Jairo Wagner

Vertical growth phase and positive sentinel node in thin melanoma

Sentinel node (SN) status is the most important prognostic factor for localized melanoma. Usually, patients with Breslow thickness of less than 1.0 mm are not included in SN protocols. However, the literature presents a rate ranging from 3 to 7% of nodal recurrence in thin melanoma. Ulceration, regression and high mitotic rate have been considered to be indications for an SN biopsy. The metastatic potential of the vertical growth phase is uncertain. To correlate pathological features in thin melanoma with SN metastasis, we reviewed 358 patients submitted to SN biopsy. Seventy-seven patients with lesions of 1 mm or smaller were included in the study group. Histological evaluation of the primary tumor included thickness, Clark level, mitotic rate, ulceration, regression, and growth phase. Lymphoscintigraphy was performed on all patients. Lymphatic mapping and gamma probe detection were both used for SN biopsy. Histological examination of SN consisted of hematoxylin-eosin and immunohistochemical staining. Median follow-up was 37 months. Six patients had micrometastases. Statistical analysis by the Fisher test showed that ulceration (P = 0.019), high mitotic rate (P = 0.008) and vertical growth phase (P = 0.002) were positively correlated with micrometastases. If other studies confirm these results, more melanoma patients must be submitted to SN biopsy.

Higher nigrostriatal dopamine neuron loss in early than late onset Parkinson's disease?-A [99mTc]-TRODAT-1 SPECT study

Early‐onset Parkinsons disease (EOPD) is distinct from the classic late‐onset PD (LOPD) because of its slower disease progression. The aim of this study was to compare dopamine neuronal loss in EOPD with that of LOPD with the same disease duration, through dopamine transporter (DAT) estimation. Fourteen patients, seven EOPD (<50 years) and seven LOPD, matched for disease duration were scanned with [99mTc]‐TRODAT‐1‐SPECT (INER‐Taiwan), and were assessed with standard PD scales. EOPD patients had 34% lower striatal DAT binding potential (BP) compared with that of LOPD patients (BP = 0.29 ± 0.12, BP = 0.44 ± 0.12, P < 0.02) with similar PD severity. These results suggest that EOPD patients have greater dopamine density loss than LOPD patients without motor‐symptom worsening.

The effect of catecholamines on the glucose uptake in brown adipose tissue demonstrated by 18F-FDG PET/CT in a patient with adrenal pheochromocytoma

A 50-year-old man had the diagnosis of right adrenal pheochromocytoma made by computed tomography (CT) scan together with the evidence of raised plasma catecholamine and urinary catecholamine metabolite levels. A positron emission tomography (PET)/CT study with Ffluorodeoxyglucose (FDG) demonstrated intense, bilateral, and symmetric uptake in brown adipose tissue (BAT) in the neck, supraclavicular, axillary, mediastinal, paravertebral, and perinephric regions and also in the right adrenal gland (a, arrows). Histologic examination of the excised tumor demonstrated a typical presentation of pheochromocytoma. Five days after the surgery, another PET/CT scan showed no uptake in BAT. A slight uptake was seen in the right adrenal bed which was attributed to an inflammatory process (b, arrow). Symmetrically increased F-FDG uptake occurring in areas of fat of the neck, supraclavicular, paravertebral, mediastinal, and perinephric regions has been described with F-FDG PET/CT [1]. Brown fat has the ability to increase its blood flow with norepinephrine stimulation and is rich in adrenergic innervation [2]. Glucose uptake increases when the BAT sympathetic nervous system is activated [3, 4]. Although BAT is more

(18) F-FDG PET imaging of rheumatoid articular and extraarticular synovitis.

