Jasna Mihailovic

Recurrent Disease in Juvenile Differentiated Thyroid Carcinoma: Prognostic Factors, Treatments, and Outcomes

The overall prognosis in pediatric differentiated thyroid carcinoma (DTC) is excellent. Recurrent disease is frequent, however, and requires additional treatment. We analyzed the probability of recurrence, prognostic factors, treatment, and outcome of juvenile DTC. Methods: Fifty-one DTC patients (32 girls and 19 boys; ≤20 y old; mean age, 16.5 y) were treated with 131I (radioiodine, or radioactive iodine [RAI]); the median follow-up was 10 y. Patients underwent different initial treatments: 46 patients received total thyroidectomy and RAI, 3 patients received total thyroidectomy, and 3 patients received subtotal thyroidectomy. The probability of recurrence and prognostic factors were tested with the Kaplan–Meier method. Results: Initially, 36 of 51 patients achieved complete remission, 14 of 51 achieved partial remission, and 1 of 51 had progressive disease. By the follow-up, 11 of 51 patients (21.6%) had developed recurrent disease; the median appearance time was 4 y (range, 1–15 y). The probabilities of recurrence were 16.7% at 5 y, 22.3% at 10 y, and 33.3% at 15 and 23 y after the initial treatments. Factors that were strongly predictive of recurrence were age (P = 0.001), initial treatment (P = 0.0001), and tumor multifocality (P = 0.011). Sex, nodal metastases at presentation, distal metastases at presentation, histologic type of the tumor, T stage, and clinical stage had no influence on relapse (P = 0.180, P = 0.786, P = 0.796, P = 0.944, P = 0.352, and P = 0.729, respectively). Patients with recurrent disease, partial remission, and progressive disease were retreated, with either surgery or surgery and RAI, receiving cumulative activities of up to 40 GBq. The overall outcome in our patients was excellent: 90.2% complete remission, 3.92% partial remission, 1.96% stable disease, 1.96% disease-related death, and 1.96% another cause of death. Conclusion: Younger age at diagnosis, less radical primary surgery without subsequent RAI, and tumor multifocality are factors that are strongly prognostic for recurrence. For reducing the rate of relapse and improving surveillance for recurrent disease, total thyroidectomy followed by RAI appears to be the most beneficial initial treatment for patients with juvenile DTC. The use of RAI seems to be safe, with no adverse effects on subsequent fertility and pregnancy or secondary malignancy.

Metastatic differentiated thyroid carcinoma: clinical management and outcome of disease in patients with initial and late distant metastases.

ObjectiveOur objective was to analyze the clinical management and the outcome of disease in differentiated thyroid carcinoma with initial and late distant metastases (M1). Patients and methodsRadioiodine (131I) therapy was applied in 77 differentiated thyroid carcinoma patients with M1 (31 patients with M1-initial and 46 patients with M1-late). The median follow-up of patients was 72.7 months. Probability of disease-specific survival (DSS) was analyzed by the Kaplan–Meier method and the log rank test, while the significance of differences between groups was calculated by the t-test of proportions. ResultsFollicular carcinomas were more frequent in patients with M1-late (P<0.05). During the follow-up, 58% of the patients died: 39% of cases had disease related deaths, while 42% had complete remission of disease. Stable disease and progressive disease were significantly influenced by age only (P = 0.0122), while 131I uptake, histological type, and sex had no influence (P = 0.1235; P = 0.340; P = 0.8540, respectively). Remission of disease (complete and partial) was not significantly influenced by age, sex, histological type, and 131I accumulation (P = 0.0644; P = 0.8452; P = 0.6308; P = 0.7675, respectively). DSS in patients with M1-initial and M1-late at 5 years was 71 and 50%, respectively and 62 and 41% at 10 years, respectively, without significant difference (P = 0.2582). Disease related deaths appeared more frequent in patients at 45 years of age or older, significantly caused by distant metastases (P<0.001). ConclusionDistant metastases occur late more often in patients with follicular carcinoma while M1-initial is detected more often in patients with papillary carcinoma. DSS was not significantly different among patients with M1-intial and M1-late. The risk of death from M1 increased after the age of 45 years.

