We investigated whether Tc-DTPA galactosyl human serum albumin (GSA) liver scintigraphy could help evaluate post-Kasai procedure hepatic functional reserve in order to inform therapeutic strategies, including liver transplantation. GSA scintigraphy was performed post-Kasai procedure. Patients were classified as having favorable (native liver survival) or poor (liver transplantation or death) prognoses. The clearance index (HH ), receptor index (LHL ), and time at which cumulative liver radioactivity reached 85% of heart plus liver activity (T ) were compared to laboratory data and prognosis. GSA scintigraphy was performed 106 times on 35 patients. T correlated well with laboratory variables associated with liver function (platelet count, international normalized ratio of prothrombin time, serum albumin, total cholesterol, and cholinesterase). HH correlated moderately and LHL , poorly. HH and T values were significantly higher in the poor-prognosis than in the favorable-prognosis group, and LHL was significantly lower. The T cutoff value (6.25min) corresponded with division into prognosis groups, and had high sensitivity (0.78) and specificity (0.83). Hepatic functional reserve post-Kasai procedure can be evaluated using the GSA scintigraphy T value. A value consistently >6.25min indicates the need for liver transplantation. Diagnostic Test. Level III.
Selective internal radiation therapy (SIRT) is an effective treatment option for liver tumors, using Y-90-loaded polymer microspheres that are delivered via catheterization of the hepatic artery. Since Y-90 is a beta emitter and not conveniently imaged by standard clinical instrumentation, dosimetry is currently evaluated in each patient using a surrogate particle, Technetium-labeled macroaggregated albumin ( Tc-MAA). We report a new composite consisting of Tc-labeled nanoparticles attached to the same polymer microspheres as used for SIRT, which can be imaged with standard SPECT. Carbon nanoparticles with an encapsulated core of Tc were coated with the polycation protamine sulfate to provide electrostatic attachment to anionic polystyrene sulfonate microspheres of different sizes (30, 12, and 8 µm). The in vivo stability of these composites was determined via intravenous injection and entrapment in the capillary network of normal rabbit lungs for up to 3 hours. Furthermore, we evaluated their biodistribution in normal rabbit livers, and livers implanted with VX2 tumors, following intrahepatic artery instillation. We report distribution tests for three different sizes of radiolabeled microspheres and compare the results with those obtained using Tc-MAA. Lung retention of the radiolabeled microspheres ranged from 72.8% to 92.9%, with the smaller diameter microspheres showing the lowest retention. Liver retention of the microspheres was higher, with retention in normal livers ranging from 99.2% to 99.8%, and in livers with VX2 tumors from 98.2% to 99.2%. The radiolabeled microspheres clearly demonstrated preferential uptake at tumor sites due to the increased arterial perfusion produced by angiogenesis. We describe a novel use of radiolabeled carbon nanoparticles to generate an imageable microsphere that is stable in vivo under the shear stress conditions of arterial networks. Following intra-arterial instillation in the normal rabbit liver, they distribute in a distinct segmented pattern, with the smaller microspheres extending throughout the organ in finer detail, while still being well retained within the liver. Furthermore, in livers hosting an implanted VX2 tumor, they reveal the increased arterial perfusion of tumor tissue resulting from angiogenesis. These novel composites may have potential as a more representative mimic of the vascular distribution of therapeutic microspheres in patients undergoing SIRT.
