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Plenary 4: Highlights Lecture:
OP635 Highlights Lecture I. Roca (ES)
POSTER WALKS (Posters with oral presentation) PW01 ‐ Sunday, October 11, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 1: physics, instrumentation, basic science
PW001 Improved quantification in multiple-pinhole SPECT by anatomy based reconstruction using micro-CT information C. Vanhove1, M. Defrise2, A. Bossuyt1, T. Lahoutte2; 1UZ Brussel, Brussels, BELGIUM, 2VUB, Brussels, BELGIUM. The aim of this study was to evaluate the potential of anatomy based reconstruction, using micro‐CT information, to minimize the impact of partial‐volume‐effects in multiple‐pinhole SPECT and, hence, to improve quantitative accuracy. A cylindrical software phantom containing eight rods with diameters ranging from 1mm to 10mm was designed. The rods were filled with 4 counts/mm3, while the surrounding background was filled with 1 count/mm3. Circular orbit multiple‐pinhole (6 apertures of 1.5mm diameter) SPECT projections were simulated taking into account imperfect camera motion, collimator response, angular variation of the sensitivity for each aperture, intrinsic camera resolution, and photon attenuation. One hundred different Poisson noise realizations were computed. Micro‐CT images containing contrast agent in the rods were generated to simulate noise‐free images of the SkyScan 1178 in vivo scanner. Pinhole SPECT images were reconstructed by OS‐EM using an anatomical prior, and for comparison using conventional post‐smoothing and an edge‐preserving prior. The anatomic prior allows incorporation of micro‐CT information during reconstruction, so that smoothing is encouraged within, but not across boundaries. Significant boundaries were defined from micro‐CT images, using an automatic contrast selection algorithm based on the histogram of the grey value differences between the micro‐CT voxels and their neighbours. A probability p (0≤p≤1) that a SPECT voxel contains a boundary was obtained by down‐sampling this micro‐CT information to the SPECT images during image registration. Correctly aligned and intentionally misaligned micro‐ CT images (±0.5mm translation; ±1° rotation) were evaluated. For each rod, the recovery coefficient (measured count density / true count density), averaged over the 100 noise realizations, was expressed as a function of the noise, measured over the 100 noise realizations. This showed that at 5% noise level the recovery coefficient, averaged over the 8 rods, increased from 0.74±0.19 using post‐smoothing, to 0.79±0.21 using an edge‐preserving prior, and to 0.85±0.21 using correctly aligned anatomical information. When intentionally misaligned information was incorporated during reconstruction a value of 0.81±0.22 was observed. The distribution of the recovery coefficients within the eight rods demonstrated that 74% of the voxels had a recovery coefficient between 0.90 and 1.10 when anatomical information was used compared to 56% when an edge‐preserving prior was used, and to 49% when conventional post‐ reconstruction smoothing was applied. When the structural information was misaligned, 70% of the voxels had a recovery coefficient between 0.90 and 1.10. In conclusion, anatomy based reconstruction using micro‐CT information has the potential to improve quantitative accuracy in multiple‐pinhole SPECT.
PW002 2D/3D registration of freehand SPECT and planar scintigraphy for clinical evaluation of 3D thyroid scintigraphy T. Wendler, X. Feng, K. Herrmann, T. Lasser, J. Traub, S. I. Ziegler, N. Navab, A. K. Buck; Technische Universität München, Muenchen, GERMANY. Objectives: Freehand SPECT has been introduced lately as a 3D imaging modality for small anatomies, like axilla and neck. In this work, the freehand SPECT technology is applied for the first time for 3D thyroid scintigraphy. Further methods are developed, implemented and evaluated with the aim of comparing the obtained 3D images using conventional 2D scintigraphy and thus validating the novel approach. Methods: A freehand SPECT system based on a positioning system (Vicra, NDI, Waterloo, Ontario, Canada), a handheld probe (NodeSeeker, IMI, Los Angeles, California, USA) and ad hoc tomographic reconstruction was adapted to reconstruct a 3D Tc99m distribution in the region of the thyroid (15x15x5cm3 region, 5x5x5mm3 voxels). Further a method for 2D/3D registration was designed and implemented in order to compared conventional 2D thyroid scintigraphy with the new 3D freehand SPECT images. Results: In order to evaluate the 2D/3D registration algorithms a synthetic thyroid data set was generated. Given known displacements in position and orientation, the 2D/3D were used to register the images. The maximum registration errors were 0.2mm and 2° for position and orientation respectively if the starting displacement was below 5cm and 20°. Further, a first trial in 10 patients (40‐78y, mean 61y) undergoing indicated thyroid scintigraphy (57‐71MBq i.v. Tc99m pertechnectate, mean 65MBq) was performed for the purposes of testing and evaluation of this technology in a pilot study setup. The scanning protocol consisted of a 2min scan from each side of the neck and 2min from frontal (6min total). Freehand SPECT could generate qualitatively good images in 8 of the 10 patients. The average normalized cross‐correlation of the aligned freehand SPECT projection and planar images was 69.8% (range 48‐81%) for the said 8 patients. Conclusions:
Regarding the evaluation method, the 2D/3D registration algorithm yielded excellent results for the synthetic data. Thus it seems to be an appropiate tool for validation of freehand SPECT data. Regarding freehand SPECT, the system was capable of reconstructing qualitatively good images in 8 of 10 patients. Although the novel system seems to require still technical improvements, the results reveal that the freehand SPECT is a promising approach that may open new doors towards flexible 3D nuclear imaging.
PW003 Development of three-dimensional position sensitive CdTe detector block for high resolution human body PET scanner K. Ishii, Y. Kikuchi, M. Nakhostin, H. Yamazaki, S. Matsuyama, A. Terakawa; Tohoku University, Sendai, Miyagi, JAPAN. We have developed new detector blocks for PET scanners which achieves both high spatial resolution and high sensitivity. Photon interaction points can be determined three‐dimensionally (transaxial, axial and depth of interaction), and position resolutions are less than or about 1mm in all of the coordinates. The detector blocks will be applied to a PET scanner that we will construct. In our previous research, we developed an ultra high resolution small animal PET scanner using CdTe strip detectors, and less than 1mm resolution was achieved. Downsizing detector elements enables such a resolution. On the other hand, it is possible that downsizing decreases scanners’ sensitivity because packing of detectors is affected by electronics which are needed for processing signals from detectors. As a solution, we propose applying position sensitive detectors based on charge division method, because electronics channels can be reduced. Based on this concept, our new detector block is made by stacking thin two‐dimensional position sensitive CdTe detectors. A position resolution in transaxial is determined by stacking pitch. In our block, the pitch is 1.2mm, so that high resolution can be obtained. Resolutions in axial and DOI depend on performances of the stacked detector. The detector is composed of a 16‐strip type CdTe 3 detector (size is 19.1×20×1.0t mm ) and two resistive chains for position readout. The strip type detector is characterized by an anode plane which has a resistive layer and consists of parallel strips which are 1mm wide and are aligned in 1.2mm pitch. The first coordinate of photon interaction point is determined by the signal from each strip. The charge division method is employed for this purpose. Both ends of all strips are connected to resistive chains, and the signals from both sides of the chains are readout. The ratio of the signals obtained from both sides of the resistive chain determines the hit strips. Excellent accuracies of about 90% are confirmed in the central strips. To determine the second coordinate along the strips, again charge division method is applied, and the resolutions are 0.8 ‐ 1.4 mm FWHM.As described above, high resolutions are achieved three‐dimensionally. Particularly, a remarkable point is that fine DOI information can be obtained as well as transaxial and axial. This indicates that high spatial resolution is achieved at whole FOV.
PW004 The PIM-Imager: a high sensitive multi-modality numerical beta autoradiograph J. Donnard1, N. Arlicot2, R. Berny1, H. Carduner1, S. Chalon2, A. FaivreChauvet3, P. Leray1, E. Morteau1, N. Servagent1, D. Thers1; 1Subatech, Nantes, FRANCE, 2Inserm U930, Tours, FRANCE, 3Inserm U892, Nantes, FRANCE. The beta autoradiography is a widely used technique in preclinical research where high spatial resolution and good quantification are needed. We report on the recent development of an innovative apparatus based on the PIM (Parallel Ionization Multiplier) gaseous detector devoted to beta autoradiography. Our device is able to process the image of 10 microscope slides in the same time over an area of 18*18 cm². The main advantage comes from the event by event measurement resulting in “on‐line” imaging availability in which no “after development” has to be performed. Thin slices of organs can be labelled with beta emitters of low energy like 3H / 14C or Auger electrons emitters such as 125I / 99mTc. Thanks to a vacuum pump and a regulation gas circuit, 5 minutes is enough to begin an acquisition. All the electronics and the gas supply are included in the structure leading to a transportable device. Special software has also been developed to process data in real time with image visualization. Tests were performed with 3H and 125I on rat brain sections mounted on microscope slides. The measured spatial resolution is 30 µm (FWHM in 2 dimensions) over the whole sensitive surface, giving to our device a great potentiality regarding the present state of art. The sensitivity threshold is around 0.005 cps/min/mm². This device shows a good homogeneity of response over the whole area. In case of 3 H labelling, images can be performed 80 times faster than those on films. An overall review containing all the recent results will be presented.
PW005 A Breath Control Device with EKG monitoring (ABCDE) for PET/CT imaging S. Chauvie, G. Perno, A. Biggi; S Croce and Carle Hospital, Cuneo, ITALY. Aim: respiration during PET/CT examination could lead to underestimation of the activity of a lesion or, if blurring is high enough, to mask lesion that could have been detectable in non moving organs. Moreover misregistration could occur if CT and PET are acquired in different phase of patient’s breathing. To overcome this problems we constructed a new device for breath monitoring to be used in PET/CT exams. Material and methods: ABCDE (Automatic Breath Control Device with EKG gating) uses a sensor to detect the thorax movement during respiration and gate this information to the imaging device using the EKG connector. ABCDE is fast and easy to use because the radiographers need only few seconds to set‐up the patient before the scan start. Moreover, once connected, it should not be moved or programmed for all day long. ABCDE is comfortable for the patients because they have only to wear nasal cannula, normally used for oxygen. It is safe because patient is electrical isolated from the imaging system. Even if ABCDE is not to be used as an alternative of optical or infra‐red system for detecting real‐time thorax movement, it permits to gain sufficient accuracy to avoid respiratory artefacts in PET/CT imaging. Moreover, ABCDE could be used in combination with EKG to obtain respiration‐free images of the heart. Results We tested the system on a small cohort of patients. The patients were instructed to follow the breath command given by the technologist during PET acquisition. The CT was
Poster Presentation
1801 ‐ Wednesday, October 14, 2009, 12:00 – 13:00, Hall 211/212
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acquired in end of expiration phase. During PET the commands given were to inhale, exhale and then keep the breath for 5‐6 seconds in end of expiration. The patients tolerated well the system and the trigger was detectable easier if patients could breath deeply. To obtain a set of PET images motion‐free we accumulated the bins of the trigger in which we visually saw the lesion standing in the same position. That happened in average for 6 of 10 bins, the ones in which the patient was in end of expiration. We observed a enhancement of SUV value with motion‐free images of up to 150%. Conclusions We constructed a system for breathing trigger during PET‐CT examination. This demonstrated to be useful in determining motion free part of the PET study. The system should be validated on a large cohort of patients to verify its applicability in the clinical routine.
PW006 Performance of collimators for a new noninvasive blood radioactivity monitor in PET N. Kubo1, T. Akiya2; 1Hokkaido University, Sapporo, JAPAN, Neurosurgical-Rehabilitation Hospital, Abashiri, JAPAN.
2
Abashiri
Objectives: We have investigated a new noninvasive blood‐radioactivity monitor that uses a collimator. The monitor estimates the input functions for quantitative PET and SPECT by sequentially percutaneously measuring the radioactivity of the radial artery in the forearm. The system consists of gamma ray detectors, a collimator and an ultrasound scanner system. The blood‐vessel diameter and depth are measured from an echo image and the echo image data is used for partial volume effect, attenuation and scatter corrections of the blood radioactivity of the radial artery. The use of a collimator allows the monitor to count radiation from blood radioactivity in both SPECT and PET. For PET, a collimator is used for counting 511‐keV photons from positron emitters. Septal penetration of the collimator is a known problem. In this study we have simulated and evaluated the performance of parallel‐hole and converging collimators for this monitor at 511 keV. Methods: We simulated the collimation for 511‐keV photon counting using a Visual C++ program. The field of view of the detector was set at 25.6 mm. Two collimator types (parallel‐hole and converging) were considered. The collimators were constructed from tungsten, with a length of 25.6 mm and an inner diameter at the patient side of 2 mm. The septum thickness of both collimators was changed from 1 mm to 3 mm in the simulation. In the converging collimator, the focal distance was set at 25.7 mm. An imaginary point source (representing the radial artery in the forearm) was placed 5 mm from the collimator face. Results: The sensitivity of the converging collimator was 2.0 times that of the parallel‐hole collimator for all thicknesses. The penetration‐peak to direct‐radiation ratio for 1, 2 and 3‐mm thicknesses were 18%, 5% and 2% for the parallel‐hole collimator and 35%, 23% and 12% for the converging collimator. Conclusion: We simulated and evaluated the performance of parallel‐hole and converging collimators for a new noninvasive blood‐radioactivity monitor at 511 keV. The sensitivity of the converging collimator is greater than that of the parallel‐hole collimator. However, the converging collimator exhibits larger penetration than the parallel‐hole collimator. Consequently, the septum thickness should be thicker than 3 mm for the noninvasive blood‐ radioactivity monitor in PET.
PW007 Preliminary studies to quantify the effective dose delivered by the CT phase of two different SPECT/CT systems using clinical imaging procedures using an ImPACT CT Dose Index (CTDI) phantom. I. S. Hufton1, P. Charnock2, M. Ward2, M. Carroll1; 1Royal Liverpool University Hospital, Liverpool, UNITED KINGDOM, 2Integrated Radiological Services Ltd, Liverpool, UNITED KINGDOM. Aim Discussion at a UK regional Nuclear Medicine conference highlighted the requirement to investigate and quantify the effective dose received during the CT phase of routine SPECT/CT procedures using non‐diagnostic quality CT. Our objective was to provide quantification of the effective dose received by patients on two different SPECT/CT systems. Material & Methods CTDIvol measurements on an ImPACT CTDI phantom were taken using either a Radcal Control Monitor 9010 with 10cm pencil ionisation chamber or a Keithley TRIAD Dosimeter 3050A with a Welhoffer CT chamber, both calibrated to a national standard. Two SPECT/CT systems were assessed; GE Infinia Hawkeye and Siemens SymbiaT1. Measurements were taken on systems at four different sites. On the Infinia, the CTQA protocol was used because it allowed single slice measurement. Clinical protocols use the same exposure factors but restrict the examination to 20cm, which, being longer than the chamber would result in dose cut‐off. On the SymbiaT1 the clinical protocol was used with a 5mm slice, with and without Care Dose4D. Results Average CTDIvol values for body and head examinations were 4.09mGy and 5.69mGy on the Infinia. Taking the clinical scan length of 20cm, a Dose Length Product (DLP) was calculated. Then using the conversion factors provided by Shrimpton et al (2005) the effective doses were calculated (table 1). It should be noted however that the reference values (Shrimpton et al, 2005) and effective dose factors used are given for a limited number of standard diagnostic CT examinations. The closest appropriate match to SPECT/CT brain and thorax are Head and Chest respectively. Therefore, effective dose values calculated should only be taken as estimates. Table 1 ‐ DLP and Effective dose estimates for different regions of the body. DLP for 20cm scan Region of (mGycm2) on GE Body Infinia
Effective dose (mSv) on GE Infinia
DLP for 20cm scan (mGycm2) on Siemens Symbia
Head
113.8
0.24
Neck
113.8
0.67
Head & Neck
113.8
0.35
Chest
81.8
1.15
Results awaiting confirmation
Effective dose (mSv) on Siemens Symbia
Conclusions Effective dose can be estimated for SPECT/CT systems with the use of standard CT QA techniques; however a larger study would be required to ensure confidence in the results. The lower resolution Infinia is of a different level of technology to the SymbiaT and Diagnostic CT systems and therefore comparison to reference DPL and effective dose values for a head CT scan
(DLP 690mGy, Eff. Dose 1.5mSv) may not be appropriate. However Hi‐Res Chest CT reference values (DLP 80mGy, Eff. Dose 1.2mSv) are comparable. Further measurements on the SymbiaT1 are currently awaiting confirmation and appear to be marginally lower than the Infinia for clinical procedures. Initial measurements with and without Care Dose 4D appear to make little difference, however the homogenous composition of the ImPACT phantom would explain this observation.
PW008 Scatter Correction in PET-CT by Beam Stoppers T. Chen1, K. Chuang2, H. Lin2, M. Jan3, W. Yao4; 1Department of Medical Imaging and Radiology, Shu-Zen College of Medicine and Management, Luju Shiang, Kaohsiung, Taiwan 82144., Kaohsiung, TAIWAN, 2Department of Biomedical Engineering & Environmental Sciences National Tsing-Hua University, Taiwan, Hsinchu, TAIWAN, 3Physics Division, Institute of Nuclear Energy Research Atomic Energy Council, Taiwan, Hsinchu, TAIWAN, 4 Department of Nuclear Medicine, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan., Tainan, TAIWAN. With the increasing use of 3D acquisition mode for positron emission tomography (PET) scanning, scatter coincidence is becoming a more and more relevant issue. Scatter coincidence causes an approximately uniform distribution of background on the image and degrades the accuracy of quantitative analysis. Most commercial PET systems employ the single scatter simulation (SSS) algorithm for scatter correction. However, the SSS method achieves limited accuracy because it estimates scatter from single scatter event and does not consider the scatter from out of field of view. This work uses the beam stoppers (BS) devise for correcting scatter coincidence. The method is based on the idea that the line of response (LOR) of a scatter event will not intercept their annihilation site. Placing a BS near the object will absorb a particular fraction of the true events but has little effect on the scatter events. The subtraction of the two scanned data, with and without the BS, can be employed to estimate the scatter events. Preliminary results indicate that the proposed method is feasible for clinical application. Keywords: Scatter coincidence, beam stopper, PET‐CT
PW009 Voxel-based Kinetic Fragmentation
Analysis
Method
utilizing
ROI
U. Simoncic1, R. Jeraj2; 1Institut Jozef Stefan, Ljubljana, SLOVENIA, 2 University of Wisconsin - Madison, Madison, WI, UNITED STATES. Introduction: Kinetic analysis is important for accurate quantification of positron emission tomography (PET) images. As the kinetic analysis is typically done on a region of interest (ROI) level, it does not preserve the spatial information of the tracer uptake. On the other hand, if it is done on a voxel level (voxel‐based kinetic analysis) the results are severely affected with the high signal to noise ratio (SNR) of individual voxels. We developed a novel method for the voxel‐based kinetic analysis on various spatial levels, which overcomes the problem of high voxel noise level in the dynamic PET data. Methods and materials: The proposed method starts with an ROI‐based kinetic analysis with the standard least‐squares method. Then a series of optimizations on sub‐ regions is performed, where estimated parameters from the super‐region are used as initial guesses and a‐priori values for the Bayesian parameter estimation procedure on sub‐regions. Procedure is repeated until sub‐regions consist of a single PET image volume element. The method was tested by comparing the model estimated parameters with the true parameters on a mathematical phantom. Several different a‐priori weighting schemes were tested on human cancer patients, dynamically imaged with the FLT (18F‐3'‐fluoro‐3'‐deoxy‐L‐thymidine) PET. Tracer kinetics was modeled with a two‐compartment four‐parameter kinetic model. Spatial variation of the kinetic parameters on parametric images was quantified. Results: Adding Bayesian part in the objective function greatly reduces the spatial variation of kinetic parameters making images to appear smoother. On the other hand, the accuracy of parameter estimation is not compromised, as shown through phantom simulation studies. The reduction of spatial variation of kinetic parameter was found to be the most distinctive for the k3 parametric images, where variation was reduced approximately 6‐fold. The reduction was least evident for the FLT influx ki=k1k3/(k2+k3) parametric images, where the reduction was approximately 2‐fold. Conclusion: The proposed method is unique because it does not incorporate the population‐based prior knowledge, but develops the prior knowledge by kinetic analysis on different spatial levels. It reduces the spatial variation in parametric images, which reduces sensitivity to the image registration errors, without compromising quantitative accuracy.
