Emel Öztürk

The visualization of granulomatous disease with somatostatin receptor scintigraphy

In-111 labeled pentetreotide scintigraphy was applied to three patients with proven granulomatous disease (two with sarcoidosis, one with tuberculosis). All revealed accumulation of ln-111 labeled pentetreotide in the granulomatous lesions, which was considered to be due to the presence of activated lymphocytes in these regions. This method may be of value in assessing the activity and extent of sarcoidosis and tuberculosis.

Detection of widespread neurolymphomatosis with 18F-FDG PET

Brain MRI of a 21-year-old male with diffuse large B-cell lymphoma revealed lymphomatous infiltration in bilateral cavernous sinuses and fifth cranial nerves. Whole-body F-FDG PET revealed increased FDG uptake in the entire left brachial (a, left: solid arrow) and right lumbosacral plexus (middle), the proximal portion of the left lumbosacral plexus and areas around the cervical cord (a, left: dotted arrow). There was also increased FDG uptake in the spinal and sacral canal from T12 through the sacrum (a, right: solid arrow) as well as in multiple vertebrae, including the axis, C6 (a, right: dashed arrow), T5 and T11. In contrast, hypometabolism was noted in the L2 vertebral body (a, right: dotted arrow). MRI evaluation of these abnormal sites demonstrated enlargement and thickening of the right lumbosacral plexus, left proximal lumbosacral plexus (b, left) and left brachial plexus (b, middle). Dural thickening at the level of C6 through T2 was also noted. Diffuse leptomeningeal and dural infiltration obscured the conus medullaris and cauda equina from T12 to the sacral canal. MRI also depicted low T1 and high T2 signal intensity in the bone lesion in the L2 vertebral body (b, right). The infiltrated neural plexus, lumbar dura and bone lesion were enhanced mildly on intravenous contrast-enhanced series. These concordant PET and MRI findings suggested widespread neurolymphomatosis. Neurolymphomatosis is a rare neurological manifestation of systemic lymphoma [1]. The diagnosis is often difficult during lifetime and usually requires nerve biopsy [2]. Only a few case reports exist that show findings of neurolymphomatosis on CT, MRI and PET [3–5]. Although histopathological confirmation was unavailable, the concordant PET and MRI findings and the known systemic and cranial nerve involvement in this patient strongly suggest that the lesions were due to neurolymphomatosis. This approach to diagnosis is in concordance with the suggestions of Baehring et al.: in their extensive review, they added a surrogate criterion for neurolymphomatosis, in the form of CT, MRI or intraoperative evidence of nerve infiltration beyond the dural sleeve in the setting of known central nervous system or systemic lymphoma [6]. Emel Öztürk ()) Department of Nuclear Medicine, Gülhane Military Medical Academy and Medical School, 06018 Etlik, Ankara, Turkey e-mail: eozturk@gata.edu.tr Tel.: +90-312-3044806; Fax: +90-312-3044800

Use of CA15-3, CEA and prolactin for the primary diagnosis of breast cancer and correlation with the prognostic factors at the time of initial diagnosis

The main goals of the clinical use of tumor markers are to evaluate the adequacy of the treatment, monitor recurrence and follow up response to the treatment applied. For this purpose a baseline level for the commonly used tumor marker must be known at the time of initial diagnosis, before any therapy, in order to compare with the tumor marker levels which will be obtained after the treatment and during the clinical follow-up. The aim of this study was to investigate the correlation, if there is any, of the baseline levels of CA15-3, CEA and prolactin (PRL) in patients with breast cancer with the most commonly used prognostic factors, i) the presence of distant metastasis, ii) the presence of axillary lymphatic invasion, iii) the number of invaded axillary lymph nodes, iv) tumor size and v) stage of the disease, for breast cancer. Baseline serum CA15-3, CEA and PRL levels of 172 patients with breast masses were determined prior to biopsy. The sensitivity and specificity of baseline CA15-3, CEA and PRL were; 23.2% and 95.3%, 17.4% and 83.7%, 5.8% and 97.6%, respectively. At least one of the three tumor markers was high in 36% (31/86) of the breast cancer patients. Baseline CA15-3 levels were frequently higher than CEA in patients with bone metastasis (60% vs. 20%) and axillary lymphatic invasion (31.8% vs. 25%), and showed a better correlation with the stage of disease. Baseline tumor marker levels showed no statistically significant correlation with either the number of invaded axillary lymph nodes or tumor size. In conclusion, sensitivities and negative predictive values for baseline CA15-3, CEA and PRL were not satisfactory for primary diagnosis of breast cancer. Correlation of baseline CA15-3 was found superior to CEA and PRL in terms of stage of disease, presence of axillary invasion and distant metastasis.