Abstract Objectives To map the primary prostatic lymphatic landing sites using a multimodality technique. Methods Thirty-four patients with organ-confined prostate cancer (cT1–cT2; cN0) underwent single-photon emission computed tomography fused with data from computed tomography (SPECT/CT) ( n = 33) or magnetic resonance imaging (SPECT/MRI) ( n = 1) 1 h after ultrasound-guided intraprostatic injection of technecium (Tc-99m) nanocolloid. The presence of lymph nodes (LNs) containing Tc-99m was confirmed intraoperatively with a gamma probe. A backup extended pelvic lymphadenectomy (PLND) was performed to preclude missed primary lymphatic landing sites. The SPECT/CT/MRI data sets were used to generate a three-dimensional projection of each LN site. Results A total of 317 LNs (median, 10 per patient; range, 3–19) were detected by SPECT/CT/MRI, 314 of which were confirmed by gamma probe. With an “extended” PLND, two thirds of all primary prostatic lymphatic landing sites are resected compared with only one third with a “limited” PLND. Conclusions The multimodality technique presented here enables precise mapping of the primary prostatic lymphatic landing sites. PLND for prostate cancer should include not only the external and obturator regions as well as the portions medial and lateral to the internal iliac vessels, but also the common iliac LNs at least up to the ureteric crossing, thus removing approximately 75% of all nodes potentially harbouring metastasis.
Safety of sentinel lymph node (SLN) biopsy for breast cancer during pregnancy is insufficiently explored. We investigated efficacy and local recurrence rate in a large series of pregnant patients.Women diagnosed with breast cancer who underwent SLN biopsy during pregnancy were identified from the International Network on Cancer, Infertility and Pregnancy, the German Breast Group, and the Cancer and Pregnancy Registry. Chart review was performed to record technique and outcome of SLN biopsy, locoregional and distant recurrence, and survival.We identified 145 women with clinically N0 disease who underwent SLN during pregnancy. The SLN detection techniques were as follows: 99mTc-labeled albumin nanocolloid only (n = 96; 66.2%), blue dye only (n = 14; 9.7%), combined technique (n = 15; 10.3%), or unknown (n = 20; 13.8%). Mapping was unsuccessful in one patient (0.7%) and she underwent an axillary lymph node dissection (ALND). Mean number of SLNs was 3.2 (interquartile range 1-3; missing n = 15). Positive SLNs were found in 43 (29.7%) patients and 34 subsequently underwent ALND. After a median follow-up of 48 months (range 1–177), 123 (84.8%) patients were alive and free of disease. Eleven patients experienced a locoregional relapse, including 1 isolated ipsilateral axillary recurrence (0.7%). Eleven (7.6%) patients developed distant metastases, of whom 9 (6.2%) died of breast cancer. No neonatal adverse events related to SLN procedure during pregnancy were reported.SLN biopsy during pregnancy has a comparably low axillary recurrence rate as in nonpregnant women. Therefore, this method can be considered during pregnancy instead of standard ALND for early-stage, clinically node-negative breast cancer.
The aim of this study was to compare radiological and pathological changes and test the adjunct efficacy of Sorafenib to Y90 as a bridge to transplantation in hepatocellular carcinoma (HCC). 15 patients with 16 HCC lesions were randomized to Y90 without (Group A, n = 9) or with Sorafenib (Group B, n = 7). Size (WHO, RECIST), enhancement (EASL, mRECIST) and diffusion‐weighted imaging criteria (apparent diffusion coefficient, ADC) measurements were obtained at baseline, then at 1 and every 3 months after treatment until transplantation. Percentage necrosis in explanted tumors was correlated with imaging findings. 