Mariapaola Cucinotta

Is Malignant Nodule Topography an Additional Risk Factor for Metastatic Disease in Low-Risk Differentiated Thyroid Cancer?

BACKGROUND Differentiated thyroid cancer (DTC) is the most common endocrine malignancy. In recent decades, the incidence has been increasing, largely due to increased detection of patients with low-risk or very low-risk DTC. According to European Thyroid Association and American Thyroid Association guidelines, radioiodine (RAI) thyroid remnant ablation is not indicated in very low-risk patients, while its role is still debated in low-risk patients. Accordingly, risk stratification of DTC patients is pivotal when deciding for or against RAI ablation. Presently, risk stratification is based on pTNM staging integrated with clinical parameters. The aim of our study was to evaluate the relationship between location of malignant thyroid nodules within the thyroid gland and the presence of loco-regional and/or distant metastases in patients with pT1a-pT1b DTCs. METHODS We reviewed the records of 246 patients (214 women, 32 men; female-to-male ratio 6.7:1) affected by unifocal DTC ≤ 2 cm, who had undergone RAI thyroid remnant ablation (activity ranged 555-4588 MBq) after levothyroxine withdrawal or after recombinant human TSH (rhTSH) stimulation. The majority of the patients (91.5%) were affected by papillary thyroid carcinoma. RESULTS Metastases were discovered by posttreatment whole-body scintigraphy in 29 out of 246 (11.8%) patients. In patients with metastases, malignant thyroid nodules were located in the right lobe (14/123, 11.4%), left lobe (7/95, 7.4%), and isthmus (8/27, 29.6%). The prevalence of metastases was significantly higher in patients with DTC located in the isthmus, compared to other sites (χ(2) = 9.6, p = 0.002). CONCLUSIONS Our data show for the first time that a location of a thyroid cancer in the isthmus is an additional risk factor for RAI avid metastatic disease in pT1a-pT1b DTC patients, regardless of the presence or absence of other risk factors.

Is detection of additional lesions in post-peptide receptor radionuclide therapy scans with respect to diagnostic imaging only due to different affinity of ligands?: a report of discordance between diagnostic and posttherapy imaging using the same ligand.

It is known that different affinity profiles for somatostatin receptor subtypes among different radiopharmaceuticals result in different organ and tumor uptakes and even in different sensitivities in the detection of lesions. Such differences are considered main factors explaining cases of detecting additional lesions in posttherapy scans with respect to diagnostic imaging. We show a posttherapy scan revealing more lesions--namely, a diffuse bone involvement with many small focal bony uptake areas--than the diagnostic scan using the same radiopharmaceutical (111In-pentetreotide) in a 71-year-old man with metastases from a well-differentiated ileal neuroendocrine tumor.

Role of molecular imaging in the management of patients affected by inflammatory bowel disease: State-of-the-art

AIM To present the current state-of-the art of molecular imaging in the management of patients affected by inflammatory bowel disease (IBD). METHODS A systematic review of the literature was performed in order to find important original articles on the role of molecular imaging in the management of patients affected by IBD. The search was updated until February 2016 and limited to articles in English. RESULTS Fifty-five original articles were included in this review, highlighting the role of single photon emission tomography and positron emission tomography. CONCLUSION To date, molecular imaging represents a useful tool to detect active disease in IBD. However, the available data need to be validated in prospective multicenter studies on larger patient samples.

Gliomas with intratumoral abscess formation: Description of new cases, review of the literature, and the role of 99mTC-Leukoscan

Abscess formation within a brain tumor is uncommon. Intrasellar or parasellar tumors are the most common neoplasms that develop such complications. Cerebral gliomas with abscesses are extremely rare. In this paper three rare cases of glioma associated with abscess formation are described. The diagnosis of brain tumor associated with abscess is particularly difficult by conventional neuroradiological studies. 99mTc‐labeled sulesomab can be useful in the diagnosis of brain tumors with intratumoral abscesses. There are no precise guidelines for the diagnosis and treatment of cerebral gliomas associated with abscesses formation for the low number of cases reported to date. Appropriate treatment, aimed at radical surgery, and a suitable antibiotic‐protocol, deferring adjuvant postoperative therapy, is associated with a more favorable outcome. A review of the pertinent literature is also performed.

