Kursat Okuyucu

Clinicopathologic features and prognostic factors of tall cell variant of papillary thyroid carcinoma: comparison with classic variant of papillary thyroid carcinoma.

ObjectiveTall cell variant (TCV), an aggressive form of papillary thyroid carcinoma (PTC), frequently presents with extrathyroidal disease and recurrence. The aim of this study was to evaluate the clinicopathologic features and outcomes of patients with TCV by comparing them with a larger group of patients with classic variant of papillary thyroid carcinoma (cPTC). Patients and methodsA total of 2500 patients with differentiated thyroid carcinoma were treated and monitored during a 23-year period (1992–2015). Of them, 2250 (90%) had PTC and 235 (9.5%) had follicular thyroid carcinoma. Of the 2250 patients, 862 (38.3%) and 70 (3.1%) had cPTC and TCV, respectively. Cases of TCV and cPTC of PTC were compared on the basis of risk factors. ResultsPatients with TCV were significantly older compared with cPTC patients (P<0.001). Tumor size was significantly bigger (P=0.01) and preablation thyroglobulin level was significantly higher (P<0.001) in TCV patients than in cPTC patients. The incidence of capsule invasion, extrathyroidal extension, and vascular invasion was significantly higher in TCV (P=0.003, <0.001, and 0.011, respectively). The incidence of initial lymph node metastasis was significantly higher in TCV (P<0.001). Patients with TCV were mostly at an advanced stage compared with patients with cPTC (P<0.001). Development of local or distant metastasis during the follow-up was significantly higher in TCV than in cPTC. Sex and multifocality were not statistically significant. ConclusionTCV has a higher incidence of local or distant metastasis and mortality rate. Thus, it must be treated with the highest possible 131I ablation doses and followed up carefully.

Complete remission on 18-fluorodeoxyglucose positron emission tomography/computed tomography after nivolumab treatment in a patient with indolent Hodgkin lymphoma

Most patients with Hodgkin lymphoma (HL) get a remission after induction chemotherapy with or without radiation therapy (RT). However, relapse rates range from 10–20% in cases of stage I–II disease to 30–40% in patients with more stage III–IV disease. In addition, approximately 10–15% of patients suffer disease progression after a partial initial response. Nivolumab is an immunotherapeutic antineoplastic developed as a totally human immunoglobulin G4 (IgG4) monoclonal antibody against programmed death-1 (PD-1), an immune checkpoint inhibitor that negatively controls T-cell proliferation and functions. Intravenous administration of nivolumab was approved for the treatment of unresectable malignant melanoma in 2014 in Japan. Phase 1 or 2 studies in certain malignities including HL has been going on. Herein, we present a patient with relapsed/refractory HL not responded to multiple protocols, but successfully treated by nivolumab as depicted on 18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT).

Sphenoid Bone Fibrous Dysplasia Detected Incidentally on Bone Scintigraphy by the Contribution of SPECT/CT Hybrid Imaging

Fibrous dysplasia (FD) is a benign fibroosseous bone disorder. It has poliostotic and monostotic patterns. Monostotic FD is frequently asymptomatic and is usually discovered incidentally by radiologic imaging performed for other reasons. Bone scintigraphy is valuable for identifying disease extent. Craniofacial FD (CFD) is a form of the disease where lesions are limited to contiguous bones of the craniofacial skeleton. We presented a case with monostotic CFD who was detected incidentally on bone scintigraphy single-photon emission computed tomography/computerized tomography while being investigated for inflammatory arthropaties.

Angiographic results of the patients with positive transient ischemic dilatation on their gated myocardial perfusion imaging scans

Objectives: Gated myocardial perfusion imaging (gMPI) is an established tool for the diagnosis and risk stratification of patients with coronary artery disease (CAD) providing a variety of parameters regarding to perfusion and function of left ventricle (LV). Transient ischemic dilation (TID) is one of them. The presence of TID has been shown as a marker of severe and extensive CAD. The aim of this study was to correlate scintigraphic and angiographic findings of patients with positive TID on their gMPI scans.