100%, 50%‐99% and <50% pathological necrosis was observed in 6 (67%), 1 (11%), and 2 (22%) tumors in Group A and 3 (42%), 2 (28%), and 2 (28%) in Group B, respectively (P = 0.81). While ADC (P = 0.46) did not change after treatment, WHO (P = 0.06) and RECIST (P = 0.08) response at 1 month failed to reach significance, but significant responses by EASL (P < 0.01/0.03) and mRECIST (P < 0.01/0.03) at 1 and 3 months were observed. Response was equivalent by EASL or mRECIST. No difference in response rates was observed between groups A and B at 1 and 3 months by WHO, RECIST, EASL, mRECIST or ADC measurements. Despite failing to reach significance, smaller baseline size was associated with complete pathological necrosis (CPN) (RECIST: P = 0.07; WHO: P = 0.05). However, a cut‐off size of 35 mm was predictive of CPN (P = 0.005). CPN could not be predicted by WHO (P = 0.25 and 0.62), RECIST (P = 0.35 and 0.54), EASL (P = 0.49 and 0.46), mRECIST (P = 0.49 and 0.60) or ADC (P = 0.86 and 0.93). Conclusion: The adjunct of Sorafenib did not augment radiological or pathological response to Y90 therapy for HCC. Equivalent significant reduction in enhancement at 1 and 3 months by EASL/mRECIST was noted. Neither EASL nor mRECIST could reliably predict CPN. (HEPATOLOGY 2013;58:1655–1666)
Abstract Purpose To determine if perfusion of the prostate can be mapped using technetium-99m (99m Tc) macroaggregated albumin (MAA) after selective prostate artery catheterization. Materials and Methods Selective prostate artery injections of MAA were performed and analyzed in 14 patients; 9 patients received unilateral injection, and 5 patients received bilateral injections (37 MBq/1 mCi per injection). Fused single-photon emission computed tomography/computed tomography (SPECT/CT) images were subsequently acquired using a fiducial marker technique. Perfusion distribution was assessed, and relative intraprostatic versus extraprostatic activity was quantified and compared between groups. Results The percentage of the prostate gland containing activity was significantly greater for the bilateral injection group compared with the unilateral injection group (76.6% vs 44.3%, P < .05). The percentage of relative intraprostatic versus extraprostatic activity was significantly lower for the bilateral injection group compared with the unilateral injection group (40.3% vs 75.9%, P < .05). Sites of visualized extraprostatic activity included the seminal vesicles (8 of 14 patients), internal iliac vessels (7 of 14 patients), bladder wall (5 of 14 patients), space of Retzius (3 of 14 patients), rectal wall (3 of 14 patients), and penis (1 of 14 patients). Conclusions Perfusion mapping with99m Tc-MAA can be effectively performed with SPECT/CT after selective prostate artery catheterization. The relative percentage of intraprostatic versus extraprostatic activity can be quantified, and the distribution of activity within and outside the prostate gland can be determined.
Abstract Objective Retrospective and perspective series have shown the feasibility of sentinel lymph-node (SLN) identification of pelvic nodes in endometrial cancer using a cervical injection of tracers. We designed a perspective study to assess the detection rate and diagnostic accuracy of the SLN procedure by means of hysteroscopic injection of a radiolabeled tracer in endometrial cancer patients. Methods Patients with endometrial cancer underwent hysteroscopic technetium injection. SLN assessment was performed intraoperatively. A systematic pelvic and paraaortic dissection was carried out thereafter. SLNs were examined by standard and immunochemistry methods. The primary endpoint was estimation of sensitivity and negative predictive value (NPV) of sentinel-node biopsy. Results From 2005 to 2010, 80 consecutive patients entered the study. No severe complications occurred during or after the injection or during surgical SLN biopsy. At least one SLN was detected in 76 of the 80 eligible patients. Fifty nine patients were evaluable according to the study protocol. Ten of these patients (17%) had node metastases. Thirty-three patients (56%) had SLN in the para-aortic area. NPV was 98% (95% CI 89.4–100) and sensitivity 90% (55.5–99.8). Conclusions SLN detection for endometrial cancer patients has a high sensitivity and NPV when injection is carried out by hysteroscopy. The occurrence of a 56% of sentinel node in paraaortic area may suggest a better sensitivity in this area using hysteroscopic injection compared to cervical injection.
