AIM:To assess the potential role of 18F-Fluorodeoxiglucose (FDG) Positron Emission Tomography (PET)/Computed Tomography (CT) in characterizing indeterminate lung nodules detected at CT scan in patients previously treated for a breast cancer (BC).MATERIALS AND METHODS:Twenty-nine consecutive BC patients (28 females, mean age 65 ± 12 years) with evidence of indeterminate lung nodules at contrast-enhanced CT (CECT) scan (lesions with axial diameter ≥8 mm) were retrospectively analysed: all patients underwent 18F-FDG PET/CT within a mean 2 ± 1 months from CECT imaging. PET/CT was considered positive in the presence of abnormal FDG uptake in the pulmonary nodules and/or in other organs. The nature of lung nodules was defined at histopathology and/or imaging follow-up.RESULTS:Fourteen (48%) patients showed negative and 15 (52%) positive PET/CT scan in the lungs: of these 15 patients, 7 (47%) had pathologic FDG-uptake in lungs only, whereas 8 (53%) showed abnormal FDG-uptake also in sites different from lungs. At histology and/or imaging follow-up, five (17%) patients were considered positive for BC lung metastases while in seven (24%) a second cancer was diagnosed. In this subset of patients, the sensitivity and specificity for FDG PET/CT in revealing lung lesions were 17% and 100%, respectively, for nodules <8 mm in diameter, and 77% and 85%, respectively, for nodules with diameter ≥8 mm. The therapeutic planning was changed to surgery in seven patients, chemotherapy in one patient and continued hormonal therapy in five. The inclusion of PET/CT in the diagnostic algorithm of the evaluated patients helped avoid unnecessary over-treatment in 12 of 29 patients.CONCLUSION:FDG PET/CT appears useful in characterizing indeterminate lung nodules found at CECT scan in BC patients, with a sensitivity that is proportional to nodule size. In addition, PET/CT helped in avoiding over-treatment in a significant proportion of patients.

Poster: ECR 2012 / B-0657 / PET-guided prognosis: a promising role of metabolic imaging in oesophageal cancer by: L. Evangelista , A. R. Cervino, R. Alfieri, C. Castoro, P. C. Muzzio, F. Pomerri; Padova/IT

AIMThe purpose of the study was to assess the comparison of 18F-FDG PET/CT and CT in patients with breast cancer (BC) already treated with primary therapy, in evaluating the diagnostic and prognostic values.METHODSWe retrospectively studied 190 patients (187 women and 3 men, mean age 61±11 years) with previous BC (all stages) after surgery and other primary treatments. They underwent within three months CT and 18F-FDG PET/CT examinations for the evaluation of disease status. Disease relapse was confirmed by clinical evaluation and/or radiological findings. Survival curves of disease-free survival (DFS) and overall survival (OS) were computed using Kaplan-Meier method. Cox analysis regression was used to determine predictive factors of DFS and OS.RESULTSOf the overall 190 patients, 82 (43%) had evidence of clinical and/or imaging disease relapse, while 108 (57%) did not. Sensitivity, specificity, negative predictive and positive predictive values for disease relapse or progression were of 89% vs. 77%, 73% vs. 53%, 90% vs. 75% and 72% vs. 55%, respectively for PET/CT and CT. DFS curves were significantly different in patients with both negative and positive PET/CT and CT (log-rank test 33.6; P<0.0001 and 12.7; P=0.003, respectively). OS curves were similar in patients with positive/negative PET/CT and CT (P=NS). By both univariate and multivariate Cox regression analysis positive PET/CT was found to be related to the disease recurrence (HR 0.18 and 0.20, both P<0.0001, respectively).CONCLUSIONPET/CT is more accurate than CT in identification of disease relapse in a large population of BC patients. In women at high-risk of recurrence, PET/CT imaging can provide the early detection of BC metastases, tailoring a proper treatment.

