Hedva Lerman

Lymphoscintigraphic sentinel node identification in patients with breast cancer: the role of SPECT-CT.

PurposeLymph node status is a major factor in determining the stage, appropriate therapy and outcome in patients with breast cancer. It is therefore of clinical importance to accurately identify all sentinel nodes (SNs) for each individual tumour before surgery. The purpose of this study was to assess the role of SPECT-CT lymphoscintigraphy in SN identification in patients with breast cancer.MethodsLymphoscintigraphy comprising planar and SPECT-CT acquisition was performed in 157 consecutive patients with breast cancer (mean age 54.7±10.6, range 27–81 years) with a palpable mass (n=100), with a non-palpable mass (n=52) or post lumpectomy (n=5). Planar and SPECT-CT images were interpreted separately and the two imaging techniques were compared with respect to their ability to identify hot nodes.ResultsPlanar imaging alone was negative for identification of hot nodes in 15% of the patients. SPECT-CT alone was negative in 10% and both techniques were negative in 9% of the patients. Forty-six of the total of 361 (13%) hot nodes identified by lymphoscintigraphy were detected only on SPECT-CT, including 21 nodes obscured by the scattered radiation from the injection site, nine adjacent nodes misinterpreted on planar images as a single node and 16 nodes which were missed on planar images and detected on SPECT data. SPECT-CT detected additional sites of drainage unexpected on planar images, including axillary (n=23 patients), internal mammary (n=5 patients), interpectoral (n=3 patients) and intramammary (n=2 patients) lymph node sites. Fourteen of the 329 (4%) hot lesions seen on planar images were false positive non-nodal sites of uptake that were accurately assessed by SPECT-CT and further validated by surgery. In a single patient, SPECT-CT was negative while planar images identified the SN.ConclusionSPECT-CT may improve the preoperative localisation of draining nodes in patients with breast cancer. It may detect hot nodes missed by planar imaging, exclude non-nodal false positive sites of uptake and accurately localise axillary and extra-axillary nodes.

Lymphoscintigraphy for sentinel node mapping using a hybrid single photon emission CT (SPECT)/CT system in oral cavity squamous cell carcinoma.

We assessed the added clinical value of fused single photon emission computed tomography (SPECT) and low‐dose CT images compared with planar images for sentinel node (SN) mapping in patients with oral cavity squamous cell carcinoma (SCC).

The presentation of malignant tumours and pre-malignant lesions incidentally found on PET-CT

PurposeThe purpose of the study was to determine the general and organ-specific presentation of incidental primary tumours on PET-CT.MethodsPET-CT reports of 2,360 consecutive patients were reviewed and revealed 156 lesions suspicious for a new unexpected malignancy, in 151 patients. One hundred and twenty of these lesions, in 115 patients, were further assessed, by biopsy (n=84 patients) or by clinical and imaging follow-up (n=31 patients) for a mean of 17±4 months (range 12–25 months).ResultsForty-four unexpected malignancies were found in 41 of the study patients (1.7%). Twenty-seven of the 44 incidental tumours were identified on the basis of their location, which was uncommon for metastasis of the known malignancy. Eight were detected as a result of either the difference in FDG avidity of the known malignancy and the incidental lesion or the presence of an incidental non-FDG-avid mass on the CT part of the study. Four tumours were synchronous carcinomas in patients with known colorectal malignancy, three were identified by virtue of the discordant response to treatment compared with the known primary tumour and two were detected as new sites of disease after a prolonged disease-free period. There was organ variability in the positive predictive values (PPV) of PET-CT findings for incidental primary malignancy or pre-malignant lesions: 62% for colonic lesions, 54% for lung lesions and 24% for thyroid lesions.ConclusionIncidental primary tumours may be identified on PET-CT based on their location, FDG avidity, response to therapy and time of appearance. The PET and CT parts of the study appear to complement each other and assist in identification of these incidental tumours.