Clinical and prognostic significance of preoperative and postoperative neutrophil/lymphocyte ratio and platelet/ lymphocyte ratio in patients undergoing major abdominal surgery

Aims: Acute inflammatory processes are associated with perioperative complications. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) were reported to have prognostic importance in various diseases. We aimed to investigate the clinical importance of preoperative (preop) and postoperative (postop) NLR and PLR as predictors of morbidity and surgical or nonsurgical complications after major abdominal surgery. Methods: Patients who had a major abdominal surgery were retrospectively evaluated. Age, gender, American Society of Anesthesiologist (ASA) score, and the type of operation were recorded. Preop and postop days 1, 3 and 5 white blood cell (WBC), neutrophil, lymphocyte and platelet counts, duration of intensive care unit stay and hospitalization, Clavien Dindo classification, and surgical or non-surgical complications were determined. Results: The study included 462 subjects. Concerning increased need for red blood cell transfusions, NLR was significantly higher on postop day 3 but lower on day 5, and PLR was higher on postop day 1 compared to preop state. Regarding a worse ClavienDindo classification, NLR was higher on postop day 3 but lower on day 5, and PLR was higher on postop day 1 and 3 compared to baseline. In those with increased surgical complications, NLR was lower on postop day 5, and postop day 1 and 3 PLR were higher compared to baseline values. In subjects with higher non-surgical complications, NLR was higher on postop day 3 but lower on day 5 compared to preop measurements. PLR was similar across the days of follow up in terms of non-surgical complications. Conclusions: Higher NLR on postoperative day 5, and higher PLR on postoperative days 1 and 3 compared to preop values were the indicators of increased complications in this study.

Review of the Utility of FDG-PET/CT in the Management of Primary Testicular Lymphoma

Objective: Primary testicular lymphoma (PTL) is a form of extra-nodal lymphoma originating from the testicles. Currently, positron emission tomography (PET) with glucose analogue 18F-fluorodeoxyglucose (18F-FDG) is the most popular and widely used modality for evaluating tumor metabolism, and PTL usually displays increased 18F-FDG uptake. Despite the rapid increase in clinical applications of FDG PET/ computed tomography (CT), its role in PTL has neither been clearly defined nor reviewed systematically. This study reviews the usefulness and limitation of FDG PET/CT in the diagnosis and treatment of PTL. Methods: This study included 12 patients with PTL between 2004 and 2015. We retrospectively examined PET/CT results along with patient outcome. The maximum standardized uptake value (SUVmax) was calculated. Results: The mean overall survival (OS) and disease-free survival (DFS) was 44.5 months and 35.5 months, respectively. The mean SUVmax was identified as 18.5 in recurrent/metastatic group. The 1-year and 3-year OS was 94% and 69%, while the 1-year and 2-year DFS was 93.5% and 56%, respectively. Conclusion: FDG PET/CT is very helpful in both staging and evaluating treatment response. Although it is not a perfect tool in the initial diagnosis, it might aid in the differential diagnosis of challenging testicular tumors. Pre-treatment and post-treatment FDG uptake values may also have a prognostic value in patients with PTL.

Uptake Patterns of Untreated Primary Gastrointestinal Extranodal Lymphomas on Initial Staging 18F-FDG PET/CT and Metabolic Tumor Parameters