PW010 Engineer R. Ghiassi; Clinical Physiology & Nuclear Med., Copenhagen, DENMARK. Aim: To evaluate the precision of PET results by comparing SUV obtained by repeated measurements in two scanners using a phantom with two different volumes of interest (VOI) and varying activities. Method: Two PET‐CT scanners (Philips Gemini, Dual slice and TF16 Slice) were investigated with a Perspex phantom containing three different cylindrical volumes. One volume is a massive cylinder and the other two cylinders have volumes of 100 ml and 30 ml, respectively. The phantom was placed inside a larger cylinder which holds about 10 liter. Both small cylinders were filled with water and varying activity levels of 18F. The amount of the activity in the background cylinder was 5.29 MBq per liter similar to the average activity in a patient during a medical examination by PET‐scanning at Herlev Hospital (SUV ~ 1). In the small cylinder the activity varied in steps (0.5, 1, 2, 3, 5 and 10 times the background activity in the large cylinder). The phantom was scanned using a standard clinical protocol with Low dose CT and without a diagnostic CT. A total of 29 measurements were performed in a time interval of 90 days. Analysis of the results were performed with Syntegra processing software, by choosing five VOIs representing the massive, small and large cylinders as well as two background volumes. A SUV was measured for each of these volumes. The line of measurements for each VOI was analyzed using linear regression. Results The differences between the two scanners are presented in the following table in form of normalized trend line drawn for samples of tests.
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The slope of the line α
standard point of intersection β regression index R deviation σ*
Small volume
Dual slice
0.5759
0.3306
0.9861
0.7377
TF 16 slice
0.8087
0.5872
0.9921
0.3287
large volume
Dual slice
0.6546
0.3133
0.9889
0.6268
TF 16 slice
0.9081
0.5757
0.9942
0.15348
Background
Dual slice
‐0.0202
0.8329
0.505
0.1879
TF 16 slice
‐0.0174
1.2053
0.5329
0.05212
2
*Here the standard deviation is calculated for each measured sample and in each category a mean value is calculated..
Conclusion A difference up to 40% was found in SUV values between the two scanners implying that patients have to be investigated sequentially in the same scanner. The reproducibility was high in the same scanner, thus values are highly reliable in a treatment evaluation. Cross calibration between scanners is demanding, but necessary if investigations should be comparable (f.inst. if a certain SUV value is critical). Measurements in a second TF, 16 slice scanner are being performed and will be included in the finale presentation.
PW02 ‐ Sunday, October 11, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 2: neurology
PW011 Longitudinal study of FP-CIT and ECD SPECT in Essential Tremor and Parkinson’s Disease G. Marotta1, I. U. Isaias2, S. Hirano3, R. Benti1, R. Cilia2, D. Eidelberg3, A. Antonini2, P. Gerundini1; 1Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Nuclear Medicine Department, Milano, ITALY, 2 Parkinson Institute, Milano, ITALY, 3The Feinstein Institute for Medical Research, Manhasset, NY, UNITED STATES. Background and obiective: Essential tremor (ET) is the most common movement disorder; still little is known about its pathophysiology and disease progression. Aim of the study was to investigate over time basal ganglia dopaminergic innervation loss and to compared regional brain networks (PD related covariance pattern: PDRP) in subjects with essential tremor (ET), Parkinson disease (PD) and healthy controls (HC). Methods: We examined the rate of progression of dopaminergic terminal loss in ET subjects with two sequential FP‐CIT SPECT scans at least three years apart and compared them with results obtained in 13 subjects with PD. FP‐CIT uptake values were compared at baseline with results of 23 HC. Nine of the 20 ET patients additionally performed an ECD SPECT exam; results were compared with a second group of 18 PD patients (9 tremor dominant, tPD and 9 akinetic‐rigid dominant, arPD) and a second group of 8 HC. The reconstructed images were analyzed for regionally specific effect in FP‐CIT uptake using Statistical Parametric Mapping (SPM2). In all images the binding ratio values of caudate nucleus and putamen were obtained again using the AAL VOI in WFU PickAtlas software. Discriminant analysis was used to categorize ET, HC and PD subjects. PD‐related covariance pattern (PDRP) was utilized in assessing ECD SPECT scans. In this spatial covariance analysis, we used a fully automated voxel‐ based network quantification approach to quantify its PDRP expression in each scan. Results: At baseline, PD subjects showed lower dopaminergic uptake than ET and HC; no difference was found between ET subjects and HC. FP‐CIT uptake decline/year in PD ranged from 5.6% in the contralateral caudate nucleus to 7.3% in the contralateral putamen; no uptake decline was found for ET subjects. No difference in brain network analysis was found between ET patients and HC but both differed from tPD and arPD. No difference was found between the two PD sub‐groups. Discriminant analysis grouped 30% ET subjects (first scan) and 5% (second scan) as PD. Partition analysis for contralateral putamen was able to distinguish completely PD from ET and HC, but not for contralateral caudate nucleus that showed a high overlap between ET and PD. Conclusions: PD and ET do not share a common dopaminergic uptake and progression loss. PDRP clearly differentiate ET from arPD and tPD. However, a mild dopaminergic denervation of the caudate nucleus might be necessary for tremor onset and link the two diseases.
PW012 [123I]FP-CIT SPECT in the Evaluation of Parkinson’s Disease: Comparison between Patients with the Tremor and the RigidAkynetic Variants D. Volterrani1, R. Ceravolo2, G. Manca1, C. Rossi2, E. Filidei1, D. Frosini2, F. Guidoccio1, I. Paglianiti1, S. Chiacchio1, M. Grosso1, G. Boni1, E. Borsò1, U. Bonuccelli2, G. Mariani1; 1Regional Center of Nuclear Medicine, University of Pisa, Pisa, ITALY, 2Neuroscience Dept., University of Pisa, Pisa, ITALY. The tremor variant (TV) and the rigid‐akynetic variant (RAV) are the two main clinical phenotypes of Parkinson’s Disease (PD). Patients with the TV clinical phenotype usually present a slower disease progression and a lower risk of cognitive decline. Aim of the study: to evaluate the degree of nigro‐striatal impairment in these two different groups of patients, with the TV and the RAV variants respectively, by means of the dopamine transporter SPECT. Methods: we retrospectively evaluated sixty‐two patients with a diagnosis of probable PD, who had undergone a SPECT study with [123I]FP‐CIT within 3 years from clinical onset. Using the UPDRS III scale at first clinical evaluation, 38 patients were included in the group with RAV and 24 in the group of those with TV. SPECT studies were acquired at equilibrium by using a dual head gamma camera. Data were acquired in a 128x128 matrix (pixel 3 mm) recording 128 projections over an overall
360° circular orbit. FBP with a Butterworth prefilter was used for reconstruction and uniform attenuation correction (Chang method) was applied. Binding potential values within striatal, caudate and putamen nuclei were obtained by using the free software BasalGanglia Matching Tool according to the following formula: (striatum mean counts ‐ occipital mean counts)/occipital mean counts. Results: the two groups of patients did not show any statistical difference regarding age (RAV 64.8 yrs, TV 64.3 years), disease duration (RAV 25.5 months, TV 30.5 months) and severity (UPDRS III: RAV 18.1, TV 15.2). In the group of patients with RAV [123I]FP‐CIT binding ratios within the putamen contralateral to the clinically more affected side resulted to be significantly decreased when compared to those of the TV group (1.29±0.54 vs 1.52±0.68, p<0.01). However, no significant differences between groups were observed when binding potentials within the striatum (RAV 2.07±0.78 vs TV 2.13±0.82) and caudate nuclei (RAV 2.42±0.90 vs TV 2.44±0.91) were evaluated. Conclusions: our data suggest a more severe degree of putaminal dopaminergic impairment in patients with RAV than in those with VT. The lower putaminal dopaminergic impairment in the group of patients with TV could explain the trend to a slower progression of PD in these patients. Moreover, this finding is consistent with the lack of relationship between the severity of tremor and the degree of nigro‐striatal impairment (as described by some Authors) and support the hypothesis of the possible role of other neurotransmission systems in determining this symptom.
PW013 Therapeutic Clinical Impact of Ioflupane-I123 Brain SPECT in Movement Disorder Patients R. Nieto-Serrano, M. Carrero-Lérida, M. Mariscal-Cerrato, M. FernándezMayorga, C. Dávila-Arias, A. Yampara Gutiérrez, A. García-Mendoza, O. Padilla-Bolivar, J. Martínez-Sampere; H.U. San Cecilio, Granada, SPAIN. Objective: To determine clinical impact of Ioflupane‐I123 SPECT therapeutic use in Movement Disorder (MD) Patients. Methods: 101 MD patients (58 female, 43 male; mean age of 66,1 years (22‐84) were included in the study and all were scanned using Ioflupane‐I123 SPECT (SPECT). Pre and Post‐SPECT clinical status was established by two clinical neurologists who were both specialists on MD. Results: Esential Tremor (ET) was diagnosed on 38 patients. 33 out of those 38 were not on treatment with L‐DOPA and SPECT results were positive among 6 all of whom were put on L‐DOPA resulting in clinical improvement at 12 month follow‐up. Among the three patients who were originally on L‐DOPA showed normal SPECT and subsequently such drug was discontinued and changed to Beta‐blockers also showing clinical improvement 12 months later. SPCET induced a therapeutic management change in 9 out of 38 patients scanned (23.7%). 51 patients had a parkinsonian syndrome, 36 with no L‐DOPA treatment, showing positive (pathological) SPECT results in 22 patients. Treatment was changed to include L‐DOPA for the latter 22 patients with a subsequent clinical improvement 16 months later, SPECT hence determining therapeutic management change in 66.6% of patients (i.e., 22 out of 33). 4 out of 7 patients with a clinical suspicion of Parkinsons Disease were not on L‐DOPA prior to their SPECT scan showed positive results. Following SPECT they were put on L‐DOPA and clinical improvement was seen at 12 months follow‐up so that therapeutic management change occurred in 57.1% of SPECT scanned patients. 1 patient with Lewy Body Dementia on no previous treatment with L‐DOPA was put on it after a positive SPECT scan being then put on such drug and acquiring clinical improvement at 6 months follow‐up Finally, among the four patients with a diagnosis of iatrogenic parkinsonism, on whom SPECT was normal, all showed clinical improvement at 12 months follow‐up following discontinuation of the drug inducing parkinsonism. This medication change was decided after SPECT results in all 4 patients (100%) Conclusions: Ioflupane‐I123 SPECT appears, in our experience, as a great value test to establish diferential diagnosis between degenerative parkinsonism and essential tremor. It is also most useful in distinguishing secondary from degenerative parkinsonian syndromes demonstrating a considerable diagnostic‐therapeutic impact on 69,5% patients in our series.
PW014
123
Cardiac I-MIBG scintigraphy and probable Dementia with Lewy Bodies
123
I-FP-CIT SPECT in
V. Camacho, M. Estorch, M. Marquié, A. Flotats, C. Artigas, A. RodríguezRevuelto, E. Rivera, J. Duch, A. Lleó, I. Carrió; Hospital de Sant Pau, Barcelona, SPAIN. Aim: Dementia with Lewy Bodies (DLB) must be to distinguished from other types of dementia because of important differences in patient management and outcome. Both reduction in cardiac 123 I‐ metaiodobenzilguanidine (MIBG) uptake and decreased 123I‐FP‐CIT uptake in the basal ganglia have been described in DLB. The aim of this study was to evaluate the possible role of 123 cardiac MIBG scintigraphy and I‐FP‐CIT SPECT in patients with probable DLB. Materials & Methods: Thirty‐five patients (19 males; mean age 77y, range 64‐88y) with clinical international criteria of probable DLB (cognitive impairment, visual hallucinations and falls) were included in the study. All patients underwent a cardiac MIBG scintigraphy and a 123I‐FP‐CIT SPECT. MIBG imaging was performed 4h after tracer injection, with a total acquisition time of 5‐10 min. Global cardiac MIBG uptake was semiquantified by means of heart‐to‐mediastinum ratio (HMR) (normal>1.56). Brain SPECT was performed 3h after 123I‐FP‐CIT injection, with a total acquisition time of 45 min. Specific binding ratio for striatum was calculated and compared with a control group. Results: Cardiac MIBG uptake was decreased in 28 of 35 patients (HMR=1.32, range 0.95‐ 1.85). The 123I‐FP‐CIT study was abnormal in 29 of 35 patients, and the specific binding ratio for striatum was significantly decreased as compared to a control group (2.10±0.5 vs 2.82±0.29, p< 0.05). There was significant correlation between the HMR and specific binding ration of striatum (p<0.05). Conclusion: In probable DLB cardiac adrenergic activity and nigroestriatal activity are severely impaired. Cardiac MIBG imaging has the advantage of a shorter acquisition time. A 123 combination of cardiac MIBG and I‐FP‐CIT nigroestriatal imaging may help in appropriate patient classification.
Poster Presentation
S284
PW015 The role of cardiac Iodine-123-Metaiodobenzylguanidine scintigraphy in the early diagnosis of Lewy body diseases in patients with mild extrapyramidal symptoms G. Treglia1, E. Cason1, A. Romeo1, M. Rossi1, S. Zoboli1, M. Santoro1, A. Gabellini2, G. Fagioli1; 1Nuclear Medicine Unit Maggiore Hospital, Bologna, ITALY, 2Neurology Unit Maggiore Hospital, Bologna, ITALY. Aim: Parkinson’s disease (PD), dementia with Lewy bodies (DLB) and pure autonomic failure share clinical and neuropathological features. Lewy body diseases (LBD) has thus become a general term for all three diseases. Decreased cardiac uptake of radiolabelled MIBG has been reported in early stages of LBD; this finding suggests that degeneration of cardiac sympathetic nerve begins in the early phase of these diseases. According to the clinical criteria, it might be difficult to prove the diagnosis of LBD in patients with mild symptoms and, in these cases, MIBG scintigraphy may contribute to the early diagnosis. We report our preliminary experience about the role of MIBG scintigraphy in the early diagnosis of LBD in patients with mild extrapyramidal disturbances. Materials & methods: 20 patients (12 males; mean age 69 y.o.) with mild extrapyramidal symptoms underwent MIBG scintigraphy. Exclusion criteria were cardiac diseases and previous cardiotoxic therapy. In 6 cases there was a clinical suspicion of DLB; in 14 cases the examination was performed to differentiate a PD from a parkinsonian syndrome after a scintigraphic finding of nigro‐striatal dopaminergic dysfunction revealed by I‐123‐Ioflupane scintigraphy. MIBG scintigraphy was performed 4h after i.v. injection of 111MBq of I‐123‐MIBG. Planar images of thoracic region were used for visual and semi‐quantitative analysis of cardiac MIBG uptake. Regions of interest (ROI) were set in the heart (H) and the mediastinum (M), after which the H/M mean count ratio is calculated; a H/M ratio >1.7 was considered as normal. Results: MIBG scintigraphy showed a markedly decreased cardiac uptake of radiopharmaceutical in all patients with suspected DLB confirming the clinical suspicion (H/M ratio was <1.35 in all cases). In 5/14 patients examined to differentiate a PD from a parkinsonian syndrome, a normal cardiac MIBG uptake was reported, orienting the clinician to exclude a PD; in 8/14 patients a decreased MIBG cardiac uptake was reported (H/M ratio <1.5), orienting the clinician to confirm a PD. In one case H/M ratio had a borderline value, not allowing an univocal interpretation of the scintigraphic findings. Conclusion: MIBG scintigraphy may be a very useful tool for early diagnosis of LBD. Particularly in patients with DLB we report a marked decrease of I‐123‐MIBG cardiac uptake. Furthermore MIBG scintigraphy allowed a good differential diagnosis between PD and parkinsonian syndromes in patients with scintigraphic evidence of nigrostriatal dopaminergic dysfunction. However further studies with more patients and an accurate follow‐up period is needed to clarify these findings.
PW016 Attentional, neurological and autistic components of Asperger disorder. A 11C-butanol PET/CT study M. M. Pagani1, I. Manouilenko2, S. Stone-Elander3, R. Odh1, D. Salmaso4, A. Danielsson1, R. Hatherly1, M. Fränden1, H. Jacobsson1, S. A. Larsson1, S. Bejerot2; 1Department of Nuclear Medicine, Karolinska Hospital, Stockholm, SWEDEN, 2Department of Psychiatry, St:Göran's Hospital, Stockholm, SWEDEN, 3Dept Clin Neurosciences, Karolinska Institutet, Stockholm, SWEDEN, 4ISTC-CNR, Rome & Padua, ITALY. Background: The term Autistic spectrum disorders (ASD), including Asperger disorder, is used to describe a group of developmental disorders that share a triad of impairment in social interaction, communication and imagination and whose behaviour is typically described as restricted and repetitive. Functional studies have shown localized focal changes and abnormalities in the anatomo‐functional connectivity of the limbic‐striatal “social” brain. Moreover, ASD can present neurological symptoms and can show comorbidity with attention‐ deficit/hyperactivity disorder (ADHD). The aim of this study was to investigate at rest in both subjects with ASD and healthy controls (HC) the impact on regional cerebral blood flow (rCBF) of the scores of three symptoms related scales. Methods: Thirteen normal intelligence patients with ASD and ten HC underwent PET/CT using [1‐11C]‐butanol, a perfusion tracer produced from [11C]carbon dioxide. The whole examination time was less than 10 minutes. All subjects were administered the Adult ADHD Self‐Report Scale (ASRS) Symptom Checklist, the Neurological Evaluation Scale (NES) and the Ritvo Autism and Asperger's Diagnostic Scale (RAADS). CBF was compared by SPM (statistical thresholds p=0.05 at voxel height, pcorrected<0.001 at cluster level and puncorrected < 0.001 at voxel level) between ASD and HC and the scores of the three scales were introduced two at the time as covariates into the experimental design in order to obtain group differences specific for ADHD, neurological and Asperger symptoms, purified by the effects of the other two components. Results: In both cases in which RAADS was introduced as covariant, along with either NES or ASRS, the significant CBF group differences specific for ADHD and neurological symptoms, respectively, were mostly found in right parahippocampal (BAs 28, 30,35), limbic (BAs13, 23) and temporal (BAs 21, 37, 38, 39) cortices, putamen, caudatus and thalamus. When ASRS and NEO were used as covariants, the group differences specific for ASD were found in all the above regions with the addition of the right visual cortex (BAs 17, 18, 19) and the left putamen, caudatus and thalamus. Conclusions: Using state‐of‐the‐art neuroimaging methodologies, reduced considerably the examination time resulting in minimal stress to patient. ASD was found to have an increased CBF as compared to healthy controls and a high grade of comorbidity with ADHD and neurological symptoms, all such conditions affecting the right limbic and temporal regions. The central structure bilaterally and the right visual cortex showed a CBF increase more specific for ASD.
