfusion and Late Term Infarct Size in Patients With Acute Myocardial Infarction; NCT00302419).

Diagnostic value of PET/CT is similar to that of conventional MRI and even better for detecting small peritoneal implants in patients with recurrent ovarian cancer.

ObjectiveThe aim of this study was to evaluate the diagnostic value of 2-(fluorine-18)-fluoro-2-deoxy-D-glucose (18F-FDG) PET/CT in comparison with MRI for the detection of recurrent ovarian cancer. MethodsForty-seven patients with suspected ovarian cancer recurrence after total ablative or cytoreductive surgery, as well as neoadjuvant or adjuvant chemotherapy, who had undergone 18F-FDG PET/CT imaging were recruited for the present study. All patients also underwent MRI within a month of 18F-FDG PET/CT for the same purpose. Recurrent cancer in the abdomen and pelvis was evaluated in each of the 47 patients and classified as either distant metastasis or local pelvic recurrence involving the vaginal stump, peritoneal implants, supradiaphragmatic region, and/or abdominal and pelvic lymph nodes. Special attention was paid to peritoneal implants. These were divided into five groups according to size of the implants: less than 0.5 cm (group 1), 0.5–1 cm (group 2), 1–2 cm (group 3), 2–3 cm (group 4), and larger than 3 cm (group 5). PET/CT findings were compared with abdominopelvic MR findings. Statistical analysis was carried out using the Wilcoxon signed rank test. ResultsThirty-nine of 47 patients were found to have recurrent ovarian cancer. Both PET/CT and MRI were negative for recurrence in six patients. Overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of PET/CT were 97.5, 100, 100, 87.5, and 97.8%, respectively, whereas those of MRI were 95, 85.7, 97.4, 75, and 93.6%, respectively. For the peritoneal implants in groups 2 and 3, the sensitivity, negative predictive value, and diagnostic accuracy values of PET/CT were significantly better than those of MRI (P<0.05). ConclusionThe present study revealed that PET/CT is similar to conventional MRI for the detection of recurrent ovarian cancer. PET/CT has greater accuracy in the detection of small-to-medium-sized (<2 cm) peritoneal implants compared with MRI. This may affect surgical decision making.

Monitoring the genotoxic effects of radiosynovectomy with Re-186 in paediatric age group undergoing therapy for haemophilic synovitis

Summary.  Purpose: The aim of this study was to investigate the genotoxic effect on the peripheral blood lymphocytes potentially induced by Re‐186 in paediatric age group undergoing radiosynovectomy for haemophilic synovitis, by using chromosomal aberration analysis (CA) and the micronuclei (MN) assay for detecting chromosomal aberrations, as well as the sister chromatid exchanges (SCE) technique for assessing DNA damage. Methods: Cytogenetic analyses were evaluated in 20 boys (mean age: 13.8 ± 2.7 years) before, and 2 and 90 days after radiosynovectomy from the peripheral lymphocytes of the patients. Joint retention and extra‐articular spread of the radionuclides were evaluated by using quantitative gamma camera imaging. Results: Imaging after radiosynovectomy revealed local lymph node visualization in 8 (40%) patients and hepatosplenic visualization in 3 (15%) patients due to extra‐articular leakage of radioactive material. The mean frequency of chromosome aberrations (0.2 ± 0.4/1000 cells) determined prior to the onset of therapy was not significantly increased in comparison with control values obtained 2 days (0.4 ± 0.5/1000 cells) and 90 days (0.2 ± 0.4/1000 cells) after therapy (P = 0.754 and P = 1.0). In the analysis of MN and SCE, when we compare the baseline levels, the mean MN and SCE frequencies were slightly higher in the control analyses performed 2 and 90 days after radiosynovectomy but there were no significant differences between baseline and control levels (χ2 = 2.621, P = 0.270 and F = 0.573, P = 0.569, respectively). Conclusion: The major finding of this study with relatively small sample is that, radiosynovectomy with Re‐186 does not seem to induce early genotoxic effects on the peripheral blood lymphocytes in paediatric age group.

