Gül Nihal Nursal

Promising efficacy of sorafenib in a relapsed thymic carcinoma with C-KIT exon 11 deletion mutation

Advanced thymic carcinoma (TC) is a very aggressive disease. To date there are no established treatment options for the refractory and recurrent disease and only a few prospective trials have been conducted in patients with TC. Here we present a case of a relapsed TC patient, who, by using combination chemotherapy, showed a positive response to sorafenib with C-KIT exon 11 mutation.

Comparison of CT and integrated PET-CT based radiation therapy planning in patients with malignant pleural mesothelioma

BackgroundWhen combined with adequate tumoricidal doses, accurate target volume delineation remains to be the one of the most important predictive factors for radiotherapy (RT) success in locally advanced or medically inoperable malignant pleural mesothelioma (MPM) patients. Recently, 18-fluorodeoxyglucose positron emission tomography (PET) has demonstrated significant improvements in diagnosis and accurate staging of MPM. However, role of additional PET data has not been studied in RT planning (RTP) of patients with inoperable MPM or in those who refuse surgery. Therefore, we planned to compare CT with co-registered PET-CT as the basis for delineating target volumes in these patients group.MethodsRetrospectively, the CT and co-registered PET-CT data of 13 patients with histologically proven MPM were utilized to delineate target volumes separately. For each patient, target volumes (gross tumor volume [GTV], clinical target volume [CTV], and planning target volume [PTV]) were defined using the CT and PET-CT fusion data sets. The PTV was measured in two ways: PTV1 was CTV plus a 1-cm margin, and PTV2 was GTV plus a 1-cm margin. We analyzed differences in target volumes.ResultsIn 12 of 13 patients, compared to CT-based delineation, PET-CT-based delineation resulted in a statistically significant decrease in the mean GTV, CTV, PTV1, and PTV2. In these 12 patients, mean GTV decreased by 47.1% ± 28.4%, mean CTV decreased by 38.7% ± 24.7%, mean PTV1 decreased by 31.1% ± 23.1%, and mean PTV2 decreased by 40.0% ± 24.0%. In 4 of 13 patients, hilar lymph nodes were identified by PET-CT that was not identified by CT alone, changing the nodal status of tumor staging in those patients.ConclusionThis study demonstrated the usefulness of PET-CT-based target volume delineation in patients with MPM. Co-registration of PET and CT information reduces the likelihood of geographic misses, and additionally, significant reductions observed in target volumes may potentially allow escalation of RT dose beyond conventional limits potential clinical benefits in tumor control rates, which needs to be tested in future studies.

Intense FDG Uptake around the Inguinal Surgical Mesh 5 Years after Operation: Case Report and Review of the Literature

We present the case of a 40-year-old man who underwent a FDG PET/CT study for restaging of renal cell carcinoma treated with left nephrectomy, for suspected metastasis in lung and retroperitoneal lymph nodes. The patient had a history of left inguinal hernia repair with implantation of mesh prosthesis 5 years ago. PET/CT image revealed linear intense FDG uptake in left inguinal region most likely corresponding to a persistent foreign body reaction. In this article, a case with an intense FDG uptake around mesh prosthesis after many years was reported, and a summary of the literature about surgical mesh and foreign body reaction causing FDG uptake was reviewed. Conflict of interest:None declared.

Is PET/CT Necessary in the Management of Early Breast Cancer?

Purpose Advanced imaging methods in early breast cancers are not recommended before surgery. In contrast to the accepted guidelines, some recent studies have shown some benefits with the use of PET/CT in early-stage breast cancer. In this study, we aimed to document the efficacy of PET/CT in detection of distant metastasis as well as other primary cancers. Patients and Methods In this retrospective study, we reviewed the records of all women patients diagnosed with early breast cancer between March 2012 and December 2014. Besides demographics, we recorded the clinical TNM stage, histology of the tumor, and hormone receptor status. As PET/CT imaging is a routine procedure in our center for early breast cancer, tumor size, lymph node status, distant metastasis, and possible other primary malignancies detected by PET/CT were also recorded. Results Of the 419 women included in the study, 24.8% were clinically staged as stage I while the rest were stage II. Distant metastases were detected in 42 patients (10%). The yield of PET/CT in detecting metastasis was significant in stage II patients compared with stage I patients (12.4% vs 2.9%). In subgroup analysis of stage II patients, the performance of PET/CT in detecting metastasis was still evident in stage IIA patients (9.5%). In logistic regression analysis of the significant and near-significant factors (as detected by univariate analysis) effecting PET/CT detected distant metastasis, only nodal status (P = 0.053) was found to be significant. Conclusions We suggest the use of PET/CT in investigating metastasis in axilla positive and clinically stage II early breast cancer patients.

Diffuse splenic F-18 FDG uptake in visceral leishmaniasis.

A 51-year-old woman had splenomegaly and enlarged multiple splenic hilar lymph nodes. The patient was referred to our department for F-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) evaluation to determine the metabolic activity of lymph nodes and define a biopsy site. PET/CT images showed diffuse increased FDG uptake in an enlarged spleen and hypermetabolic splenic hilar lymph nodes. The metabolic activity in bone marrow also seemed diffusely increased. After splenectomy, histopathologic analysis showed the growth of Leishmania amastigotes in splenic tissue, and bone marrow biopsy did not reveal any significant pathology but only mild hypercellularity.