AIMSThe aim of this study was to assess the diagnostic value of positron emission tomography/computed tomography (PET/CT) in staging of esophageal cancer and to evaluate the prognostic role of metabolic parameters before and after neo-adjuvant treatment.SETTINGS AND DESIGNMono-institutional retrospective study.MATERIALS AND METHODSWe retrospectively evaluated 29 patients who underwent PET/CT at initial staging and after neo-adjuvant therapy. Metabolic parameters were calculated: mean, average, maximum standardized uptake value (SUVmax), and total lesion glycolysis (TLG). Diagnostic advantages of PET/CT over conventional imaging (CI) were determined. The relationships between baseline and after-therapy SUVmax and TLG, change in SUV and TLG (reported as ∆) for the primary tumor and prognosis were assessed.STATISTICAL ANALYSIS USEDNon-parametric statistic (e.g. Wilcoxon test and chi-square test).RESULTSTwenty-nine patients were eligible for the initial staging. Thirteen patients were incorrectly staged based on CI; PET/CT was able to identify distant lymph nodes in seven patients (59%) and distant metastases in four (31%). The median SUVmax before and after neoadjuvant therapy was 10.38 and 3.53 (P = 0.0005), respectively. Only few semi-quantitative parameters obtained by PET/CT after neoadjuvant therapy seemed to have a prognostic value. TLG and ∆TLG were significantly different between disease-free and died patients (0.49 versus 15.51 and 100% versus 94%, respectively; all P = <0.05).CONCLUSIONSPET/CT is confirmed as being able to detect distant metastases and to avoid unnecessary surgery. Although not routinely reported, post-neoadjuvant TLG and ∆TLG might be considered as useful prognostic parameters and should be further evaluated prospectively.

PURPOSE:This paper presents computed tomography (CT) features of three patients with primary synovial sarcoma of the lung (PSSL) who came to our attention and underwent surgery; reviews of the literature on this rare thoracic tumour are also presented.MATERIALS AND METHODS:The patients, all men, with a mean age of 58 years, underwent clinical and radiological re-evaluation after receiving a histological diagnosis. None of the patients had multifocal disease or other concomitant neoplasms. All patients had undergone both chest X-rays and computed tomography, and two had also been studied with positron emission tomography (PET)-CT. Two patients underwent surgical removal of the tumour, whereas the third initially underwent surgery (following an incorrect diagnosis) and then thoracoscopic biopsy of the pleural lesions that subsequently arose.RESULTS:In each case, chest X-rays showed changes, with the presence of pulmonary masses noted in all patients. In one patient, pleural effusion was also visible. CT scans showed parenchymal masses that were largely of a colliquative nature (in two out of three patients). Ipsilateral pleural effusion was present in two patients, associated in one with solid nodules within the pleura. Mediastinal lymphadenopathy, which was not radiologically significant, was present in only one patient. The two patients who also underwent PET-CT examination showed pathological tracer uptake confined to the lesion site without other thoracoabdominal or musculoskeletal localisations. CT-guided biopsy, performed in one patient only, was positive for mesenchymal tumour. In the two patients who underwent surgery, a definitive diagnosis of monophasic synovial sarcoma of the lung was made. The diagnosis of monophasic synovial sarcoma in the third patient was confirmed using thoracoscopic biopsyDISCUSSION:Both in the cases described and in those identified in the literature review, standard chest X-rays mainly showed a parenchymal mass of pleural origin with either irregular or well-defined margins. CT characteristics are more definite, with evidence of a mass with regular and sharply defined margins, occasionally polycyclic, with inhomogeneous density due to the presence of colliquative areas within the tumour.CONCLUSIONS:Although PSSL is a rare tumour, a pulmonary mass of inhomogeneous density, associated with pleural effusion but without lymphadenopathy, detected in an asymptomatic or poorly symptomatic patient, should lead to PSSL being considered in the differential diagnosis, provided that metastases from the more common synovial sarcomas of the musculoskeletal system have been excluded.