Quantitative three-phase bone scintigraphy in the evaluation of intravenous regional blockade treatment in patients with stage-I reflex sympathetic dystrophy of upper extremity

Objective: To investigate the role of quantitative three phase bone scintigraphy (QTPBS) in the evaluation of efficacy of intravenous regional blockade treatment in patients having reflex sympathetic dystrophy (RSD) of the upper extremity.Material and Methods: Twenty-six patients with stage-I RSD were focused on in this study. Patients were treated with physical therapy and intravenous (I.V.) regional blockade therapy consisting of dexamethasone and lidocaine. All patients were clinically evaluated before and 1 month after the completion of the therapy protocol. QTPBS was applied to patients before therapy and 1 month after the therapy. As a control group, 11 healthy subjects also underwent QTPBS. Perfusion, hyperemic and fixation indices were calculated from three-phase bone scintigraphy.Results: All patients showed statistically significant clinical improvement after the therapy (p < 0.01). Pre-treatment, perfusion (1.67 ± 0.63), hyperemic (1.44 ± 0.48) and fixation (1.69 ± 0.48) indices of patients were higher than those of healthy subjects (PI: 0.95 ± 0.05, HI: 0.94 ± 0.06, FI: 1.01 ± 0.2) (p < 0.01) and all indices significantly decreased after the treatment (PI: 1.33 ± 0.46, HI: 1.18 ± 0.23, FI: 1.42 ± 0.26) (p < 0.01).Conclusion: I.V. regional blockade therapy combined with corticosteroids is a simple, safe and effective method for the treatment of patients with stage-I RSD in the upper extremity. QTPBS is a valuable and objective method to evaluate the response to therapy and may be useful for staging of patients and predicting the response to therapy.

The comparison of dual phase Tc-99m MIBI and Tc-99m MDP scintimammography in the evaluation of breast masses : Preliminary report

The aim of this prospective study was to determine the diagnostic value of Tc-99m MDP scintimammography (SMG) for the detection of breast cancer in patients with breast masses and to compare the results with Tc-99m MIBI scintimammography. Twenty patients, categorized as suspicious, positive or benign for breast cancer according to the mammographic findings were included in the study. Dual phase Tc-99m MIBI and Tc-99m MDP SMG were performed in the prone lateral position within 5 days of each other. Although early and late Tc-99m MIBI SMG showed equal (90.4%) sensitivity, the specificity of late Tc-99m MIBI (87.5%) was found superior to early (62.5%) imaging. The overall sensitivity and specificity of early Tc-99m MDP SMG were 71.4% and 62.5%, respectively. Although late Tc-99m MDP imaging showed 100% specificity, its sensitivity was only 23.8%. In the patients with palpable masses, both early Tc-99m MDP and Tc-99m MIBI showed equal sensitivity (100%), but the sensitivity of early Tc-99m MIBI (37.5%) was found slightly higher than Tc-99m MDP (25.0%) for nonpalpable breast lesions. The sensitivity of Tc-99m MIBI and Tc-99m MDP SMG in detecting metastatic axillary involvement was 66.6% and 50%, respectively. High sensitivity and specificity together with its low cost, easy availability and the possibility of detecting bone metastases seems to make Tc-99m MDP a contributive agent in the evaluation of breast lesions as an alternative to Tc-99m MIBI.

Baseline serum levels of cardiac biomarkers in patients with stable coronary artery disease

Abstract Stable coronary artery disease (CAD) can cause repetitive reversible myocardial ischaemia, and it seems to be possible that reversibly injured myocardium releases small amounts of soluble cytoplasmic proteins. Hence, the aim was to evaluate the effect of stable CAD on baseline serum levels of cardiac biomarkers. We studied 68 consecutive outpatients referred for gated myocardial perfusion imaging. Before a treadmill exercise test, blood samples for measurement of creatine kinase (CK), CK-myocardial band (CK-MB) mass, myoglobin, aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) were collected. Normal perfusion patterns were detected in 29 (43%) patients (group 1) and perfusion defects were detected in 39 (57%) patients (group 2). Baseline serum levels of biomarkers except CK were significantly higher in group 2 (p=0.001). Stable CAD increases baseline levels of CK-MB mass, myoglobin, AST and LDH in the serum and this increase is related to the extent and severity of the perfusion defect and to some extent the ejection fraction of the left ventricle.