PW017 Automated injection system for ictal SPECT in epilepsia X. Setoain1, J. Pavía1, R. Garcia2, E. Seres1, A. Donaire1, C. Piera1, S. Rubi1, N. Bargallo1, J. Rumia1, F. Pons1; 1Hospital Clinic, Barcelona, SPAIN, 2 Universidad de Barcelona, Barcelona, SPAIN. Aim: To evaluate the clinical usefulness of an automated injector system (AIS) for administration of ictal SPECT doses to reduce injection time/time lag and to improve SPECT localisation of the seizure focus. Material and Method: We developed an AIS that takes into account the radioactive
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 decay rate of technetium, calculating the volume to be injected (25 mCi of 99mTc‐HMPAO) over 6 hours and performing an automated injection to the patient. The study consisted of 41 patients with drug‐resistant complex partial seizures who were undergoing presurgical evaluation. Tracer injection for ictal SPECT was performed using the AIS in 20 patients (mean age 36 years, 10 males and 10 females) and with manual standard injection (Manual) in the remaining 21 patients (mean age 34 years, 9 males and 12 females). Injection time using AIS was measured in seconds (s) from seizure onset to the start and to the end of volume injection. Ictal and interictal SPECT were acquired using an ECAM gammacamera (SIEMENS) and followed by subtraction ictal SPECT coregistered to MRI (SISCOM) methodology for SF localisation. The definition of seizure focus was made by review of video‐electroencefalogram monitoring (V‐EEG), clinical data and MRI. Results: Injection time with Manual was 37 s, with a range of 17‐102 s. while with AIS it was 25 s with a range of 17 to 38 s. These differences were statistically significant (P<0.05). Moreover, using the AIS, time lag from seizure onset to start of injection was only 10 s, with a range of 4‐24 s. Ictal SPECT and SISCOM demonstrated hyperperfusion that localised seizure focus in 14 of the 20 patients (70%) by AIS and in 10 of the 21 patients (48%) by Manual, although these differences were not statistically significant (P=0.14). Injected dose with AIS was 25 mCi in all patients, while with Manual, due to the hurry to inject, the dosage is not so accurate. Furthermore, the AIS was more convenient than Manual method for nursing staff. Conclusion: The AIS improves the quality of work of the nursing staff in the neurology ward and allows a finer adjustment of the 99mTc‐ HMPAO dose injection. Early results are promising in reducing injection time and improving SPECT accuracy using an AIS.
PW018 FocusDET: A software tool to locate epileptogenic foci in intractable partial epilepsy B. Martí1, Ó. Esteban2, X. Planes3, P. Omedas3, G. Wollny2, A. Cot1, X. Setoain4, A. Frangi3, M. Ledesma-Carbayo2, J. Pavia1; 1Universitat de Barcelona. CIBER-BBN, Barcelona, SPAIN, 2Universidad Politécnica de Madrid. CIBER-BBN, Madrid, SPAIN, 3Universidad Pompeu Fabra. CIBERBBN, Barcelona, SPAIN, 4Hospital Clínic, Barcelona, SPAIN. Purpose: Accurate localization of epileptogenic foci in intractable partial epilepsy is essential for assessing the possibility of surgery as a treatment. A specific software package was developed to locate the epileptogenic focus using Ictal and Inter‐ictal SPECT images and MRI employing the SISCOM methodology. Materials & Methods: FocusDET was developed using GIMIAS facilities. GIMIAS (Graphical Interface for Medical Image Analysis and Simulation), which is used as the prototype tool in the VPHTk (Virtual Physiological Human Toolkit) CIBER‐BBN project, is an integrative tool for fast prototyping of medical applications. VPHTk allows us to develop tools for the creation and customization of models based on the European standards of VPH being defined in the context of the European project VPHNoE (Virtual Physiological Human Network of Excelence). The application is object‐oriented programming in C++ language. Results: The work‐ flow of the program consists of the following steps: 1) Exploration and visualization of medical image files in DICOM and Analyze formats including orientation control, 2) Generation of masks for SPECT studies to avoid extra cerebral activity and thus, improve the robustness of the register, 3) Registration of Ictal and Inter‐ictal SPECT studies using a Local Correlation Coefficient as a penalty function, 4) Subtraction and normalization of Ictal and Inter‐ictal SPECT files, 5) Co‐ registration of SPECT and MRI studies using Mattes Mutual Information from ITK (open‐source library acronym of Insight Segmentation and Registration Toolkit), 6) Fusion of foci information with MRI, 7) Storing the results in a PACS Server or their transfer to the Neuronavigator for subsequent use by the surgeon. Each step of the program must be validated by the user, thus providing a good quality control. Conclusions: A new tool to locate epileptogenic foci using SPECT and MRI studies was developed. The package is reliable and suitable for clinical routine.
PW019 99mTc-HMPAO brain scintigraphy as a confirmatory test in patients with clinical diagnosis of brain death A. Santapau, A. Andrés, L. Tardin, J. Araiz, J. Larraga, P. Razola, E. Prats, J. Banzo; Hospital Clinico Universitario Lozano Blesa, Zaragoza, SPAIN. For the purpose of explanting donor organs current Spanish law, decree‐law 2070/99, considers the brain scintigraphy using perfusion tracers as a confirmatory test for the diagnosis of brain death. Material and Methods: From January 2000 to December 2008 we performed 262 brain scans using 99mTc‐HMPAO, associated or not with transcranial Doppler ultrasound, in 244 patients, 91 females and 153 males, who were in brain‐death by clinical examination criteria. Brain death was the result of vascular cerebral disorder in 139 (hemorrhagic in 114, ischemic in 25), head trauma in 79, brain tumor surgery in 6, anoxic encephalopathy in 5, other causes in 13 and unknown cause in 2 patients. In all cases single doses of 10.6‐13.2 MBq/kg 99mTc‐HMPAO was administrated intravenously, using central venous catheter. Immediately after tracer injection dynamic study(60 images of 1 s. duration)and static images, anterior and lateral views(90‐120 seconds acquisition)were obtained. 99mTc‐HMPAO lipophilic fraction was >90% in all cases. We have established a scintigraphic diagnosis of brain death when non brain perfusion was detected in the dynamic study, and a complete absence of supra‐ and infratentorial tracer uptake was observed in the static images. Results: Brain scintigraphy confirmed the diagnosis of brain death in 225 patients. In the remaining 26 patients brain perfusion was observed: supra‐ and infratentorial in 13,supratentorial in 6 and infratentorial in 7. In 18 of these patients,a definitive diagnosis was performed by control scintigraphy or transcranial Doppler ultrasound,16‐ 48 hours after the first study;16 patients had a diagnosis of brain death;in 2 patients brain perfusion remained: one patient died soon after and the other one remained in an anoxic encephalopathy. In the others 8 patients with no control brain scintigraphy: 6 died soon after, one patient was transferred to his original hospital in a chronic vegetative status; and one patient was discharged from hospital two months after the study. When brain death diagnosis was established, in 60 patients intensive care was discontinued, and in 158 patients family consent for donation was obtained.Conclusions: 99mTc‐HMPAO brain scintigraphy is a reliable method, superior to the clinical evaluation, in the diagnosis of brain death. It is specially useful in order to take a decision in hospitals with organ transplantation programme, since brain scintigraphy completes the previous clinical evaluation, confirms the global loss of encephalic function (cerebral, cerebellum and brainstem), supports the irreversibility of the process, and reduces the waiting time for a firm diagnosis of brain death.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
99mTc-ECD SPECT in patients with equivocal brain death diagnosis E. Puta1, S. Lucchini1, B. Paghera2, F. Bertagna2, G. Bosio2, M. B. Panarotto2, G. C. Magri2, L. Rebuffoni3, O. Barozzi3, R. Giubbini4; 1Chair of Nuclear Medicine, Brescia, ITALY, 2Nuclear Medicine Unit, Brescia, ITALY, 3 local coordination for transplant procurement management, Brescia, ITALY, 4 Chair of Nuclear Medicine and Nuclear Medicine Unit, Brescia, ITALY. Background. Death diagnosis must be done with maximum certainty. Mechanical ventilators in combination with new cardiac stimulation measures can maintain cardiovascular function even in presence of brain death. The correct diagnosis of brain death is foundamental and ethically controversy. The Harvard Criteria were introduced in clinical practice in August 1968 for the diagnosis of brain death. In the presence of confounding factors these criteria are not satisfied and confirmatory imaging tests documenting the absence of cerebral blood flow are required. Materials and methods: Aim this study was the assessment of clinical value of 99mTc‐ECD SPECT in the diagnosis of brain death in a cohort of patients with confounding factors as TPS withdrawal < 24h, no brainstem reflexes, anesthesia <24h, hypothermia, barbiturate use, EEG artefacts, toxic state and pediatric criteria. Fiftytwo patients, from 1/1/2000 to 23/9/2008, were studied with 99mTc‐ECD SPECT by dual‐headed camera with HR collimator. Hospital admission's causes were trauma (27 pts), SAE (16 pts), anoxia (6 pts), neoplasia (1pt) and ischemia (2pts). Images were interpreted by two experienced observers. Results: All patients underwent 99mTc‐ECD SPECT. Every patient reached the empty skull condition after 1 or multiple studies. Spots of residual brain viability were observed in 13 pts, who were younger (30,92 ± 17,28 yrs) versus pts with no viability (41,91 ± 18,77 yrs) p<0,031. The criteria of elegibility to transplantation were satisfied in 12/13 pts in the residual viability group and in 31/39 of the no viability group, p<0,0001. The opposition to donation was observed in 6/12 pts with spots of viable brain tissue and in 3/31 with no signs of residual viability p<0,001. Conclusion: in pts with confounding factors, brain death diagnosis is equivocal and 99m‐Tc‐ECD SPECT is a helpful and safe diagnostic approach. It allows a 3‐D evaluation of cortical and brainstem viability and guarantees an unequivocal diagnosis of brain death for subjects candidate to organ donation. The presence of viable spots of brain tissue was found in 25% of our patients at their first examination and it is more frequent in young patients. 99m‐Tc‐ECD SPECT affects the opposition to donation. .
PW03 ‐ Sunday, October 11, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 3: cardiovascular - miscellaneous
PW021 The clinical consequences of a new software package for the quantification of gated-SPECT myocardial perfusion studies L. J. Van der Veen, M. P. M. Stokkel; LUMC, Leiden, NETHERLANDS. Purpose: Gated SPECT data is routinely analyzed with semi‐quantitative software packages, such as QGS and 4D‐MSPECT, to provide functional parameters. Although earlier studies indicated that these two systems are highly correlated (15,17‐21), discrepancies between the two software packages are also present. Thus, the primary purpose of this study was to compare the functional parameters obtained by 4D‐MSPECT and QGS. Additionally, the influence of external factors on the obtained values was studied. Methods: Prospective analysis of 176 patients undergoing diagnostic post‐stress and rest myocardial gSPECT with either Tc99m‐MIBI or Tc99m‐tetrofosmin was preformed. This data was visually analysed and numerical values for EDV, ESV and LVEF were calculated by both 4D‐MSPECT and QGS. The patients were subdivided into groups based on external factors, such as gender, physical state before acquisition, stressor type and heart size. The relationship between the two systems was analyzed using correlation, Bland‐Altman and linear regression analysis. Results: Data analysis of the entire population revealed high correlations between the software packages, ranging from 0.893 to 0.980, in post‐stress and rest acquisitions for all parameters. Nonetheless, significant (p<0.001) mean differences between the systems were present in both post‐stress and rest acquisitions. Regression and Bland‐Altman analysis showed overestimations of EDV, ESV and LVEF calculated by 4D‐MSPECT, compared to QGS. Analysis of the external factors demonstrated that gender, physical state and stressor type did not affect the relation between the software packages. The influence of heart size, on the other hand, was found to be substantial. Patients with small hearts showed reduced differences between the systems, which was especially pronounced for LVEF, whereas these differences increased considerable with increasing heart size. Conclusion: The results provided in this study show a general trend of overestimations by 4D‐MSPECT for EDV, ESV and LVEF, that is influenced by heart size. These discrepancies between the software packages are clinically relevant, and should not be underestimated when software transitions are made or when multiple software systems operate within one institution.
PW022 Combined Adenosine and Low-level Exercise Stress Protocol, AdenoEx, for Myocardial Perfusion Imaging A. Jiménez-Heffernan, C. Sánchez, E. Sánchez de Mora, J. Delgado, C. Salgado, R. López, J. López, B. Prado, J. Roa, B. Martinez, J. Diaz, A. Tobaruela, J. Paz; Hospital Juan Ramón Jiménez, Huelva, SPAIN. AIM: To assess the benefits of a combined adenosine and low‐level exercise protocol (AdenoEx) in patients unable to perform a full Bruce protocol, in terms of image quality, side effects and hemodynamic response. MATERIAL & METHODS: 235 consecutive patients scheduled for myocardial perfusion imaging (MPI) were studied. One hundred patients, 59 women and 41 men, mean age 66.2 (SD 8.7), underwent pharmacologic stress with adenosine (AO). The subsequent 135 patients were prospectively directed to AdenoEx protocol. Eight of the latter had COPD/asthma and were stressed with dobutamine, 26 patients were unable to walk comfortably on the treadmill and underwent adenosine stress and 12 patients were found fit to perform standard Bruce protocol exercise MPI. The AdenoEx group comprises 88 patients, 47 women and 41 men, mean age 65.5 (SD 9.4). In the protocol exercise begins on the treadmill one minute before and ends one minute after a 4‐minute adenosine infusion. This is a 6‐minute exercise 4‐
minute adenosine protocol with 99mTc‐tetrofosmin injected halfway through the adenosine infusion. Treadmill exercise is stage 0 of a modified Bruce protocol at 0 grade and either 2.7 km/h ( 72 patients) or 3.5 km/h (16 patients). Heart‐to‐liver count ratios were determined from an anterior planar image acquired before SPECT on the poststress and rest studies in 18 patients, the rest image acting as control. Side effects, peak heart rate (HR) and peak systolic blood pressure (SBP) were recorded. RESULTS: Reversible of fixed perfusion defects were found in 55% of AdenoEx and 50% of AO patients. Heart‐to‐liver count ratios were significantly higher (p<0.001) on the poststress versus the rest study (1.96 and 1.49 respectively). Side effects (flushing, dizziness and throat discomfort) were reported in only 10.2% of AdenoEx compared to 69% of AO patients (p<0.001). Peak HR was significantly higher (p<0.001) in the AdenoEx versus the AO patients (107.1 and 89.7 bpm respectively). Peak SBP was not different (147.8 and 146.2 mmHg respectively) between both groups. CONCLUSIONS: The AdenoEx protocol is safe and easy to perform in patients who cannot exercise to an adequate workload. It greatly improves the image quality of adenosine studies and shows a marked reduction in the frequency and severity of side effects.
PW023 99m
Tc-MIBI SPECT myocardial perfusion in the patients with coronary syndrome X and 5-HT metabolism disturbance
L. E. Samoylenko, S. Goreltzeva, G. Soboleva, N. Drobkova, Y. Karpov; Russian Cardiology Research Center, Moscow, RUSSIAN FEDERATION. Aim. Assessments of the potential role of the 5‐HT metabolism disturbance as a possible pathogenic mechanism of the myocardial ischemia in the patients with coronary syndrome X. Methods. 42 pts (35 males, mean age 52.5±1.7 yrs) with typical chest pain, positive exercise tests, and intact coronary vessels were included. Concentrations of epinephrine (E), norepinephrine (NE), dopamine (D), dihydroxyphenylacetate (DHPA), serotonin (5‐HT), 5‐ hydroxyindolacetate (5‐HIA) in serum and platelets were obtained. All the patients were underwent 2‐days rest/stress 99mTc‐MIBI SPECT. Presence, localization, extent and severity of the perfusion defects were assessed. Results. Imaging study was positive in 31 pts (74%), and negative in 11 pts (26%). Extent and severity of the perfusion impairment were 26.2±2.4% and 216±28SD in patients with positive scan, and 10.2±4.7% and 50.7 ±16 SD in patients with negative scan. Patients with positive scans showed significantly increased concentrations of NE (p<.001), D (p<.05), dopamine and serotonin serum and platelets turnover (p<.01), and decreased concentration of dopamine metabolite (p<.001). According to 5‐HT concentration there was some heterogeneity in the patients with positive scan, the most severe and extensive perfusion defects being in patients with the lowest 5‐HT concentration compared with normal concentration (273.4±47.9SD vs 160.6±26SD; <0.05; 31.6 ±4,6% vs 26,7±3,9%; NS). Conclusion. Patients with coronary syndrome X demonstrate some heterogeneity in 5‐HT concentration and turnover. Disturbance in the 5‐HT metabolism might play a role in the myocardial ischemia in a part of the patients with coronary syndrome X.
PW024 Fractional functional reserve findings compared to myocardial perfusion imaging results A. Peter1, S. Lucic1, K. Nikoletic1, R. Jung2, J. Kmezic- Grujin2, J. Stojiljkovic2, S. Tadic2, M. Stefanovic2; 1Institute of Oncology Vojvodina, Sremska Kamenica, SERBIA, 2Institute for cardiovascular diseases of Vojvodina, Sremska Kamenica, SERBIA. Introduction: Evaluation of the functional significance of intermediate coronary narrowings (40% to 70% diameter stenosis) is important for clinical decision making and risk stratification. A Fractional Flow Reserve (FFR) can determine the significance of individual stenoses and value below the 0.75 threshold is a means of assessing the significance of a coronary stenosis during coronarography. Aim of the study: To evaluate the findings of fractional flow reserve and myocardial perfusion imaging results. Material and methods: In 10 patients FFR was performed using a pressure wire with hyperemia from intracoronary adenosine and the hemodynamic significance of individual stenoses was determined. They also underwent a two‐ day protocol, dipyridamole stress/ rest Tc‐ 99m‐ MIBI myocardial perfusion imaging (MPI). Myocardial perfusion images were analyzed quantitatively and segments assigned to a specific coronary artery. The relation between FFR and perfusion was determined for each vascular zone. Results: Average age in the examined group was 57.25 +/‐ 6.21 years. Coronary artery disease risk factors were: arterial hypertension, hyperlipoproteinemia and impaired glucose metabolism. A total number of 12 coronary stenoses were verified during coronarography, 3 on RIA (25%), 2 on RCX (16.66%), 2 on OM2 (16.66%), 3 on RIM (25%) and 2 on ACD (16.66%). Mean FFR was 0.82 +/‐ 0.05, with the lowest value of 0.44 and the highest 0.96. According to FFR values 8 narrowing (66.66%) were determined as not significant, 2 stenoses (16.66%) were evaluated as significant and 2 (16.66%) narrowing were defined as gray zone or undetermined. The stenoses that were not significant on FFR were also normal on MPI. Out of 2 narrowing that were significant on FFR, both were confirmed as ischemia on MPI. The 2 stenoses that were undetermined on FFR showed normal perfusion on MPI. Conclusion: The hemodynamic significance of coronary stenoses evaluated with FFR showed a good correlation with MPI findings. MPI was useful in the evaluation of functional significance of stenoses that were undetermined (gray zone values) according to FFR. Key words: Fractional Flow Reserve, myocardial perfusion imaging, undetermined stenoses.
PW025 Long-term prognostic value of Tc-99m tetrofosmin early poststress lung uptake during myocardial perfusion imaging. V. Valotassiou1, N. Demakopoulos2, C. Tzavara1, S. Giannakou1, I. Tsougos3, G. Keramida1, A. Orfanakis1, P. Georgoulias1; 1Department of Nuclear Medicine, University Hospital of Larissa, Larissa, GREECE, 2 Department of Nuclear Medicine, NIMTS Hospital, Athens, GREECE, 3 Department of Medical Physics, University Hospital of Larissa, Larissa, GREECE.
Poster Presentation
PW020
S286 Aim. The aim of this study was to evaluate the long‐term prognostic value of early post‐stress lung/heart ratio (LHR) of Tc‐99m tetrofosmin radioactivity compared to gated‐SPECT findings and angiographic results. Materials and Methods. We studied 276 patients (aged 62.2±8.9 years, 168 men) with stress/rest Tc‐99m tetrofosmin myocardial SPECT and coronary angiography. Rest scans were obtained as gated‐SPECT and the left ventricular ejection fraction (LVEF) and end‐ diastolic volume were calculated. To evaluate myocardial ischaemia, we calculated the summed stress score (SSS), summed rest score (SRS) and summed difference score (SDS) indices. For the LHR calculation, we acquired an anterior image, 4‐6 minutes after radiotracer injection at stress. LHR was defined as mean counts/pixel in the lung region of interest (ROI) divided by the mean counts/pixel in the myocardial ROI. Cardiovascular death and non‐fatal myocardial infarction were considered as hard cardiac events, while late revascularization (>3 months after myocardial SPECT) procedures as soft events. The mean follow‐up period was 2.7 years (SD=0.8) with median equal to 2.7 years (interquartile range 2.2 to 3.3 years). Cox proportional‐hazard model in a stepwise method was used in order to determine the independent predictors for hard and soft cardiac events. Results. During the follow‐up hard cardiac events occurred in 28 (10.1%) patients and soft cardiac events in 32 (11.6%) patients. Family history, use of β‐blockers or calcium channel antagonists, number of diseased vessels, exercise duration, Duke score, chronotropic response, HRR, TID index, LVEF, EDV, SSS, SDS, SRS and LHR were significantly associated with both soft and hard cardiac events in univariate analysis. Age, smoking, use of nitrates and male sex were significantly associated only with soft cardiac events in univariate analysis. When multiple Cox regression analysis was implied LHR was found to be an independent predictor for both soft and hard cardiac events. The hazard ratio (for 0.1 unit increase) was 4.93 (95%CI: 1.39‐ 17.51, P=0.014) for soft events and 17.58 (95%CI: 4.08‐75.72, P<0.001) for hard events. The other factors that remained significant in the multiple model for soft events was age (HR=0.94; 95%CI: 0.90‐0.98), smoking (HR=2.69; 95%CI: 1.15‐6.30), use of nitrates (HR=3.67; 95%CI: 1.52‐8.83) and SSS (HR=1.07; 95%CI: 1.02‐1.13). For hard cardiac events the other independent prognostic factors except LHR, were exercise duration and SSS with hazard ratios equal to 0.76 and 1.08, respectively. Conclusion. Early post‐stress Tc‐99m tetrofosmin LHR has an independent and powerful value to predict hard and soft cardiac events.
