Dominick Lamonica

Sentinel node biopsy in breast cancer

AbstractBackground: Sentinel lymph node biopsy (SNB) in breast cancer may be used in place of axillary lymph node dissection (ALND) if SNB accurately stages the axilla. This study assessed the success and accuracy of axillary SNB with isosulfan blue (ISB) and technetium-99 sulfur colloid (TSC) compared to ALND. Methods: Forty-two women with T1 or T2 breast cancer underwent SNB and ALND. Sixty to 90 minutes before anesthetic induction, a mixture of 3 mL ISB and 1 mCi TSC was injected around the primary cancer or prior biopsy site. Intraoperatively, the SLN was identified using a gamma detector (Neoprobe 1000) or by visualization of the blue-stained lymph node and afferent lymphatics. The SLN was excised separately, and a level I/II ALND was completed. The histologic findings of the axillary contents and SLN were compared. Results: An axillary SLN was found in 38 of 42 (90%) cases. SLN localization rate and predictive value were the same for women who had and those who had not undergone excisional biopsy before the date of SNB. Fifteen of 42 (36%) patients had lymph node metastases. The SLN was positive in all women with axillary metastases (negative predictive value, 100%). Conclusions: If confirmed by larger series, a negative SNB may eliminate the need for ALND for select women with breast cancer.

Positron emission tomography in the evaluation of the N0 neck

The presence of cervical lymph node metastasis in patients with head and neck cancer is associated with an unfavorable prognosis. Reports vary as to whether various conventional radiographic studies, such as computed tomography (CT) and magnetic resonance imaging, confer an advantage over physical examination in the patient without clinical findings of cervical metastasis (N0). Positron emission tomography (PET) is a functional imaging modality that has recently been used for head and neck neoplasms. The use of PET in the evaluation of the N0‐staged neck in 14 consecutive patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract is reported. Seven patients (50%) undergoing 13 neck dissections had pathologic evidence of disease. PET scans were positive in five patients with pathologically confirmed cervical metastasis. PET scans were negative in seven patients (11 neck dissections) with no pathologic evidence of disease. PET scans were positive for unilateral cervical metastasis in two of three patients with involvement of a single lymph node. PET scans were positive in two of three patients with more than two lymph nodes involved. PET had an accuracy of 100% in the eight patients with SCC of the oral cavity. In patients with oropharyngeal or hypopharyngeal carcinoma PET localized cervical metastasis in two of four patients with neck metastasis. In the patient with an N0‐staged neck on clinical examination, PET was found to have an overall sensitivity of 78%, specificity of 100%, positive predictive value of 100%, negative predictive value of 88%, and accuracy of 92%. CT demonstrated sensitivity of 57%, specificity of 90%, positive predictive value of 80%, negative predictive value of 75%, and accuracy of 76%. PET showed a trend in increased accuracy (P= 0.11) over CT. PET appears to be a promising diagnostic aid that may be applied when evaluating the N0‐staged neck, especially for SCC of the oral cavity.

Association of Technetium99m MAG-3 renal scintigraphy with change in creatinine clearance following chemoradiation to the abdomen in patients with gastrointestinal malignancies

BACKGROUND Information on differential renal function following abdominal chemoradiation is limited. This study evaluated the association between renal function as measured by biochemical endpoints and scintigraphy and dose volume parameters in patients with gastrointestinal malignancies. MATERIALS AND METHODS Patients who received abdominal chemoradiation between 2002 and 2009 were identified for this study. Technetium(99m) MAG-3 scintigraphy and laboratory data were obtained prior to and after chemoradiation in 6 month intervals. Factors assessed included age, gender, hypertension, diabetes, and dose volume parameters. Renal function was assessed by biochemical endpoints and renal scintigraphy. RESULTS Significant reductions in relative renal function of the primarily irradiated kidney and creatinine clearance were seen. Split renal function decreased from 49.75% pre-radiation to 47.74% and 41.28% at 6-12 months and >12 months post-radiation (P=0.0184). Creatinine clearance declined from 90.67ml/min pre-radiation to 82.23ml/min and 74.54ml/min at 6-12 months and >12 months post-radiation (P<0.0001). Univariate analysis of patients who had at least one post-radiation renogram showed the percent volumes of the primarily irradiated kidney receiving ≥ 25 Gy (V(25)) and 40 Gy (V(40)) were significantly associated with ≥5% decrease in relative renal function (P=0.0387 and P=0.0438 respectively). CONCLUSION Decline in split renal function using Technetium(99m) MAG-3 scintigraphy correlates with decrease in creatinine clearance and radiation dose-volume parameters following abdominal chemoradiation. Change in split perfusion can be detected as early as 6 months post-radiation. Scintigraphy may provide early determination and quantification of subclinical renal injury prior to clinical evidence of nephropathy.

