Renee Moadel

Positron emission tomography agent 2-deoxy-2-[18F]fluoro-D-glucose has a therapeutic potential in breast cancer.

BackgroundNovel approaches are needed for breast cancer patients in whom standard therapy is not effective. 2-Deoxy-2-[18F]fluoro-D-glucose (18F-FDG) was evaluated as a potential radiomolecular therapy agent in breast cancer animal models and, retrospectively, in patients with metastatic breast cancer.MethodsPolyoma middle T antigen (PyMT) and mouse mammary tumor virus-NeuT transgenic mice with tumors 0.5–1 cm in diameter were imaged with 18F-FDG, and tumor to liver ratios (TLRs) were calculated. The radiotoxicity of 18F-FDG administration was determined in healthy mice. PyMT mice with small (0.15–0.17 cm) and large (more than 1 cm) tumors were treated with 2–4 mCi of 18F-FDG, and control C3H/B6 mice with 3 mCi of 18F-FDG. At 10 days after treatment the tumors and control mammary glands were analyzed for the presence of apoptotic and necrotic cells. Five patients with breast cancer and metastatic disease were evaluated and standardized uptake values (SUVs) in tumors, maximum tolerated dose, and the doses to the tumor were calculated.ResultsDoses up to 5 mCi proved to be non-radiotoxic to normal organs. The 18F-FDG uptake in mouse tumors showed an average TLR of 1.6. The treatment of mice resulted in apoptotic cell death in the small tumors. Cell death through the necrotic pathway was seen in large tumors, and was accompanied by tumor fragmentation and infiltration with leukocytes. Normal mammary tissues were not damaged. A human 18F-FDG dose delivering 200 rad to the red marrow (less than 5% damage) was calculated to be 4.76 Ci for a 70 kg woman, and the dose to the tumors was calculated to be 220, 1100 and 2200 rad for SUVs of 1, 5 and 10, respectively.ConclusionWe have shown that positrons delivered by 18F-FDG to mammary tumors have a tumoricidal effect on cancer cells. The study of breast cancer patients suggests that the tumor and normal organ dosimetry of 18F-FDG makes it suitable for therapy of this malignancy.

Using the intraoperative hand held probe without lymphoscintigraphy or using only dye correlates with higher sensory morbidity following sentinel lymph node biopsy in breast cancer: A review of the literature

BackgroundThere are no studies that have directly investigated the incremental reduction in sensory morbidity that lymphoscintigraphy images (LS) and triangulated body marking or other skin marking techniques provide during sentinel lymph node biopsy (SLNB) compared to using only the probe without LS and skin marking or using only dye. However, an indirect assessment of this potential for additional sensory morbidity reduction is possible by extracting morbidity data from studies comparing the morbidity of SLNB to that of axillary lymph node dissection.MethodsA literature search yielded 13 articles that had data on sensory morbidity at specific time points on pain, numbness or paresthesia from SLNB that used radiotracer and probe or used only dye as a primary method of finding the sentinel node (SN). Of these, 10 utilized LS, while 3 did not utilize LS. By matching the data in studies not employing LS to the studies that did, comparisons regarding the percentage of patients experiencing pain, numbness/paresthesia after SLNB could be reasonably attempted at a cutoff of 9 months.ResultsIn the 7 studies reporting on pain after 9 months (> 9 months) that used LS (1347 patients), 13.8% of patients reported these symptoms, while in the one study that did not use LS (143 patients), 28.7% of patients reported these symptoms at > 9 months (P < 0.0001). In the 6 studies reporting on numbness and/or paresthesia at > 9 months that used LS (601 patients), 12.5% of patients reported these symptoms, while in the 3 studies that did not use LS (229 patients), 23.1% of patients reported these symptoms at > 9 months (P = 0.0002). Similar trends were also noted for all these symptoms at ≤ 9 months.ConclusionBecause of variations in techniques and time of assessing morbidity, direct comparisons between studies are difficult. Nevertheless at a minimum, a clear trend is present: having the LS images and skin markings to assist during SLNB appears to yield more favorable morbidity outcomes for the patients compared to performing SLNB with only the probe or performing SLNB with dye alone. These results are extremely pertinent, as the main reason for performing SLNB itself in the first place is to achieve reduced morbidity.

Lymphoscintigraphy and triangulated body marking for morbidity reduction during sentinel node biopsy in breast cancer.

Current trends in patient care include the desire for minimizing invasiveness of procedures and interventions. This aim is reflected in the increasing utilization of sentinel lymph node biopsy, which results in a lower level of morbidity in breast cancer staging, in comparison to extensive conventional axillary dissection. Optimized lymphoscintigraphy with triangulated body marking is a clinical option that can further reduce morbidity, more than when a hand held gamma probe alone is utilized. Unfortunately it is often either overlooked or not fully understood, and thus not utilized. This results in the unnecessary loss of an opportunity to further reduce morbidity.Optimized lymphoscintigraphy and triangulated body marking provides a detailed 3 dimensional map of the number and location of the sentinel nodes, available before the first incision is made. The number, location, relevance based on time/sequence of appearance of the nodes, all can influence 1) where the incision is made, 2) how extensive the dissection is, and 3) how many nodes are removed. In addition, complex patterns can arise from injections. These include prominent lymphatic channels, pseudo-sentinel nodes, echelon and reverse echelon nodes and even contamination, which are much more difficult to access with the probe only. With the detailed information provided by optimized lymphoscintigraphy and triangulated body marking, the surgeon can approach the axilla in a more enlightened fashion, in contrast to when the less informed probe only method is used. This allows for better planning, resulting in the best cosmetic effect and less trauma to the tissues, further reducing morbidity while maintaining adequate sampling of the sentinel node(s).

