Francesco Monteleone

Detection of colon cancer with 99mTc-labeled bombesin derivative (99mTc-leu13-BN1)

Breast, prostate, and lung cancer have been successfully detected with 99mTc bombesin (99mTc-leu13-BN1), the radiopharmaceutical that our group developed from synthesis to diagnostic trials. Overexpression of bombesin receptors (BNRs) in colon cancer is well known: the aim of this study was to assess whether or not colon cancer can be detected with a 99mTc-leu13-BN1 scan. Thirteen (13) patients, 7 of whom with known rectal cancer and 6 scheduled to undergo endoscopic removal of polyps for suspicion of colon cancer, were studied with a 99mTc-leu13-BN1 scan. Dynamic, single photon emission computed tomography, and whole-body scans were performed within 1 hour, before discharge of radioactivity from the liver into the duodenum. Sixteen (16) of 17 colorectal cancer locations were detected with a 99mTc-leu13-BN1 scan with 94.1% sensitivity. Six (6) lesions were benign: 1 Crohns disease, 1 polyp with mild dysplasia, 4 polyps with simple hyperplasia; 99mTc-leu13-BN1 scans were positive in two nontumoral lesions, Crohns disease, and mild dysplasia and true negative in 4: specificity was 67%. Of the 7 patients with known rectal cancer, 5, who underwent operations instead of radiation therapy, showed lymph-node invasion on 99mTc-leu13-BN1 scans. Operations confirmed the scintigraphic staging. 99mTc-leu13-BN1 is taken up by colon cancer. Scans are sensitive, although scarcely specific. 99mTc-leu13-BN1 allows for node-invasion detection.

Prostate-Specific Antigen Flare Phenomenon During 223Ra-Dichloride Treatment for Bone Metastatic Castration-Resistant Prostate Cancer: A Case Report

Clinical Practice Points Ra-dichloride is an alpha-emitting radionuclide recently approved for treatment of castration-resistant prostate cancer (CRPC) patients with symptomatic bone metastases. In this specific therapeutic setting, prostate-specific antigen (PSA) is not an objective biomarker in assessing Ra efficacy. We present a 79-year-old patient who was affected by CRPC and symptomatic bone metastases enrolled in the Ra-dichloride Early Access Program who presented a relevant rise in PSA levels after the fifth Ra administration. No radiological signs of disease progression were found, so this event was recognized as a PSA flare phenomenon and the last Ra infusion was administered. In clinical practice, PSA flare in the course of Ra treatment can be misinterpreted as a therapeutic failure with early withdrawal from a potentially effective therapy. During Ra treatment, PSA flare can be explained as a direct consequence of Ra cytotoxic effect on cancer cells. Further analysis should be conducted on large cohort to evaluate the clinical significance of PSA flare phenomenon during Ra treatment.

A modified sentinel node and occult lesion localization (SNOLL) technique in non-palpable breast cancer: a pilot study.

BackgroundThe spread of mammographic screening programs has allowed an increasing amount of early breast cancer diagnosis. A modern approach to non-palpable breast lesions requires an accurate intraoperative localization, in order to achieve a complete surgical resection. In addiction, the assessment of lymph node status is mandatory as it represents a major prognostic factor in these patients. The aim of this study is to evaluate the reliability of a modified technical approach using a single nanocolloidal radiotracer to localize both sentinel node and breast occult lesion.MethodsTwenty-five patients with a single non-palpable breast lesions and clinically negative axilla were enrolled. In the same day of surgery, patients underwent intratumoral and peritumoral administration of 99mTc-labeled nanocolloid tracer under sonographic guidance. A lymphoscintigraphy was performed to localize the sentinel lymph node and its cutaneous projection was marked on the skin in order to guide the surgeon to an optimal incision. During surgery an hand-held gamma-detection probe was used to select the best surgical access route and to guide localization of both occult breast lesion and sentinel lymph node. After specimen excision, the surgical field was checked with the gamma-probe to verify the absence of residual sources of significant radioactivity, thereby ensuring a radical treatment in a single surgical session and minimizing normal tissue excision.ResultsBoth targeted breast lesion and sentinel lymph node were localized and removed at the first attempt in every patients and histopathological diagnosis of malignancy was confirmed in 25/26 samples. Non-palpable lesions were included within the surgical margins in all patients and in all samples surgical margins were free from neoplastic infiltration thus avoiding any further reintervention. Only two patients showed metastatic involvement of sentinel lymph node.ConclusionsThe modified sentinel node and occult lesion localization (SNOLL) technique performed with a single injection of nanocolloidal radiotracer has shown an excellent intraoperative identification rate of both non-palpable lesion and sentinel lymph node. This procedure offers, as opposed to standard techniques, an accurate, simple and reliable approach to the management of non-palpable breast cancer.

Multiparametric ultrasonography and ultrasound elastography in the differentiation of parathyroid lesions from ectopic thyroid lesions or lymphadenopathies

