David Q. Wan

Impaired gastric emptying and small bowel transit in children with mitochondrial disorders.

Objectives: The primary aim of our study was to evaluate gastric emptying (GE) and intestinal transit time (ITT) in children with mitochondrial disorders (MD), and secondarily to evaluate the effect of prokinetics in those with prolonged GE. Methods: We enrolled subjects 3 to 18 years with MD and having any of the following gastrointestinal (GI) symptoms: abdominal pain, vomiting, constipation, diarrhea, or gastroesophageal reflux. Abdominal pain was scored by visual analog pain scale (1–10). Age-appropriate diet was labeled with radioactive technetium-99 sulfur colloid and its movement tracked along the GI tract. Delayed GE based on our institutional standards was defined as half emptying time >90 minutes for a solid and >60 minutes for a semisolid meal. Prolonged ITT was defined as >4 hours for the tracer to pass from mouth to cecum. A prokinetic was instituted to those with delayed GE, and the study was repeated if possible in 4 to 8 weeks. Results: Of the 26 subjects, 18 (69%) had delayed GE (median GE 99 minutes) and 12 (46%) had prolonged ITT. The study was repeated in 9 subjects after administering a prokinetic for >1 month. GE normalized in only 3 subjects (median GE on treatment 128 minutes). Mean abdominal pain score, which was 4.8 (max 10) in the 9 subjects, did not improve (5.6 after prokinetic therapy). Conclusions: A high prevalence of delayed GE and prolonged ITT was seen in children with MD having GI symptoms, and these abnormalities were poorly responsive to prokinetic therapy.

Effect of Y-90 SIR-Spheres Therapy for Multiple Liver Metastases in a Variety of Tumors

Objective To evaluate the outcomes of patients receiving Y- 90 SIR-Spheres in patients with multiple liver metastases from different tumors. Methods: 29 consecutive patients with multiple liver metastases from colorectal (13), Islet cell tumors (9), carcinoid tumors (4) or non-small cell lung cancer (3) who were treated with Y-90 SIR-Spheres between March, 2003 and February, 2006 were included. Only patients who had follow-up radiological exams at our institution were included. Data regarding Y-90 SIR-Spheres dose, lobe of liver treated, and chemotherapy (CTx) administered were collected. Patients’ outcomes were evaluated based on radiological evidence of change in size and number of liver metastases. Results: The study population included 8 females and 21 males at a mean age of 60y. The mean Y-90 SIR-Spheres dose administered was 39.8 mCi. Both lobes of the liver, the right lobe only or the left lobe only were treated in 26, 2, 1 patients, respectively. Sixteen patients received Y-90 SIR-Spheres after CTx failure, 5 patients as adjuvant therapy after completion of CTx, 7 patients as concurrent therapy and one patient refused repeat CTx. The mean interval between the last CTx and Y-90 SIR-Spheres was 108 days. Four patients (14%) demonstrated radiological improvement and 9 (31%) were stable for a mean interval of 2.8 mo. after Y-90 SIR-Spheres infusion. Sixteen patients (55%) demonstrated continued progress of liver metastases. Conclusion: Y-90 SIR-Spheres therapy is useful in reducing or stabilizing multiple liver metastases from a variety of tumors.

The impact of DaTscan in the diagnosis of Parkinson disease.