PW026 18F FDG GPET, 99mTc Sestamibi GSPECT and IVUS comparison for evaluation of Coronary Artery Disease in hearth transplant recipients M. L. De Rimini1, G. Borrelli1, M. Catalano1, S. Piccolo1, P. Calabrò2, C. Maiello3, M. Cotrufo4, A. Rotondo5, P. Muto1; 1Nuclear Medicine AORN Monaldi, Naples, ITALY, 2Cardiology Dept 2 University, Naples, ITALY, 3 Cardiac Surgery Dept AORN Monaldi, Naples, ITALY, 4Cardiac Surgery Dept 2 University, Naples, ITALY, 5Radiology Dept 2 University, Naples, ITALY. Introduction: Despite cardiac allograft vasculopathy (CAV) still remains the major limiting factor of long‐term positive outcome in heart transplant (HTx) recipients, conventional coronary angiography (CCA) screenings often fail to detect Tx coronary artery disease (CAD) appearance or progression before first clinical events. Purpose: to assess diagnostic efficacy of 18FDG G‐PET and 99mTcSestamibi Dypiridamole/Rest (D/R) perfusion GSPECT versus CCA and intravascular ultrasound (IVUS) to predict CAV development. Method: 27 HTx patients (pts) (age 45±19 yrs), who had IVUS on Left Anterior Descending (LAD) Artery following CCA, underwent Myocardial (M) 18FDG GPET/CT and 99mTcSestamibi D/R M‐GSPECT scans. CAD was quantified by assigning Stanford classes and calculating intimal thickening indices (from 0 as normal to 4 as severe) for IVUS images, these findings were compared with qualitative CCA ones. Metabolic and perfusion studies were obtained within 2 weeks each‐other. Reconstructed images were visually and quantitatively analyzed and compared to IVUS and CCA results. PET/CT fusion imaging was also obtained to detect possible misalignment in cases of pt motion, so excluding attenuation correction to avoiding the resulting artifacts affecting image interpretation. Results: Pts were subdivided in 4 groups (Gr) on the basis of IVUS findings: Gr1 n. 15 pts (grade 0‐1) with normal CCA; Gr2 n. 6 pts (grade 2) with normal CCA; Gr3 n.4 pts (grade 3), with normal CCA in 3 of them; Gr 4 n.2 pts (grade 4) with documented CAD at CCA. At GPET, D/R GSPECT and LV function analysis comparison: No defects in Gr1 pts; FDG defect / Fixed or Partially Perfusion defect and LV regional dysfunction were defined in Gr4 pts, in accordance with IVUS and CCA. Gr2 pts: No perfusion or metabolic defects in 3 pts; reversible perfusion defects in the last 3 ones, highlighting CAV involvement in the extra LAD segments in 2 of them. Gr3 pts: Reversible perfusion defects in all pts. In addition FDG defects were observed in dysfunctional segments in 2 pts, one of which underwent heart failure in 1 year follow‐up. Conclusions: IVUS is more sensitive than CCA for Tx CAV diagnosis, but it is invasive anyway and may add cost. At IVUS comparison, the combination of GPET and D/R GSPECT is effective: ‐to detect onset, progression and multivascular involvement of CAD, ‐to improve pts management and reduce the frequency of invasive techniques.
PW027 The value of blood pool SPECT in assessment of right ventricle dysfunction in children with ventricular tachyarrhythmia Y. B. Lishmanov, K. W. Zavadovskiy, I. A. Kovalev, A. A. Chernishov, V. V. Saushkin; Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. Aim: to estimate the diagnostic possibilities of quantitative blood pool single photon emission computer tomography (QBS) in diagnostic of arrhythmogenic myocardium dysfunction in children with ventricular tachyarrhythmia (VT). Materials and methods: 41 children with VT were included in the investigation (average age 12±4 years). All patients underwent a standard clinical and instrumental investigation which included QBS with marked in vivo 99mTc‐stanneus pyrophosphate erythrocyte. The investigation was carried out on gamma camera Philips‐Forte in tomographic ECG‐synchronized mode. Results: the areas of ectopic activity (according to ECG and electrophysiological study) coincided with positioning of focuses of early contraction (according to QBS) in 86% cases. There was revealed a direct correlation of the width of QRS VT complex with right ventricle (RV) ejection fraction and stroke volume ratio of left (LV) and right ventricles. For the further analysis of diagnostic opportunities of QBS the patients were divided into 2 groups according to the quantity of focuses of premature contraction according to QBS. The first
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 group included 6 children with 1‐2 areas of premature contraction, the second group ‐ 11 patients with more than two similar areas. RV peak ejection rate, peak filling rate, mean filling rate for first third of cardiac cycle, RV ejection fraction was significantly more in the first group of patients. Standard deviation of mean contraction time of LV and RV in the second group was significantly more. These alterations of right heart contractility are probably connected with the fact that the majority of focuses of ectopic activity were registered exactly in RV walls and ventricular septum. Conclusion: The scintigraphic criterion of ectopic activity area is a focus of early contraction according to QBS. This method is less paninful for children in comparison with elecrtophisiological study. Because of its noninvasiveness and simplicity of implementation QBS may be used for observation of children with VT for the purpose of arrhythmogenic myocardium dysfunction diagnostics.
PW028 Left and Right Ventricular Function at Rest and Exercise in Patients on Maintenance Hemodialysis as Assessed with Radionuclide Ventriculography - Comparison with Normal Volunteers N. Topuzovic, V. Rupcic, A. Rusic, I. Mihaljevic; Clinical Hospital Osijek, Osijek, CROATIA. Aim: To investigate left and right ventricular function at rest and during exercise in chronic hemodialysis patients. Patients and Methods: Forty patients having regular hemodialysis (mean age 38 ± 11 years, mean duration of dialysis 5.3 ± 3 years) were examined by means of maximum exercise testing and radionuclide equilibrium ventriculography after in vivo Tc‐99m labeling of red blood cells. Obtained parameters were compared to 37 age‐matched healthy volunteers. Results: Increase in heart rate during exercise was lower in patients (from 73 ± 11 to 113 ± 15 vs. 72 ± 8 to 135 ± 14 beats/min, p<0.01). At peak stress patients achieved a lower workload (76.4 ± 18.0 vs. 114.2 ± 15.2 W, p<0.01)) and lower exercise duration (8.7 ± 2.1 vs. 14.7 ± 1.2 min, p<0.01), and their mean blood pressure were significantly higher than in controls (121 ± 13 vs. 89 ± 7 mm Hg, and 143 ± 11 vs. 122 ± 9 mm Hg, respectively, p<0.01). Left ventricle end‐diastolic (EDV), end‐systolic volumes (ESV) and cardiac output (CO) at rest were significantly higher in patients (111 ± 33 vs. 71 ± 11 ml/m2; 45 ± 19 vs. 35 ± 9 ml/m2; 4.7 ± 1.7 vs. 2.6 ± 0.6 l/min/m2, respectively, p<0.001), as well during exercise (102 ± 27 vs. 69 ± 15 ml/m2; 34 ± 16 vs. 27 ± 10 ml/m2; 7.5 ± 2.2 vs. 5.4 ± 1.4 l/min/m2, respectively, p<0.001). Left ventricular ejection fraction (EF) at rest was significantly higher in patients, 59 ± 10 vs. 53 ± 8%, p<0.05. At stress LVEF did not differ significantly, but % rise in EF during exercise was significantly lower in patients. Right ventricle EDV, ESV and CO were elevated in patients at rest (124 ± 43 vs. 69 ± 19 ml/m2; 38 ± 24 vs. 32 ± 15 ml/m2; 5.1 ± 2.5 vs. 2.1 ± 1.0 l/min/m2, respectively, p<0.002), as well as in stress (112 ± 36 vs. 61 ± 23 ml/m2; 33 ± 21 vs. 25 ± 13 ml/m2; 8.1 ± 2.8 vs. 6.4 ± 1.9 l/min/m2, respectively, p<0.002). RVEF at rest was significantly higher in patients, 56 ± 10% vs. 49 ± 10%, p<0.05, but at stress did not differ significantly. Conclusion: Patients on chronic hemodialysis have significant enlargement of left and right ventricular volumes and elevated cardiac output associated with impaired maximal exercise performance, despite of preserved systolic left and right ventricular function during exercise.
PW029 Validation of blood- pool SPECT heart atria measurements M. Žigman1, M. Punda2, D. Planinc3, S. A. Rogan2, Z. Kusic2; 1Dpt. of Oncology and Nucler Medicine, UH, Zagreb, CROATIA, 2Dpt. of Oncology and Nucler Medicine, UH "Sestre milosrdnice", Zagreb, CROATIA, 3Dpt. of Internal Medicine, UH "Sestre milosrdnice", Zagreb, CROATIA. Among cardiac nuclear studies majority of investigations are focused in evaluation of left and right ventricular volume and function. The aim of the study was to determine the possible contribution of scintigraphic imaging in assessment of size and shape of atrial chambers. Materials and Methods: Study included 270 patients (pts): 70 subjects (group A) were controls without documented cardiac disease and 200 pts (group B, C and D) had cardiac disease diagnosed through clinical examination and echocardiography. 65 pts (group B) had hypertension and arrhythmias but normal echocardiography findings (LVEF above 65%), in 55 pts (group C) cardiomyopathy and mild to moderate left and/or right atrial enlargement was documented, in 80 patients (group D) severe echo atrial enlargement with LVEF below 30% was detected. Tc99m‐ labeled red blood cell (RBC) scintigraphy was performed by labeling of erythrocytes with 20 mCi Tc‐99m pertechnetate by in‐vivo method. SPECT cardiac analysis was performed in transversal, coronal and sagittal slices by determination of number of pixels in a region of interest (ROI) . In atrial analysis slices with the largest area (the max number of pixels) were included in measurement, particularly coronal slices for left atrium and sagittal slices for right atrial evaluation. Scintigraphic values (atrial ROI in pcs and cm2) in groups of pts M‐pts with dominant mitral regurgitation, T‐ pts with dominant tricuspidal regurgitation Group No. Left atrium (pcs) Right atrium
LVEF
A
40±5 (9.2 cm2)
42±7 (9.6 cm2) 65%
B*
47±4 (10.8 cm2) 50±3 (11.5 cm2) 67%
C** M T
78±11 (16.5 cm2) 57±8 (13 cm2) 45% 55±7 (12.5 cm2) 89±12 (20 cm2) 54%
D** M T
102±14 (24 cm2) 60±5 (13.4 cm2) 21% 96±10 (22 cm2) 98±11 (23 cm2) 29%
* p< 0,05; ** p< 0,01 Results: Mild enlargement of both atria was scintigraphicaly detected among group B of patients which indicated possible early atrial involvement in cardiac disease. Analysis of atrial blood pool changes in groups C and D of patients enables estimation of dominant (left of right sided) or possible combined heart impairment. Conclusion: Compared to echocardiography, scintigraphic blood pool imaging reflects regional changes in chamber volume and is largely independent of chamber geometry and patient constitution. Relative changes in left and right atrial volume can be assessed precise and reproducibly by radionuclide method and offers great promise as a method to assess atrial volumes in health and disease.
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Evaluation of Cell Type and Injection Strategy on Cell Retention in Infarcted Canine Myocardium K. J. Blackwood1, A. Mitchell1, J. Sykes1, L. Deans1, G. Wisenberg2, F. S. Prato1; 1Lawson Health Research Institute, London, ON, CANADA, 2London Health Sciences Centre, London, ON, CANADA. Introduction Given that cellular therapeutics have shown potential in augmenting various forms of cardiac disease, optimization of such therapies have been extensively investigated. Notably, parameters like cell type and route of delivery have been compared in animal models in an attempt to improve retention and engraftment of transplanted cells. We present preliminary results comparing the effects of injection strategy and cell type on retention of radiolabeled cells in a reperfused canine model of myocardial infarction. Methods Four groups of canine cells were studied: bone marrow mononuclear cells (BMMNC), muscle satellite cells (MSC), bone marrow stromal cells (BMSC), and endothelial progenitor cells (EPC). All cells were labeled with 111In‐ tropolone and autologously transplanted into infarcted canines (2‐3 hours LAD occlusion/ 2‐3 hours reperfusion) into the peri‐infarct border region. Cells were transplanted in various ways: a) intracoronary (IC) injection using a balloon catheter or, b) intramyocardial (IM) injection directed i) epicardially following left thoracotomy or, ii) endocardially using an endocardial catheter system guided by x‐ray angiography. BMMNCs were injected IC (n=3), MSCs (n=3) were injected IM epicardially, BMSCs (n=2) were injected IM endocardially, while EPCs were injected IM epicardially (n=2) and endocardially (n=4). Immediately after injection, wholebody images of animals were acquired with a gamma camera. Cell retention following cell injection was based on heart activity regions of interest compared to total activity in the body after background correction to give heart:wholebody ratios. Ratios are expressed as a percentage and values are mean±SD. Results Data grouped by injection strategy revealed that injection strategy significantly affected cell retention demonstrating that the IC route was the least effective (3.6±0.7%) compared to the endocardial (26.3±13.9; p<0.05) and epicardial (59.0±5.1;p<0.001) IM routes. Significant differences in cell retention were also found between the epicardial and endocardial injections with p<0.001, however larger variability in the latter group may account for these differences. No significance was found between EPC vs. MSC (55.9±3.0% vs. 61.1±5.7%) epicardially injected and EPC vs. BMSCs (32.3±13.3% vs. 14.3±13.7%) endocardially injected. Conclusion Intramyocardial injections through the epicardium lead to better cell retention compared to cells injected via the endocardium or intracoronary route. Data also suggests that cell type may not influence cell retention in a reperfused canine myocardial infarction model.
PW04 ‐ Sunday, October 11, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 4: molecular imaging - from bedside to bench
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The Correlation Between [ F]Flutemetamol ( F-GE-067) and 11 [ C]PIB Uptake in PET Imaging for Alzheimer's disease and MCI Patients C. J. Buckley1, L. Thurfjell2, K. Van Laere3, R. Vandenberghe3, I. Law4; GEHC, Amersham, UNITED KINGDOM, 2GEHC, Uppsala, SWEDEN, 3UZ Gasthuisberg Leuven, Leuven, BELGIUM, 4Rigshospitalet, Copenhagen, DENMARK.
1
Aim The aim of this PET study was to correlate within the same subjects [11C]PIB and [18F]Flutametamol brain uptake in patients with clinically probable Alzheimer’s Disease (AD) and amnestic mild cognitive impairment (MCI) in a phase II clinical trial. Methods Sequential studies were performed in 20 AD (MMSE 15‐26, CDR 0.5‐2) and 20 MCI (MMSE 27‐30, CDR 0‐0.5). 11 Following injection of approximately 325 MBq of [ C]PIB, PET scanning was performed 40‐70 min post injection (p.i.). Usually the same day (interval 1±5 days), approximately 175 MBq of 18 F]Flutametamol was injected and subjects were scanned 85‐115 min p.i.[11C]PIB and [18F]Flutametamol images were co‐registered with the subject’s T1 MRI and all scans were spatially normalised to MNI space. A volume of interest template was applied and target region to cerebellar grey matter uptake ratios (SUVR) were derived. Results and Conclusions Comparison of [18F]Flutametamol and [11C]PIB SUVR values across brain regions showed that SUVR values for cortical regions were very similar, with a tendency for slightly lower SUVR for [18F]Flutametamol. Subcortical white matter (SWM) and the pons, showed higher SUVR in 18 [ F]Flutametamol. One subject showed a different pattern with approximately 40% higher SUVR in [18F]Flutametamol and was excluded from the correlation analysis. For cortical regions Pearson’s R2 was greater than 85% in anterior cingulum and temporal lateral cortex. R2 for a composite region, computed as a volume weighted average of frontal, parietal and temporal lateral corticies and anterior and posterior cinguli, was 84%. The slope in these cases was close to unity. The main difference observed was the tendancy for higher uptake of [18F]Flutametamol than [11C]PIB in white matter. Specific tracer binding of [18F]Flutametamol is very similar to [11C]PIB for cortical regions, while SUVR in pons and SWM is approximately 30% higher than in [11C]PIB.
PW032 Effects of a chronic exposure to nicotine: a study in baboon by using a multi-injection PET study with [18F]fluoro-A-85380 N. Miro-Bernie, M. Bottlaender, M. A. Peyroneau, W. Saba, S. Bourgeois, S. Goutal, F. Dollé, J. Delforge, H. Valette; CEA, DSV/I2BM/SHFJ, Orsay, FRANCE. Aim: The mechanism underlying nAChR up‐regulation after chronic nicotine exposure is complex and not fully clarified to date. In the development of our program to study tobacco addiction, we aimed at studying this up‐regulation in vivo in Papio anubis baboon by estimating distribution volume (VT), nAChR concentration, and affinity (KdVr) Methods: Alzet osmotic pumps where
implanted subcutaneously to one Papio anubis baboon to get continuous nicotine deliver. At various times (15 days, 2,3,4 and 6 months), the pumps were removed and the baboon underwent a multi‐injection PET experiment, after which new pumps were reimplanted to continue the treatment. The PET protocol included three injections: a tracer injection of [18F]fluoro‐A‐85380 (time 0), a partial saturation injection (90 min) obtained by a simultaneous injection of labelled and unlabelled fluoro‐A‐85380 (35 nmol), and a saturation injection (180 min) by a large amount of only unlabelled fluoro‐A‐85380 (1500 nmol). Plasma nicotine concentration during PET experiments allowed to simulate the effect of residual nicotine concentration in the brain, to correct the ligand kinetic and therefore to estimate the ligand parameters without significant bias. Results: During treatment the mean plasma nicotine concentration was 10 to 20 ng/ml. In thalamus, VT increased from 17.7 in control to 22.5 during treatment (from 15th day to 6th month) and returned to control value 16.0 after three weeks weaning. The estimation nAChR concentration remained unchanged: 4.66 ± 0.58 pmol/ml (for the same period) versus 4.87 pmol/ml in control, and 4.44 pmol/ml after weaning. In contrast, the estimated KdVr was reduced (0.24 ± 0.07 nM vs 0.61 nM) and returned to control value (0.63 nM) after weaning. The estimates of the other model parameters were not disturbed by the chronic nicotine administration. This observed variation in nicotinic receptor affinity is in agreement with the usual response to the administration of an agonist, which induces conformational changes from low to high affinity state of the nAChR. In contrary to published data, an up‐regulation of nAChR in thalamus is not observed. However, our results are in agreement with one in vitro study (Vallejo J Neurosci. 2005). Conclusion:. Previous studies in smokers had shown an increase of distribution volume and/or binding potential (Staley, J Neurosci. 2006; Mukhin;. J Nucl Med. 2008). Our results are in agreement with these findings, but show that this increase is only a consequence of an affinity change, all the other parameters, including the nicotinic receptor concentration, remaining unchanged.
