Sukanta Barai

Left ventricular ejection fraction and volumes on rest gated 201Tl perfusion SPECT: comparison with two-dimensional echocardiography.

BackgroundRest gated 201Tl images are considered to be of poor count statistics due to lower energy and low photon flux of 201Tl in addition to increased attenuation and low dose that can be administered. We compared the left ventricular ejection fraction (LVEF), end diastolic (EDV) and end systolic volume (ESV) obtained on 4 h gated rest 201Tl myocardial perfusion single photon emission computed tomography (SPECT) with those obtained by two-dimensional echocardiography (2-D ECHO) in patients with known or suspected coronary artery disease (CAD). MethodsEighty-two consecutive patients who underwent gated 201Tl stress–rest myocardial perfusion SPECT and 2-D ECHO were studied. The gated thallium images were processed with Siemens e-soft autocardiac processor and LVEF, EDV and ESV were evaluated using Emory Cardiac Toolbox. The same parameters were also assessed on the 2-D ECHO using the modified Simpson method for comparison. ResultsOut of 82 rest gated images, one study was excluded because of poor count statistics. In 81 (99%) patients there was good linear correlation with 2-D ECHO values and rest gated 201Tl SPECT images for EDV, ESV and LVEF. Pearsons correlation co-efficient (r value) for EDV, ESV and LVEF between the two methods was 0.78, 0.79 and 0.88, respectively. A Bland–Altman plot showed close agreement with LVEF but not for EDV and ESV. ConclusionThese results suggest that the 4 h rest gated 201Tl study gives a reliable value for the LVEF compared to 2-D ECHO and can be used in routine clinical practice.

Imaging in extrapulmonary tuberculosis

Tuberculosis (TB) remains a major global public health problem, with 1.5 million deaths annually worldwide. One in five cases of TB present as extrapulmonary TB (EPTB), posing major diagnostic and management challenges. Mycobacterium tuberculosis adapts to a quiescent physiological state and is notable for its complex interaction with the host, producing poorly understood disease states ranging from latent infection to active clinical disease. New tools in the diagnostic armamentarium are urgently required for the rapid diagnosis of TB and monitoring of TB treatments, and to gain new insights into pathogenesis. The typical and atypical imaging features of EPTB are reviewed herein, and the roles of several imaging modalities for the diagnosis and management of EPTB are discussed.

Bone scan demonstrating metastasis to the breast from an ovarian carcinoma and a review of the literature.

Breast metastasis from a primary ovarian neoplasm is very rare. We report a case of breast metastasis along with involvement of the liver, spleen, and pelvis from ovarian carcinoma in a 54-year-old woman demonstrated by whole-body bone scanning. Ovarian metastatic deposits frequently show calcification, and a Tc-99m MDP bone scan could be useful in determining the extent of calcified soft tissue metastatic spread in these patients. A review of the literature of breast metastases form ovarian carcinoma is discussed.

Multiple ectopic thyroid masses in a hypothyroid child.

A 6-year-old boy presented with neck swelling and global developmental delay since birth.A small swellingwas noted in the posterior part of the tongue in the region of the foramen caecum. Thyroid stimulating hormone was grossly elevated (53 lU/ ml). Pertechnatate radionuclide scintigraphy was performed for evaluation of the neck mass (Fig. 1). This revealed the absence of normal thyroid gland in the thyroid bed, but at three ectopic locations (region of the foramen caecum, suprahyoid and in the region of the cricoid cartilage) along the path of the thyroglossal tract (triple ectopia of thyroid gland). There have been eight reported cases of dual ectopia, but this appears to be the first case of triple ectopia [1]. The thyroid gland develops from the median bud of the thyroglossal duct, which passes from the foramen caecum at the base of tongue to the isthmus of thyroid gland and descends to its normal position in the anterior neck. The ultimobranchial body that arises from a diverticulum of the fourth pharyngeal pouch of each side amalgamates with the corresponding lateral lobe. This pattern of descent explains the occasional presence of thyroid tissue in ectopic locations. Incomplete descent may lead to a thyroid mass at an abnormal position in the neck (e.g. lingual or subhyoid); excessive descent can result in a substernal thyroid. Lingual thyroid is the result of defective migration of the thyroid anlage occurring between the 3rd and 7th weeks of gestation. For the majority of cases the aetiopathology of thyroid ectopia remains unclear. Mutations in thyroid transcription factor 2, which is required for the downward migration of the thyroid gland, has been proposed as a possible mechanism [2]. The majority of patients with thyroid ectopia are asymptomatic, but obstructive symptoms and hypothyroidism have been observed [3]. Hyperthyroidism is an exceptionally rare finding.

