Ramón Herranz

Strontium-89 for palliation of pain from bone metastases in patients with prostate and breast cancer

Abstract.We have used strontium-89 chloride (89Sr) for the palliative treatment of metastatic bone pain. Seventy-six patients (50 males with prostate carcinoma and 26 females with breast cancer) were treated with 148 MBq of 89Sr. Sixteen patients were retreated, receiving two or three doses; the total number of injected doses was consequently 95. The Karnofsky performance status was assessed and pain and analgesia were scored on scales of 9 and 5 points, respectively. The efficacy of 89Sr was evaluated at 3 months of treament. Three levels of response were considered: good – when there was an increase in the Karnofsky status and a decrease in the pain score (equal to or higher than 4) or analgesic score (equal to or higher than 1); partial – when there was an increase in the Karnofsky status and a decrease in the pain score (2 or 3 points) without significant changes in the analgesic score; no response – if no variation or deterioration in these parameters was observed. In prostate cancer patients, the response was good in 64% of cases and partial in 25%, and there was no response in the remaining 11%. In breast cancer patients, the response was good in 62% of cases and partial in 31%, and there was no response in the remaining 8%. Duration of the response ranged from 3 to 12 months (mean 6 months). In the patients who were retreated the effectiveness was as good as after the first dose of 89Sr. A decrease in the initial leucocyte and platelet counts was observed after the 1st month of treatment, with a gradual partial to complete recovery within 6 months. It is concluded that 89Sr is an effective agent in palliative therapy for metastatic bone pain in patients with prostate or breast carcinoma. If required, retreatment can be administered safely and with the same efficacy as is achieved by the first dose.

Role of the cingulate gyrus during the Wisconsin Card Sorting test : a single photon emission computed tomography study in normal volunteers

The purpose of this study was to investigate the effect of the Wisconsin Card Sorting Test (WCST) on frontal regional cerebral blood flow (rCBF) in normal subjects, separating the cingulate gyrus from the prefrontal cortex. Two technetium-99m-hexamethyl-propylene-amine-oxime brain single photon emission computed tomography (SPECT) scans, at rest and during WCST performance, were performed in randomized order on 13 right-handed normal volunteers. A statistically significant rCBF increase was found in the left inferior cingulate and the left posterior frontal region, although rCBF ratios in the left and right prefrontal cortex, and in the right inferior cingulate, were slightly higher during WCST performance in nine of the 13 subjects studied. No differences in activation scores (activated-resting rCBF ratios) were found between subjects who had the resting SPECT first and subjects who had the resting condition second. These results suggest that the inferior cingulate cortex, a limbic region that has been implicated in attentional mechanisms, plays a significant role in WCST performance. Furthermore, the motor component of the WCST may account for the activation of the left posterior frontal region. In addition, no order effect was found in this study. These findings illustrate the advantage of independently evaluating the cingulate gyrus and the prefrontal cortex in SPECT studies of frontal cognitive function.

Mid-arm Sentinel Lymph Nodes Showing Surprising Drainage From a Malignant Melanoma in the Forearm

A 51-year-old man with a malignant melanoma in his left forearm was studied to detect the sentinel lymph node and to assess the possibility of micrometastases in regional lymph nodes. Lymphoscintigraphy demonstrated two sentinel lymph nodes in the midarm. Two other nodes in the same location as well as in the left axilla were also observed. The exact location of the sentinel lymph nodes was identified with a gamma-ray detector. At the time of surgery, blue dye was injected around the primary lesion and the two sentinel lymph nodes on the inner side of the left arm were resected. Both lymph nodes were pigmented black. The histopathologic study demonstrated metastases from malignant melanoma in both nodes. This case reflects the main role of lymphoscintigraphy in identifying draining lymph nodes in unusual locations as observed in this patient.

Optimization of technetium-99m-HMPAO leukocyte scintigraphy in evaluation of active inflammatory bowel disease.

Although [99mTc]HMPAO-labeled leukocyte scintigraphy is widely used in the assessment of IBD, the time point chosen for imaging is still controversial. The aim of the present study was to determine the optimal scanning sequence to assess IBD extension and activity. Sixty-two consecutive patients with active and 18 with inactive IBD were prospectively studied. Clinical evaluation, colonoscopy, radiology, and scintigraphy were performed within three days, without changes in the patients treatment. Compared to early scan (45 min), late scan (3 hr) had a higher sensitivity (85% vs 100%) and accuracy (85% vs 95%) in identifying patients with active IBD and in defining IBD extension. Combinations of values from both scans did not improve accuracy of scintigraphy, which is lower in Crohns disease than in ulcerative colitis and also in patients receiving steroid treatment. In conclusion, a single late scintigraphy scan provides the best means to identify patients with active IBD and to assess disease extension.

Segmental contour pattern in a case of pulmonary venoocclusive disease

A V/Q mismatch (segmental contour pattern) is described in a patient suffering from dyspnea. Chest roent-genography revealed a mild interstitial pattern and enlarged pulmonary arteries. A lung biopsy demonstrated pulmonary venoocclusive disease.