Iodine 131 (131I) as adjuvant therapy of differentiated thyroid cancer

The importance of the optimization of the up front management of DTC cannot be underestimated. An aggressive approach is advocated, except in situations widely accepted to be low risk (i.e., female patients <40 y, with tumors <1.0 cm confined to the gland). Distant tumor greatly reduces the chances for survival in all patients. The loss of iodine-concentrating ability removes systemic radioiodine from the therapeutic equation and thereby virtually eliminates chances for cure. The role of chemotherapy in non iodine responsive DTC is still in question, and a benefit in advanced disease has not been established. For non iodine-concentrating tumor that cannot be approached surgically, external beam therapy remains an option, both within the neck and for dominant foci of distant metastatic tumor (i.e., brain and bone). Any distant lesion demonstrating the capacity for radioiodine uptake also should be addressed with (131)1, because this will potentially treat tumor not evident on diagnostic survey. In conclusion, (131)1 has demonstrated efficacy for the postsurgical management of DTC. Although its acute and long-term side-effect profile is not especially worrisome relative to other forms of systemic cancer therapy, the administration of (131)1 is not entirely without risk. Taking into account many of the issues described in this article, the administration of (131)I should in every case be optimized. It also should be applied carefully and judiciously to patients expected to derive benefit.

A Comparative Study of 511 keV SPECT and PET Using Separate 370 MBq F-18-FDG Doses on Different Days.

All previously reported comparative studies of 511 keV single-photon emission computed tomography (SPECT) and positron emission tomography (PET) have used one fluorine-18-fluorodeoxyglucose (FDG) dose, followed by PET and SPECT on the same day. This approach is inherently biased against the second imaging study. Therefore, we prospectively compared conventional PET and 511 keV SPECT in 23 patients with proven malignancy using separate 370 MBq FDG doses on different days employing an ECAT 951/31R PET scanner and a Trionix XLT-20 for SPECT. Discrepancies were evident in twelve of 23 patients (52%). In eight of these (66%) findings were seen exclusively on PET and represented the only metabolic evidence of disease. Thirty-seven of the 52 lesions (71%) detected at PET were also defined by SPECT, most above 2 cm. In 4 cases of extrahepatic abdominal disease (3 colorectal, 1 melanoma), both PET and SPECT missed small recurrent omental and perivesical lesions; several lesions up to 1.2 cm were also missed by CT and MRI.

Chapter 104 – 131Iodine in Thyroid Cancer: Use of 131I in the Diagnosis and Therapy of Differentiated Thyroid Carcinoma

131 Iodine ( 131 I) has proven efficacy in the post-surgical management of differentiated thyroid carcinoma (DTC). Following definitive surgical resection of tumor, 131 I has a major role in the detection and treatment of persistent or recurrent disease. It is used for the post-surgical ablation of the normal gland remnant and for the diagnosis and therapy of sites of iodine-concentrating thyroid tumor. Beyond surgery there is no more effective treatment for iodine concentrating metastatic thyroid cancer. The acute and long-term side effects of 131 I are less severe than those of other systemic cancer therapies. The ablation of postsurgical thyroid remnants with 131 I has proven benefit for reduction of morbidity related to intermediate-stage thyroid tumors. Both pre and post-therapy 131 I WBS have the potential to provide clinically relevant information that is not available through other testing. After surgical resection, 131 I is the most effective means to deliver potentially curative radiation to sites of persistent or recurrent iodine-concentrating thyroid tumor. Optimized use of this radioisotope has the potential to improve outcome and greatly facilitates further management of this disease. Emerging treatment paradigms incorporating rhTSH may further reduce morbidity associated with radioiodine therapy of DTC. However, the therapeutic administration of 131 I is not entirely without risk.