The effects of cinacalcet treatment on bone mineral metabolism, anemia parameters, left ventricular mass index and parathyroid gland volume in hemodialysis patients with severe secondary hyperparathyroidism.

The aim of this study was to investigate the effects of cinacalcet therapy on anemia parameters, bone mineral metabolism, left ventricular mass index (LVMI) and parathyroid gland volume in hemodialysis (HD) patients with secondary hyperparathyroidism. Twenty-five HD patients (M/F: 11/14, mean age: 45.2±17.9 years, mean HD duration: 96.4±32.7 months) were included in this prospective pilot study. The indication to start calcimimetic therapy was persistent serum levels of parathyroid hormone (PTH)>1000 pg/mL, refractory to intravenous (i.v.) vitamin D and phosphate-binding therapy. The initial and one-year results of adjusted serum calcium (Ca+2), phosphate (P), Ca×P product, PTH, hemoglobin (Hb) and ferritin levels, transferrin saturation index (TSAT), median weekly erythropoietin (EPO) dose, LVMI, and parathyroid volume by parathyroid ultrasonography were determined. There were no differences between pre- and post-treatment levels of serum Ca+2 (P=0.853), P (P=0.447), Ca×P product (P=0.587), PTH (P=0.273), ferritin (P=0.153) and TSAT (P=0.104). After 1 year of calcimimetic therapy, the Hb levels were significantly higher than the initial levels (P=0.048). The weekly dose of EPO decreased with no statistical significance. The dose of cinacalcet was increased from 32.4±12.0 to 60.0±24.4 mg/day (P=0.01). There were no differences between the pre- and post-treatment results regarding weekly vitamin D dose, parenteral iron dose, LVMI and parathyroid volume. The results of our study suggest that cinacalcet therapy might have an additional benefit in the control anemia in HD patients.

A Case of a Man With Isolated Breast Metastasis From Lung Adenocarcinoma Incidentally Detected by FDG PET/CT.

Breast metastases from an extramammary primary tumor are very rare, particularly in men. In this study, we present a case of a 74-year-old man with isolated breast metastasis from lung adenocarcinoma as an incidental finding on PET/CT and diagnosed concomitantly with the primary tumor. Detection of isolated incidental metastatic lesions in the breast on PET/CT imaging has a significant clinical impact on patients with known malignant disease due to change of disease stage, management, and also treatment method.

Demonstration of cerebrospinal fluid leakage on radionuclide cisternography by SPECT/CT.

We report a case of a 37-year-old woman with severe headache provoked by postural changes who was referred to the nuclear medicine department for radionuclide cisternography to demonstrate suspected cerebrospinal fluid leakage. There was an increased uptake laterally on the left paraspinal region of upper thoracal spine and posteriorly on the upper cervical region. Fused SPECT/CT images located the exact leakage site as at the first costovertebral junction level on the left side laterally and on the posterior region of the first and second cervical spine. The treatment with epidural blood patch was successful.

Incidental diagnosis of tumor thrombosis on FDG PET/CT imaging

OBJECTIVE Clinical data are presented on patients with tumor thrombosis (TT) incidentally detected on FDG PET/CT imaging, as well as determining its prevalence and metabolic characteristics. MATERIALS AND METHODS Out of 12,500 consecutive PET/CT examinations of patients with malignancy, the PET/CT images of 15 patients with TT as an incidental finding were retrospectively investigated. A visual and semiquantitative analyses was performed on the PET/CT scans. An evaluation was made of the pattern of FDG uptake in the involved vessel as linear or focal via visual analyses. For the semiquantitative analyses, the metabolic activity was measured using SUVmax by drawing the region of interest at the site of the thrombosis and tumor (if any). RESULTS The prevalence of occult TT was 0.12%. A total of 15 patients had various malignancies including renal (1 patient), liver (4), pancreas (2), stomach (1), colon (1), non-Hodgkin lymphoma (1), leiomyosarcoma (1), endometrial (1), ovarian (1), malign melanoma (1) and parotid (1). Nineteen vessels with TT were identified in 15 patients; three patients had more than one vessel. Various vessels were affected; the most common was the inferior vena cava (n=7) followed by the portal (n=5), renal (n=3), splenic (n=1), jugular (n=1), common iliac (n=1) and ovarian vein (n=1). The FDG uptake pattern was linear in 12 and focal in 3 patients. The mean SUVmax values in the TT and primary tumors were 8.40±4.56 and 13.77±6.80, respectively. CONCLUSION Occult TT from various malignancies and locations was found incidentally in 0.12% of patients. Interesting cases with malign melanoma and parotid carcinoma and with TT in ovarian vein were first described by FDG PET/CT. Based on the linear FDG uptake pattern and high SUVmax value, PET/CT may accurately detect occult TT, help with the assessment of treatment response, contribute to correct tumor staging, and provide additional information on the survival rates of oncology patients.

Focal 99mTc-DMSA Uptake in Lung Parenchyma Without Structural Alterations on SPECT/CT.

Static renal scintigraphy with Tc-DMSA is commonly used for the evaluation of renal morphology and function. Extrarenal uptake of Tc-DMSA is a rare finding described previously on sites such as bone metastasis, hemangioma, and splenic amyloidosis. We report a case with Tc-DMSA activity in the lungs.