Effects of low-dose capecitabine on Samarium-153-EDTMP therapy for painful bone metastases.

Introduction: Samarium-153 (Sm-153)-EDTMP is routinely used for pain palliation in skeletal metastasis, however most patients report partial response. Many strategies have been contemplated to make radiation therapy for pain more effective, one of them being the use of radiosensitizers. Capecitabine is a chemotherapeutic drug and is routinely combined with external beam radiation to make the target more radio-sensitive. Aim of the study was to evaluate whether combining capecitabine in radiosensitizing dose with Sm-153-EDTMP produces superior analgesia compared to Sm alone. Materials and Methods: Forty-four patients with skeletal metastases from various primaries were randomized into two groups: The study group received 1 mCi/kg Sm-153-EDTMP plus capecitabine (1,650 mg/m2) orally for 8 days (equivalent to four t½ of 153Sm-EDTMP) and the control arm received 1 mCi/kg Sm-153-EDTMP plus placebo for the 8 days. After treatment, the patients were followed up for 12 weeks to evaluate the degree and duration of pain palliation and hematologic toxicity. Results: All 44 patients reported different degrees of pain relief with none reporting complete pain relief for the entire duration of 12 weeks posttherapy observation period. However the level of pain relief obtained in study arm was significantly better than the control arm with mean posttherapy pain score being 1.29 ± 1.05 and 3.59 ± 2.77 respectively with P of 0.001. Transient and mild hematologic toxicity, as determined by World Health Organization criteria, was apparent in both arms without significant differences. Conclusion: The addition of a low-dose of capecitabine significantly enhances the analgesic effect of Sm-153 without any additional side effects.

Left ventricular remodeling after late revascularization correlates with baseline viability.

The ideal management of stable patients who present late after acute ST-elevation myocardial infarction (STEMI) is still a matter of conjecture. We hypothesized that the extent of improvement in left ventricular function after successful revascularization in this subset was related to the magnitude of viability in the infarct-related artery territory. However, few studies correlate the improvement of left ventricular function with the magnitude of residual viability in patients who undergo percutaneous coronary intervention in this setting. In 68 patients who presented later than 24 hours after a confirmed first STEMI, we performed resting, nitroglycerin-enhanced, technetium-99m sestamibi single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) before percutaneous coronary intervention, and again 6 months afterwards. Patients whose baseline viable myocardium in the infarct-related artery territory was more than 50%, 20% to 50%, and less than 20% were divided into Groups 1, 2, and 3 (mildly, moderately, and severely reduced viability, respectively). At follow-up, there was significant improvement in end-diastolic volume, end-systolic volume, and left ventricular ejection fraction in Groups 1 and 2, but not in Group 3. We conclude that even late revascularization of the infarct-related artery yields significant improvement in left ventricular remodeling. In patients with more than 20% viable myocardium in the infarct-related artery territory, the extent of improvement in left ventricular function depends upon the amount of viable myocardium present. The SPECT-MPI can be used as a guide for choosing patients for revascularization.

Role of skeletal scintigraphy in advanced retinoblastomas.

Purpose: To document the incidence of skeletal metastases exclusively in advanced cases of retinoblastoma and to rationalize the use of preoperative skeletal scintigraphy in such patients. Material and Methods: Preoperative bone scans of 36 consecutive patients with advanced retinoblastoma who underwent skeletal scintigraphy during 1998 to 2003 were analyzed retrospectively. Bone scans were classified as: Grade 1 (high probability scan for skeletal metastases), Grade 2 (equivocal malignant or benign abnormalities), or Grade 3 (normal or certainly benign lesions). Results: Grade 1 scan was found in 3 (8.33%) patients; bone metastases were confirmed by additional investigations. Grade 2 scan was found in 5 (13.88%) patients; bone metastases were excluded in all by additional investigations. Grade 3 scan was found in the remaining 28 (77.77%) patients. Extraorbital extension of disease was demonstrated by fine needle aspiration of lymph nodes in five patients, which included all three patients with Grade 1 scan. In addition to lymph node metastases, two patients had intracranial extension of the disease; demonstrated by contrast‐enhanced magnetic resonance imaging of the head. One patient had liver metastases detected on abdominal ultrasound. None of the patients had skeletal metastases only. Conclusion: Routine preoperative bone scan is not justified in patients with locally advanced retinoblastoma. Bone scan should only be performed in patients with documented extraocular metastatic disease.