PW033 In vivo imaging of the immediate effect of mesenchymal stem cells on dendritic cells migration and consequent function. S. Morbelli1, S. Chiesa2, M. Massollo1, S. Morando2, S. Bodrato1, E. Traggiai3, C. Marini4, A. Uccelli5, G. Sambuceti1; 1Nuclear Medicine Unit, San Martino Hospital, University of Genoa, Genoa, ITALY, 2Advanced Biotechnology Center, University of Genoa, Genoa, ITALY, 3Institute G Gaslini, Genoa, ITALY, 4Institute of Molecular Bioimaging and Physiology, CNR, Genoa, ITALY, 5Department of Neuroscience Ophthalmology and Genetic, San Martino Hospital, University of Genoa, Genoa, ITALY. Background:Dendritic cells (DCs) are antigen presenting cells who migrate to T cell area in lymphoid organs to initiate the immune responses. Mesenchymal stem cells (MSCs) possess a wide range of immunosuppressive function. Radioisotopic studies, owing to their high temporal resolution, can explore DCs behavior as soon as they are injected in a living recipient. Aim: to estimate the effects of MSCs on DCs migration to draining lymph node in mice and to correlate this rate with other DCs function parameters. Methods: Bone marrow‐derived‐DCs were coltured in the presence of granulocyte macrophage colony‐stimulating factor and batteria lipopolysaccharides and pulsed in vitro with OVA‐peptide. DCs were labeled with 500 μCi of 99mTc‐HMPAO following a procedure validated in our laboratory (labelling efficiency 30%;stability during 15 hour period >90%). Labelled‐DCs were subcutaneously injected in the right footpad of untreated Balb‐c mice (Control,n=6) or in mice who received intravenous injection of lymphocytes CD4+ one day before the imaging study (Activated‐Condition,n=7). Effect of MSCs on DCs biology was tested in two ways: MSCs‐DCs co‐coltivation before DCs labelling and injection (in vitro MSCs‐treated,n=6) or injection of activated‐DCs followed by the intravenous injection of MSCs at 20 minutes (in vivo MSCs‐treated, n=4). All mice underwent a one hour dynamic acquisition after s.c. injection of 2 milions 99mTC‐HMPAO‐labelled‐DCs in 150 μl of PBS. Regions of interest (ROIs) were positioned on injection site and draining lymphnode. A time activity curve was obtained expressing ROIs counting rate (counts/second) thus divided by the whole body counting rate to obtain fraction of the injected DCs. All DCs subgroups were assayed for their phenotype, co‐stimulatory capacity, cytokine secretion and expression of Toll‐ like Receptor (TLR) genes Results:Activated‐condition displayed a faster clearance from injection site and a marked increase in lymphnode DCs recruitment with respect to Controls (132± 1.9 versus 88± 1.9X103 DCs;p<0.05). The powerful inhibitory effect of MSCs on DCs migration was highlighted both in vitro (100±5X103 DCs;p<0.004 versus Activated‐condition) and in vivo MSCs‐ 3 treated DCs (96±6X10 DCs versus Activated‐condition;p<0.05). MSC‐treated DCs failed to up‐ regulate MHC class I/II and co‐stimulatory molecules, reduced secretion of IL‐12 cytokine, down‐ modulated molecules involved in TLR signaling and significantly decreased surface expression of CCR7, a key receptor for homing into lymphnodes. Conclusion: These data document that DCs biology is profoundly modified by the contact with MSCs as the reduction in their homing rate to the draining lymphnode begins immediately after MSC injection and persists in vivo even after in vitro pre‐conditioning.
PW034 Effects of Total Colectomy on the Biodistribution of pertechnetate in Rats
99m
Tc-
A. C. M. Rego1, R. A. O. Ramalho1, E. S. T. Egito1, I. Araújo-Filho1, C. J. Palestro2, A. C. Medeiros1; 1Federal University of Rio Grande do Norte, Natal, BRAZIL, 2North Shore-Long Island Jewish Health System, Manhasset & New Hyde Park, NY, UNITED STATES. Objectives: Many factors, including diseases, drugs, and radiation affect radiopharmaceutical biodistribution. Few data exist, however, about effects of major surgery on radiopharmaceutical biodistribution. The aim of this investigation was to evaluate the effects of total colectomy on the ‐ biodistribution of technetium‐99m pertechnetate (99mTcO4 ). Methods: Eighteen rats, divided into three groups of six, were included. Group 1 underwent total colectomy with end‐to‐end ileoanal anastomosis. Group 2 underwent a sham procedure consisting of midline laparotomy with gentle manipulation of the intact colon. Group 3 did not undergo surgery and served as controls. Animals were weighed weekly after surgery. On the 28th postoperative day animals were injected through the orbital plexus with 0.l mL (0.76 MBq) 99mTcO4‐ and sacrificed 30 minutes later. Blood was collected by cardiac puncture for determination of hemoglobin, total protein, aminotransferase, T3 and T4. Samples of liver, spleen, stomach, ileum, duodenum, pancreas,
Poster Presentation
PW030
S288 kidney, heart, lung, thyroid, bladder, muscle, femur and brain were harvested. Percent of injected radioactivity per gram of tissue (%ATI/g) in each sample was determined using a gamma‐ counter. Tissue samples from ileum, thyroid, stomach and bladder were processed and stained with hematoxylin‐eosin for morphometric analysis. Statistical analyses were performed using ANOVA and post‐hoc Bonferroni test, with p<0.05 considered significant. Results: The survival rate after surgery was 100%. Group 1 rats progressively lost weight over the 28 day postoperative period. Groups 2 and 3 rats gained weight. The %ATI/g in Group 1 in the stomach and ileum, was significantly higher than in Groups 2 and 3 (p=0.03). The %ATI/g in bladder and thyroid were significantly lower in Group 1 than in Groups 2 and 3 (p=0.01). T3 and T4 were significantly lower in Group 1, than in Groups 2 and 3. No significant differences were detected in hemoglobin, total protein and aminotransferase levels, among the groups. An increase in mucosa and muscularis size of ileum wall was observed in Group 1, but not in groups 2 & 3. All urinary bladders were inflamed in Group 1, but not in Groups 2 & 3. . Increased ileal activity may be due to increased muscle/mucosal thickness. Increased gastric activity likely is related to known gastric acid hypersecretion after colectomy. Decreased bladder & thyroid activity are not explained. Conclusion: In addition to physiological & morphological alterations, total colectomy altered the biodistribution of 99mTcO4‐ in rats, which potentially could have patient care implications.
PW035 The presence of BRAFT1799A mutation in the primary tumour is associated to patient’s age and tumour’s size, but not with the recurrence of papillary thyroid carcinoma M. Cañadas Garre, E. Cabrera Cazorla, P. Becerra Massaré, M. A. Muros de Fuentes, M. López de la Torre Casares, M. A. López Nevot, J. Villar del Moral, Á. Concha López, F. Garrido Torres-Puchol, A. Ferrón Orihuela, J. M. Llamas Elvira; Hospital Universitario Virgen de las Nieves, Granada, SPAIN. INTRODUCTION Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy (80% of all thyroid cancers). BRAFT1799A mutation is the most prevalent genetic alteration in thyroid cancers, occurring in about 30% to 80% of sporadic papillary thyroid carcinoma (PTC). Though BRAFT1799A mutation is a good diagnostic indicator, and it has been proposed as a prognostic factor by several reports, its prognosis value is still controversial. AIM Assess the association of BRAFT1799A mutation with high risk clinicopathologic features of the tumour and recurrence of PTC MATERIALS AND METHODS Paraffin‐embedded tissue samples of 97 patients with available follow‐up records (mean follow‐up: 63 months) were selected by an expert pathologist and extracted from the block using a 0.6 mm stylet with the Manual Tissue Arrayer I © (Beecher Instruments). Genomic DNA was isolated from this sample. The presence of the BRAFT1799A mutation was determined by polymerase chain reaction (PCR) amplification of exon 15 followed by digestion of the 224 bp product by the restriction endonuclease TspRI. DNA sequencing was performed in positive samples to confirm the presence of the BRAFT1799A mutation. Bivariant analysis was used to assess the association between BRAFT1799A mutation and clinicopathologic parameters/recurrence and multivariant analysis was used to identify the possible confounding factors. RESULTS The prevalence of the BRAFT1799A mutation was 46,4% (45/97). 22 patients showed recurrence of PTC (22/97; 22,7%); 9 out of these patients were positive for BRAFT1799A mutation (40,9%). Bivariant analysis showed an association of BRAFT1799A mutation to age (older than 60 years), AJCCII/III/IV stage and tumour size (larger than 1 cm), but not to recurrence of PTC and other parameters, such as gender, capsular invasion, vascular invasion, tumoral necrosis, mitotic activity, presence of lymph node or distant metastases, tumour stage, histotype, extrathyroid extension or multifocality. Multivariant analysis for the variables BRAFT1799A, age, stage and tumour size showed that age older than 60 years and tumour size higher than 1 cm were the only independent associations. CONCLUSIONS In these group of patients, the presence of BRAFT1799A mutation in the primary tumour is associated to patient’s age and tumour’s size, but not with the recurrence of papillary thyroid carcinoma. Consequently, it does not predict a poorer prognosis and should be used carefully as a risk factor for recurrence.
PW036 Evaluation of the Effectiveness of Low Level Laser Therapy on Inflammation of Temporomandibular Joint in Rabbit: A Tc99m-HIG Imaging Study N. A. Selcuk1, T. Toklu1, B. Bal2, G. Civi3; 1Yeditepe University Hospital, Department of Nuclear Medicine, istanbul, TURKEY, 2Yeditepe University,Hospital Dentistry, Istanbul, TURKEY, 3Euromed Imaging Center, istanbul, TURKEY. Inroduction Inflammatory joint disorders of temporomandibular joint (TMJ) are defined as a group of disorders in which internal and related structures of TMJ become inflamed. Tc‐99m‐ polyclonal human immunoglobulin G (HIG) scintigraphy can be used to detect active joint inflammation. The aim of this study is to investigate the anti‐inflammatory effects of low level laser therapy on aseptic inflammation of temporomandibular joint (TMJ) space using by Tc‐99 m HIG scintigraphy. Method: 12 male, New Zealand rabbits were included in the study. To evaluate recovery of inflammations, 6 randomly selected rabbits imaged before developing inflammation as normal group. Five percent formalin solution was locally injected to both right and left TMJ of all rabbits. Following the induction of inflammation with formalin, low level laser therapy was performed 6 times for two weeks to left TMJs as treatment group. Right TMJs selected as control group. Scintigraphic imaging was performed before and after each treatment with I.V administration of 3‐5 mCi Tc‐99m‐HIG. Regions of Interests (ROI) were drawn on images for both sides of TMJ and background. Results: Scintigraphic values were compared with treatment/background, normal/background and control/background counts. For before and first week after treatment, statistically significant differences were observed for both treatment and control groups compared with normal group (p<0.05). Meaningful difference was found for both groups after second week. There was also statistically significant difference between control and treatment groups (p<0.001). Conclusion: In this study, Low Level Laser Therapy on TMJ inflammations was evaluated as effective and accuracy of Tc‐99m‐HIG scintigraphy on inflammation detection was pointed out.
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Immuno-PET imaging of Ga-NOTA-Cetuximab Fab in EGFR over-expressing cancer xenograft model O. Awh1, D. Kim1, T. Lee2, G. Cheon2, C. Choi2, S. Lim2; 1Department of Biomedical Laboratory Science, College of Health Science, Yonsei Univ., Wonju, REPUBLIC OF KOREA, 2Molecular Imaging Research Center, KIRAMS, Seoul, REPUBLIC OF KOREA. Aim: The importance of immuno‐PET have enlarged in diagnosis and therapeutic monitoring of cancer. 68Ga (T1/2 ; 67.6 min) is a useful PET imaging tracer because it is easily obtained using 68 Germanium/68Ga generator. Cetuximab, chimeric monoclonal antibody that specifically binds to the epidermal growth factor receptor (EGFR) with a high affinity. In this study, 68Ga labeled radio‐ imaging agent targeted to EGFR over‐expressing cancer cells was prepared and evaluated in nude mice bearing cancer xenograft. Methods: Cetuximab Fab fragments were produced by enzyme digestion and their purity was assessed by SDS‐PAGE. EGFR expression in A549 and CT26 cells was confirmed by RT‐PCR, Western blot and immunocytochemistry. 1,4,7‐triazacyclononane‐ 1,4,7‐triacetic acid (NOTA) bifunctional chelator was adopted to label 68Ga to Cetuximab Fab fragments. The immunoreactivity was examined by the in vitro cellular binding test. PET images of 68Ga‐NOTA‐Cetuximab Fab fragments were acquired at 1 hr and 3 hr post injection in A549 tumor bearing mice model. Results : According the RT‐PCR, Western blotting and immuno‐ cytochemistry analysis, A549 cells have mRNA transcripts of EGFR and highly express EGFR. The radiolabeling yield of 68Ga‐NOTA‐Cetuximab Fab fragments was above 95%. The immunoreactivity of NOTA conjugated Cetuximab Fab fragments was approximately 55% of whole Cetuximab at eqi‐molar concentration. 68Ga‐NOTA‐Cetuximab Fab fragments was specifically localized in the A549 tumor xenograft in mice. Conclusion : PET imaging of 68Ga‐ Cetuximab Fab fragments could be used as a efficient and non‐invasive method for the evaluation of EGFR expression in aspect of tumor detection and therapeutic monitoring.
PW038 Spinal LTP is associated neurotransmission in the rat brain
with
reduced
opioid
T. Hjornevik1, B. W. Schoultz2, J. Marton3, J. Gjerstad4, A. Drzezga5, G. Henriksen5, F. Willoch6; 1Centre for Molecular Biology and Neuroscience & Institute of Basic Medical Sciences, University of Oslo, Oslo, NORWAY, 2 Department of Chemistry, University of Oslo, Oslo, NORWAY, 3ABX advanced biochemical compounds Biomedizinische Forschungsreagenzien GmbH, Radeberg, GERMANY, 4National Institute of Occupational Health, Oslo, NORWAY, 5Department of Nuclear Medicine, Klinikum rechts der Isar, Technische Universitat Munchen, Munich, GERMANY, 6Akershus University Hospital, Lørenskog, NORWAY. Objectives Neuronal events leading to development of long‐term potentiation (LTP) in the nociceptive pathways may be a cellular mechanism underlying hyperalgesia. Opioid receptors control the descending modulatory system to the spinal cord, and play an important role in antinociception. In the present study, we examine how induction of spinal LTP affects the supraspinal opioidergic system. Methods All animals were for the following experiments anesthetized with isoflurane gas. The left sciatic nerve was given a high‐frequency conditioning stimulation (HFS) to induce LTP (5 trains/1 s, 100 Hz, 1 ms pulses, 10 s intervals). 1) Spinal field potential recordings. Field potentials were recorded from neurons at depths of 100‐300 μm from the surface of the spinal cord (n=6). 2) PET measurements. PET studies were performed in parallel. Data was acquired (Inveon, Siemens) for 60 min after i.v. injection of [11C]PEO, a tracer which selectively depicts μ‐OR in the rat brain. All rats (n=8) underwent the first day a rest study without any intervention. On the second day, tracer acquisition was performed 2.5 hrs after HFS conditioning. The data was 3DRP reconstructed and binding potentials (BPnd) were calculated using a reference tissue model (MRTM0) in PMOD. Statistical comparisons (p<0.05) between baseline and stimulation condition were performed with SPM5 after anatomic standardization to an average PET uptake template. The result image (HFS>baseline) was registered to a 2‐D digital version of the Rat Brain atlas by Paxinos and Watson, and statistical values were extracted from predefined volumes of interest (VOIs). Results Increased C‐fibre response and reduced c‐fibre threshold were observed following sciatic nerve HFS throughout the observation time of 3 hours. 11 Increased [ C]PEO binding was observed ipsilaterally in the amygdala, hippocampus, somatosensory cortex, and the superior colliculus. In addition, significant increased signal was located bilaterally in the nucleus accumbens, caudate putamen, and the hypothalamus. Conclusions The data shows that HFS applied to the sciatic nerve lead to a long lasting C‐fibre LTP representative for hyperalgesia. Concomitantly, HFS was associated with a regional increased opioid receptor availability that is interpreted as reduced opioid tonic activity. The involved structures, amygdala in particular, are part of a pain modulatory circuitry. Therefore, a reduced descending opioid, anti‐nociceptive activity may be related to the observed spinal C‐fibre LTP and associated abnormal pain states, such as hyperalgesia. Furthermore, the dynamic changes in opioid neurotransmission in the limbic structures may connect the findings with an affective‐ emotional response to the applied noxious stimulus.
PW040 Gender and species differences in HSV-tk expression measured by 18F-FHBG-PET in rodents: correlation with immunohistochemistry M. Collantes1, A. Pañeda2, J. Snapper3, I. Aurrekoetxea2, C. Olague2, G. Quincoces4, P. Areses5, E. Prieto5, A. Fontanellas2, H. Petry3, S. van Deventer3, M. S. Rodriguez-Peña3, J. A. Richter5, G. GonzálezAseguinolaza2, I. Peñuelas5; 1Small Animal Imaging Research Unit, CIMACUN, University of Navarra, Pamplona, SPAIN, 2Gene Therapy and Hepatology, CIMA, University of Navarra, Pamplona, SPAIN, 3Amsterdam Molecular Therapeutics, Amsterdam, NETHERLANDS, 4Radiopharmacy Unit, Department of Nuclear Medicine, University Clinic of Navarra,
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Aim: Non‐invasive in vivo imaging of transgene expression provides a very important tool to quantify the transduction efficiency of different vectors and the duration of transgene expression. In this study, we used PET imaging to monitor the liver transduction efficacy in rats and mice of an AAV serotype 5 vector containing the herpes simplex virus thymidine kinase (HSV1‐tk) as reporter gene and correlate [18F]9‐(4‐[18F]‐fluoro‐3‐hydroxymethylbutyl)‐guanine (18F‐FHBG) uptake with TK expression measured by immunohistochemistry. Material and methods: C57BL/6 mice (n=11) and Sprague‐Dawley rats (n=12) of both sexes were intravenously injected with AAV serotype 5 vector and three weeks later TK expression was analysed by PET using18F‐FHBG as reporter probe in a dedicated small animal tomograph (Mosaic, Philips). 18F‐ FHBG was injected in a tail vein (rats: 37 ± 15 MBq; mice: 14.1 ± 7.4 MBq), and 60 minutes after radiotracer administration, a static acquisition of 15 minutes was performed with the animal under continuous isoflurane anaesthesia. For rats, a transmission scan was performed after image acquisition. For quantitative analysis of 18F‐FHBG uptake, regions of interest (ROIs) were drawn in the liver and maximum standardized uptake value (SUVmax) was calculated. To validate data obtained for 18F‐FHBG uptake, TK expression was also analysed in the liver of some animals by immunohistochemistry (rats n=6; mice n=6) using a policlonal anti‐TK antibody. To calculate the % of transduction, positive cells versus negative cells for TK were counted over 20 microscopic images (x20) for each animal using Image J software. Results and conclusions: All data obtained with PET imaging studies and immunohistochemistry showed large differences on liver transduction depending on the species and sex. For the same virus dose, mice presented about ten times higher transduction rate than rats (4.6±1.4 versus 0.45±0.06 SUVmax). For both species, males showed two times higher transgene expression than females. Moreover, MicroPET quantification data showed a very high correlation with transduction rate calculated by inmunohistochemistry after sacrifice (r=0.916), detecting 18F‐FHBG uptake also in animals with a very low transduction efficiency (0.05% of transduced hepatocytes). This fact points out the high sensitivity of PET technique to detect gene expression in living animals using HSV‐tk and 18F‐FHBG system, confirming the usefulness of PET imaging in the quantification of transgene expression even at low expression levels.