Multiple Myeloma: 18F-FDG-PET/CT and Diagnostic Imaging

Multiple myeloma (MM) is a relatively rare hematologic disorder characterized by proliferation of plasma cells, primarily involving the bone marrow. Extramedullary involvement also occurs with poor prognosis. Asymptomatic plasma cell disorders, monoclonal gammopathy of uncertain significance, and smoldering MM, which do not require therapy, should be distinguished from symptomatic MM, which requires treatment. MM may present with CRAB, elevated Calcium levels, Renal insufficiency, Anemia, and Bone lesions (including lytic lesions and osteopenia), as well as elevated levels of serum M protein or urine M protein or both. Nonsecretory myeloma in which serum and urine M proteins are absent occurs rarely, accounting for 1%-5% of patients with myeloma, but low levels of abnormal immunoglobulins are often present. Staging of patients with MM is done according to the Durie and Salmon criteria based on laboratory testing (determination of hemoglobin, serum calcium, and serum and urine M proteins) and conventional radiography. A variety of diagnostic imaging procedures have been employed to assess the extent of disease in MM and to evaluate the response to treatment as well as provide surveillance for the detection of recurrent disease. These include whole-body x-ray, which despite its limitations is regularly used to detect lytic bone lesions; CT radiography; MRI; and a variety of radionuclide imaging procedures, with (18)F-FDG-PET/CT emerging as the radionuclide procedure of choice. Recently, the Durie-Salmon criteria have been upgrade to the Durie-Salmon PLUS system, which includes (18)F-FDG-PET/CT and MRI of the spine and pelvis.

RELIABILITY OF POSITRON EMISSION TOMOGRAPHY-COMPUTED TOMOGRAPHY IN EVALUATION OF TESTICULAR CARCINOMA PATIENTS.

INTRODUCTION The study was aimed at assessing the reliability of 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan in evaluation of testicular carcinoma patients. MATERIAL AND METHODS The study sample consisted of 26 scans performed in 23 patients with testicular carcinoma. According to the pathohistological finding, 14 patients had seminomas, 7 had nonseminomas and 2 patients had a mixed histological type. In 17 patients, the initial treatment was orchiectomy+chemotherapy, 2 patients had orchiectomy+chemotherapy+retroperitoneal lymph node dissection, 3 patients had orchiectomy only and one patient was treated with chemotherapy only. Abnormal computed tomography was the main cause for the oncologist to refer the patient to positron emission tomography-computed tomography scan (in 19 scans), magnetic resonance imaging abnormalities in 1 scan, high level oftumor markers in 3 and 3 scans were perforned for follow-up. Positron emission tomography-computed tomography imaging results were compared with histological results, other imaging modalities or the clinical follow-up of the patients. RESULTS Positron emission tomography-computed tomography scans were positive in 6 and negative in 20 patients. In two patients, positron emission tomography-computed tomography was false positive. There were 20 negative positron emission omography-computed tomography scans perforned in 18 patients, one patient was lost for data analysis. Clinically stable disease was confirmed in 18 follow-up scans performed in 16 patients. The values of sensitivty, specificity, accuracy, and positive- and negative predictive value were 60%, 95%, 75%, 88% and 90.5%, respectively. CONCLUSION A hgh negative predictive value obtained in our study (90.5%) suggests that there is a small possibility for a patient to have future relapse after normal positron emission tomography-computed tomography study. However, since the sensitivity and positive predictive value of the study ire rather low, there are limitations of positive positron emission tomography-computed tomography scan to suggest persistent disease.

DIAGNOSTIC ROLE OF FLUORINE-18 (18F) FLUORODEOXYGLUCOSE POSITRON EMISSION TOMOGRAPHY COMPUTED TOMOGRAPHY IN DETECTING RECURRENT DISEASE IN PATIENTS WITH COLORECTAL CANCER AND ELEVATED CARCINOEMBRYONIC ANTIGEN.

INTRODUCTION Early detection of recurrence is an important factor for long term survival of patients with colorectal cancer. Measurement of serum levels of carcinoembryonic antigen has been commonly used in the postoperative surveillance of colorectal cancer. The purpose of this study was to evaluate the ability of positron emission tomography-computed tomography to detect pathological substrate of elevated serum carcinoembryonic antigen in patients with colorectal cancer. MATERIAL AND METHODS The patients with colorectal cancer who underwent curative surgical resection and/ or chemotherapy, who were found in our database, were analyzed retrospectively. Forty-eight 18F-fluorodeoxyglucose positron emission tomography-computed tomography studies including 45 patients (14 women, 31 men; mean age: 62.93 years) with elevated serum, carcinoembryonic antigen levels, which had been performed between January 2011 and January 2014, were evaluated. Serum levels of carcinoembryonic antigen were measured within 3 months after positron emission tomography-computed tomography examination. Final diagnosis of recurrence was made by histopathological findings, radiology studies or clinical follow-up. RESULTS Recurrences were diagnosed in 37 patients, the prevalence being 77.1%. Liver metastases were found in 18 patients, abdominal, pelvic and/or mediastinal lymph nodes were positive in 19 patients, 11 patients had loco regional recurrences and 4 patients had pulmonary metastasis, and bone metastases were found in one patient. One patient was diagnosed with metastasis in scar tissue. The overall sensitivity and specificity of positron emission tomography-computed tomography was 90.24% and 71.42%, respectively. The positive and negative predictive values were 94.87% and 55.56%, respectively. CONCLUSION 18F-fluorodeoxyglucose positron emission tomography-computed tomography is a powerful tool that could be used in determining colorectal cancer recurrence in patients with elevated carcinoembryonic antigen levels and could have an important clinical impact on the management in patients with suspected recurrent colorectal cancer.