The Value of Somatostatin Receptor Imaging with In-111 Octreotide and/or Ga-68 DOTATATE in Localizing Ectopic ACTH Producing Tumors

Objective: We aimed to evaluate the value of somatostatin receptor imaging (SRI) with In-111 octreotide and Ga-68 DOTATATE in localizing ectopic ACTH producing tumors. Methods: Nineteen patients who had In-111 octreotide somatostatin receptor scintigraphy (SRS) and/or Ga-68 DOTATATE PET-CT to localize ectopic ACTH producing tumors between the years 2000 and 2012 were included retrospectively in our study. The results of SRI were compared with clinical onset, radiological findings and surgical data of the patients. Results: Sixteen In-111 octreotide SRS and five Ga-68 DOTATATE PET-CT were performed in 19 patients. In eight out of 19 patients, ectopic ACTH secretion site could be detected. In five patients, SRS showed pathologic uptake. In four of these patients, surgery revealed pulmonary carcinoid tumors and in one patient pancreatic neuroendocrine tumor. In one patient, Ga-68 DOTATATE PET-CT revealed pathologic uptake in lung nodule which came out to be pulmonary carcinoid tumor. In another patient who had resection of metastases of atypical carcinoid tumor prior to scans, new metastatic foci were detected both with SRS and Ga-68 DOTATATE PET-CT imaging. In one patient, although SRS was negative, CT which was performed three years later showed a lung nodule diagnosed as pulmonary carcinoid tumor. In 11 patients, ectopic ACTH secretion site could not be detected. In 10 of those patients, scintigraphic and radiological imaging did not show any lesions and in one patient, Ga-68 DOTATATE PET-CT was false positive. Conclusion: SRI has a complementary role with radiological imaging in localizing ectopic ACTH secretion sites. PET-CT imaging with Ga-68 peptide conjugates is a promising new modality for this indication. Conflict of interest:None declared.

The role of peritoneal scintigraphy in the detection of continuous ambulatory peritoneal dialysis complications.

While continuous ambulatory peritoneal dialysis (CAPD) offers several advantages over hemodialysis in patients with end-stage renal disease, several complications have been recognized. The intraperitoneal instillation of dialysate increases intra-abdominal pressure and consequently predisposes the patient to leaks and herniations through defects in the abdominal wall. The use of an intraperitoneal radiolabeled colloid has been previously described to image entities such as hernias, patent processus vaginalis, abdominal wall, and diaphragmatic leakage. This study shows a simple, non-invasive method of determining the site of dialysate leak and its importance to assist further patient management. There has been a continuing increase in the number of end stage renal disease patients maintained on chronic peritoneal dialysis (CPD). Many patients choose CPD as their preferred chronic dialysis treatment, though approximately 20% of patients who drop out transfer to hemodialysis annually.1 Although peritonitis remains the major reason for transfer to hemodialysis, other factors such as exit site infections, catheter-related problems, abdominal wall and inguinal hernias, loss of ultrafiltrations, and poor clearance contribute to CPD technique failure.2 In order to permit the continuation of long-term therapy with CPD, these complications should be resolved. Routine laboratory evaluation or physical examination can detect some CPD-related problems; however, some patients require more complicated investigations to evaluate their problems properly.

Excision Efficiency of Radioguided Occult Lesion Localization in Reoperative Thyroid and Parathyroid Surgery