Objective: Non-Hodgkin’s lymphomas arising from tissues other than primary lymphatic sites are classified as primary extranodal lymphomas (PEL). PELs of the gastrointestinal system (PGISL) originate from the lymphatic tissues within the gastrointestinal tract. The prognostic value of 18F-FDG PET/CT in lymphomas is high in terms of both overall survival (OS) and disease-free survival (DFS). Our aim was to investigate the uptake patterns and properties of low-grade and high-grade PGISL on primary staging 18F-FDG PET/CT, as well as the prognostic significance of metabolic tumor parameters in high grade PGISL. Methods: Thirty-nine patients with PGISL were enrolled in this retrospective cohort study between 2004-2015. Primary staging 18F-FDG PET/CT have been performed and quantitative parameters of SUVmax, SUVmean, metabolic tumor volume (MTV), total lesion glycolysis (TLG) have been calculated for all patients prior to treatment. Low-grade and high-grade PGISL were compared in terms of metabolic tumor parameters. Cox regression models were performed to determine factors that correlate with DFS in high-grade PGISL. Results: There were statistically significant differences between high-grade and low-grade PGISL in terms of SUVmax, SUVmean, MTV, TLG, recurrence, mortality, DFS and OS. None of the potential risk factors (sex, age, site, SUVmax, SUVmean, MTV, TLG) for recurrence and metastasis in high grade PGISL was identified as a risk factor on univariate and multivariate Cox regression analysis. Conclusion: Metabolic tumor parameters are not predictive markers in high-grade PGISL, especially in diffuse large B cell variant and primary gastric lymphoma. The first implications suggest they will not play a role in patient management.

Utility of FDG-PET/CT in primary central nervous system lymphoma and its contribution to prognosis estimation

Aims: Primary central nervous system lymphoma (PCNsL) is an aggressive form of extra-nodal non-Hodgkin’s lymphoma confined to CNs at initial presentation. The role of FDG-PET/CT in PCNsL is not fully defined and reviewed systematically. This study was conducted to summarize the utility of FDG-PET/CT in the management of PCNsL and show its contribution to predicting survival. materials and methods: This study included 19 patients with PCNsL treated with high dose methotrexate between 2004 and 2015. We retrospectively examined PET/CT and outcome of the patients. maximum standardized uptake value (sUVmax) was calculated. Results: mean overall survival (Os) and disease-free survival (DFs) was 22.7 months, 16.8 months, respectively. mean sUVmax was 19.9 ± 6.7 in recurrent/ metastatic group, 15.3 ± 7.2 in nonmetastatic (complete remission) group. There was a statistically significant difference between them according to sUVmax values (p=0.199). Os at 1st year was 84%, 58% at 2nd year. DFs at first year was 47%, 31.5% at second year. Conclusion: The utility of FDG-PET/CT can be summarized as initial diagnosis, baseline staging and restaging, evaluation of treatment response and prognosis estimation in PCNsL. sUVmax derived from FDG-PET/CT is a strong predictor for progression and survival of the disease.

Paraganglioma Necessitating Aggressive Surgical Staging After Primary Staging of Malignant Melanoma by FDG-PET/CT: Case Report

Malignant melanoma (MM) is a dermal cancer originating from melanocytes locating in epidermis. Its mortality is high and treatment option is determined by the stage of the disease. Therefore all patients with MM should be staged properly even if it requires aggressive surgical staging. Herein we presented a patient with MM who was staged with aggressive surgical approach that includes left axillary lymph node biopsy, video assisted thoracic surgery (VATS) thymectomy and resection of intrapericardial lesion via median sternotomy. This aggressive surgical approach avoided upstaging of the patient and unnecessary treatment.

Total Eclipse of FDG-PET Scan Caused by Hyperphysiological FDG Uptake of Masticatory Muscles Due to Chewing

In routine oncological 18F-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) scan, the patients rest in a quite, dimly lit room for 60 minutes after intravenous (IV) injection of FDG and they are instructed not to move during this time (uptake phase) before FDG-PET/CT scanning to prevent and decrease unwanted FDG accumulations on muscle traces caused by muscle movements. In conditions of patient inconsistency, undesirable activities can be seen and reach high levels making difficult or even impossible to interpret the images. Different muscle groups form various physiological or over- physiological uptake patterns depending on their specific motion. Herein we represent a good didactic example to this phenomenon.