Purpose The aim of this study was to evaluate the impact of DaTscan in a heterogeneous group of patients with movement disorders as well as the degree of confidence in scan findings between different readers. Procedures A retrospective evaluation of consecutive patients who underwent DaTscan during 1 year was performed. The patients’ demographics, symptoms, duration, clinical diagnosis, and medications were collected. The scan findings were categorized by 2 blinded observers on a semiquantitative scale as follows: 0, normal; 1, mild; 2, moderate; 3, marked; and 4, absent uptake for each of the caudate heads and putamina separately. A correlation of the scan findings with the clinical symptoms and diagnosis as well as interobserver agreement was performed. Disagreement was considered when a difference greater than 2 in more than 1 area of the basal ganglia was recorded. Descriptive statistics and &kgr; test for interobserver agreement were used for data analysis. Results Fifty-seven patients were included (mean age, 63.4 years; 29 men, 28 women). Clinical diagnosis of Parkinson disease (PD) was certain in 26 and uncertain in 31 patients. DaTscan was markedly abnormal in 24 (92%) of 26 patients with certain clinical diagnosis of PD and normal in the remaining 2 (8%). In 31 patients with uncertain diagnosis, 15 (48%) had markedly abnormal scans, 5 (16%) had mild abnormalities, and 11 (36%) had normal scans. Each of the sensitivity and positive predictive value of DaTscan in patients who had certain clinical diagnosis of PD (26 patients) is 92%. Interobserver agreement occurred in 52 (91%) of 57 scans and disagreement in 5 (9%) of 57 (&kgr; = 0.82). There was also a good correlation with laterality of symptoms in 32 (82%) of 39 positive studies. Conclusions Markedly abnormal DaTscan is confirmed as the diagnostic pattern for PD. This pattern helps confirm the diagnosis in patients with unclear clinical diagnosis. Good interobserver agreement is easily obtained in reading DaTscans.

The value of fused SPECT/CT in the evaluation of solitary skull lesion.

Aim: The aim of this study was to evaluate the role of single photon emission computed tomography and/or computed tomography (SPECT/CT) in differentiating metastatic from benign solitary skull lesions. Materials and Methods: Consecutive patients who had a SPECT/CT of the head subsequent to a whole-body bone scan (WBS) for the evaluation of a single skull lesion were selected. A single skull lesion on the WBS was further evaluated with SPECT/CT to characterize the lesion. The results of the SPECT/CT were correlated with other radiologic examinations performed within 2 weeks. An average follow-up interval after the SPECT/CT was 8.9 months to correlate with additional radiologic imaging studies and clinical information. Results: A total of 19 lesions in 19 patients were seen on the WBS and 2 additional lesions on the SPECT/CT. All lesions demonstrated focal increased tracer uptake. The SPECT/CT correctly identified 3 out of 3 metastatic lesions and 12 out of 17 benign lesions, that is 71% of lesions were correctly classifised as metastatic or benign lesions. Only 1 patient was classified incorrectly as metastatic lesion with SPECT/CT when it was proven benign by other imaging modalities and follow-up. The sensitivity, specificity, positive and negative predictive values of SPECT/CT images in identifying metastatic lesions were 100%, 92%, 75%, and 100%, respectively. Five lesions remained indeterminate even after the SPECT/CT interpretation and were confirmed benign by other imaging modalities. Conclusion: SPECT/CT can help identify benign versus metastatic solitary skull lesions in most of the patients with high sensitivity and specificity.

Interpretation of Tc-99m sestamibi parathyroid SPECT-CT scans made easy for better surgical outcomes in patients with primary hyperparathyroidism

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Radionuclide tagged blood cell patch to monitor spine coverage for spontaneous diffuse CSF leaks

We present a 14-year-old female patient with a 2 yr history of positional headache secondary to spontaneous diffuse cerebrospinal fluid (CSF) leaks. We treated the leak with an epidural blood patch which was radioactively labeled by a well- established nuclear medicine technique. Because spontaneous CSF leaks were frequently multifocal or diffuse throughout the spine, the extent of coverage or distribution of an epidural patch was generally determined by best estimate. Traditional radiographic contrast media mixed with the blood cellshad been used to monitor the patch coverage and it is questionable whether the contrast can be representative of the cell distribution. We applied a nuclear medicine technique to label the autologous red blood cells to monitor the range of spinal cord coverage of each epidural patch. After two visible epidural patches covered both the lumbar and thoracic spine, computed tomography myelogram demonstrated significantly decreased leakage when compared to the pre-patch images. However, the patients symptoms remained essentially unchanged in the long term, which is consistent with refractory spontaneous CSF leaks. We believe that this sophisticated nuclear medicine blood labeling technique is a simple and accurate way to monitor the true cell coverage of the spine and the pattern of distribution.