BACKGROUND The purpose of this study was to investigate the efficiency of a radioguided occult lesion localization technique in reoperative thyroid and parathyroid procedures in patients who had undergone previous neck exploration for thyroid or parathyroid disease. METHODS Twenty-one consecutive patients who were scheduled for reoperative thyroid or parathyroid surgery were studied. The indication for reoperation was recurrent papillary thyroid cancer (PTC) in eight patients, completion thyroidectomy for PTC in eight patients who had previously undergone a bilateral subtotal thyroidectomy, recurrent goiter in two patients, primary hyperparathyroidism in two patients, and recurrent parathyroid cancer in one patient. Ninety minutes before surgery, 0.1 mL of Technetium-99m (0.2 mCi)-labeled macroaggregated albumin was injected directly into the lesion under ultrasonographic guidance. During surgery, a handheld gamma probe was used to localize and excise the lesions. The background and postexcisional site radioactivities were compared to confirm the completeness of each procedure. The radiation dose in the operating room environment, duration of surgery, and postoperative complication rates were evaluated in all patients. In patients with PTC, the change in serum thyroglobulin (Tg) following surgery was noted. RESULTS Thirty lesions were marked and excised. The postexcisional bed gamma counts (610 ± 141) were markedly decreased compared with the pre-excisional site counts (21,415.8 ± 4993.4; p = 0.0001). The ratio of the postexcisional and background counts (4.6 ± 4.3) was significantly lower than the ratio of the pre-excisional and background counts (173.7 ± 156.4; p = 0.0001). The mean operation duration was 53.3 ± 7.5 minutes. The dose absorbed by the hands of the surgeon was estimated as 0.07 ± 0.02 and 0.15 ± 0.05 millisievert/h when one or three lesions were marked, respectively. One patient developed postoperative transient hypoparathyroidism. After surgery, serum Tg levels dropped to <2 ng/mL in 86% (6/7) of the patients with PTC whose preoperative serum Tg was elevated. CONCLUSIONS The radioguided occult lesion localization technique was efficient in the perioperative identification of thyroid and parathyroid tumors in patients who were undergoing reoperation for PTC and hyperparathyroidism.

Concurrent Microvascular and Infarct Remodeling After Successful Reperfusion of ST-Elevation Acute Myocardial Infarction

Background—Connection between the course of microvascular and infarct remodeling processes over time after reperfused ST-elevation acute myocardial infarction has not been fully elucidated. The aim of this study is to investigate the association of temporal changes in hemodynamics of microcirculation in the infarcted territory and infarct size (IS) after primary percutaneous coronary intervention in patients with ST-elevation acute myocardial infarction. Methods and Results—Thirty-five patients admitted with ST-elevation acute myocardial infarction undergoing primary percutaneous coronary intervention were enrolled in the study. Coronary flow reserve (CFR), index of microvascular resistance (IMR), and IS were assessed 2 days after primary percutaneous coronary intervention and at the 5-month follow-up. The predictors of the 5-month IS were the baseline values of IS (&bgr;=0.6, P<0.001), IMR (&bgr;=0.280, P=0.013), and CFR (&bgr;=−0.276, P=0.017). There were significant correlations between relative change in IS and relative change in measures of microvascular function (IS and CFR [r=−0.51, P=0.002]); IS and IMR ([r=0.55, P=0.001]). In multivariate model, relative changes in IMR (&bgr;=0.552, P=0.001) and CFR (&bgr;=−0.511, P=0.002) were the only predictors of relative change in IS. In patients with an improvement in IMR >33%, the mean IS decreased from 32.3±16.9% to 19.3±14% (P=0.001) in the follow-up. Similarly, in patients with an improvement in CFR >41%, the mean IS significantly decreased from 29.9±20% to 15.8±12.4% (P=0.003). But in patients with an improvement in IMR and CFR, which were below than the mean values, IS did not significantly decrease during the follow-up. Conclusions—Improvement in microvascular function in the infarcted territory is associated with reduction in IS after reperfused ST-elevation acute myocardial infarction. This link suggests that further investigations are warranted to determine whether therapeutic protection of microvascular integrity results in augmentation of infarct healing.

Diagnostic spectrum of congenital hypothyroidism in Turkish children

Background:  Congenital hypothyroidism (CH) is classified as transient or permanent. Transient CH can be treated with short‐term thyroxine replacement therapy or followed up without therapy, whereas lifelong thyroxine replacement is needed in permanent CH. Determination of the underlying etiology is essential for determination of follow‐up strategy. The purpose of the present study was therefore to assess the role of color Doppler ultrasonography (CDU) in etiologic diagnosis of CH together with radionuclide method and grayscale ultrasonography (GSU).