PURPOSE:In this study, a comparison was made of the accuracy and clinical usefulness of anal endosonography and fistulography in the preoperative classification of fistulas-in-ano.MATERIALS AND METHODS:A total of 113 patients with a clinical diagnosis of cryptoglandular fistula-in-ano who were awaiting surgery were included in this retrospective review. Patients were preoperatively investigated by anal endosonography and/or modified fistulography by inserting a Foley catheter into the rectum and a metal ring close to the anus. The catheter and ring served as radiopaque anal markers. Fistula classification obtained by the two diagnostic modalities was compared with surgical classification as the criterion standard.RESULTS:Endoanal ultrasound and fistulography identified 82.8% and 100% of primary tracks, 79% and 74.2% of internal openings, 98% and 91.8% of secondary tracks and 92.9% and 87.8% of abscesses, respectively.CONCLUSIONS:Anal endosonography and fistulography with radiopaque markers are important complements to surgical exploration for investigating anal sepsis and may be of value to the surgeon in planning a therapeutic strategy.

Background. The aim of the study was to assess the accuracy of imaging techniques in predicting pathologic tumor (ypT), node (ypN) stages and the circumferential resection margin (ypCRM) status of rectal cancers after preoperative chemoradiotherapy (CRT).Methods. Using pelvic computed tomography (CT), magnetic resonance imaging (Mill), and endorectal ultrasound)(ERUS), 90 consecutive patients with locally advanced mid-to-low rectal cancer were prospectively assessed. Postirradiation T and N stages and infiltration of the CRM, as assessed by CT, MRI and ERUS, were compared with histopathologic findings.Results. The accuracy of ypT staging was low, whatever the imaging technique used (37% by CT, 34% by MRI, and 27% by ERUS), the most frequent inaccuracy being overstaging. Imaging showed a good specificity and good negative predictive values (ATV) when mural staging was grouped into ypT <= 3 and ypT4 categories; in particular; ERUS achieved a 92% specificity and 95% NPV. CRM involvement was correctly predicted in 71% of patients by CT (74% specificity; 93% NPV) and in 85% by MRI (88% specificity; 95% NPV). The accuracy for nodal staging was 62%, 68%, and 65% by CT, MRI and ERUS, respectively; the corresponding NPV were 88%, 78%, and 76%.Conclusion. Current imaging techniques are inaccurate in restaging rectal cancer after CRT but are useful in predicting T <= 3 tumors, cases with negative nodes and tumor-free CRM. These findings may be of clinical relevance for planning less invasive surgery. (Surgery 2011;149:56-64.)

PURPOSE:This study was done to determine colonic transit times in healthy Italian adults.MATERIALS AND METHODS:Institutional review board approval and informed patient consent were obtained. Colonic segmental radiopaque markers were counted and transit times calculated in 36 healthy subjects studied using a technique involving daily radiopaque marker ingestion and single radiological visit, with oral administration of 8-10 ml of a thick barium paste as a colonic trace for the marker count. Two independent radiologists counted the marker twice. Observer agreement was assessed using comparison analysis.RESULTS:There was very good observer agreement for the segmental marker counts. The upper limit for colonic transit times was: 45.6 h in the colon as a whole, 31.2 h in the right colon, 19.2 h in the left colon and 16.8 h in the rectosigmoid. Colonic transit times were not gender-related.CONCLUSIONS:In healthy subjects, a barium trace affords optimal visibility of the different colonic segments, enabling accurate location of all markers and thus providing an anatomy-related, repeatable and reproducible fluoroscopic segmental marker count. We suggest that the reference values for normal colonic transit times could be adopted for Italian people irrespective of gender.

Aim: Rectal cancer staging represents a crucial step to select the best treatment for this tumour. Particularly after neo-adjuvant chemoradiotherapy (CRT), it may influence the surgical procedure (e.g. radical resection vs. local excision). The aim of this study was to determine the best lymph node size cut-off at computed tomography (CT) to predict nodal metastasis in rectal cancer patients with and without preoperative CRT.Methods: A consecutive series of patients operated on for primary mid-low rectal adenocarcinoma, all staged with pelvic CT scan, were sub-divided as follows: those who underwent surgery alone treatment without CRT (Group A) and those who underwent preoperative CRT (Group B). All CT scans were re-viewed by a single radiologist and, based on the lymph node size, findings were compared with pathologic lymph node status (pN). At each lymph node size cut-off value. the following were calculated: accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The best cut-off value was defined as having an accuracy >= 70% with the highest NPV.Results: The study population consisted of 162 patients: Group A (n = 52) and Group B (n = 110). Patients classified as pN-positive (n = 45) had a higher number of and larger sized lymph nodes by CT scan than patients classified as pN-negative (n = 117). The cutoff values with an accuracy >= 70% ranged between 7 and I I runt in Group A and between 9 and 14 mm in Group B. The cut-off with the best NPV was 7 mm for Group A and 10 mm for Group B.Conclusions: Acknowledging the limitations of the dimensional criterion, lymph node size cut-off values found in our study may be useful for planning rectal cancer treatment using CT scan. (C) 2008 Elsevier Ltd. All rights reserved.

