Luda Guralnik

The role of FDG-PET/CT in suspected recurrence of breast cancer

Early diagnosis of recurrent breast cancer is crucial to selection of the most appropriate therapy. The current study evaluated the role of FDG‐PET/CT in the assessment of suspected recurrent breast cancer in patients who presented with elevated serum tumor markers.

Technetium-99m-MIBI SPECT/CT in Primary Hyperparathyroidism

The novel trend toward focused parathyroidectomy requires precise preoperative localization of the parathyroid adenoma in patients with primary hyperparathyroidism (PHPT). The present study evaluated the impact of hybrid single photon emission computed tomography/computed tomography (SPECT/CT), using 99mTc-sestamibi (MIBI), on the surgical management of these patients. In a retrospective study of 36 patients with PHPT, SPECT/CT was undertaken when planar 99mTc-MIBI scintigraphy was negative or when an ill-defined focus in the neck or an ectopic site on planar views was visualized. Imaging data were compared with intraoperative findings, and the incremental value of SPECT/CT to lesion localization and surgical procedure was assessed. Three patients with both negative planar and SPECT/CT studies subsequently underwent bilateral neck exploration, with multiglandular hyperplasia diagnosed in two patients and a parathyroid adenoma in one. Of 33 patients with a positive MIBI study, parathyroid adenoma was confined to the neck in 23 patients and to the lower neck-mediastinum in 10. SPECT/CT facilitated the surgical exploration of all 10 ectopic parathyroid adenomas and 4 of 23 cervical parathyroid adenomas, the latter four either at reexploration or in patients with nonvisualization of the thyroid after thyroidectomy. SPECT/CT contributed to the localization of parathyroid adenomas in patients with PHPT and to planning the surgical exploration in 14 of 36 (39%) patients, predominantly those with ectopic parathyroid adenomas or who had distorted neck anatomy.

Rheumatoid lung nodulosis and osteopathy associated with leflunomide therapy

BackgroundLeflunomide (LEF) is indicated in adults for the treatment of active rheumatoid arthritis (RA). LEF inhibits dehydroorotate dehydrogenase, a key enzyme of the pyrimidine synthesis in activated lymphocytes. Among rare adverse effects, fatal interstitial lung disease has been recently reported during treatment of RA with LEF in Japan. Clinical trials outside Japan do not suggest that LEF causes an excess of pulmonary adverse effects. Development and increase of peripheral rheumatoid nodules in typical sites of RA patients following LEF therapy has been recently reported.ObjectivesTwo cases with new and accelerated development of rheumatoid lung nodulosis during LEF therapy were described in this study.MethodsLEF treatment was administered to two male patients (77 and 66 years old) with long-standing active seropositive nodular RA with failure of multiple second line drugs and without lung involvement. Clinical and laboratory assessment using the American College of Rheumatology response criteria, chest computed tomography (CT), quantification of serum rheumatoid factor (RF), and monocyte count of peripheral blood along with routine laboratory follow up were performed on both patients before and during therapy. In case 1, a bone scan was performed due to sustained limbs pain. Open lung biopsy was performed in case 1 and core lung biopsy in case 2.ResultsBoth patients achieved full clinical remission during 2 months of LEF therapy. In case 1, the first complaints were limbs pain after 10 months of treatment associated with intensive bone uptake on a bone scan consistent with hypertrophic pulmonary osteopathy. Productive cough developed after 3 months of the therapy in case 2. Initially, these complaints were not attributed to therapy. New lung disease was present on CT with cherry-like progressive cavitary nodules, predominantly involving the basal segments of the right lung. The first lung lesions were found by CT 13 months (case 1) and 7 months (case 2) after the beginning of therapy and were erroneously related to bronchiectasia in case 2. In both cases, the lung biopsy showed necrosis surrounded by epithelioid mononuclear inflammation with giant cells, consistent with rheumatoid lung node. The time that elapsed between the beginning of the first symptoms to LEF discontinuation was very long: 13 months in case 1 and 24 months in case 2. Discontinuation of LEF therapy was followed by an arrest in growth of lung nodules, resolution of limb pain, and gradual improvement of bone scan. A significant decrease of monocyte count and RF level in peripheral blood was observed during LEF therapy in both cases.ConclusionFor the first time, we described rheumatoid lung nodulosis as complication of successful LEF therapy for RA. Hypertrophic pulmonary osteopathy with severe limbs pain and dry cough were the first manifestations of the lung nodulosis. Monocytopenia during LEF therapy is proposed to be involved in pathogenesis of this rare complication of LEF therapy.

The incremental value of 18F-FDG PET/CT in paediatric malignancies

Purpose18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) imaging has been used in the assessment of paediatric malignancies. PET/CT increases the diagnostic accuracy in adult cancer patients. The present study assesses the incremental value of FDG PET/CT in paediatric malignancies.MethodsA total of 118 18FDG PET/CT studies of 46 paediatric patients were reviewed retrospectively. PET and PET/CT results were classified as malignant, equivocal or benign, compared on a site- and study-based analysis, and also compared with the clinical outcome.ResultsThree hundred and twenty-four sites of increased FDG uptake were detected. Discordant PET and PET/CT interpretations were found in 97 sites (30%) in 27 studies (22%). PET yielded a statistically significant higher proportion of equivocal and a lower proportion of benign lesion and study results (p < 0.001) than PET/CT. With PET there were 153 benign (47%), 84 (26%) equivocal and 87 (27%) malignant sites, while PET/CT detected 226 benign (70%), 10 (3%) equivocal and 88 (27%) malignant lesions. PET/CT mainly improved the characterisation of uptake in brown fat (39%), bowel (17%), muscle (8%) and thymus (7%). The study-based analysis showed that 17 equivocal and seven positive PET studies (20%) were interpreted as benign on PET/CT, while three equivocal studies were interpreted as malignant. The study-based sensitivity and specificity of PET/CT were 92% and 78% respectively.ConclusionPET/CT significantly improved the characterisation of abnormal 18FDG foci in children with cancer, mainly by excluding the presence of active malignancy in sites of increased tracer activity.