We evaluated the clinical significance of follow-up data, including Tc-DTPA galactosyl human serum albumin ( Tc-GSA) liver scintigraphy data, as prognostic indicators for jaundice-free patients with biliary atresia (BA). Of 87 patients who underwent Kasai portoenterostomy (KP) between 1991 and 2012, 45 jaundice-free patients aged 1-2 years underwent Tc-GSA scintigraphy and were classified into 2 groups: those who survived with a native liver (Group A, n = 34) and those who required liver transplantation (LTx) (Group B, n = 11). We compared Tc-GSA scintigraphy data (HH15, LHL15, and HH15/LHL15 [H/L15]) and liver function test (LFT) results between the groups. The patients underwent a second Tc-GSA scintigraphy at approximately 5 years of age. All patients survived. HH15, H/L15, total bilirubin, direct bilirubin, gamma-glutamyl transpeptidase, and alanine transaminase levels were higher in Group B than in Group A (p<0.05). Total and direct bilirubin levels were associated with H/L15 (p<0.05). There were no significant changes in results between the first and second Tc-GSA scintigraphy in Group A. Mid- and long-term prognoses may be predicted using Tc-GSA scintigraphy data and LFTs in patients aged 1-2 years. We recommend regular monitoring of postoperative data following KP, even in jaundice-free patients. III.
The aim of the study is to compare the efficacy of SPIO as a tracer in sentinel node biopsy (SNB) in breast cancer with Tc and patent blue in a multicentre prospective study and perform a meta-analysis of all published studies. It also aims to follow skin discoloration after SPIO injection and describe when and how it resolves. Totally 206 patients with early breast cancer were recruited. Tc and patent blue were administered in standard fashion. Patients were injected with SPIO (Sienna+) preoperatively. SNB was performed and detection rates were recorded for both methods. Skin discoloration was followed and documented postoperatively. Data extraction and subsequent meta-analysis of all previous studies were also performed. SN detection rates were similar between standard technique succeeded and SPIO both per patient (97.1 vs. 97.6 %, p = 0.76) as well as per node (91.3 vs. 93.3 %, p = 0.34), something which was not affected by the presence of malignancy. Concordance rates were also consistently high (98.0 % per patient and 95.9 % per node). Discoloring was present in 35.5 % of patients postoperatively, almost exclusively in breast conservation. It fades slowly and is still detectable in 8.6 % of patients after 15 months. Meta-analysis depicted similar detection rates (p = 0.71) and concordance rates (p = 0.82) per patient. However, it seems that SPIO is characterized by higher nodal retrieval (p < 0.001). SPIO is an effective method for the detection of SN in patients with breast cancer. It is comparable to the standard technique and seems to simplify logistics. Potential skin discoloration is something of consideration in patients planned for breast conservation.
Background: Computer modeling is used to predict inhaled aerosol deposition in the lung based on definition of the aerosol characteristics and the breathing pattern and airway anatomy of the subject. Validation of the models is limited by the lack of detailed experimental data. Three-dimensional imaging provides an opportunity to address this unmet need. Methods: Radioactive aerosol was administered to six male asthmatic subjects on two occasions under carefully monitored input conditions. Input parameters varied in particle size, depth of breathing, and carrier gas. The aerosol distribution was measured by combined single photon emission computed tomography and x-ray computer tomography (SPECT/CT) and airway anatomy by high resolution CT. The deposition distribution was measured by both a 2D and 3D analysis and described in terms of the percentage of inhaled aerosol deposited in sections of the respiratory tract and in both spatial and anatomical subdivisions within each lung. The percentage deposition in the conducting airways was also assessed by 24 h clearance. Results: A set of imaging data of aerosol deposition has thus been produced in which the input parameters of inhalation are well described. The results in asthmatics were compared to previous measurements in healthy controls using an identical inhalation protocol. The percentages of deposition in extra-thoracic and thoracic compartments of the airways were not significantly affected by disease, but the regional pulmonary deposition pattern was, with asthma leading to increased deposition in the conducting airways. Conclusions: The dataset acquired in this study will be useful in validating computer models of aerosol deposition in asthmatic subjects. Asthma did not affect the fraction of inhaled aerosol depositing in the lungs, but gave rise to a more central deposition pattern. The use of 3D SPECT imaging in combination with 24 h clearance measurements enables differentiation of deposition between bronchial and bronchiolar airways.