Persistent symptoms of constipation, such as straining, hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual manoeuvres to facilitate defecation, and infrequent defecation are diagnostic criteria identifying patients with functional constipation, 1 Thompson W.G. Longstreth G.F. Drossman D.A. et al. Functional bowel disorders and functional abdominal pain. Gut. 1999; 45: II43-II47 Crossref PubMed Scopus (2010) Google Scholar but symptoms alone do not enable a distinction between constipation due to slow transit and cases due to obstructive defecation. Nor do they identify patients who complain of constipation but have a normal transit and pelvic floor function. 2 Rao S.S. Ozturk R. Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am J Gastroenterol. 2005; 100: 1605-1615 Crossref PubMed Scopus (209) Google Scholar Various function tests are used today to assess functional constipation states, including scintigraphy, 3 van der Sijp J.R. Kamm M.A. Nightingale J.M. et al. Radioisotope determination of regional colonic transit in severe constipation: comparison with radio opaque markers. Gut. 1993; 34: 402-408 Crossref PubMed Scopus (104) Google Scholar , 4 Cremonini F. Mullan B.P. Camilleri M. et al. Performance characteristics of scintigraphic transit measurements for studies of experimental therapies. Aliment Pharmacol Ther. 2002; 16: 1781-1790 Crossref PubMed Scopus (164) Google Scholar fluoroscopy and magnetic resonance imaging, 5 Halligan S. Spence-Jones C. Kamm M.A. et al. Dynamic cystoproctography and physiological testing in women with urinary stress incontinence and urogenital prolapse. Clin Radiol. 1996; 51: 785-790 Abstract Full Text PDF PubMed Google Scholar , 6 Ganeshan A. Anderson E.M. Upponi S. et al. Imaging of obstructed defecation. Clin Radiol. 2008; 63: 18-26 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar anorectal and colonic manometry, 2 Rao S.S. Ozturk R. Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am J Gastroenterol. 2005; 100: 1605-1615 Crossref PubMed Scopus (209) Google Scholar , 7 Rao S.S. Sadeghi P. Beaty J. et al. Ambulatory 24-h colonic manometry in slow-transit constipation. Am J Gastroenterol. 2004; 99: 2405-2416 Crossref PubMed Scopus (150) Google Scholar and colonic transit time radiological studies. Colonic segmental transit time is commonly estimated from the distribution of radio-opaque markers using abdominal radiography. This method is useful as an objective criterion for diagnosing constipation and may help to differentiate between three types of delayed transit, i.e. colonic inertia (right colon), 8 Preston D.M. Lennard-Jones J.E. Severe chronic constipation of young women: idiopathic slow transit constipation. Gut. 1986; 27: 41-48 Crossref PubMed Scopus (337) Google Scholar hindgut dysfunction (left colon), 9 Likongo Y. Devroede G. Schang J.C. et al. Hindgut dysgenesis as a cause of constipation with delayed colonic transit. Dig Dis Sci. 1986; 31: 993-1003 Crossref PubMed Scopus (13) Google Scholar and outlet obstruction (sigmoid colon and rectum). 10 Martelli H. Devroede G. Arhan P. et al. Mechanisms of idiopathic constipation: outlet obstruction. Gastroenterology. 1978; 75: 623-631 PubMed Google Scholar However, patterns of colonic hypo-motility may overlap because slow colonic transit can be secondary to impaired rectal emptying. 11 Kuijpers H.C. Bleijenberg G. de Morree H. The spastic pelvic floor syndrome. Large bowel outlet obstruction caused by pelvic floor dysfunction: a radiological study. Int J Colorectal Dis. 1986; 1: 44-48 Crossref PubMed Scopus (65) Google Scholar Colonic transit is also known to vary considerably due, for example, to dietary fibre intake, hydration, and medications, which can have a physical impact upon bowel content and flora, as well as cholinergic effects. Although the relevance of segmental transit disorders is a controversial issue, 2 Rao S.S. Ozturk R. Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am J Gastroenterol. 2005; 100: 1605-1615 Crossref PubMed Scopus (209) Google Scholar the generally accepted rationale for assessing segmental transit time is that each type of constipation calls for different types of treatment: customized medical treatment, especially for colonic inertia; biofeedback therapy, especially in pelvic floor dyssynergia-related outlet obstruction; or surgical approaches in selected cases of colonic inertia and pelvic prolapse-related outlet obstruction. Several different radiological approaches have been used to measure colonic transit times: single marker ingestion and daily radiographs, 12 Arhan P. Devroede G. Jehannin B. et al. Segmental colonic transit time. Dis Colon Rectum. 1981; 24: 625-629 Crossref PubMed Scopus (392) Google Scholar triple marker ingestions and single or double radiographs, 13 Metcalf A.M. Phillips S.F. Zinsmeister A.R. et al. Simplified assessment of segmental colonic transit. Gastroenterology. 1987; 92: 40-47 Abstract PubMed Google Scholar and sextuple marker ingestions and single radiograph. 14 Bouchoucha M. Devroede G. Arhan P. et al. What is the meaning of colorectal transit time measurement?. Dis Colon Rectum. 1992; 35: 773-782 Crossref PubMed Scopus (173) Google Scholar However, these techniques incur exposure to radiation, or may underestimate colonic transit time in cases of delayed transit. The aim of the present study was to test the reliability of a technique enabling a precise segmental count of retained markers and reduction in the exposure to radiation of patients undergoing segmental colonic transit time measurements.