PW05 ‐ Sunday, October 11, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 5: therapy - miscellaneous 1
PW041 Clinical implications of bone formation and resorption markers after palliative therapies for painful osseous metastases with 186Re-HEDP in prostate cancer patients A. Zafeirakis1, G. Papatheodorou1, G. S. Limouris2; 1401 Army Hospital of Athens, Athens, GREECE, 2Araiteion University Hospital, Athens, GREECE. AIM: To evaluate the clinical value of serum bone makers in patients with bone only metastases from prostate cancer, after palliative treatments with 186Re‐HEDP, for predicting long‐term response, the duration of it and also to determine specific cut‐off values for identifying the group of responders. MATERIALS‐METHODS: Thirty six males with prostate carcinoma (median age 71 years, range 43‐82 years), suffering from painful osseous metastases and having been treated with the standard dose of 186Re‐HEDP, were studied. None had received therapies that interfere with bone metabolism, such as biphosphonates, chemotherapy, or radiotherapy before 186Re‐ HEDP therapy and throughout the follow up period. Patients with soft tissue or visceral metastases were also excluded. For each patient, the following post‐treatment variables were compared with respective pre‐treatment data (baseline): Osteocalcin (OC), bone alkaline phosphatase (BALP) amino‐terminal and carboxy‐terminal propeptides of type I collagen (PINP and PICP), amino‐terminal and carboxy‐terminal telopeptides of type I collagen (NTx and CTx), clinical status and pain scoring (performed by multiplying the severity of pain by its frequency, both on a 4‐point scale). Marker values were correlated to pain response levels and duration of response. With respect to pain, four levels of response were considered (Level I; no response, to level IV; excellent response). RESULTS: Pre‐treatment values of ΝΤx/PINP, PICP/PINP and NTx/CTx ratios as well as the maximum percentile post‐treatment decrease of baseline NTx and PICP values correlated with pain response (P=0.0025‐0.035). According to multivariate and ROC analyses, the best marker‐derived predictors of better and longer duration of pain response after 186Re‐HEDP therapies proved pre‐therapy NTx/PINP >/= 1.2 (RR=3.04, P=0.036) and post‐ therapy drop of NTx >/= 20% (RR=3.44, P=0.0005). Not such apparent correlations were found with the rest of the single markers or marker ratios. CONCLUSIONS: According to these findings, there is a strong rationale for the established use of a potent collagenous marker of bone resorption, such as NTx, along with a novel resorption/formation ratio model such as NTx/PINP. Both parameters provide useful information for daily practice by using cut‐off values for identifying a group of patients suffering from painful osseous metastases, with an increased risk of no response to palliative treatments with radionuclides. This information could prevent an inefficient and expensive therapy. The second implication is that, in the cohort of patients who will eventually undergo palliative treatments with 186Re‐HEDP, the early post‐therapy changes of the NTx values offer prompt predictive information regarding longer‐term palliative response.
PW042 Peptide receptor radionuclide therapy with 90Y-DOTATOC in neuroendocrine tumours: correlation between radiobiological parameters and clinical outcomes in 50 patients. V. Mattone, G. Sarti, C. Fabbri, M. Casi, M. Agostini, F. De Lauro, S. Vecchio, N. Bartolini, M. Bartolomei; Bufalini Hospital, Cesena (FC), ITALY. Aim. Peptide receptor radionuclide therapy (PRRT) with radiolabelled somatostatin analogues has been having an expanding role in the clinical management of neuroendocrine tumours (NETs). The goals of the present study were to evaluate the absorbed dose to tumour and kidneys and to correlate the cumulative adsorbed dose with the response and renal toxicity. Materials & Methods. Fifty patients (pts) affected by NET (80% with gastro‐entero‐pancreatic primary tumour), over‐expressing subtype 2 an 5 somatostatin receptors, underwent PRRT with
90Y‐DOTATOC. Most of then presented metastases principally involving the liver and abdominal lymphnodes. At enrolment for PRRT, morphological (CT or MRI) and functional (OctreoScan® or 68Ga‐DOTANOC) evaluations were performed, and then repeated 6 months after the end of the treatment. Blood cell‐count and chemistry (creatinine) were also monitored. Response and toxicity were assessed according to RECIST and WHO criteria, respectively. The mean cumulative injected activity was 8.4 GBq (range 6.7‐12) divided into 4‐5 intravenous administrations, 6‐8 weeks apart. Lysine was infused for renal protection. Imaging included a Bremsstrahlung whole‐ body after each course of PRRT. Moreover, all pts were studied with a 24‐ and 48‐hour SPECT‐CT acquisition for dosimetric purpose, at first and last PRRT with 90Y‐DOTATOC. The absorbed dose, in terms of biological effective dose (BED), to lesions and kidneys was calculated according to MIRD formalism. Moreover, the 3D‐dose distribution by applying the S‐voxel method was assessed in order to obtain the dose volume histograms (DVH), the biological‐dose volume histograms (BVH) and the equivalent uniform dose (EUD). Then, we also evaluated the ratio between EUD and mean BED (EUD/mBED), which is, together with the mean BED, directly correlated with the tumour response. Results: The median cumulative BED to tumour and kidney was 133 Gy (range 33‐487) and 39.5 Gy (range 9.5‐85), respectively. The EUD/mBED in the studied lesions ranged from 0.85 to 0.90. Partial response was gained in 19/50 pts (38%), the same percentage obtained a stable disease, while 12 pts (24%) progressed. Reversible grade 1 bone‐ marrow toxicity and mild increase of serum creatinine were reported in 22% and 8%, respectively. Conclusions: The dosimetric results showed a large variability in our study group. The patient‐specific radiobiological evaluation, performed at the first administration of PRRT, could allow to adjust the activity‐amount and the timing of the further courses of PRRT, thus offering the patient a tailored treatment. Based on qualitative evaluation, a significant correlation between the BED and response was documented.
PW043 Preloading in Radioimmunotherapy (RIT) with Anti-CD45 Antibody: Investigation of the Optimal Timing P. Kletting, S. N. Reske, G. Glatting; Universität Ulm, Ulm, GERMANY. Aim: In previous studies the amount of unlabelled antibody has been identified being an important determinant in achieving a favourable biodistribution for RIT using anti‐CD45 antibody. Simulations of anti‐CD45 antibody biodistribution using a simplified model indicated a considerable influence of the time delay Δt between the administration of labelled and unlabelled antibody. In the presented work, the time delay leading to the most favourable biodistribution is investigated for a more complex physiologically based pharmacokinetic (PBPK) model of the patient. Methods: Time activity data of five patients and a PBPK model were used to investigate the optimal Δt. The biokinetic data were obtained in a study where a preload of 0.5 mg/kg unlabelled antibody was administered 16‐34 min before the application of 1 mg ln‐111 labelled anti‐CD45 antibody (121±21 MBq). Simulations of the biodistribution of different time delays (0 ‐ 120 min) were conducted for all patients. The residence times tau of the critical organs liver, spleen, red marrow and blood were determined. As a measure of favourable biodistribution the ratio tau rm / tau liver was calculated for each time delay. Results: The most favourable time delay between the application of unlabelled and labelled antibody for all five patients was identified. The optimal Δt is decreasing with an increasing ratio of antibody to antigen from 10 min to 0 min. For three patients the simulations yielded an optimal time delay of 5 min after the preload. The ratio ratio tau rm / tau liver could be improved by a factor of 1.3 (range 1.2‐1.6) using the optimal time delay. Conclusions: The results indicate that for each patient the optimal Δt has to be determined individually. It is important to note that for each antigen to antibody ratio and for each distribution of antigens the optimal Δt will be different. Taking into account the observations made in other studies we conclude that preloading needs to be individualized, as the optimal timing and dosing of the preload could significantly improve RIT with anti‐CD45 antibody. Research support: German research foundation (DFG GL 236/7‐1)
PW044 Quantitative Analysis of Diffuse Liver Uptake of I-131 in Thyroid Cancer Patients Following Post-ablative or Follow-up Scan Dose T. Erselcan, G. Ozer, Z. Hasbek, B. Turgut, P. Kelkit, S. Gul; Cumhuriyet University School of Medicine, Sivas, TURKEY. Some patients with differentiated thyroid cancer (DTC) have liver uptake of I‐131 in whole body scans (WBS). While some of researchers suggest that diffuse liver involvement may be related to the existence of a functional thyroidal remnant or metastasis, there are claims for the other reasons. The aim of the present study was to assesses relationship between the administer dose, residual thyroidal tissue, liver uptake of I‐131, level of concurrent free T3, T4, TSH, TG, Anti TG Ab. Materials and methods: the liver involvement was assessed quantitatively and visually after WBS with I‐131. 98 DTC patients were divided into two groups; scanning dose group (ScDS) consisted of 42 follow‐up patients (35 women, 7 men, mean age(±SD)=47±13 years) who received 5 mCi I‐131 for WBS. The treatment dose group (TrDS) consisted of 56 patients (46 women, 10 men, age=45±13) who received 100‐250 mCi I‐131 for ablation purposes and underwent WBS. Imaging was performed 24 hours later in ScDS group and on the 7th day in TrDS group. Anterior images of WBS were used in the quantitative analysis. Region of interests were defined on the liver, thyroid and skull which were 1cm² in dimension. The liver and thyroid counts were normalized by subtracting cranial counts. Results; Diffuse liver uptake was seen in all patients with thyroid remnant in the TrDS group, except in one patient. There were a strong correlation between the thyroidal count and liver count in both study groups in quantitative analysis (in TrDS r= 0.73, p<0.001; in ScDS r= 0.67, p<0.001). There was also a positive correlation between visual score of liver and residual thyroid tissue count (r=0.40, p<0.03) in the TrDS group. There was no correlation between administered dose and I‐131 counts in residual thyroid tissue and also with liver count. However, there was a negative correlation between TSH levels and liver and residual thyroid tissue counts (r=‐0.43, p <0.02; r= ‐0.39, p <0.04, respectively); thyroid and liver counts were declining with the increase in TSH. Conclusion; The quantitative findings of the present study suggested that the liver uptake of I‐131 was most probably due to circulating thyroid hormones, supporting the idea of presence of functional thyroid tissue in DTC patients.
Poster Presentation
Pamplona, SPAIN, 5Department of Nuclear Medicine, University Clinic of Navarra, Pamplona, SPAIN.
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PW045 Successful Addition of Sr-89 into the Therapeutic Strategy in an Advanced Case of POEMS Syndrome M. P. Yaneva, V. S. Goranova-Marinova, S. Goranov; Medical University, Plovdiv, BULGARIA. POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M‐grade and skin changes) is a plasma cell discrasia with low tumor burden and multisystemic involvement. Other important characteristics are not included in the acronym ‐ the osteosclerotic bone lesions, the Castelman‐ like alterations in the lymph nodes and the disseminated angioproliferation. Treatment options include radiotherapy for solitary bone lesions, resulting in prolonged remissions and excellent prognosis; alcylator ‐ based chemotherapeutic regimens ± corticosteroids for patients with multiple bone lesions, and these with resistant and progressive disease. Autologous stem cell transplantation seems successful method in the latter group. Currently there are no randomized data for an optimal therapeutic strategy. Literature review showed only one case of application of 89‐Sr in POEMS syndrome. Aim:To present a case with POEMS syndrome, where 89‐Sr was successfully added to the complex treatment. Material and methods:We present an advanced case of POEMS syndrome, successfully treated with combination of chemotherapy, corticosteroids, radiation therapy of the major lesions and two applications of radioactive Sr‐89. Diagnosis was made two years after the initial symptoms when severe peripheral polyneuropathy appeared and parapropretin IgA(λ) was detected in the serum by immunofixation. The patient also had generalized osteosclerotic lesions organomegaly, Castelman‐like changes in the lymph nodes, pleural effusions, ascites, hypertrichosis and subclinical hypothyreoidism. At the beginning of the treatment the patients was in a wheelchair, suffered from severe pain in the lower limbs and had manifestations of respiratory and renal insufficiency. Treatment with alkylators+corticosteroids was started, the major osteosclerotic lesions were irradiated but therapeutic effect was most expressed after the addition in the treatment of Sr‐89, 4 mCi ‐ two applications in 6 months interval. Results: The general condition of the patient was improved, considerable pain relief occurred, mostly detected after the second application of Sr‐89, no lymphadenomegaly, pleural effusions and ascites were found, respiratory and renal function returned to normal, as well as slow improvement of the neurological symptoms was observed. The patient is back to his previous job, which is mostly intellectual. Conclusion:Along with the application of alkylator agents, corticosteroids, radiotherapy and autologous stem cell transplantation, Sr‐89 is a good therapeutic option in patients with POEMS syndrome. Key words: POEMS syndrome, treatment, Sr‐89
PW046 Treatment of bones and neck lymph nodes metastases of differentiated thyroid carcinoma : " radioguided surgery " R. Belakroum; HCA, Algiers, ALGERIA. objectives The purpose of this presentation on the radioiodine therapy (RAIT) of differentiated thyroid carcinoma is to show the interest of per‐operative detection in the improvement of the surgical treatment of iodine‐avid bone and neck lymph nodes metastases functionals. Materials and methods • Materials: 4 patients (2 M and 2 W), average of age: 52 years (43 ‐ 68 years). All differentiated thyroid carcinoma: 2 papillary, 1 follicular variant of papillary and 1 follicular. Initial surgery: Total Thyroïdectomy + lymph node dissection. Secondary surgery: Surgical recovery under per‐operative detection. Criteria of inclusion: iodine‐avid neck lymph node metastases (N = 3); iodine‐avid bone metastases (N= 1). • Methods: Day1: Administration of 3.7 GBq of iodine 131; Day4:Whole‐body scan; Day5: Surgery with per‐operative detection; Day6: Post‐surgical whole‐body scan. Results • Per‐operative detection of neck lymph node metastases Surgical ablation of the iodine‐avid lymph node (2000 Kcounts): Number of counts decreased to 20 Kc. Post‐ surgical whole‐body scan: disappearance of the foci’s neck captation. • Per‐operative detection of iodine‐avid bone metastases: Surgical ablation (a number of counts: 4000 Kc) A significant reduction of number of counts (tending towards zero). Post‐ surgical whole‐body scan: disappearance of the foci’s bone captation. Conclusion Radioguided surgery thus ensures of new prospects in carcinological surgery in general; and of thyroid disease particularly in the recurrent disease and as makes it possible to make sure as the excision were complete. The benefits of radioguided surgery include reduced operating time, reduced cost, smaller incisions, and fewer complications.
PW047 Pain response and haematological toxicity after repeated treatments with 186Re-HEDP combined with zoledronic acid in metastatic bone disease A. Zafeirakis1, A. Zissimopoulos2, N. Baziotis3, G. S. Limouris4; 1401 Army Hospital of Athens, ATHENS, GREECE, 2Demokriteion University of Thrace, Alexandroupolis, GREECE, 3St Savvas Anticancer Hospital, Athens, GREECE, 4Araiteion University Hospital, Athens, GREECE. AIM: Treatment with 186 Rhenium‐l,l‐hydroxyethylidene diphosphonate (186Re‐HEDP) has long been proven safe for palliation of bone pain in patients with widespread osseous metastases. The combination of Re‐186 HEDP and biphosphonates (especially zoledronic acid) in patients with painful bone metastases might prove a more effective analgesic option. However, it is not clear to date whether repeated administrations of Re‐186 HEDP benefits the patient. This study focused on the comparison of pain response and haematological toxicity between single and multiple therapies with 186 Re‐HEDP combined with zoledronic acid in the same group of patients. MATERIALS‐METHODS: Twelve patients suffering from painful osseous metastases from prostate or breast cancer, who all received multiple therapies of 186Re‐HEDP (N=31) during a period of pain relapse without extra‐osseous disease progression were evaluated. Of these, seven patients received three therapies and the rest five received two doses of 186Re‐HEDP. All patients were under stable regimen of analgesics and zoledronic acid, far off other therapeutic manipulations. Haematological status (HGB, WBC and PLT count), Karnofsky Performance Scale (KS) and pain score index were followed up regularly for 3 months after each therapy. With respect to pain, four levels of response were considered (Level I; no response, to level IV; excellent response). RESULTS: After the first therapy with 186Re‐HEDP, the mean percentile decrease for HGB was 4.7% (P > 0.1), for WBC 21.4% (P = 0.07) and for PLT 12% (P > 0.1). After
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 multiple therapies, the respective declines were 7.0% (P = 0.058), 16.0% (P = 0.0014) and 23.4% (P = 0.0012). With respect to baseline blood counts, only thrombocytes showed a tendency for higher decrease after repeated treatments (P = 0.024), yet not of clinical significance. Favourable clinical response occurred after the first therapy in 10/12 patients (83.3%), in 15/19 (78.9%) after multiple doses and overall in 25/31 (80.6%) of 186Re‐HEDP therapies. The corresponding median pre‐ and post‐therapy values of KS were 77.5 and 87.5, 82.6 and 89, and 80.6 and 88.4, respectively. Significant post‐therapy improvement in pain indices was observed in all cases, regardless of the number of therapeutic doses. CONCLUSIONS: Repeated treatments of 186Re‐ HEDP combined with zoledronic acid provide continuing effectiveness in metastatic bone pain control with minimal side‐effects if an acceptable baseline haematological status exists.
PW048 Impact of Image Co-Registration On The Treatment Planning of Y-90 Microsphere Therapy M. F. Bozkurt1, B. Peynircioglu2, B. Cil2, C. Kapulu1, M. Aslan1, O. Ugur1; Hacettepe University Faculty of Medicine Department of Nuclear Medicine, Ankara, TURKEY, 2Hacettepe University Faculty of Medicine Department of Radiology, Ankara, TURKEY.
1
Aim: Y‐90 microsphere therapy serves as a successful therapeutic option for non‐resectable primary and metastatic liver tumors. The success of therapy depends on precise treatment planning. This study was aimed to assess the impact of image co‐registration on treatment planning with respect to dose calculation and side‐effects. Materials and Methods: Total of 11 patients (1f, 10m, median age: 52) were evaluated for appropriateness of Y‐90 microsphere therapy using SPECT‐CT fusion after hepatic angiography and MAA scan in which MAA SPECT images were co‐registered with CT images. Pretreatment evaluation also included liver function tests, complete blood counts, dynamic liver CT and PET‐CT. According to SPECT‐CT fusion results, 9 patients with the diagnosis of inoperable primary (n= 3) and metastic liver tumors (n= 6) were found to be suitable for the radionuclide therapy and were transarterially treated with resin Y‐90 microspheres. Therapy doses were calculated according to body surface area and tumor‐to‐liver ratio based formula. SPECT‐CT fusion image data were used for calculation of tumor‐to‐liver ratio as well as evaluation of extrahepatic shunts. Results: Median therapy dose of 1,25 GBq was successfully administered to all patients. Image co‐registration provided important information with regard to extrahepatic uptake focus not localized with SPECT alone in 4/11 (36%) patients. Two out of these 4 patients were excluded due to extreme extrahepatic shunting. In one patient gastrointestinal shunting was clearly detected with the use of fused SPECT‐CT image,and two small accessory arteries were then identified and coiled in the repeated angiography. After SPECT‐CT fusion imaging confirmed absence of shunt, therapy was given.In the other patient who was impossible to coil‐embolize, the dose was given more distally from posterior branch of right hepatic artery instead of right hepatic artery. Posttheapy Brehmstrahlung imaging confirmed correct localization of Y‐90 microspheres and no extrahepatic shunting due to misadministration was found. Image co‐registration was also helpful to presume lodging of the microspheres in the tumor and assessment of tumor‐to‐liver ratio for therapeutic dose calculations in all 9 patients. Conclusion: Co‐registration of MAA SPECT and CT images provides valuable information with regard to treatment planning and radioprotection of normal hepatic and extrahepatic tissues from side effects of Y‐90 microsphere therapy, which cannot be provided with SPECT or CT alone.