A study investigating the acute dose— response effects of 13 mg and 17 mg Δ 9- tetrahydrocannabinol on cognitive—motor skills, subjective and autonomic measures in regular users of marijuana

Heavy use of marijuana is claimed to damage critical skills related to short-term memory, visual scanning and attention. Motor skills and driving safety may be compromised by the acute effects of marijuana. The aim of this study was to investigate the acute effects of 13 mg and 17 mg Δ 9-tetrahydrocannabinol (THC) on skills important for coordinated movement and driving and on subjective and autonomic measures in regular users of marijuana. Fourteen regular users of marijuana were enrolled. Each subject was tested on two separate days. On each test day, subjects smoked two low-nicotine cigarettes, one with and the other without THC. Seventeen mg THC was included in the cigarette on one test day and 13 mg on the other day. The sequence of cigarette types was unknown to the subject. During smoking, heart rate and blood pressure were monitored, and the subjects performed a virtual reality maze task requiring attention and motor coordination, followed by 3 other cognitive tasks (Wisconsin Card Sorting Test (WCST), a “gambling” task and estimation of time and distance from an approaching car). After smoking a cigarette with 17 mg THC, regular marijuana users hit the walls more often on the virtual maze task than after smoking cigarettes without THC; this effect was not seen in patients after they smoked cigarettes with 13 mg THC. Performance in the WCST was affected with 17 mg THC and to a lesser extent with the use of 13 mg THC. Decision making in the gambling task was affected after smoking cigarettes with 17 mg THC, but not with 13 m THC. Smoking cigarettes with 13 and 17 mg THC increased subjective ratings of pleasure and satisfaction, drug “effect” and drug “high”. These findings imply that smoking of 17 mg THC results in impairment of cognitive—motor skills that could be important for coordinated movemen and driving, whereas the lower dose of 13 mg THC appears to cause less impairment of such skills in regular users of marijuana.

Attenuation of cue-induced smoking urges and brain reward activity in smokers treated successfully with bupropion.

Twenty-two regular smokers (15+ cigarettes per day) were treated with bupropion and group therapy for 2 months. Subjects underwent positron emission tomography (PET) studies using measures of brain global and regional glucose metabolism (regional cerebral metabolic rates of glucose [rCMRglc]) with [18F]-Fluorodeoxyglucose (FDG) twice, after watching a videotape showing smoking scenes and after watching a control movie in counter-balanced order. A questionnaire of smoking urges (QSU) was filled in before and after watching both the movies. Changes in brain metabolic rates of FDG were analysed using Statistical Parametric Maps (SPM 2) in 11 smokers who abstained from smoking in comparison with 11 smokers who continued to smoke during the second month of treatment. Still-smokers had higher craving scores after watching the videotape showing smoking scenes compared with non-smokers. Second, watching the videotape showing smoking scenes compared with the control videotape in still-smokers resulted in increased metabolic rates in the striatum, thalamus and midbrain. Third, the ratings of the urge to smoke cigarettes while watching the videotape showing smoking scenes in still-smokers were associated with brain metabolic activity in the ventral striatum, anterior cingulate, orbitofrontal cortex, middle temporal lobe, hippocampus, insula, midbrain and thalamus. In conclusion, successfully treated smokers showed attenuated craving and reduced activity in the mesolimbic reward circuit.

The Value of PET/CT in Detecting Bone Marrow Involvement in Patients With Follicular Lymphoma.

AbstractFollicular lymphoma (FL) is the 2nd most common type of lymphoma diagnosed in the Western World. Bone marrow (BM) involvement is an adverse prognostic factor in FL, routinely assessed by an arbitrary biopsy of the iliac crest. This study was aimed to investigate the role of positron emission tomography/computed tomography (PET/CT) in identifying BM involvement by FL.In this retrospective, single-center study we reviewed the records of consecutive patients with FL at diagnosis or relapse who underwent staging/restaging workup visual assessment of BM uptake was categorized as either normal, diffusely increased, or focally increased. Quantitative BM fluorine-18-fluro-deoxyglucose (FDG) uptake was measured using mean standardized uptake value (BM-SUVmean). The diagnosis of BM involvement was based on either BM histological findings or disappearance of increased uptake at end-treatment PET/CT in patients who responded to treatment.Sixty eight cases with FL were included. Sixteen (23.5%) had BM involvement, 13 (19.1%) had a biopsy proven involvement, and 3 (4.4%) had a negative BM biopsy, but increased medullary uptake that normalized post-treatment. BM FDG uptake in these patients was diffuse in 8 (50%) and focal in 8 (50%). Focal increased uptake was indicative of BM involvement; however, diffuse uptake was associated with 17 false positive cases (32.7%). Overall, visual assessment of BM involvement had a negative predictive value (NPV) of 100% and a positive predictive value (PPV) of 48.5%. On a quantitative assessment, BM-SUVmean was significantly higher in patients with BM involvement (SUVmean of 3.7 [1.7–6] vs 1.4 [0.4–2.65], P < 0.001). On receiver operator curve (ROC) analysis, BM-SUVmean > 2.7 had a PPV of 100% for BM involvement (sensitivity of 68%), while BM-SUVmean < 1.7 had an NPV of 100% (specificity of 73%).Visual assessment of PET/CT is appropriate for ruling out BM involvement by FL. Although focal increased uptake indicates marrow involvement, diffuse uptake is nonspecific. SUV measurement improves PET/CT diagnostic accuracy, identifying additional 19% of patients with BM involvement that would have been otherwise missed.