Role of bone scanning in the management of non-united fractures: a clinical study

Technetium-99m methylene diphosphonate (99mTc-MDP) bone scintigraphy was performed in 45 patients (42 male and 3 female) with established non-united fractures to predict the healing response to pulsing electromagnetic field stimulation therapy. The bone scans revealed 3 different scintigraphic patterns. The most frequent pattern was an increased uniform uptake of the tracer at the non-union site (group 1). The second pattern was increased activity at the bone ends with a photon-deficient area between the fracture sites (group 2a) or a generalized decrease in the radionuclide concentration in the region of bone fragments (group 2b). When the scintigraphic pattern did not fit either of the two patterns or when the presence of the cold area between the bone fragments could not be judged with certainty, it was called indeterminate (group 3). All patients underwent pulsing electromagnetic field stimulation. The healing rate was 87.5% and 42.8% in group 1 and group 3 patients, respectively. None of the group 2 patients had any evidence of healing, and they all underwent surgical exploration, revealing complicated non-unions. We conclude that 99mTc bone scintigraphy is a useful tool in determining complicated non-unions and selecting the proper therapy mode.

The role of Tc-99m (V) DMSA scintigraphy in the evaluation of superscan on bone scintigraphy.

PURPOSE This study evaluated the biodistribution of Tc-99m (V) DMSA in patients with superscans on bone imaging and defined its role in differentiating the underlying cause. METHODS Nine patients (five with metastatic and four with metabolic bone disease) with classical superscans were entered into the study. All patients had the necessary radiologic and biochemical studies and a final diagnosis was reached accordingly. Tc-99m (V) DMSA scintigraphy was performed 1 week after Tc-99m MDP whole-body bone imaging. RESULTS In four of five patients with widespread skeletal metastases, Tc-99m (V) DMSA scan showed diffusely increased bone uptake. In the remaining patient, the Tc-99m (V) DMSA scan showed a normal distribution pattern. All patients with metabolic bone disease had increased bone uptake on Tc-99m (V) DMSA scans. CONCLUSION Tc-99m (V) DMSA shows increased bone uptake in patients having a superscan appearance in metastatic or metabolic bone disease. Tc-99m (V) DMSA imaging may play a role in the evaluation of patients with equivocal bone scan findings for a superscan.

Visualization of gastrointestinal bleeding during Tc-99m DTPA renal scintigraphy

A 21-year-old man underwent ileolleostomy, and right hemicolectomy following an abdominal gunshot injury. An enterocutaneous fistula developed in the right hypochondrium. The patient started to have melena 7 days after surgery. Melena discontinued 4 days after initialization of medical therapy. On day 15 after the operation, an elevated serum urea level of 75 mg/dL was detected. Tc-99m DTPA renal scintigraphy revealed mildly impaired renal function and an unexpected area of tracer accumulation in the mid and distal right periureteric region suggested the possibility of a urine leakage. However the patients IVP revealed no urinary tract abnormality. Two days later, a Tc-99m RBC scintigraphy was performed and demonstrated a bleeding site at the same localization, previously interpreted as urine leakage on Tc-99m DTPA renal scintigraphy.

Platelet aggregation in children with Helicobacter pylori infection.

This study was performed to investigate the platelet aggregation alterations in platelet-rich plasma (PRP) samples of children with Helicobacter pylori (H pylori) infection. Platelet aggregation induced by adenosine diphosphate (ADP), collagen, ristocetin, or epinephrine was studied with photometric aggregometry in 30 patients before and after eradication therapy and in a control group including 15 children. The pretreatment mean maximum aggregation values and slope were significantly lower (P < .0001) in the study group at 10 μmol/L concentrations of ADP (ADP-like defect). The maximum aggregation values and slope revealed no significant differences (P > 0.05) between the study group after therapy and the control group. We concluded that H pylori infection may cause dysfunction of platelets in children and can be reversed by H pylori eradication therapy. Further studies should be carried out to determine the mechanisms of platelet dysfunction in children with H pylori infection.