PW049 Investigating the Biodistribution of Anti-CD66 Antibody: Physiologically Based Pharmacokinetic (PBPK) Modelling and Radioimmunotherapy P. Kletting, M. Luster, T. Kull, S. N. Reske, G. Glatting; Universität Ulm, Ulm, GERMANY. Aim: The aim of the presented work is the development of a PBPK model which allows describing and predicting the biodistribution of RIT for different amounts of anti‐CD66 antibody based on 90 biokinetic measurements. Furthermore, the optimal amount of antibody for Y labelled anti‐ CD66 therapy is determined. Methods: Two PBPK models were developed to describe the distribution of anti‐CD66 antibody. The models were fitted to 111In time activity data (N=8 pats.) of liver, spleen, red marrow, total body and blood (1‐144h). The best model was selected employing the corrected Akaike Information Criterion (AICc) and subsequently validated comparing the predicted 90Y blood serum concentration during therapy and the actually measured concentration. Furthermore, the residence times of the predicted and the measured blood serum curves were compared. The amount of antibody leading to the most favourable biodistribution was determined using PBPK model simulations. Results: The fits for all data were excellent. The estimated amounts of antigens for red marrow, liver and for spleen were (7.0±1.6), (0.1±0.1), and (0.2±0.1) nmol, respectively. The prediction errors of the serum concentration and the serum residence time (the relative deviations of the predicted and the measured values), were 23±5% and 15±21% respectively. The simulations show that reducing the amount of antibody increases the residence times for the red marrow and decreases the residence times in all other organs. Using the smallest investigated amount of antibody would enhance the residence time in the marrow by (202±27) % while reducing the residence times of blood, spleen and liver. Conclusions: Modelling biodistribution with anti‐CD66 antibody allows the determination of important physiological quantities such as the number of antigens in the organs. Simulations using the validated model indicate that reducing the used amount of antibody would lead to a more efficient therapy: More activity is delivered to the target organ and the radiation burden of the critical organs, especially the kidneys, may be decreased. Research support: German research foundation (DFG GL 236/7‐1)
PW050 Therapeutic efficacy of proton therapy combined with tumor 18 blood flow interruption evaluated by high-resolution [ F]FDGPET A. Terakawa1, K. Ishii1, H. Yamazaki1, Y. Funaki1, M. Tashiro1, S. Furumoto1, S. Matsuyama1, Y. Kikuchi1, J. Arikawa1, T. Togashi1, W.
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Tohoku
Charged particles have advantages in radiotherapy over an X‐ray such as large energy deposition at the end of their path, the so‐called Bragg peak and superior radiobiological properties. In order to enhance therapeutic efficacy of charged particle therapy, we have studied the proton therapy in combination with the vascular disrupting agent, AVE8062. In this study, the therapeutic efficacy of the AVE8062 combined proton irradiation was evaluated based on high‐resolution [18F]FDG‐PET measurements for NFSa fibrosarcoma implanted into C3H/He mice. The proton therapy experiment was performed by using the proton therapy facilities dedicated to small animals at Cyclotron and Radioisotope Center (CYRIC), Tohoku University. NFSa fibrosarcoma cells were transplanted into both hind legs of C3H/He male mice around 12 weeks old. When each tumor diameter was about 7mm, single‐dose irradiation was given to the tumor of the right hind leg. The tumor was covered with the maximal dose region ( spread‐out Bragg peak ) in the depth dose distribution and received 15 Gy at 5 Gy/min. The normal tissue surrounding the tumor was shielded from the irradiation. Thus, we used the tumors of the right and left hind legs as the proton therapy group and the control group, respectively. For the combination treatment, single intraperitoneal administration of AVE8062 (40 mg/kg ) was given to the mice at 1 hour after irradiation . In this case we used the right and left tumors as the combination treatment group and the AVE8062 treatment group, respectively. The time‐course of changes in tumor volume for each group was measured after the treatments. Although the proton therapy and AVE8062 treatment groups provided similar tumor growth delay, the combination treatment inhibited tumor growth more strongly than the irradiation or AVE8062 did. On the other hand, the [18F]FDG‐PET measurements with less than 1mm FWHM resolution were performed before and after the treatments by using the semiconductor animal PET scanner at CYRIC. Results of the PET scan showed fine distributions of glucose uptake inside the tumor tissue and stronger reduction of glucose uptake inside the tumor tissue for the combination treatment group than those for the other group. In conclusion, enhancement of therapeutic efficacy of the AVE8062 combined proton therapy was observed in the present therapeutic experiments. Significant decrease in glucose uptake was observed inside the tumor tissue from high‐resolution [18F]FDG‐ PET scan.
PW06 ‐ Monday, October 12, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 6: therapy - miscellaneous 2
PW051 The kinetic aspects of thyroid remnant stunning in the patients with differentiated thyroid cancer O. Kozak1, O. Butrim2, O. Trembach3; 1Region Oncological Hospital, Kiev, UKRAINE, 2Central Clinical Military Hospital, Kiev, UKRAINE, 3Cancer Institute, Kiev, UKRAINE. Stunning represents the decrease in radioiodine accumulation in the thyroid remnant in radioiodine treatment upon administration of small activities. This phenomenon may affect significantly the treatment outcome. While the various aspects of stunning have not yet been completely elucidated, the problem is still of high importance taking into account that the diagnostic scintigraphy post‐thyroidectomy is the conventional procedure. The stunning is well characterized as the phenomenon. Nevertheless, the quantitative aspects are still far from being clear. The aim of the study was to assess the parameters of radioiodine kinetics in various times after the diagnostic scintigraphy. Patients and methods. The diagnostic scintigraphy with 74 MBq of radioiodine‐131 was performed in 19 patients with differentiated thyroid cancer followed by radioiodine therapy. In all patients only thyroid remnant was visualized both in diagnostic and therapeutic radioiodine administration. The therapeutic activities were within the range of 1574‐ 5120 MBq. The time between the diagnostic examination and the treatment was 2‐120 days. The half‐elimination of radioiodine from thyroid remnant was calculated according to scintigraphy data. The relation between (Td‐Tt) /Td and the interval between the diagnostic and the treatment was followed. The accumulation level in the remnant in the first days upon radioiodine administration was assessed relative to the background value. The following average values were obtained Td = 5,72 days (min 1,41d ; max 12,6d), Tt = 2,79 days (min 1,13d ; max 10 d). The average value of (Td ‐ Tt)/Td was equal 0, 67 (from 0 to 0, 88) with the trend of its decrease with increasing the interval between the diagnostic and the treatment. Results. In 10 days and later, the difference between the effective half‐elimination time in diagnostic and therapeutic administration becomes insignificant. At the same time, the accumulation level of radioiodine in the remnant lowered rapidly with the increasing interval between the diagnostic and the treatment. Conclusion. Stunning affects the kinetic parameters mostly within first 10 days after the administration of the low activity. The radioiodine treatment is advisable as soon as possible after the radioiodine diagnostic examination.
PW052 Papillary Thyroid Carcinoma associated with Thyroglossal Duct Cysts and Iodine-131 treatment: a retrospective analysis H. M. L. Carvalho, A. Martins, T. C. Ferreira, O. Cid, V. Leite, E. Limbert, L. Salgado; Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisboa, PORTUGAL. Aim: to evaluate the role of Iodine‐131 treatment in the management of papillary thyroid carcinomas (PTC) associated with thyroglossal duct cysts (TDC), influence and impact in their long term follow‐up and prognosis. Materials and Methods: clinical files from our database from 1974 to 2008, were evaluated, taking into account medical and pathology records. Results: From 3458 patients (pts) with PTC, 22 pts (0,63%) had PTC of TDC: 4 male and 18 female; mean age: 36.9 years (range 15‐63 years). From the 22 pts with PTC of TDC, 14 were submitted to subsequent thyroidectomy (64%) and from those, 11 (79%) were treated with Iodine‐131 (3 male and 11 female; mean age: 39.4 years; range 21‐63 years). Only two pts repeated Iodine‐131 treatment: 1 pt did a second therapy due to elevated serum thyroglobulin (Tg) levels during follow‐up and the other one was submitted to 3 treatments (total activity 339 mCi), due to lung metastases. Three pts submitted to thyroidectomy were not treated with Iodine‐131, because histopathology
unequivocally excluded tumour within the thyroid gland, and despite the fact that 2 of them had lymph node metastases. Lymph node metastases were found in 5 out of the 14 pts (36%). After a mean follow‐up of 5 years (range 1‐23 years), 12 pts are still under evaluation. Two pts were lost to follow‐up. Ultrasound, when performed, did not show evidence of local recurrence. No tumour associated mortality was observed. Serum thyroglobulin (Tg) levels at the last evaluation of 12 pts still under follow‐up: <0,2 ng/ml in 10 pts, <2 ng/ml and > 0,2 ng/ml in 1 pt and > 2 ng/ml in 1 pt (14,1 ng/ml). Conclusions: PTC of TDC is a rare disease. It was present in less than 1% of our patients. Thyroidectomy is usually performed because TDC carcinoma frequently co‐ exists with carcinoma of the thyroid gland. After this procedure, the vast majority of pts are submitted to Iodine‐131 treatment, depending on histopathology of the thyroid gland. In the present series 79% of the pts were treated with Iodine‐131. The prognosis in pts with carcinoma in the TDC is good.
PW053 Lu-177 octreotate therapy in patients with disseminated neuroendocrine tumors. Analysis of dosimetry with impact on future strategy J. Tennvall1, M. Garkavij1, M. Nickel2, K. Sjögren-Gleissner2, M. Ljungberg2, T. Ohlsson2, K. Wingårdh2, S. E. Strand2; 1Oncology, Lund, SWEDEN, 2 Radiation Physics, Lund, SWEDEN. Aim. 177Lu‐[DOTA0,Tyr3] octreotate is a new treatment modality for disseminated neuroendocrine tumors. According to a consensus protocol, the calculated maximally tolerated absorbed dose to the kidney should not exceed 27 Gy. The aim was to evaluate efficacy, toxicity but above all compare three types of kidney dosimetry. Material & Methods: 21 patients suffering from disseminated neuroendocrine tumors, previously heavily treated, with sufficiently 177 high somatostatin receptor expression received 61 administrations of Lu‐Dotatate. In 12 tumors Ki67 index was < 2% and in 8 tumors 2‐20 %. The cumulative injected activity was <29.6 GBq. Whole‐body imaging and SPECT were performed after 0.5h, 24h, 96h and 168h p.i. Three different methods were used to evaluate the absorbed dose to the kidneys. Method 1 involved common planar activity imaging, and the absorbed dose was calculated using the MIRD formalism. The choice of background region for background correction was investigated. Method 2 also included SPECT data which were used to scale the amplitude of the time‐activity curve obtained from planar images. The absorbed dose was calculated as in method 1. Method 3 used quantitative SPECT images converted to absorbed dose rate images. The median absorbed dose rate in the kidneys was calculated in a volume of interest defined over the renal cortex. Results: The treatments were well tolerated without SAE. Of 12 evaluated patients 2 had PR, 2 had minimal response, 3 patients showed SD and 1 had PD (18 mo+). 9 patients showed improved performance status. Hematological toxicity was mild. Hitherto, all patients have unchanged kidney function. The average kidney absorbed dose according to 3 calculation methods used, were 0.90±0.18, 0.75±0.15 and 0.82±0.14 mGy/MBq, respectively. Whole body absorbed dose was 0.07±0.02 mGy/MBq. In 8 patients estimated tumor absorbed dose varied between 3‐20 mGy/MBq. Methods 2 and 3 generally gave consistent values, although the calculations are based on different assumptions. Dosimetry based on planar images (Method 1) gave higher absorbed dose values compared to methods including SPECT, in 12 out of the 16 evaluated patients. The first two of the four planned therapy cycles made the major contribution to the tumor absorbed dose.Conclusions: This implies that patients evaluated according to planar dosimetry (method 1) may have been undertreated. Hematology and creatinine did not indicate any restriction for a more aggressive approach which would be especially useful in patients with more aggressive tumors where there is not time for more protracted therapy.
PW054 Pretargeted radioimmunotherapy (PT-RAIT) in progressive medullary thyroid cancer (MTC). P. Y. Salaun1, A. Oudoux2, C. Bournaud3, S. Bardet4, J. Vuillez5, D. Taieb6, C. Ansquer2, C. Rousseau7, B. Bridji7, J. Barbet8, D. M. Goldenberg9, J. Chatal8, F. Kraeber-Bodere2; 1University Hospital of Brest, Brest, FRANCE, 2 University Hospital of Nantes, Nantes, FRANCE, 3University Hospital of Lyon, Lyon, FRANCE, 4Baclesse Cancer Institute, Caen, FRANCE, 5 University Hospital of Grenoble, Grenoble, FRANCE, 6University Hospital of Marseille, Marseille, FRANCE, 7Gauducheau Cancer Institute, Nantes, FRANCE, 8CRCNA Inserm U892, Nantes, FRANCE, 9Center for Molecular Medicine and Immunology, Belleville, NJ, UNITED STATES. Backround Two prior studies showed efficacy of anti‐CEA PT‐RAIT in MTC patients (pts), with a longer survival in high‐risk pts with calcitonin doubling times (Ct‐DT) <2 years. We report initial results of PT‐RAIT study in progressive MTC pts. Patients and Methods 41 patients (pts) (23M, 18F) received anti‐CEA x anti‐DTPA bispecific monoclonal antibody (BsMAb, Immunomedics, Inc., Morris Plains, NJ, USA). hMN‐14xm734 and 1.8 GBq/m2 131I‐di‐DTPA 4‐6 days apart (45 treatments); 6 were retreated, one received only BsMAb infusion. Targeting, toxicity, morphological, FDG‐PET and biomarkers were evaluated with 12 mo (3‐36) follow‐up. A pt was considered as non‐responder if progression according to RECIST, FDG‐PET or biomarker level was observed at 3 mo or no effect on CEA or Ct‐DT was obtained. Results Sensitivity of immunoscintigraphy , assessed in 33 pts, was 92%. Allergy signs were observed during 4 BsMAb (including 2 retreatments), grade‐I liver toxicity after 4/44 (9%), and grade‐III/IV hematological toxicity after 24/44 (54.5%) infusions. Efficacy was found after 24/45 (53.3%) infusions, with a time‐to‐progression of 12 mo (6‐>36) for RECIST, PET and biomarker levels changes. Efficacy rate was 70% (7/10) in low‐risk pts (Ct and CEA‐DT >2y), 54% (13/24) in intermediate‐risk with (Ct and CEA‐DT between 6 mo and 2y) and 30% (3/10) in high‐risk pts (Ct or CEA‐DT <6 mo). Conclusion PT‐RAIT is effective in progressive MTC patients, with hematological toxicity as main side‐effect. Support French National Cancer Research Program 2004.
Poster Presentation
Yamashita1, H. Akiyama1, K. Koyata1, S. Wada2, N. Itoh2; University, Sendai, JAPAN, 2Kitasato University, Towada, JAPAN.
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IART (Intra-operative Avidination for Radionuclide Therapy) vs conventional External Beam (EBRT) and Intra-operative Radiotherapy (IORT). Radiobiological comparison using the Linear Quadratic (LQ) model. A. Di Dia, M. Cremonesi, M. Ferrari, F. Botta, C. De Cicco, G. Pedroli, G. Paganelli; European Institute of Oncology, Milano, ITALY. Introduction: A new technique for partial breast irradiation has been developed based on the avidin‐biotin system as anticipated boost. It consists of intra‐operative avidination of the tumour bed followed by tumour targeting through the administration of 90Y‐biotin. The objective of this study was to evaluate the potential biological efficacy of IART®+EBRT and to compare it with conventional or accelerated EBRT and IORT+EBRT, taking into account tumor repopulation. Methods: Comparison was performed on 15 patients undergoing IART®, who received avidin (100 mg) during surgery, and 3.7 GBq of 90Y‐biotin (+185 MBq of 111In‐biotin for imaging) one day after surgery. Based on patient‐specific dosimetry (methods described elsewhere), the therapeutical schedules were considered: i) IART®+EBRT protocol applied in our centre (20Gy anticipated boost to target area + 20 fractions x 2Gy EBRT); ii) conventional EBRT with or without a boost (25 fractions x 2Gy + boost 5 fractions x 2Gy); iii) accelerated EBRT (13 fractions x 3.2Gy); iv) IORT+EBRT (12Gy anticipated boost + 13 fractions x 2.85Gy EBRT). The therapeutical biological efficacy was compared based on the LQ model, by evaluating the Biological Effective Dose (BED), tumor cell Survival Fraction (SF) vs. time at completation of treatment, and Tumor Control Probability (TCP). The following radiobiological parameters were used: α/β=10Gy; half‐lifes for 2 3 repair and doubling of clonogenic cells: Trepair=1.4h, Tave=40days; K=10 clonogenic cells/cm (hypotesis of complete tumor resection); Teff=39h (previously derived in phase I‐II study); ‐1 ® α=0.3Gy . Results: The BED results were: i) 69Gy, IART +EBRT ii) 72Gy and 60Gy, EBRT with/without boost; iii) 55Gy, accelerated EBRT; iv) 74Gy, IORT+EBRT. IORT and IART® lead to SF reduction immediately after surgery, while slight but inevitable repopulation occurs until the EBRT begins. However, all procedures reach similar SF values 10 weeks after surgery. Both intra‐ operative procedures (IART®/IORT+EBRT) lead 100% TCP 6 weeks after surgery, with an advance of 2 weeks as compared to EBRT (standard/accelerated EBRT requires 8 weeks). Conclusions: The LQ model suggests comparable biological efficacy for all schedules. The intra‐operative procedures anticipate the tumour control probability, with similar SF decrease immediately after surgery. This offers crucial advantage for combination with other therapeutic approaches. The lower number of EBRT fractions needed with the IART®/IORT+EBRT provides additional benefit to the patients. Finally, the therapeutical potential of IART® could be further improved by increasing the local uptake (e.g. by varying the administered specific activity) with minor irradiation of normal tissues, as confirmed by dosimetry.
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patients was 44,8 ± 15,4 yr (range, 24‐72yr). An ablative dose of 131I was given 10 weeks after Rg treatment and posttherapeutic 131I total body scan was obtained to evaluate RAI uptake.Oral rosiglitazone tratment (4 mg daily for one week, then 8 mg daily for 9 weeks). Was given to all patients and levothyroxin was withdrawn in seventh week of Rg treatment. Clinically important toxicity associated with Rg treatment was not observed. Results. Before Rg treatment, TSH level was 68,36 ± 28,09 mIU/ml and Tg level was 131,62 ± 102,56 ng/ml.: After Rg treatment, just before RAI treatment TSH level was 70,98 ± 31,62 mIU/ml (p = 0,8) and Tg level was 94,67 ± 119,89 ng/ml (p = 0,4). After treatment with Rg, tg level decreased in 9 patients but increased in 4 patients. Of thirteen patients, 8 patients had negative posttherapeutic 131I total body scan after Rg therapy. But 5 patients (39%) had positive scans with uptake in the neck in 1 patient, in the upper mediastium in 1 patient and both in the neck and upper mediastium in 3 patients. Conclusion: Rg treatment may increase RAI uptake in thyroid tissue in some patients with Tg‐ positive and RAI‐negative differentiated thyroid cancer. But unlike some studies, Tg level decreased after Rg treatment. Longer treatment periods may increase positive results.
PW058 Effectiveness of Radiosynovectomy in Hemophilic Synovitis A. Polat1, G. Buyukdereli1, I. Sasmaz2, O. Sargın1, C. Özkan3, M. Kibar4, B. Antmen2; 1Department of Nuclear Medicine in Cukurova University Faculty of Medicine, Adana, TURKEY, 2Department of Pediatric Hematology in Cukurova University Faculty of Medicine, Adana, TURKEY, 3Department of Orthopedics and Traumatology in Cukurova University Faculty of Medicine, Adana, TURKEY, 4Acibadem Hospital, Adana, TURKEY. Aim: Intra‐articular hemorrhage is the most common musculoskeletel manifestation of hemophilia. Recurrent bleeding can lead to chronic synovitis. Radiosynovectomy (RSO) is an effective treatment option for chronic hemophilic synovitis. The aim of this study was to evaluate the usefulness and the outcome of RSO in patients with hemophilia and recurrent joint bleedings. Materials & Methods: A total of 24 hemophilic patients ranging in age 6‐18 years underwent RSO due to recurrent bleedings in 34 joints (elbow; n:11, knee; n:20, ankle; n:3). Nineteen of them had hemophilia A and 5 had hemophilia B. RSO of the knee was performed using Y‐90 (4‐4.5 mCi), all other joints were treated with Re‐186 (1.5‐2 mCi). In all cases, before and after RSO, factor replacement therapy was given. Follow‐up period was between 1‐2 years. The success of RSO was scored clinically as 0 (no effect on bleeding frequency) and 1 (at least %50 reduction of joint bleedings) Results: RSO was performed without any periinterventional complication in all treated joints. With regard to the clinical success, a score of 0 was not observed whereas score 1 was found in 34/34 joints. Relapse occured within the first 6 months after RSO in 1/20 treated knees and in 2/11 treated elbow. There was no recurrent joint bleedings in the other 31/34 joints. Conclusion: In our study, RSO has proven to be a effective therapeutic option providing a favorable outcome in hemophilic patients with recurrent joint bleedings.