A potentially misleading finding at somatostatin receptor scintigraphy: Focal pulmonary areas of intense accumulation without computed tomography-detectable lung lesions

Somatostatin receptor (SSR) scintigraphy with In-111 pentetreotide is currently used for the diagnosis and staging of neuroendocrine tumors which overexpress SSR. However, In-111 pentetreotide uptake is not specific for neuroendocrine tumors (NET) because SSR are also expressed by other cells and also radiotracer excretion may result in misleading accumulations. Many cases of false positive SSR scintigraphy have been reported; namely, several non-NET chest lesions have been shown to accumulate In-111 pentetreotide. A 75-yr-old female patient, who had undergone surgical resection of the lower lobe of the left lung for an atypical carcinoid (Ki-67=2%) 1 yr before, underwent In-111 pentetreotide examination; the patient had high chromogranin A (CgA) serum level (227 ng/ml; normal value: <100 ng/ml) and no significant abnormal findings in a previous whole-body computed tomography (CT) scan (3 months before). Whole-body scan (Fig. 1A and B) and single photon emission CT images (Fig. 1C) obtained 4 h after iv administration of 185 MBq of In111 pentetreotide as well as planar images of the thorax (Fig. 1D and E) obtained 24 h after radiotracer administration (1) showed 4 focal areas of intense radiotracer uptake in both lungs (right lung: 2 in the lower and 1 in the upper field; left lung: 1 in the middle field). Their spot appearance and high-intensity accumulation strongly suggests tumor localizations. A new chest CT scan obtained the same day confirmed the absence of any focal lung abnormality correlated with pulmonary radiotracer uptake. No lung lesions were found by both In-111 pentetreotide examinations and CT scans during a 2-yr follow-up; moreover, CgA levels normalized after proton-pump inhibitor therapy withdrawal. SSR scintigraphy allows in vivo visualization and characterization of NET; however, false-positive scans can occur since non-NET, non-tumoral cells in the tumor surrounding, and inflammatory cells can express SSR (2). Moreover, non-specific areas of increased accumulation can result from non-specific uptake of the radiopeptide, of its related catabolites and complexes and other in vivo-produced radiochemical forms, including the free radionuclide and by presence of radiolabeled tracers in the emunctory system (2). Many cases of false-positive SSR scintigraphy have been reported (3-5); namely, accumulation of In-111 pentetreotide in chest benign lesions, including pneumonia, chronic bronchitis, lung abscess, tuberculosis, sarcoidosis, aspergillosis, Wegener’s granulomatosis, idiopathic pulmonary fibrosis, radiation fibrosis, hamartoma, inflammatory pleural plaques, and mediastinal thrombus, has been reported. All the above-reported causes refer to CT detectable lesions. Our case shows that pulmonary In-111 pentetreotide uptake without evidence of a macroscopic (i.e. CT-detectable) lesion can also occur; it is probably due to microembuli formed during the iv injection process which are characterized by dimension not detectable by CT and are retained in the pulmonary capillary filter, determining multiple lung localizations.

Phylloid Tumor of the Breast

Phylloid tumor, formerly called cystosarcoma phylloides, is a very unusual neoplasia. It accounts for <0.5 % of all breast neoplasms and approximately 2.5 % of fibro-epithelial tumors. Like fibroadenoma, it consists of two tissue types, with the connective tissue predominating. Genomic mutations seem to be involved in the progression of fibroadenoma to phylloid tumor. There is also a high local recurrence rate, independent of the degree of malignancy. Consequently, surgical therapy should always consist of a complete resection, with tumor-free margins.