Osteopoikilosis: A Benign Condition With the Appearance of Metastatic Bone Disease

Case Report A 37-year-old woman with a history of migraines and gastritis presented to the emergency department with 1 day of right adnexal pain. A computed tomography (CT) scan of the pelvis performed to evaluate the pelvic pain showed a fluid-filled structure in the right adnexa, indicating a possible tubo-ovarian abscess. The patient was subsequently admitted to the hospital for treatment with antibiotics. Incidentally found on CT imaging were diffuse sclerotic foci (Fig 1) throughout the visualized spine and pelvis, suggesting asymptomatic metastatic disease. Physical examination was only significant for right lower quadrant tenderness, corresponding to the CT findings. There was no lymphadenopathy, mass, or obvious tenderness of her spine and pelvis. Initial laboratory results showedanormalcompletebloodcountandserumchemistries, including calcium of 9.8 mg/dL, and alkaline phosphatase of 63 U/L, and normal CA125 level. CT imaging of the chest showed diffuse blastic-appearing lesions throughout the skeleton without notable lymphadenopathy or mass. A nuclear bone scan was found to be normal, without evidence of any blastic metastatic lesions (Fig 2). The patient was ultimately given the diagnosis of osteopoikilosis, a rare benign condition of the bone.

The role of positron emission tomography in gastrointestinal imaging

Although the use of PET in studies of the gastrointestinal tract is still relatively new, its value is clear. The future will provide a better definition of the indications for PET, refinement of the technology, and its relative value compared with other modalities such as peptide and antibody imaging, CT, MR imaging, and US.

Focal thoracic uptake mimicking lung metastasis on 131I post-therapy whole-body scan in patients with thyroid carcinoma.

Whole-body 131I scan after total thyroidectomy is important in the evaluation of radioiodine avid metastatic foci in patients with differentiated thyroid carcinoma. False-positive uptakes are occasionally seen in the thoracic region which should be evaluated carefully and not mistaken as lung metastases. We report here 2 cases of abnormal focal thoracic uptake, 1 case of a pleuropericardial cyst and 1 case of focal bronchiectasis, that could potentially be confused with lung metastasis. Careful correlation with diagnostic CT and subsequent follow-up studies suggested that these were not metastatic lesions.

Performance of Low-Dose Perfusion Scintigraphy and CT Pulmonary Angiography for Pulmonary Embolism in Pregnancy

Background The symptoms of normal pregnancy overlap those of pulmonary embolism (PE). Limited literature suggests that low‐dose perfusion scanning (LDQ), which yields lower maternal–fetal radiation exposure than CT pulmonary angiography (CTPA), performs well in excluding PE in pregnant patients. Methods We performed a retrospective cohort study of sequential pregnant women who underwent imaging for PE with LDQ or CTPA between 2008 and 2013 at Montefiore Medical Center. Our practice recommends LDQ for patients with negative results on chest radiographs. Patients were categorized according to initial imaging modality, and a subgroup analysis was performed in patients with asthma. The primary outcome was the negative predictive value (NPV) of imaging determined by VTE diagnosis within 90 days. Results Of 322 pregnant women (mean age, 27.3 ± 6.3 years), initial imaging was positive for PE in 2.7% (6 of 225) of LDQs and 4.1% (4 of 97) of CTPAs, negative in 88.0% (198 of 225) of LDQs and 86.6% (84 of 97) of CTPAs, and indeterminate/nondiagnostic in 9.3% (21 of 225) of LDQs and 9.3% (9 of 97) of CTPAs (P = .79). Ten patients (3.1%) were treated for PE. The NPV was 100% for LDQ and 97.5% for CTPA. Subgroup analysis of patients with asthma (23.9% of this population) revealed a high likelihood of a negative study in the LDQ and CTPA groups (74.1% and 87.0%, respectively) and 100% NPV for both modalities. Conclusions PE is an uncommon diagnosis in pregnancy. LDQ and CTPA perform well, with less maternal–fetal radiation exposure with LDQ. Therefore, when available, LDQ is a reasonable first‐choice modality for suspected PE in pregnant women with a negative result on chest radiograph.

Unusual metastases of thyroid cancer to mediastinal blood vessels.

Poorly differentiated thyroid cancer is a rare thyroid cancer, accounts for approximately 5% of all thyroid cancer cases, and is associated with a poor prognosis. It commonly metastasizes to regional lymph nodes, lung, and bones. We present a patient with poorly differentiated thyroid cancer with unusual extensive spread to mediastinal blood vessels.