Caroli's disease versus polycystic hepatic disease. Differential diagnosis with Tc-99m DISIDA scintigraphy.

Four patients with multiple hepatic cysts were studied: two were diagnosed with Carolis disease (CD) and two with polycystic hepatic disease (PHD). In CD, hepatic scintigraphy with Tc-99m DISIDA showed areas of focally increased radiotracer accumulation that persisted more than 120 minutes, whereas in PHD, areas of focally decreased radiotracer accumulation were observed with normal liver washout and biliary excretion. When multiple hepatic cysts are shown by abdominal echography or CT scan, hepatic scintigraphy with Tc-99m DISIDA should be performed. This examination is safe and noninvasive, and permits differential diagnosis between CD and PHD.

Scintisplenoportography in assessing patency of distal splenorenal shunts

Scintisplenoportography was performed on 33 occasions in 28 cirrhotic patients who had bled from esophagogastric varices. In 17 cases scintisplenoportography was carried out after a retroperitoneal distal splenorenal shunt procedure and in the remaining 16 instances in patients without any surgical shunt. In four patients scintisplenoportography was performed before and after a surgical shunt procedure, and in one case, before and after the shunt thrombosed. Gammagraphic patterns and spleen-heart times helped determine which patients did not have a surgical shunt, which had a patent shunt, and which patients had a thrombosed shunt. A patent shunt pattern and a thrombosed shunt pattern have been defined. It is concluded that scintisplenoportography is a useful, reproducible, and safe method to assess the patency of distal splenorenal shunts.

Gamma‐detecting probe used intraoperatively to locate the sentinel lymph node in patients with malignant melanoma

OBJECTIVE To assess the usefulness of lymphoscintigraphy and intraoperative gamma probe in the detection of sentinel lymph nodes. DESIGN Prospective open study. SETTING University hospital, Spain. SUBJECTS 40 patients with malignant melanoma (24 stage I/II, 16 stage III). INTERVENTION The day before operation a lymphoscintigram with 99mTc-nanocolloid was taken and the first lymph node identified was considered to be the sentinel node. A hand-held gamma probe was used for intraoperative mapping. MAIN OUTCOME MEASURE Identification of the sentinel node. RESULTS Sentinel nodes were identified in 39/40 patients (98%). In 24 patients with stage I/II disease, 34 sentinel nodes were found (6 invaded and 28 clear of melanoma). A total number of 161 regional lymph nodes were harvested, none of them invaded by melanoma. In 16 patients with stage III disease, 22 sentinel nodes were located (14 invaded and 8 clear of melanoma). A total of 89 regional lymph nodes were excised in patients with invaded sentinel nodes (44 of which were invaded and 45 clear of disease). 41 lymph nodes were excised from patients with clear sentinel nodes, and all were also clear of melanoma. CONCLUSIONS We conclude that this is a useful technique for the selection of patients with melanoma who may require lymphadenectomy.

Gallbladder visualization on RBC scintigraphy.

The gallbladder was observed 24 hours after labeled RBC reinjection on a Tc-99m RBC gastrointestinal bleeding site imaging study. in come cases, the presence of the tracer in the gallbladder could represent hematobilia. in other cases, it may also be due to Tc-99m labeled to the porphyrin portion of hemoglobin.

Indium-111 labelled platelet scintigraphy can predict the immunological origin of fever in patients on dialysis carrying a non-functioning renal allograft.

Abstract.The purpose of this study was to evaluate the usefulness of labelled platelet scintigraphy in the differential diagnosis of a prolonged febrile syndrome (PFS) in patients on dialysis carrying a non-functioning renal allograft. We prospectively performed an indium-111 mercaptopyridine-labelled platelet scan on 91 patients (54 men, 37 women; mean age 39.6±12 years). The mean duration of PFS was 35 days (range 7–122). Forty-six of the 91 patients underwent steroid therapy (2– 10 mg/day). Platelet labelling was carried out following Thakur’s method. Platelet scans were performed 48 h after reinjection of labelled platelets. The platelet uptake index (PUI) was calculated by dividing the cpm/pixel in the allograft ROI by cpm/pixel in a mirror background ROI. The final diagnosis of PFS was established depending on the outcome after treatment. In 61/91 patients the fever had an immunological origin because it disappeared after graft embolisation or transplantectomy. In 30/91 patients the PFS disappeared after antibiotic therapy (non-immunological origin). The PUI in patients with immunological PFS was 1.80±0.7, while in patients with non-immunological PFS it was 1.12±0.1 (P<0.05). When a PUI of ≥1.5 was considered as the threshold to establish PFS of immunological origin, the sensitivity of platelet scan was 76%, the specificity 100%, and the negative and positive predictive values 69% and 100%, respectively. In patients classified with immunological PFS who underwent steroid therapy, the PUI was significantly lower than in patients without steroids (P<0.05). These results suggest that 111In-labelled platelet scintigraphy can accurately predict an immunological PFS in patients on dialysis carrying a non-functioning renal allograft. Therapy with steroids could reduce the sensitivity of 111In-labelled platelet scintigraphy in detecting immunological PFS.