Domenico Rubello

Intradermal lymphoscintigraphy at rest and after exercise: a new technique for the functional assessment of the lymphatic system in patients with lymphoedema.

AimThe aim of this study was to evaluate the effect of implementing a new technique, intradermal injection lymphoscintigraphy, at rest and after muscular exercise on the functional assessment of the lymphatic system in a group of patients with delayed or absent lymph drainage. MethodsWe selected 44 patients (32 women and 12 men; 15 of 44 with upper limb and 29 of 44 with lower limb lymphoedema). Thirty of 44 patients had bilateral limb lymphoedema and 14 of 44 had unilateral disease; 14 contralateral normal limbs were used as controls. Twenty-three patients had secondary lymphoedema after lymphadenectomy and the remaining 21 had idiopathic lymphoedema. Each of the 44 patients was injected with 50u2009MBq (0.3–0.4u2009ml) of 99mTc-albumin-nanocolloid, which was administered intradermally at the first interdigital space of the affected limb. Two planar static scans were performed using a low-energy general-purpose collimator (acquisition matrix 128×128, anterior and posterior views for 5u2009min), and in which drainage was slow or absent, patients were asked to walk or exercise for 2u2009min. A postexercise scan was then performed to monitor and record the tracer pathway and the tracer appearance time (TAT) in the inguinal or axillary lymph nodes. ResultsThe postexercise scans showed that (i) 21 limbs (15 lower and six upper limbs) had accelerated tracer drainage and tracer uptake in the inguinal and/or axillary lymph nodes. Two-thirds of these showed lymph stagnation points; (ii) 27 limbs had collateral lymph drainage pathways; (iii) in 11 limbs, there was lymph drainage into the deeper lymphatic channels, with unusual uptake in the popliteal or antecubital lymph nodes; (iv) six limbs had dermal backflow; (v) three limbs did not show lymph drainage (TAT=not applicable). TAT=15±3u2009min, ranging from 12 to 32u2009min in limbs with lymphoedema versus 5±2u2009min, ranging from 1 to 12u2009min in the contralateral normal limbs (P<0.001). ConclusionIntradermal injection lymphoscintigraphy gives a better imaging of the lymph drainage pathways in a shorter time, including cases with advanced lymphoedema. In some patients with lymphoedema, a 2-min exercise can accelerate tracer drainage, showing several compensatory mechanisms of lymph drainage. The effect of the exercise technique on TAT and lymphoscintigraphy findings could result in a more accurate functional assessment of lymphoedema patients.

Diagnostica per immagine integrata dei feocromocitomi e paragangliomi

RiassuntoLa diagnostica del femocromocitoma e dei paragangliomi, oltre a prevedere un’iniziale valutazione biochimica che accerti le caratteristiche secretive del tumore, consta dell’applicazione di metodiche di imaging integrato, morfologico e funzionale, al fine della localizzazione del tumore stesso. Nella maggior parte dei casi l’imaging integrato risulta sinergico ai fini di ottenere una diagnosi corretta e un’accurata valutazione dell’estensione della malattia. Abitualmente l’imaging morfologico, principalmente tomografia assiale computerizzata (TAC) e risonanza magnetica nucleare (RMN), viene utilizzato nella prima fase dell’iter diagnostico di localizzazione e consente di valutare l’anatomia della lesione primitiva, mentre quello funzionale medico-nucleare entra in gioco in un secondo tempo per confermare la diagnosi, caratterizzare la lesione e stadiare la malattia. A questo scopo la medicina nucleare offre numerosi traccianti radiomarcati idonei per esami ad emissione di singolo fotone (scansione whole-body e SPECT) e per indagini ad emissione di positroni /doppio fotone (PET). La presente review, alla luce delle rilevanti innovazioni avvenute negli ultimi anni in termini di tecnologia avanzata, si pone il fine di descrivere le metodiche che rappresentano attualmente lo stato dell’arte nella diagnostica di queste patologie, proponendo anche delle flowchart diagnostiche.

Role of PET-CT in the Prediction of Response to Neoadjuvant Treatment

Even if surgery is still the main therapeutic option in patients with esophageal squamous cell carcinoma (SCC), recent studies have shown that neoadjuvant chemoradiotherapy (CRT) can reduce the incidence of local recurrence and improve the overall survival rate [1, 2, 3].

Nuclear Medicine in the Diagnosis and Treatment of Hyperparathyroidism

The parathyroid glands arise from the pharyngeal pouches; usually, there are four such glands but the incidence of a supernumerous gland is 2–5% [1, 2]. The parathyroid glands are usually localized behind the thyroid gland. The two behind the upper lobe are also called the superior glands or P4 (originating from the fourth pouch), and the two behind/beyond the lower lobe are also referred to as the inferior glands or P3 (originating from the third pouch) [1, 2]. It is worth noting that the location of normal inferior parathyroid glands is more variable than that of the superior glands, probably due to their longer developmental pathway and more difficult developmental migration process. Consequently, the P3 glands can be intrathyroidal, within the thyrothymic ligament, within the thymus, or in the mediastinum. The parathyroid glands are generally found in the peri-thyroid sheath but may also occur outside the thyroid capsule or, very rarely, in a subcapsular site [1, 2, 3, 4, 5].