The Clinical Impact of Camera-Based Positron Emission Tomography Imaging in Patients With Recurrent Colorectal Cancer

Rationale and ObjectivesF18-fluorodeoxyglucose (FDG)–positron emission tomography (PET) studies have clinical value in suspected recurrent or metastatic colorectal cancer cases. Because this modality is not accessible for many patients, a camera-based FDG (CB-FDG) coincidence imaging was suggested as an alternative. Although inferior in resolution to a dedicated PET system, it can make FDG studies available to more patients. We assessed the clinical value of CB-FDG in patients with recurrent colorectal cancer. MethodsThe disease stage and treatment approach in 83 patients were twice determined by an oncologist and a surgeon, first based on the patient’s records and blind to CB-FDG findings and then with the inclusion of FDG results in the decision-making analysis. ResultsOn a lesion-based analysis, the sensitivity of CB-FDG was 95% and the specificity was 81% compared with 88% and 64%, respectively, for computed tomography. Adding FDG findings led to disease-stage alteration in 47 patients (57%), upstaging in 35 (42%), and downstaging in 12 (15%). FDG localized the tumor sites in 21 of 26 patients (81%) with suspected clinical recurrence and a negative conventional imaging workup. In 8 patients, FDG ruled out viable tumor tissue suggested by other modalities. The oncologist’s suggested treatment approach was altered in 54% of the patients and the surgeon altered the decision on operability in 28%. ConclusionCB-FDG assessment has clinical value for both staging and selecting treatment in patients with recurrent colorectal cancer and can be considered an alternative to an nonaccessible dedicated PET system.

Sentinel node-guided evaluation of drainage patterns for melanoma of the helix of the ear.

The head and neck region, and especially the ear and its helix, is notorious for its ambiguous pattern of lymphatic drainage. Therefore, the primary nodal drainage basins in melanoma of the helix of the ear are often unpredictable. The aim of the study was to examine the value of sentinel lymph node biopsy in melanoma of the helix of the ear and to describe the natural history of the disease. Fifteen consecutive patients (14 men) with primary melanoma of the helix of the ear (median thickness, 1.2 mm; range, 0.7–10.0) underwent preoperative lymphoscintigraphy, followed by intraoperative lymphatic mapping, using blue dye in combination with a hand-held gamma probe and sentinel lymphadenectomy. The melanomas were characterized by low mitotic rate, low lymphocytic infiltrate, low spontaneous-regression rate, and mostly epitheloid cell type. In one patient, preoperative lymphoscintigraphy failed to demonstrate the draining nodes. The sentinel lymph nodes were identified and retrieved in all patients during surgery. In 13 patients (87%), they were found in the upper jugular lymphatic basin (level IIA); none were found in the retroauricular region. All sentinel lymph nodes were tumor-negative. At a median follow-up of 39 months (range, 12–73), all 15 patients were disease-free. In conclusion, sentinel lymph node biopsy for helix melanoma is an excellent alternative to elective lymph node neck dissection and superficial parotidectomy, with a high success rate and low morbidity. Melanoma of the helix of the ear has an indolent natural history.

Estrogen-dependent variations in 18F-fluorodeoxyglucose uptake in uterine leiomyomas.