Accidental discovery of lung metastases from differentiated thyroid cancer by 99mTc sodium pertechnetate scan in a patient with secondary hyperparathyroidism.

We present a 75-year-old-man affected by chronic renal failure in whom metastases from differentiated thyroid cancer (DTC) were incidentally discovered at TcO4 neck-thorax scan in the setting of a diagnosis of secondary hyperparathyroidism. Ten years before, he had undergone near-total thyroidectomy for a multinodular goiter. Result of the pathological examination was negative for DTC. At our observation, serum thyroglobulin was high in the absence of Tg-Ab, consistent with metastatic disease. Neck ultrasonographynography was negative. The patient underwent I therapy (3700 MBq) after stimulation with recombinant human thyroid-stimulating hormone. Postdose whole-body scan confirmed the metastases already demonstrated by TcO4.

Thionamides-Related Vasculitis in Autoimmune Thyroid Disorders: Review of Current Literature and Case Reports

Graves’ disease is the most common cause of hyperthyroidism. It is an autoimmune disorder, caused by the presence of autoantibodies directed against the thyroid-stimulating hormone (TSH) receptor (TRAb), chronically stimulating thyroid hormone synthesis and secretion, and resulting in an excessive amount of triiodothyronine (T3) and thyroxine (T4) and gland growth. In iodine sufficient areas, this prototypical autoimmune disease is the most common cause of thyrotoxicosis in young women as well as in children and adolescents, and it is characterized by thyrotoxicosis, goitre and typical manifestations such as ophthalmopathy and pretibial myxedema. According to the American Association of Clinical Endocrinologists guidelines (AACE, 2002), the diagnosis of hyperthyroidism relates on TSH values. Thus, with the exception of the excess of TSH secretion, hyperthyroidism of any cases results in a lower-than-normal or

Castleman’s Disease

Castleman’s disease (CD) is an uncommon lymphoproliferative disorder. Its etiology is related to HHV-8 infection, with immunocompromised patients as the most vulnerable population. Patients with the multicentric variant of CD require systemic treatment but the disease course often includes severe complications or evolution into malignant neoplasm. PET with 18F-FDG is useful in the early detection of metabolically active CD lesions, in assessing disease extent, guiding biopsy, discriminating disease persistence/recurrence from post-therapeutic changes, and monitoring the response to treatment. The value of PET/CT in the differential diagnosis between CD and malignancies such as lymphoma requires further study.

Is %ΔSUVmax a Useful Indicator of Survival in Patients with Advanced Nonsmall-Cell Lung Cancer?

Purpose. To investigate the impact of the maximum standardized uptake value (SUVmax), size of primary lung lesion, and %ΔSUVmax on outcome (overall survival (OS) and 2-year disease-free survival (2-year DFS)) of patients with advanced nonsmall-cell lung cancer (NSCLC). Materials and Methods. 86 stage III-IV NSCLC patients underwent 18 F-FDGPET/CT, before and after chemotherapy, and were classified into subgroups according to the response criteria of the European Organization for Research and Treatment of Cancer. SUVmax values and tumor size with the best prognostic significance were searched. Correlation between the SUVmax value and the initial response to therapy (best response) and the relationship between %ΔSUVmax and OS were assessed. Results. In patients in PD (20/86), the average pretreatment SUVmax was 11.8 ± 5.23, and the mean size of the primary lesion was 43.35 mm ± 16.63. In SD, PR, and CR patients (66/86), the average pretreatment SUVmax was 12.7 ± 8.05, and the mean size of the primary lesion was 41.6 mm ± 21.15. Correlation was identified only for %ΔSUVmax; patients with PD (ΔSUVmax > +25%) showed a worse OS than patients with ΔSUVmax < +25% (CR, PR, and SD) (P = 0.0235). Conclusions. In stage III-IV NSCLC, among the assessed factors, only %ΔSUVmax may be considered as a useful prognostic factor.