Michael C. Roarke

A Multi‐site Validation Trial of Radioactive Seed Localization as an Alternative to Wire Localization

Abstract:  This study aims to validate radioactive seed localization (RSL) as an alternative to wire localization (WL) in the operative excision of nonpalpable breast lesions. Eligible patients were recruited sequentially. A sample of 99 patients treated with WL was compared to the next 383 patients treated with RSL. Margins were considered “negative” if ≥2 mm from in‐situ and invasive disease. Pain and convenience scores were recorded on a 10‐point scale. Patient characteristics and histology were similar. The lesion and localization device were retrieved in all patients. Margins of the first specimen were negative in 73% of RSL patients, versus 54% of WL patients (p < 0.001). A second operation was required in 8% of RSL patients to achieve negative margins, versus 25% of WL patients (p < 0.001). Pain scores were not statistically different. However, the RSL group had higher convenience scores (p = 0.015). RSL is safe, effective, and compared to WL, reduces the rates of intraoperative re‐excision and reoperation for positive margins by 68%. Patient satisfaction is improved with RSL. We strongly favor RSL over WL.

PROVOCATIVE IMAGING: Diuretic Renography

Diuretic renography remains the noninvasive functional study of choice in patients with hydronephrosis resulting from apparent UPJ obstruction. Meticulous attention to proper patient preparation, radiopharmaceutical selection, furosemide dosage and administration, and image interpretation and an awareness of potential pitfalls are essential for accurate diagnosis. For most patients, the F + 20 protocol is sufficient, however; the F-15 protocol allows clarification in cases of equivocal baseline F + 20 studies. Invasive antegrade techniques such as the Whitaker pressure/perfusion test are best reserved for patients in whom the diagnosis remains equivocal after diuretic renography, or in patients with massive hydronephrosis or renal insufficiency. New standardized protocol guidelines should help to ensure studies that are reproducible in different nuclear medicine laboratories.

Image-Guided Radiotherapy for Prostate Cancer: A Prospective Trial of Concomitant Boost Using Indium-111–Capromab Pendetide (ProstaScint) Imaging

PURPOSE To evaluate, in a prospective study, the use of (111)In-capromab pendetide (ProstaScint) scan to guide the delivery of a concomitant boost to intraprostatic region showing increased uptake while treating the entire gland with intensity-modulated radiotherapy for localized prostate cancer. METHODS AND MATERIALS From September 2002 to November 2005, 71 patients were enrolled. Planning pelvic CT and (111)In-capromab pendetide scan images were coregistered. The entire prostate gland received 75.6 Gy/42 fractions, whereas areas of increased uptake in (111)In-capromab pendetide scan received 82 Gy. For patients with T3/T4 disease, or Gleason score ≥8, or prostate-specific antigen level >20 ng/mL, 12 months of adjuvant androgen deprivation therapy was given. In January 2005 the protocol was modified to give 6 months of androgen deprivation therapy to patients with a prostate-specific antigen level of 10-20 ng/mL or Gleason 7 disease. RESULTS Thirty-one patients had low-risk, 30 had intermediate-risk, and 10 had high-risk disease. With a median follow-up of 66 months, the 5-year biochemical control rates were 94% for the entire cohort and 97%, 93%, and 90% for low-, intermediate-, and high-risk groups, respectively. Maximum acute and late urinary toxicities were Grade 2 for 38 patients (54%) and 28 patients (39%) and Grade 3 for 1 and 3 patients (4%), respectively. One patient had Grade 4 hematuria. Maximum acute and late gastrointestinal toxicities were Grade 2 for 32 patients (45%) and 15 patients (21%), respectively. Most of the side effects improved with longer follow-up. CONCLUSION Concomitant boost to areas showing increased uptake in (111)In-capromab pendetide scan to 82 Gy using intensity-modulated radiotherapy while the entire prostate received 75.6 Gy was feasible and tolerable, with 94% biochemical control rate at 5 years.

Indolent Enterococcal Abscess Mimicking Recurrent Renal Cell Carcinoma on MR Imaging and PET/CT after Radiofrequency Ablation

A case of asymptomatic enterococcal abscess was found to mimic recurrent renal cell carcinoma (RCC) on gadolinium-enhanced magnetic resonance (MR) imaging and positron emission tomography/computed tomography (CT) 15 months after radiofrequency ablation for RCC. This case illustrates that indolent infection can closely mimic recurrent neoplasm on imaging. The authors suggest that if bacterial and fungal cultures had been performed during the CT-guided biopsy, the subsequent open surgical procedure might have been avoided.

Can lymphatic drainage of head and neck melanoma be predicted

The lymphatic drainage patterns of the head and neck (H&N) is complex. Therefore, identification of the sentinel lymph node (SLN) for H&N melanoma can be challenging.

Applications of SPECT/CT in nuclear radiology.

OBJECTIVE The purpose of this pictorial essay is to illustrate several clinical situations in which SPECT/CT can be effectively applied in nuclear radiology practice. CONCLUSION SPECT/CT has recently emerged as a valuable adjunct to standard techniques in clinical nuclear radiology. This technique provides significantly improved scintigraphic localization and characterization of disease, increasingly important in this era of minimally invasive surgery and targeted radiotherapy.

Salivary duct carcinoma with perineural spread to facial canal: F-18 FDG PET/CT detection.

Salivary duct carcinoma is a highly aggressive malignancy targeting predominantly the parotid gland. It frequently involves the extracranial portion of the facial nerve and has a propensity to metastasize through the temporal bone via perineural spread. The authors present a case of treated parotid malignancy with F-18 FDG PET/CT detecting abnormal radiotracer uptake within the facial canal from perineural tumor recurrence. The positive PET/CT finding was confirmed by subsequent MR examination. Postradiation PET/CT surveillance showed resolution of the perineural metastasis with unfortunate distant ischial bone dissemination.

Choroidal and extraocular muscle metastases from non-small-cell lung carcinoma: F-18 FDG PET/CT imaging.

Lung carcinoma may metastasize to the orbit involving predominantly the choroidal layers. Secondary malignancy targeting extraocular muscles is uncommon. The authors present a case of recurrent non–small-cell lung cancer with serial F-18 FDG PET/CT examinations showing successive right choroidal and medial rectus muscle tumor dissemination.

Familial Hemiplegic Migraine: Permanent Attack‐Related Neurologic Deficits

Hemiplegic migraine (HM) is characterized by motor weakness and at least one other aura symptom or sign that is fully reversible within 24 hours. While prolonged neurological impairment lasting weeks has been observed, persistent attack‐related neurological deficits have not been described. This case illustrates the potential for permanent neurological deficits to occur as a sequelae of HM in the absence of infarction, and highlights potentially important pathophysiological and treatment implications.

Utility of subtraction ictal SPECT when video-EEG fails to distinguish atypical psychogenic and epileptic seizures

This study was designed to evaluate the utility of subtraction ictal SPECT coregistered to MRI (SISCOM) in atypical psychogenic nonepileptic seizures (PNES). Video-EEG monitoring (vEEG) is the gold standard for PNES diagnosis but, like any modality, has limitations. In difficult cases in which the diagnosis is suspected but remains in question after vEEG, a complementary study that could help differentiate epilepsy from PNES would be desirable. Thirteen SISCOM studies performed in patients with a final diagnosis of PNES were retrospectively reviewed. Common indications for SISCOM were semiology consistent with partial epilepsy (9/13), abnormal head MRI (5/13), and reported abnormal routine EEG (5/13). SISCOM was negative in 85% (11/13) of patients and was helpful in increasing the diagnostic certainty of PNES in these exceptional cases.