To evaluate the accuracy of ultrasound elastography with ElastoscanTM Core Index in the differential diagnosis of parathyroid lesions from ectopic thyroid nodules and lymph nodes. Seventy nine patients with repeatedly high levels of circulating intact parathyroid hormone, normal vitamin D and renal function tests, with an ultrasound scan showing a neck lesion, sharply demarcated from the thyroid lobules, were consecutively enrolled. Ultrasound with and without Color Doppler and ultrasound elastography were performed before histological examination. All ultrasound features, vascularization and ultrasound elastography diagnostic performance were assessed using ROC curves. Histological examination confirmed 47 parathyroid lesions, 18 thyroid ectopic nodules and 14 reactive lymph nodes. In distinguishing parathyroid from thyroid nodules, shape had a 100 % sensitivity (95 % CI 92.4–100) and 50 % specificity (95 % CI 37.2–64.7), cleavage had a 85.1 % sensitivity (95 % CI 72.3–92.6) and 77.8 % specificity (95 % CI 65.1–88) while peripheral vascularization had a sensitivity of 91.5 (95 % CI 79.6–97.6) and specificity of 72.2 (95 % CI 46.5–90.3). An ElastoscanTM Core Indexof 1.28 was 46 % sensitive (95 % CI 33.4–58.7) and 77 % specific (95 % CI 66.2–89.1) in discriminating parathyroid lesions from thyroid nodules. An ElastoscanTM Core Index of 1.0 was 78 % sensitive (95 % CI 65.1–88) and 71 % specific (95 % CI 56–81.3) in discriminating parathyroid lesions from lymph nodes (p = 0.045). An ElastoscanTM Core Index greater than 2.58 had a 100 % sensitivity (95 % CI 43.8–100) and 95.4 % specificity (95 % CI 38.3–99.7) in discriminating malignant from benign parathyroid nodules. ElastoscanTM Core Index was significantly higher in thyroid nodules than in reactive lymph nodes (1.18 ± 0.62, p = 0.008). The ultrasound features of cleavage and peripheral vascularization help to differentiate parathyroid from thyroid nodules. ElastoscanTM Core Index can improve ultrasound discrimination of parathyroid lesions from lymph nodes. The ElastoscanTM Core Index is significantly higher in malignant than in benign parathyroid lesions.

99mTc-labeled White Blood Cell Scan as a Guide to Open Biopsy in the Management of Hip and Knee Prosthesis Infection: Preliminary Results

OBJECTIVE The aim of the present prospective study was to evaluate the usefulness of labeled leukocyte scan as a guide to open biopsy for the management of hip and knee prosthesis infection in patients without loosening of orthopedic device. METHODS Twenty-six patients with suspected hip (24) and knee (2) prosthesis infection underwent routine analysis of blood, plain radiography and 99mTc-HMPAO labelled leukocyte scan (WBCS). On these basis, patients were subdivided in the following groups: bone infection without loosening (n°=14), septic loosening (n°=8), superficial infection (n°=2), no infection (n°=2). Patients with septic loosening underwent empirical antibiotic therapy in order to avoid two-stage reimplantation. When the medical treatment was effective patients were submitted to one-stage operation. Patients without loosening of prosthesis but positive WBCS results underwent open biopsy: bone samples and periprosthetic tissues were taken from the regions showing pathological leukocyte uptake at the scan. Samples were submitted to microbiological examination and antibiotic treatments were undertaken in cases of bacterial growth. A 24-months clinical and instrumental follow-up was carried out in all patients. RESULTS WBCS showed 22 patients affected by bone infection, 2 by superficial infection and 2 not infected. Height out of the 22 patients affected by deep infection had a septic loosening. In these cases, the medical treatment was inadequate in 6 patients and effective in 2. Fourteen patients with bone infection without loosening were submitted to open biopsy: in 9 cases a complete remission of the disease was found. Two patients, without infection, underwent single-stage surgery for mechanical problems. Superficial infection was assessed and successfully treated in 2 patients. CONCLUSION The obtained results indicate that a multidisciplinary approach to infection of orthopedic prostheses, characterized by the combined use of open biopsy, WBC, and microbiological examination, produced positive outcome in 9 out of 14 patients.

Ra-223 dichloride management in a Nuclear Medicine Unit: experience of a referral institution

Prostate cancer is the most common male cancer and one of the leading causes of cancer-related morbidity and death [1]. In prostate cancer natural history, approximately 10% of patients will develop a castration-resistant disease, with a median survival of 2 years [2]. The majority of patients with metastatic CastrationResistant Prostate Cancer (mCRPC) has a radiological evidence of bone metastases, which are the main cause of pain and disability, leading to a reduced quality of life. Moreover, in patients with mCRPC bone metastases are independently associated to mortality [3].

Technetium-99m tetrofosmin imaging in malignant lymphomas.

Aim To assess the utility of 99mTc tetrofosmin (TF) scintigraphy as a diagnostic modality in lymphomas. Methods Seventeen patients (14 with Hodgkins disease and three with non-Hodgkins lymphomas; age range, 10-59 years) were investigated. Planar and SPECT images of the supradiaphragmatic region (including neck and chest) were obtained. All patients were untreated at the time of the first scintigraphy. Follow-up scans after therapy were acquired in six patients (in five twice), so a total of 28 scintigraphic studies were performed. Mediastinal, pulmonary, cervical, supraclavicular and axillary activity was evaluated and results were compared in a blinded fashion with those of CT. Results TF imaging demonstrated pathological focal uptake at 38 sites (16 in the mediastinum, eight in the lungs, four in the axillae, eight in the supraclavicular region and two in the cervical region) in 16 of 17 untreated patients; CT identified 24 lesions (16 in the mediastinum, two in the lungs, two in the axillae, two in the supraclavicular and two in the cervical region) in 17 patients. Scintigraphy detected 22 of the 24 lesions demonstrated by CT and revealed 16 unknown tumor sites in 10 patients. The only negative pre-treatment scintigraphy result was found in a patient with axillary lymph node involvement. On the first post-treatment scintigrams there was a reduction in the number of visualized pathological sites (seven vs 16) in five of the six patients examined. The second follow-up study demonstrated only two lesions in two of the five patients examined. Conclusions Our preliminary results indicate that TF imaging is effective in depicting supradiaphragmatic lymphoma lesions in untreated patients and suggest that serial scintigraphic studies may be suitable for monitoring response to treatment. However, larger series are needed to better define the possible role of TF scintigraphy in the follow-up of the response to therapy.