During the past few years (18) F-FDG fluor deoxyglucose positron emission tomography (FDG-PET) has become a major advance in the staging of tumors and monitoring of treatment. FDG-PET can also be used to image active synovitis and its usefullness in monitoring treatment is currently being evaluated. Patient DGC is a 62-year-old male attending our clinic with long standing rheumatoid arthritis. He failed to respond to DMARDs and was assigned to biologic therapy. He received 3 infusions of Infliximab in a 6 week period. He had whole body FDG-PET images acquired prior to and 2 months after the first infusion (Figs. 1 and 2). Image analysis shows significant uptake of FDG in several joints indicating severe metabolic activity before treatment followed by marked reduction after anti TNF therapy. DAS28 before and after therapy was 5.6 and 3.4,

Vital dye is enough for inguinal sentinel lymph node biopsy in melanoma patients

PURPOSE The importance of gamma probe detection (GPD) combined with vital dye for sentinel node (SN) biopsy is well accepted. We evaluated the efficacy of patent blue dye (PBD) in identifying inguinal SN. METHODS Ninety-four cutaneous melanoma patients with inferior extremity lesions were submitted to SNB according to a established protocol. Patients were randomized in two groups: Blue group, where SN was identified by PPD and Probe group, where SN was identified by GPD. The median age was 44.2 years and median Breslow thickness was 2.1 mm. Preoperative lymphoscintigraphy, lymphatic mapping with PBD and intra-operative GPD was performed on all patients. Histological examination of SN consisted of hematoxylin-eosin and immunohistochemical staining. If micrometastases were present complete lymphadenectomy was performed. The SN was considered as identified by PBD if it was blue and identified by GPD if it demonstrated at least ten times greater radioactivity than background. RESULTS It was explored 94 inguinal lymphatic basins, 145 SN were excised (70 guided primarily by blue dye and 75 guided primarily by probe). All SN identified by preoperative lymphoscintigraphy were excised. In the Blue group PPD identified all SN and all of them were hot. In the Probe group all SN were identified by probe and were blue. The coincidence of PPD and GPD was 100%. CONCLUSION Patent blue dye is enough to identify superficial inguinal SN in cutaneous melanoma.

F-18 FDG PET/CT imaging in small cell prostate cancer.

Abstract: Positron emission tomography/computed tomography scan with F-18 fluorodeoxyglucose was performed in a 77-year-old patient with prostatic adenocarcinoma treated with hormonal therapy, who presented 2 years later with an abdominal mass and slowly increasing prostate specific antigen and carcinoembryonic antigen. Positron emission tomography-computed tomography scan showed intense uptake of F-18 fluorodeoxyglucose in the prostate tumor, iliac, and periaortic lymph nodes and also in a focal area in the right lobe of the liver. The new biopsy of the tumor and lymph nodes was compatible with small cell prostate cancer.

Basal serum thyroglobulin measured by a second-generation assay is equivalent to stimulated thyroglobulin in identifying metastases in patients with differentiated thyroid cancer with low or intermediate risk of recurrence.

Background: Guidelines for the follow-up of differentiated thyroid cancer (DTC) recommend the measurement of TSH-stimulated thyroglobulin (s-Tg) instead of basal Tg on T4 therapy (b-Tg). However, these guidelines were established using first-generation Tg assays with a functional sensitivity (FS) of 0.5-1.0 ng/ml. Current more sensitive second-generation Tg assays (Tg2G; FS 0.05-0.10 ng/ml) have shown that low-risk DTC patients with undetectable b-Tg rarely have recurrences. Objectives: This study was undertaken to compare b-Tg using a chemiluminescent Tg2G assay (Tg2GICMA; FS 0.1 ng/ml) with s-Tg in DTC patients with an intermediate risk of recurrence. Methods: We evaluated 168 DTC patients with a low (n = 101) and intermediate (n = 67) risk of recurrence treated by total thyroidectomy (147 also treated with radioiodine), with a mean follow-up of 5 years. Results: b-Tg was undetectable with the Tg2GICMA in 142 of 168 patients. s-Tg was <2 ng/ml in 138 of these 142 patients, and only 3 of these 138 (2%) presented metastases on cervical ultrasound (US). Of the 4 of 142 patients with s-Tg >2 ng/ml, 1 had cervical metastases seen after radioiodine. Furthermore, 26 of 168 patients presented detectable b-Tg with the Tg2GICMA; 17 of these 26 patients also presented s-Tg >2 ng/ml. In 10 of these 17 patients, metastases were detected. Cervical US or b-Tg were positive in 14 of 15 patients with recurrent disease. Globally, the sensitivity and negative predictive value of the Tg2GICMA plus US were 93 and 99%, respectively. Conclusion: b-Tg measured with a Tg2GICMA and cervical US, used together, are equivalent to s-Tg in identifying metastases in patients with DTC with a low or intermediate risk of recurrence.