Estimation of prevalence of pretreatment renal insufficiency and use of mathematical formulae to assess the renal dysfunction in patients of head and neck cancers undergoing concurrent chemoradiotherapy in Northern India

Background: Cisplatin (CDDP)-based concurrent chemoradiotherapy (CRT) is the standard of care in locally advanced head and neck cancers (HNCs). CDDP, a known nephrotoxic drug, has been administered in three different protocols. Baseline renal function needs to be known before CRT. Renal function can be measured directly by measuring the measured glomerular filtration rate (mGFR) using radioisotope and indirectly by either serum creatinine (SCR) levels or estimated GFR (eGFR) using mathematical formulae “abbreviated modification of diet in renal disease (aMDRD)” and “Cockcroft–Gault (CG).” The present study was performed to see the prevalence of pretreatment renal insufficiency (RI) in HNC patients and to find a realistic method using CG and aMDRD formulae for assessing RI instead of doing mGFR and to compare the nephrotoxicity in three CDDP protocols. Materials and Methods: The study was carried out between January 2005 and December 2006. Consecutive patients of HNC undergoing RT/CRT were included. Renal function using parameters SCR, mGFR, and eGFR using CG and aMDRD formulae was estimated for pre- and post-treatment and during follow-up. Results: Of 295 eligible patients, baseline prevalence of RI was in 17% by mGFR, 6% by SCR, 13% by aMDRD, and 41% patients by CG formula. aMDRD correlated better than CG with the mGFR. Of the 145 patients of CRT, pretreatment RI was seen in 9% by aMDRD and 30% by CG formula as compared to 12% by mGFR and post treatment RI was seen in 12% by aMDRD and 43% by CG formula. All the three CDDP protocols showed similar fall in GFR post treatment, and late renal injury at 6 months was seen in 2%, 4%, and 3%, respectively. Conclusions: RI exists in HNC patient. RI assessment by SCR is inadequate and should be done by eGFR estimation using aMDRD or CG formula if not able to do mGFR. Different CDDP protocols have similar nephrotoxicity.

Diagnostic significance of semiquantitative and quantitative parameters of Tc99m-Ethylenedicystine renal allograft scintigraphy

Objectives: No objective parameters for renalallograft evaluation have yet been describedfor Tc99m-Ethylenedicystine. This studyevaluates the diagnostic significance ofdifferent quantitative and semi-quantitativeparameters of renal allograft scintigraphyusing Tc99m-Ethylenedicystine.Methods: A total of 72 renal dynamicscintigraphic studies were performed within2-weeks of renal transplantation in 42patients. The graft perfusion, kidney/aortaratio, washout index and retention index werederived from all studies. All these parameterswere evaluated for their ability to distinguishbetween a normal graft, a graft with acuterejection (AR), and a graft with acute tubularnecrosis (ATN). Histopathological verificationof diagnosis was obtained in all cases.Results: Studies were subdivided into 3groups according to histopathological findings:acute rejection (n = 42), normal (n = 18) andacute tubular necrosis (n = 12). Normalallografts were visualized with in2.66 ± 0.59 seconds of visualization ofabdominal aorta. The K/A ratio, wash out indexand retention index was 15.22 ± 6.86,1.67 ± 0.45, and 5.48 ± 0.98 respectively.Allografts with ATN were visualized with in3.36 ± 0.80 seconds of visualization ofabdominal aorta. The K/A ratio, wash out indexand retention index was 12.73 ± 6.74,0.60 ± 0.14, and 9.18 ± 1.48 respectively.In AR, allografts were visualized15.18 ± 9.48 seconds after visualization ofabdominal aorta. The K/A ratio, wash out indexand retention index was 7.07 ± 2.15,0.63 ± 0.11, and 2.26 ± 1.28 respectively.Conclusions: Retention index can separateall the three condition of normal, acuterejection and acute tubular necrosis from eachother. Retention index of <4 suggests acuterejection, a value between 4 and 7 suggestsnormal allograft and avalue of ≥7 is suggestive of acutetubular necrosis. However, perfusion, K/A ratioand washout index can not segregate all thethree groups.