Objective Positron emission tomography/computed tomography (PET/CT) is an important tool in oncology for assessment of disease extent and recurrence. Recognition of benign fluorodeoxyglucose (FDG) uptake promotes correct interpretation of imaging data. This study assesses the appearance of benign uterine leiomyomas (ULs) on PET/CT and evaluates possible hormonal influences. Patients and Methods This was a retrospective study performed in a tertiary referral cancer center in Israel. One hundred fifty-two women with nongynecologic malignancies were referred for PET/CT scans, with incidental UL on imaging. Information on menopausal status and menstrual phase and on the use of oral contraceptives, hormone replacement therapy, and selective estrogen receptor modulators (SERM) was collected. Fluorodeoxyglucose uptake measured as standard uptake value (SUV) was obtained for UL, normal myometrium, and gluteus muscle. Changes associated with menopausal status, menstrual cycle phase, and the use of oral contraceptives, hormone replacement therapy, and SERM were assessed. Results The mean ± SD SUV in UL for the entire cohort was 1.39 ± 0.65 and was higher than in myometrium (1.24 ± 0.33) and gluteus muscle (0.48 ± 0.36). Fluorodeoxyglucose uptake was similar in UL and in myometrium during the preovulatory (1.42 ± 0.31 vs 1.23 ± 0.34) and postovulatory (1.23 ± 0.34 vs1.38 ± 0. 4) periods. During ovulation, SUV was significantly higher in UL (1.62 ± 0.39) than in normal myometrium (1.12 ± 0.15; P = 0.01). Uterine leiomyoma FDG uptake in premenopausal women (1.47 ± 0.32) was higher than in postmenopausal women (1.29 ± 0.41; P < 0.02). The UL/gluteus SUV ratio in patients on hormone replacement therapy (2.53 ± 0.23) was significantly higher than in untreated patients (1.27 ± 0.92; P = 0.05). Lower uptake was recorded in patients on SERM (SUV, 1.1 ± 0.24) than in untreated patients (SUV, 1.41 ± 0.36; P < 0.01). Conclusion Fluorine 18 FDG uptake in UL may be estrogen dependent. Endogenous estrogen and hormone replacement therapy increase FDG uptake, whereas withdrawal of estrogen by menopause or SERM decreases uptake.ObjectivePositron emission tomography/computed tomography (PET/CT) is an important tool in oncology for assessment of disease extent and recurrence. Recognition of benign fluorodeoxyglucose (FDG) uptake promotes correct interpretation of imaging data. This study assesses the appearance of benign uterine leiomyomas (ULs) on PET/CT and evaluates possible hormonal influences. Patients and MethodsThis was a retrospective study performed in a tertiary referral cancer center in Israel. One hundred fifty-two women with nongynecologic malignancies were referred for PET/CT scans, with incidental UL on imaging. Information on menopausal status and menstrual phase and on the use of oral contraceptives, hormone replacement therapy, and selective estrogen receptor modulators (SERM) was collected. Fluorodeoxyglucose uptake measured as standard uptake value (SUV) was obtained for UL, normal myometrium, and gluteus muscle. Changes associated with menopausal status, menstrual cycle phase, and the use of oral contraceptives, hormone replacement therapy, and SERM were assessed. ResultsThe mean ± SD SUV in UL for the entire cohort was 1.39 ± 0.65 and was higher than in myometrium (1.24 ± 0.33) and gluteus muscle (0.48 ± 0.36). Fluorodeoxyglucose uptake was similar in UL and in myometrium during the preovulatory (1.42 ± 0.31 vs 1.23 ± 0.34) and postovulatory (1.23 ± 0.34 vs1.38 ± 0. 4) periods. During ovulation, SUV was significantly higher in UL (1.62 ± 0.39) than in normal myometrium (1.12 ± 0.15; P = 0.01). Uterine leiomyoma FDG uptake in premenopausal women (1.47 ± 0.32) was higher than in postmenopausal women (1.29 ± 0.41; P < 0.02). The UL/gluteus SUV ratio in patients on hormone replacement therapy (2.53 ± 0.23) was significantly higher than in untreated patients (1.27 ± 0.92; P = 0.05). Lower uptake was recorded in patients on SERM (SUV, 1.1 ± 0.24) than in untreated patients (SUV, 1.41 ± 0.36; P < 0.01). ConclusionFluorine 18 FDG uptake in UL may be estrogen dependent. Endogenous estrogen and hormone replacement therapy increase FDG uptake, whereas withdrawal of estrogen by menopause or SERM decreases uptake.

Breast Imaging Utilizing Dedicated Gamma Camera and 99mTc-MIBI: Experience at the Tel Aviv Medical Center and Review of the Literature Breast Imaging

The scope of the current article is the clinical role of gamma cameras dedicated for breast imaging and (99m)Tc-MIBI tumor-seeking tracer, as both a screening modality among a healthy population and as a diagnostic modality in patients with breast cancer. Such cameras are now commercially available. The technology utilizing a camera composed of a NaI (Tl) detector is termed breast-specific gamma imaging. The technology of dual-headed camera composed of semiconductor cadmium zinc telluride detectors that directly converts gamma-ray energy into electronic signals is termed molecular breast imaging. Molecular breast imaging system has been installed at the Department of Nuclear medicine at the Tel Aviv Sourasky Medical Center, Tel Aviv in 2009. The article reviews the literature well as our own experience.