In the present study we investigated the role of radio-guided surgery with Iodine-131 (I-131) in a group of 31 patients with differentiated thyroid cancer (DTC) and loco-regional recurrent disease. The principal inclusion criterion for I-131 radio-guided surgery in our protocol was the presence of an I-131 positive loco-regional disease relapse after previous total thyroidectomy and at least 2 ineffective conventional I-131 treatments.The protocol we used consisted of the following. steps. Day 0: all patients were hospitalized and received a therapeutic 3.7 GBq (100 mCi) dose of I-131 after thyroid hormone therapy withdrawal in condition of overt hypothyroidism (serum TSH levels > 30 mu UI/ml). Day 3: a whole body scan following the therapeutic I-131 dose (TxWBS) administration was acquired. Day 5: neck surgery was performed through a wide bilateral neck exploration using a 15-mm collimated gamma probe, measuring the absolute intra-operative counts and calculating the lesion to background (L/B) ratio. Day 7: post-surgery TxWB S was performed using the remaining radioactivity to evaluate the completeness of tumoral lesions extirpation..The final histologic examination showed the presence of 184 metastatic foci; among them, 98 (53.2%) were evident by both TxWBS and gamma probe evaluation, 76 (41.3%) were demonstrated only by gamma probe, and 10 (5.4%) were negative by both TxWBS and gamma probe evaluation.During follow-up (8 months to 4.9 years, mean 2.8 years), DxWBS, serum Tg levels Off L-T4, and US showed absence of loco-regional disease in 25 patients (80.6%) while 6 patients had persistent disease.In conclusion, this protocol allowed us to identify neoplastic foci with high sensitivity and specificity, enabling us to remove loco-regional I-131 disease recurrences resistant to previous conventional I-131 therapies. Furthermore, the gamma probe allowed detection of some additional tumoral foci in sclerotic areas or iocated.behind vascular structures that were not visualized at the pre-surgery TxWBS evaluation. (c) 2007 Elsevier Masson SAS. All rights reserved.