Valor diagnóstico da tomografia por emissão de pósitrons / tomografia computadorizada (PET-CT) com flúor-18 fluordeoxiglicose (FDG-18F) em pacientes com carcinoma diferenciado da tireóide, níveis séricos de tireoglobulina elevados e pesquisa de corpo inteiro com iodo negativa

PURPOSE To evaluate the role of PET-CT with FDG-18F in the detection of recurrence and/or metastasis of differentiated thyroid carcinoma (DTC) in patients with elevated levels of thyroglobulin (TG) and negative whole body scan (WBS). PATIENTS AND METHOD PET-CT findings of 25 patients were compared to histopathology evaluation and conventional imaging (CI). RESULTS PET-CT scan was positive in 16 patients finding 14 true-positive and 2 false-positive cases (positive predictive value 87.5%). Nine patients had negative PET-CT; two had decrease of TG to undetectable levels. One patient had residual disease detected by post-therapeutic WBS. Six patients had no evidence of tumor during follow-up (mean time 16 months). PET-CT was concordant with CI in 52%, partially concordant in 12% and discordant in 36% (6 false-negatives and 3 false-positive of CI). We observed a tendency of increasing proportion of positive PET-CT with increasing TG. CONCLUSION PET-CT scan with FDG-18F is useful in the detection of recurrence and/or metastases of DTC with high TG levels but negative WBS. It presents elevated positive predictive value and is superior to CI being more effective as higher the serum TG levels.

A Prospective Study Showing an Excellent Response of Patients with Low-Risk Differentiated Thyroid Cancer Who Did Not Undergo Radioiodine Remnant Ablation after Total Thyroidectomy.

Objectives: To prospectively evaluate the outcome of patients with low-risk papillary thyroid carcinoma treated with total thyroidectomy (TT) who did not undergo radioiodine remnant ablation (RRA). Study Design: We prospectively followed up 57 patients; 3 months after TT, thyroglobulin (Tg) assessment and neck ultrasonography (US) were performed while patients were taking L-T4, presenting suppressed TSH. Six months after TT, patients underwent stimulated Tg testing and whole-body scan (WBS) after recombinant TSH (rhTSH). Then, 18 months after TT, the patients were evaluated by neck US and Tg under TSH between 0.5 and 2.0 mIU/ml. Two years after TT, we performed another rhTSH assessment, measuring Tg and making a WBS. The patients were then annually monitored with neck US and Tg measurement under TSH between 0.5 and 2.0 mIU/l for 36-84 months. Results: Neck US of all patients, 3 months after TT, presented no evidence of abnormal residual tissues or metastatic lymph nodes (negative neck US); at this time, the mean Tg level was 0.42 ng/ml. Six months after surgery, after rhTSH, the mean thyroid bed uptake was 1.82%, and Tg levels ranged from 0.10 to 22.30 ng/ml (mean, 2.89 ng/ml). The patients were followed up without any sign of recurrence (negative neck US and stable or decreasing Tg levels). During the ongoing follow-up, the Tg trend was stable or decreasing, independently of the initial suppressed or stimulated Tg level, or WBS uptake. Conclusions: In patients with low-risk differentiated thyroid cancer, who were operated by TT and who did not undergo RRA, an excellent response to treatment may be confirmed by annual neck US and Tg trend.

Not all that shines is cancer: pulmonary cryptococcosis mimicking lymphoma in [(18)] F fluoro-2-deoxy-D-glucose positron emission tomography

We report of a case of pulmonary cryptococcosis mimicking lymphoma in a positron emission tomography (FDG-PET) scan. A 62-year old man with diffuse large B-cell lymphoma had complete resolution of abdominal and pulmonary lesions after three cycles of rituximab-based chemotherapy (R-CHOP). However, FDG-PET showed new pulmonary nodules, suggesting active lymphoma. Chronic inflammatory granuloma was seen in the histopathological exam, with round-shaped structures compatible with fungus, later identified as Cryptococcus neoformans on culture. The lesions disappeared after 6 weeks of fluconazole therapy, and the patient could continue chemotherapy without further infectious complications.