Head and Neck

History: Seventy-three-year-old woman presented 7 months earlier was diagnosed at that time with a malignant tumor of the left parotid gland [same patient as Chap. 4, as Case 2]. Tumor was removed surgically with resection of involved lymph nodes, followed by radiation therapy. Patient was referred for FDG PET/CT as follow-up; detection of residual tumor, metastases.

Head and Neck Carcinoma

History: Patient presented with dysphonia, dysphagia, hoarseness, weight loss, and bilateral cervical adenopathy. On fiber-optic exam, he was found to have a large left true vocal cord lesion extending into the false vocal cord. There was obstruction of approximately 75% of the lumen of the airway. CT scan showed a large mass in the left vocal cord region.

Urologic Tumors Bladder

History: Eighty-four-year-old male with a remote history of bladder cancer (status post cystectomy 1998, left nephroureterectomy, radical prostatectomy) and recent history of colon cancer (diagnosed by FDG PET/CT); status post right hemicolectomy in 2008. Now, patient presents with left lower extremity pain and edema.

Bone: From planar imaging to SPECT & PET/CT

Since its introduction into clinical medicine 50 years ago, the radionuclide bone scan has played a key role in diagnosing a variety of osseous disorders; particularly metastatic disease. Using small diagnostic doses of Strontium-85 in the 1960’s, it was rapidly established that the study was much more sensitive than skeletal radiographs. The introduction of Technetium-99m phosphate agents in the early 1970’s, offered greatly improved resolution. Whole body imaging became the standard procedure. Interestingly, the positron-emitter, Fluorine 18-sodium fluoride was used by some investigators with the rectilinear scanner. Very recently, this radiotracer has been re-introduced and is witnessing considerable growth using modern PET/CT instrumentation. The cortical bone tracers, 99mTc-MDP and 18F-Fluoride assess osteoblastic response to the invading lesion. In the study of metastatic disease, it is superb for sclerotic blastic lesions. Although it detects most lytic lesions, many can be missed. This is due to a lack of osteoblastic response. The tumor may be slow growing, such as myeloma or conversely very rapidly growing and destructive, such as lung or kidney metastases. In these lesions, 18F-FDG is superior because it is concentrating in the tumor cells and does not depend on osteoblastic response to the tumor. In their early cause, many lytic lesions may be confined to the medullary portion of bone and not yet involve the cortex. Comparative studies of PET and CT have clearly shown the superior sensitivity of FDG in detecting metastatic bone lesions.

Positron emission tomography in neoplasms of the digestive system

2 SUMMARY PET/CT has proven to be extremely useful in studying neoplasms of the colon and esophagus. It has been less promising for lesions of the stomach, pancreas and hepatobiliary tract. Colorectal cancer is the third most common non-cutaneous cancer representing 13% of all malignancies. The use of colonoscopy has significantly contributed to the earlier detection and higher cure rate. PET/CT is not a screening procedure. It is very good for staging, recurrence detection and monitor- ing therapeutic interventions. It is excellent for detecting distant metastases, e.g. liver lesions, but is less accurate for detecting nodal involvement. The CT portion of the study enhances certainty of lesion localization and characterization. Esophageal cancer is less common in the U.S. in that it represents 7% of G-I cancers, but only 1% of all cancers. The major problem is that often it is advanced to Stages III or IV before it comes to clinical recognition. A 5-year survival has been improved from 3% to 10% by the use of induction chemoradiotherapy. PET has proven useful in staging and deter- mining resectability, monitoring response to therapy, radiotherapy treatment planning and distinguishing between post- op scar and residual or recurrent disease on CT. Gastric cancer results have been more variable. The intestinal (tubular variety) shows better uptake than the non-intestinal (signet ring cell) variety because of the greater mucous content of the latter which is associated with more false negatives. FDG uptake in pancreatic cancer is also variable. Attempts at distinguishing carcinoma from pancreatitis have been limited. When lesions do show uptake, PET/CT has been helpful in monitoring therapeutic interventions. Hepatocellular cancer demonstrates significant FDG uptake in only 50-70% of cases. Cholangio carcinomas; particularly the peripheral variety, do show significant FDG uptake.