OBJECTIVE:The objective of our study was to evaluate the feasibility and efficacy of a radiologic technique in increasing colon visibility in colonic transit time studies. Three radiologists counted segmental colonic radiopaque markers in two patient groups, based on classic criteria in the first group and also on a colonic barium trace in the second. Agreement between marker counts was assessed using method comparison analysis.CONCLUSION:With the barium trace technique, the anatomic conspicuity of colonic segments is improved, a correct segmental marker count can be obtained, and colonic inertia can be more easily distinguished from distal constipation.

AIM:We report here our experience in a larger series of differentiated thyroid cancer (DTC) patients who had been treated by (99m)Tc-sestamibi radio-guided surgery (RGS) for (131)Iodine ((131)I)-negative loco-regional recurrent disease. METHODS:Fifty-eight patients with loco-regional (131)I-negative recurrent disease from DTC were studied with (99m)Tc-sestamibi directed RGS using a hand-held 11-mm gamma probe as an intra-operative detector. Patients were selected for RGS on the basis of (a) progressive increase of serum thyroglobulin (Tg) levels after first treatment during follow-up, (b) negative high dose (100 mCi, 3.7 GBq) (131)I whole-body scan, and (c) positive pre-operative (99m)Tc-sestamibi scintigraphy for the presence of loco-regional recurrent disease. There were 41 papillary (1 "tall" cell variant), 13 follicular and 4 Hürthle cells tumours. In 14 patients thyroid cancer recurred in the thyroid bed while cervical lymph node metastases were found in 37 patients, and 7 patients had recurrent disease both in the thyroid bed and in cervical lymph nodes. RESULTS:At bilateral neck exploration, 147 metastatic foci ranging from 4 mm to 51 mm in largest diameter (mean tumour diameter=17.3+/-9.5mm) were removed. Eighty-five of them (58%) had been pre-operatively identified at (99m)Tc-sestamibi scintigraphy. After RGS, serum Tg levels normalised in 43 of 58 patients (serum Tg<2 ng/ml--they were considered disease-free), serum Tg remained slightly increased in 12 patients without evidence of metastatic disease at scintigraphic and radiologic imaging (serum Tg<10 ng/mg--they were considered living with microscopic disease), while serum Tg significantly increased up to values>900 ng/ml in 3 patients who developed lung metastases. The mean lesion to background (99m)Tc-sestamibi uptake ratios decreased in all 58 patients (p<0.0001). Post-surgical follow-up ranged 6-72 months (mean+/-SD=29.6+/-13.5 months). The operating surgeon assessed RGS as very useful in 14 patients in whom metastatic foci were embedded in fibrotic tissues or located behind blood vessels, useful in 22 patients, moderately useful 17 patients and not useful in 5 patients. CONCLUSION:Our data suggest that a (99m)Tc-sestamibi intra-operative gamma probe can be used to identify and guide resection of recurrent loco-regional tumour in DTC patients with (131)I-negative loco-regional metastatic foci.

AIM:The aim of the study was to evaluate the clinical role or [(99m)Tc]MIBI SPECT in selecting primary hyperparathyroid (PHPT) patients for minimally invasive radioguided surgery (MIRS).METHODS:One hundred and forty-one consecutive PHPT patients were studied by a single-session [(99m)Tc]Percethnetate/[(99m)Tc]MIBI subtraction scintigraphy, followed by [(99m)Tc]MIBI SPECT in order to localize hyperfunctioning parathyroid adenoma (PA) and plan the surgical approach.RESULTS:A solitary PA was depicted at preoperative scintigraphy in 135 of 141 patients (95.7%), two or more PA in 5 patients, and was negative in 6 patients (4.3%). In 27 patients, the PA was located deep in the paraesophageal/paratracheal space. One hundred and twenty-four patients (in 18 of them the PA was located deeply in the neck) underwent successful MIRS using the low 37 MBq (1 mCi) [(99m)Tc]MIBI dose protocol. Intraoperative quick parathyroid hormone (QPTH) assay demonstrated a fall >50% in respect to the baseline value in all patients, confirming successful parathyroidectomy. After a follow-up of 6 to 37 months (median 18 months), no case of persistent/recurrent PHPT was recorded. When comparing the parathyroid to background (P/B) ratio measured at planar and SPECT preoperative scintigraphy with that measured intraoperatively with the gamma probe, a significant linear correlation was found between the SPECT and intraoperative gamma probe measurements (r = 0.91; P <0.01) while no correlation was found with planar scintigraphic data.CONCLUSIONS:Our data suggest that the P/B ratio calculated by means of [(99m)Tc]MIBI SPECT is more accurate in predicting the intraoperative measurements with the intraoperative gamma probe. Thus, a preoperative [(99m)Tc]MIBI SPECT acquisition should be recommended for a better selection of PHPT patients to offer MIRS.

Aim: The analysis of a 37-year retrospective study on diagnosis, prognostic variables, treatment and outcome of a large group of medullary thyroid cancer (MTC) patients was conducted, in order to plan a possible evidence-based management process.Methods: Between Jan 1967 to Dec 2004, 157 consecutive MTC patients underwent surgery in our centre: 60 males and 97 females, mean age 47.3 years (range 6-79). Total thyroidectomy was performed in 143 patients (91.1%); central compartment (CC) node dissection (level VI) in 41 patients; central plus lateral compartment (LC) node dissection (levels II, III, and IV) in 82 patients. Subtotal thyroidectomy was initially performed in 14 cases: 10 of them were re-operated because of persistence of elevated serum calcitonin levels.Results: After a median post-surgical follow-up of 68 months (range 2-440 months), 42.9% of patients were living disease-free, 39.8% were living with disease, 3.1% were deceased due to causes different from NITC, and 3.2% were deceased due to MTC. The overall 10-year survival rate was 72%. At uni-variate statistical analysis (a) patient's age at initial treatment (> 45 years; > 45 years), (b) sporadic vs. hereditary MTC, (c) disease stage, and (d) the extent of surgical approach resulted as significant variables. Instead, at multivariate statistical analysis, only (a) patient's age at initial diagnosis, (b) disease stage, and (c) the extent of surgery resulted as significant and independent prognostic variables influencing survival.Conclusion: The presence of lymph node and distant metastases at first diagnosis significantly worsened prognosis and survival rate in our series. Early diagnosis of MTC is very important, allowing complete surgical cure in Stages I and II patients. Due to the relatively bad prognosis of MTC, especially for disease Stages III and IV, it appears reasonable to recommend radical surgery including total thyroidectomy plus CC lymphoadenectomy as the treatment of choice, plus LC lymphoadenectomy in patients with palpable and/or ultrasound enlarged neck lymph nodes. (c) 2006 Elsevier Ltd. All rights reserved.

AIM:Multi-headvariable-geometry gammacamera, allow us to carry out multi-dimensional scintigraphic single photon emission computed tomography (SPECT) studies, with the possibility of creating coronal, axial, sagittal, three-dimensional images like the last generation of multi-slice RMI or multislice CT scan. The aim of this paper is to weigh up the reconstruction parameters to apply in [(0111)In]Pentetreotide scintigraphy for evaluating neuroendocrine tumors and try to standardize them.METHODS:We have studied a group of 93 patients suffering from neuroendocrine tumors. Examination was carried out after administration of [111In] Pentetreotide with whole body and static acquisitions after 4 and 24 h, followed by SPECT acquisitions of head, thorax and abdomen after 24 h.RESULTS:The results obtained show that the Filtered Back Projection using Butterworth filter can produce images of greater resolution than the iterative reconstruction method. Moreover, the reconstruction parameters are easily standardizable for head and thorax while for the abdomen the choice of these parameters is more difficult.CONCLUSIONS:Our data show that filtered back projection with Butterworth filter is the best procedure to carry out a SPECT examination with [111In] Pentetreotide.

Purpose. Computed tomography (CT), magnetic resonance (MR) and positron emission tomography (PET) have a very important role in the diagnosis of malignant pleural mesothelioma (MPM) in the choice of chemoradiotherapy alone or in combination with surgery and in evaluating possible recurrence. It is also essential for assessing the possible benefits of radical surgery (pleuropneumonectomy) in terms of patient survival,Materials and methods. We considered 28 patients suffering from MPM whose mean survival after diagnosis was 15-18 months. Sixteen of these patients had radiotherapy or chemoradiotherapy alone, according to standard protocols, while 12 also underwent surgery. The CT features of MPM were thoroughly examined, as was the role of PET and CT-PET in achieving accurate disease staging and consequent selection of candidates for surgery.Results. Nine of the 12 patients who underwent pleuropneumonectomy had no significant Survival advantage over the mean survival in the 16 who were not operated whereas the other three lived 1-3 years longer. Two patients underwent surgery after an optimal response to chemoradiotherapy, but both survived less than a year due to particularly aggressive recurrences.Conclusions. CT. PET and CT-PET are indicated for diagnosis and, above all, for staging of MPM, in the selection of patients who might benefit from surgery after neoadjuvant therapy and also in identifying small recurrences and/or remote metastases. Being highly specific, PET is essential in the follow-up of patients undergoing chemoradiotherapy alone and/or surgery. Each imaging modality has its advantages and limitations, but their combined use is crucial in determining the most appropriate treatment options for patients with MPM.

PURPOSE:Prognosis and treatment of esophagus and cardia cancer (ECC) depend on the precision with which the disease is staged according to the American Joint Committee of Cancer (AJCC) criteria. Imaging modalities normally used in clinical staging are esophagography, esophagoscopy, endoscopic ultrasound (EUS), computed tomography (CT) and positron emission tomography- CT fusion (CT-PET). The combination of these methods is crucial in determining not only the right diagnosis but also the stage and follow-up after multimodal treatment. The purpose of our investigation was to define the role of each imaging modality in determining the most appropriate treatment options in patients with ECC.MATERIALS AND METHODS:Fifty-six patients with ECC diagnosed by X-ray of the upper digestive tract, endoscopy and biopsy were staged using EUS, chest and abdomen CT scan, and CT-PET. Thirty-four patients in stage II and 18 patients in stage III underwent surgery after neoadjuvant chemotherapy; four patients in stage IV were treated with the positioning of an endoprosthesis after chemoradiotherapy. In the 52 patients who had surgery, follow-up included digestive tract X-ray, endoscopy and CT of the chest and abdomen every 6-8 months for the first 3 years. CT-PET was only performed in patients with a clinical suspicion of recurrence and/or CT findings suspicious of persistent disease (12 cases).RESULTS:In all 56 patients, endoscopy, EUS, CT and CT-PET in combination were crucial in determining the site of disease, locoregional extent and depth of esophageal wall penetration (T), and any involvement of the mediastinal lymph nodes (N1), extrathoracic lymph nodes (M1) or hepatic metastases. In the locoregional staging of ECC before chemotherapy, we were able to differentiate T2-T3 from T4 in 40 patients; T4 disease was found in 12 potentially resectable cases. We were able to distinguish N0 from N1 in 12 patients. In four cases, the presence of small lymph node and/or liver metastases prompted positioning of an endoprosthesis. The specificity of CT in detecting small lymph nodes in the mediastinum was less than 50% while for CT-PET, it was more than 80%; EUS revealed sensitivity higher than 90% but a low specificity in seven cases. Only CT-PET revealed metastatic subdiaphragmatic lymph nodes (diameter <15 mm) in three cases. Presurgical restaging of the 18 patients (stage III) who had chemotherapy was based on endoscopy, EUS, CT of the chest and abdomen and CT-PET (only in suspected cases) and was compatible with surgery. Anastomotic recurrence was diagnosed in 16 patients by endoscopy with associated biopsy; any intramediastinal spread from anastomotic recurrences was evaluated by chest CT, and CT-PET in suspected cases.CONCLUSIONS:X-ray of the upper digestive tract and chest and abdomen CT scan are useful in preliminary evaluation of ECC. Endoscopy is particularly indicated for evaluating tumour morphology, taking biopsies for a histological diagnosis and the early diagnosis of anastomotic recurrences. EUS is indicated mainly for evaluating T stage before and after chemotherapy or chemoradiotherapy. CT-PET is extremely useful in identifying small mediastinal metastatic lymph nodes (N1) or extrathoracic lymph nodes (M1) and hepatic metastases (</=1 cm), which may escape multislice CT. PET alone is useful for identifying residual or recurrent tumour in the esophageal wall when an endoprosthesis is in place.