Radioiodine Therapy, Patients opinion 7 years after
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A. Zinke, J. Bartsch, U. Bohl, K. Kirsch, M. Trautmann, G. Kirsch; University, Greifswald, GERMANY.
Investigation of change in residence-time in repeated radioimmunotherapy using I-131 rituximab for non-hodgkin's lymphoma
Aim: Patient's reports or reflections of their radioiodine therapy (RIT) performed years ago are rare. We evaluated questionnaires from 781 patients who had functional RIT 7 (4 to 9) years ago in our department Materials and Methods: From 1857/3726 (50%) patients (70+‐13 years old) there were no long time follow‐up data after functional RIT (between 2000 and 2005) in our RIT database. To all of them questionnaires were sent to get information about RIT longtime results and an impression how pattients reflect the course of their thyroid disease. To simple questions preformed answers (2‐6) should be underlined or filled in with short information. During RIT the pattients had given there consent to a later questionnaire. Results: From 1857 questionnaires 865 (47%) returned, filled in with information (among them 74 from parents, that patients died), 435 (33%) returned unopened (patients no longer at that address), 557 (30%) did not return. So, baseline of this evaluation, were 781 questionnaires (14% Grave's disease, 86% functional autonomies). All questions were answered to more than 90%. The condensed answers to the 13 questions (Q) are: Q1: Thyroid illness is thought to be gone or ameliorated in 69%, unchanged in 7%, don’t know in 25%. Q2‐5: Hormone controls by practitioners had 84% (74% 1‐2/y), by specialists 20%. 47% had thyroid medication (hormones and/or iodine); 64% did know that their hormone values were o.k., 31% did not. Q6,7: After RIT 79% had remission of symptoms; 62% are now without any symptoms. Q8,9: 42% had other diseases after RIT; 68% feel good, 27% less good, 5% bad.Q10: Body weight was higher than at RIT in 29%.Q11: As unwanted side effects of RIT are regarded a relapse of hyperthyroidism (15%) and hypothyroidism (14%). Q12: In case of relapse of hyperthyroidism the preferred therapy would be RIT again (60%), drugs (14%), surgery (1%), don’t know (23%). Q13: The time spent to follow‐up examinations after RIT is regarded to be little (53%), reasonable (44%), high (1%), don’t know (21%). Conclusions: The response rate of about 50% of the meanwhile relatively old patients seems rather good. The follow‐up controls are preferently performed by practitioners in adequate intervals. In patient's opinion the course of their thyroid disease and RIT itself is judged positively in about 80%. The results of the questionnaires are not systematically different to the long time results of patients examined in our department.
PW057 Effect of Rosiglitazone on Iodine negative thyroglobuline positive thyroid cancer patients B. Gunes, F. Cinaral, L. Kabasakal, C. Onsel, I. Uslu; Istanbul University, Cerrahpasa Medical School, Nuclear Medicine Dept., Istanbul, TURKEY. Introduction: Patients with thyroglobulin (Tg)‐positive and radioiodine(RAI)‐negative are difficult to treat. As mentioned in previous studies, ligands for peroxisome proliferator‐activated receptor gamma (PPARgamma) induce apoptosis, differentiation and exert antiproliferative effects in many cancers including thyroid cancer. Aim: The aim of our study was to determine if pretreatment with PPARgamma agonist, rosiglitazone (Rg), was associated with an increase in RAI uptake in thyroid carcinoma patients with high serum Tg level and negative posttherapeutic 131I total body scan. Materials and Methods: Thirteen Tg‐positive and RAI‐negative differentiated thyroid cancer patients (10 female, 3 male) were included to the study. The histopathological types included 12 papillary carcinomas and 1 follicular carcinoma. The mean age of enrolled
S. Lim, J. Park, K. Kim, H. Kang, T. Choi, J. Kim, S. Woo, J. Kim, B. Kim, G. Cheon; Laboratory of Nuclear Medicine Research, Department of Medicine, Korea Institute of Radiological and Medical Sciences, Seoul, REPUBLIC OF KOREA. Introduction: Repeated radioimmunotheraphy (rRIT) using I‐131 rituximab has been used adopted for the improved efficacy in the treatment of refractory non‐Hodgkin’s lymphoma (NHL). In this study, we investigated the change in the residence‐time of rituximab in the rRIT, with comparing to that from single RIT for consolidation treatment, and evaluated the efficacy of the repeated RIT. Method: Twelve patients (5 for consolation and 7 for rRIT) were enrolled in this study. The patients who showed no noticeable tumor in PET/CT image, was classified in consolidation group and had single treatment of RIT. Cold‐rituximab treatment was discontinued 6 weeks before the RIT in all patients. During RIT, therapeutic dose of I‐131 rituximab (7.4 GBq) with cold rituximab (70 mg) was administrated to patients. Immediately after the administration of I‐131 rituximab, serial venous blood samples (5 min, 6, 24, 48, 96, 240 hr p.i.) were drawn from the patients, with sequential quantitative whole‐body planar imaging. The patients in rRIT group was had multiple treatments with the same amount of I‐131 rituximab (averaged cycles of RIT: 4.9±0.9, max. cycle of RIT: 6, RIT interval: 1.8±0.8 months) From the time‐activity curves of blood and whole‐body activity, the residence time of blood and whole‐body was calculated, respectively, to estimate the bone‐marrow dose. Results: Residence‐time of the first RIT in rRIT group was significantly shorter (2.7±1.1 hr) than that in the consolidation group (4.4±0.7 hr). Residence‐time in rRIT group was increased with the repetition number of RIT (Residence_Time = 0.7*RIT_number + 1.6, r2=0.88), and showed no significant difference with that of consolidation cases, after the 4the RIT (4.7 ±2.2 hr). Conclusion: Residence‐time of rituximab in both groups with different tumor burden could be well differentiated. Repeated RIT showed the increase of residence‐time that approached to the values of consolidation cases, owing to the reduced tumor burden, in addition to prior dose of rituximab. In conclusion, the evaluation of residence‐time in rRIT study should be useful in the assessment of efficacy of RIT and planning of further RIT schedule.
PW060 Selective internal radiation therapy (SIRT) with microspheres for unresectable malignant liver tumors
90Y-
N. Arslan1, M. Emi2, E. Alagoz1, B. Ustunsoz2, K. Oysul3, A. Ozet4, F. Arpaci4, T. Tufan5, M. A. Ozguven1; 1GMMA and Medical Faculty, Dept. of Nuclear Medicine, Ankara, TURKEY, 2GMMA and Medical Faculty, Dept. of Radiology, Ankara, TURKEY, 3GMMA and Medical Faculty, Dept. of Radiation Oncology, Ankara, TURKEY, 4GMMA and Medical Faculty, Dept. of Medical Oncology, Ankara, TURKEY, 5GMMA and Medical Faculty, Dept. of General Surgery, Ankara, TURKEY.
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PW07 ‐ Monday, October 12, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 7: lung cancer diagnosis
PW061 Differentiation of adrenal masses with cancer
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F DFG PET/CT in lung
T. Antonellis1, A. Festa1, A. Tofani2, P. Pizzichini2, T. Lanzolla3, F. Di Stasio1, M. Pietravalle1, E. Iannicelli1, F. Scopinaro1; 1University Sapienza, Rome, ITALY, 2S. Andrea Hospital, Rome, ITALY, 3University"Sapienza", Rome, ITALY. Aim: Discovering Adrenal Masses (AM) during the follow up of lung cancer is a problem due to the suspect of Adrenal metastases (Amet). The study is aimed to investigate the frequency of Amt and benign AM ( BAM) in pts with non small cell lung cancer (NSCLC) and to establish the accuracy of PET/CT diagnosis. Methods We retrospectively reviewed the 18F DFG PET/CT studies done on 2007 in 348 consecutive patients, 228 ( mean age 65.2 y) of whom with known NSCLC ( KLC) and 120 (mean age 63.4 y) with lung opacities. Among the latter patients 33 showed a newly diagnosed NSCLC ( NDLC), whereas 87 did not show cancer. Follow up of all the pts with cancer continued on 2008/2009. Criteria for Amt were: SUV max> 3 and Hounsfield units (HU) > 30. HU < 10 and SUV max < 2.5 were considered indicative for BAM. In the “grey zone” of SUVmax between 2.5 and 3 and HU between 10 and 30, MRI and 131I nor‐cholesterol (ICH) scan had been performed on physicians’ requirement. Final diagnosis was autoptic ( 4 Amets), histologic ( N= 16) or the AM was considered benign if stable for more than 1year ( N= 28). Results 39 of the 228 pts with KC showed BAMs (17.1%) and 7 of these 228 (3.0%) showed Amets. BAMs were detected in 2 out of the 32 pts with NDLC ( 6.25%). No Amet was found in these pts. 2 out of the 88 pts with benign lung opacities showed AMs ( 2,27%). All the Amets showed SUV max> 3.0; HU was> 30 in 6/7 Amets. Tough SUV max was< 3 and HU <30 in all the patients with BAM, 4 BAMs showed SUV max> 2.5(range 2.6‐2.8) and 6 showed HU slightly > 10 (range 11‐ 18). Among them, 2 pts with BAM showed both SUV max>2.5 and HU>10. In these cases the diagnosis had been obtained with ICH scan and MRI. BAMs were significantly more frequent in patients with KLC than with NDLC and in pts with NSCLC than in non‐cancer patients (p<0.01). Conclusions SUV max>3.0 shows 100% accuracy in detecting Amet. Cut‐off of SUV max at 2.5 and of HU at 10 shows 89.75% and 84.6% sensitivity respectively for diagnosing a BAM. ICH and NMRI can help the diagnosis of BAM. The high frequency of BAMs in patients with NSCLC needs further studies.
PW062 Stage IIIb or IV NSCLC lung cancer on CT, what is the point of a F-18 FDG PET/CT? J. D. Birchall1, G. McCulloch1, J. Mhlanga2; 1Royal Derby Hospitals NHS Foundation Trust, Derby City General Hospital, Derby, UNITED KINGDOM, 2 Imaging,Nottingham University Hospitals, Queens Medical Centre, Nottingham, UNITED KINGDOM. Aim and Background: F‐18 FDG PET/CT is established as part of the staging of patients with lung cancer in whom treatment with curative intent is being considered. Over the last few years following the result of MDT discussion were have had number of patients referred for PET/CT when other imaging suggested N3 or M1 disease ie AJCC stage IIIb or IV in whom treatment with curative intent would not normally have been considered. Method: Retrospective review 3 years PET/CT referrals for primary staging NSCLC. Determination of AJCC staging from both diagnostic CT and staging PET/CT, and subsequent assessment of whether management changed from palliative intent to curative intent. Results: In this period 731 incident cases of lung cancer and 268 patients referred for primary staging of NSCLC of whom 25% (67) had either stage IIIb (45) or IV (22) disease. 25 patients (37.3%) were downstaged understandably the number was greater in stage IIIb group 15 (33% of this group) than in stage IV group 10 (45% of this group). One patient each from IIIb and IV groups was considered on PET to have benign disease (TB and Wegner’s granulmatous). Hence, in 45% of these patients initially considered on basis of CT for palliative intent therapy being downstaged to either benign disease or curative intent therapy. Conclusion: We conclude that PET/CT is worthwhile in conventional imaging stage IIIb/IV groups and given this one may need to consider whether PET/CT should be more readily available even possibly replacing the diagnostic.
PW063 Discordant findings of skeletal metastasis between Tc-99m
MDP bone scans and F-18 FDG PET/CT imaging for non-small cell lung cancer: Absolutely normal bone scan versus disseminated bone metastases on PET/CT scans I. Ak1, M. C. Sivrikoz2, E. Entok1; 1Osmangazi University Medical Faculty Department of Nuclear Medicine, Eskisehir, TURKEY, 2Osmangazi University Medical Faculty Department of Thoracic Surgery, Eskisehir, TURKEY. At present, metastatic bone involvement is usually assessed using bone scintigraphy, which has a high sensitivity but a poor specificity. The objective of our study was to evaluate the utility of the F‐18 FDG PET/CT for the detection of bone metastasis in patients with non‐small cell lung cancer (NSCLC) those Tc‐99m MDP bone scan were absolutely normal. Material and Methods: This study based on the retrospective analysis of ninety five consecutive patients with histologically proven NSCLC who underwent F‐18 PET/CT and Tc‐99m MDP bone scan at Eski şehir Osmangazi University School of Medicine, Department of Nuclear Medicine between November 2006 and October 2008. Nineteen patients (19 of 95, 20%) with absolutely normal Tc‐99m bone scan versus multiple high‐grade F‐18 FDG avid bony metastases on F‐18 FDG PET/CT were selected for the review. Their ages ranged from 46‐73 years (15 males and 4 females; mean: 57.21 years). Results: Nine patients had squamous cell carcinoma, 6 had adenocarcinoma, 3 had large cell carcinoma and 1 had adenosquamous cell carcinoma. Tc‐99m MDP bone scan did not reveal bony abnormalities or radiotracer uptake was characteristic of benign disease (defined as absolutely normal) in these patients. Whereas, F‐18 FDG PET/CT not only showed extremely disseminated heterogeneous nest‐like high‐grade FDG avid metastatic foci within the marrow cavity of the upper and lower thoracic spine, lumbar spine, pelvis, rib cages and bilateral proximal long bones, and but also showed diseminated osteolytic bony metastases in these areas. Conclusion: Discordant findings of skeletal metastasis between Tc‐99m MDP bone scans and F‐18 FDG PET/CT imaging may be seen in 20% of the patients with NSCLC. F‐18 FDG PET/CT could detect metastatic bone involvement more accurately than bone scintigraphy Bone scans is insensitive to early bone marrow neoplastic infiltration. Assessment of glucose metabolism with FDG‐PET/CT can represent a more powerful tool to detect early bone metastases in lung cancer compared with traditional bone scans.
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99m
Comparison of F-FDG PET/CT scan and Tc - DPD bone scan for detection of bone metastases in patients with lung cancer H. Portilla-Quattrociocchi, I. Martínez-Rodríguez, I. Banzo Marraco, R. Quirce Pisano, J. F. Jiménez-Bonilla, A. Sainz Esteban, J. Barragan, P. Medina-Quiroz, J. M. Carril; Hospital Universitario Marqués de Valdecilla Medicina Nuclear, Santander, SPAIN. Aim: The aim of the study was to compare the accuracy and agreement of 18F‐FDG PET/CT (FDG) scan and 99mTc‐DPD (DPD) bone scan for the detection of bone metastases in patients with lung cancer Material and Methods: The study group included 37 patients (31 male, 6 female, mean age 65.1 ± 11.1 years) with lung cancer. Twenty‐nine patients had non‐small cell cancer (15 adenocarcinoma, 9 squamous cell, 2 large cell, and 3 without specific cell subtypes). Five patients had small cell lung cancer. Three had others lung cancer subtypes. Patients who received oncological treatments within the examinations were not included. Both DPD and FDG scans were obtained in a time interval less than 60 days (mean 15.9 ± 18.6 d.). Whole‐body DPD scan was obtained 2‐3 hours after intravenous injection of 99mTc‐DPD 750MBq. FDG scan (8 MBq/kg, 90 min tracer uptake time, 6 beds/2‐5 min per bed) was carried out from orbital region to proximal thigh region. A visual evaluation of the number and localization of bony lesions was performed. Results were compared with histological data (when available), structural techniques (X‐Rays, CT, MRI) and clinical follow‐up (mean: 179.3 ± 138.3 days). Results: In 33/37 patients bone lesions were detected with DPD, FDG or both. In 14/33 patients FDG showed more lesions than DPD. In 13/14 patients bone metastases were found (10 confirmed by structural images, 2 by clinical follow‐up, 1 by structural images and histology), and 1/14 a bening process was confirmed. In 8/33 patients both techniques showed similar findings: 6 had bone metastasis (3 confirmed by clinical follow‐up and 3, by structural images), 1 had benign lesion, and 1 had positive finding was unable to confirm. In 11/33 patients DPD showed more lesions than FDG. Two of these patients had bone metastases confirmed by structural images, 8 bening lesions (5 rib fractures, 2 degenerative, and 1 bone island), and 1 no diagnosis. FDG showed more bone metastases than DPD especially in the spine, pelvis and long bones. DPD showed more metastases in ribs. In 4/37 patients none of the techniques showed bone lesions. Conclusions: In most of the patients both techniques detected bone metastases and had a complementary role. When the techniques disagreed, FDG scan showed more bone metastases than DPD scan in spine, pelvis, and long bones (intramedullary, in the proximal third). Moreover, DPD scan showed more benign lesions than FDG scan.
PW065 Relationship among histological types, grading & SUV max in a group of lungs tumors diagnosed with PET-CT and 18F-FDG. B. Bagni, M. Cucca, C. Casali, L. Iacuzio, G. Pascale, A. Casolo, A. Franceschetto, U. Morandi; Università di Modena, Modena, ITALY. This study includes 119 patients treated at the Division of Thoracic Surgery of the University of Modena inclusion criteria were a FDG‐PET examination in the preoperative evaluation, a surgical treatment with curative intent and a definitive diagnosis of non‐small cell lung carcinoma (NSCLC) after a surgical histopathological examination. For all patients we recorded the maximal Standardized Uptake Value (SUVmax) on FDG‐PET examination, type of surgical procedure, postoperative mortality (within 30 days from the surgical procedure), pathological staging, histological diagnosis and grading, percentage of bronchioloalveolar (BAC) component in mixed adenocarcinoma (mixed ADK‐BAC). FDG‐PET examinations were performed using a PET‐CT scanner of G.E. Discovery ST‐A with a CT scanner with 16 arrays of detectors and an 18F‐FDG patients dose of 3.7 MBq/kg and a waiting time of 50 minutes. The reconstruction algorithm was the OSEM with two step iterations. Results. The mean and standard error of the SUVmax measurements for the whole series were 7.4 ± 0.4 with a 95% CI of 6.5 and 8.3. The SUVmax was
Poster Presentation
OBJECTIVE Selective Internal Radiation Therapy (SIRT) is a relatively new technique that delivers Yttrium 90 microspheres for the treatment of hepatic malignancies. The aim of this study is to review the role of liver directed radiotherapy with 90Y‐microspheres for unresectable hepatic malignancies. MATERIAL AND METHOD 15 patients with unresectable hepatic malignancies (5 HCC, 5 NET, 2 colorectal cancer, 1 unknown primary cancer, 1 malign melanoma, 1 ovarian cancer) that showed inadequate response to chemotherapy and other local treatment options such as chemo‐embolisation or radiofrequency ablation were considered for hepatic SIRT with resin microspheres. All patients had PET/CT scan for detecting any extrahepatic metastases, and also had pre‐treatment visceral angiography to define and occlude non‐target arteries. A simulation study with Tc99m MAA was performed for the evaluation of liver‐to‐lung shunt ratio and tumor vascularity. The Body Surface Area method was used to calculate the prescribed radio microspheres activity. RESULTS 15 patients with unresectable liver tumours have been treated from April 2008 to April 2009. The absorbed doses to tumour masses ranged between 120 Gy to 220 Gy (median 170 Gy), while the absorbed doses to normal liver ranged between 50 Gy to 100 GY (median 75 Gy). Follow‐up was performed with using PET/CT and tumor markers. PET/CT scans 3 months after SIRT showed decreased FDG uptake in 93% (14/15) of all patients. The decrease in tumour markers were well correlated with PET/CT findings. So far, no serious complication was recorded in any patient. CONCLUSION The selective nature of microsphere distribution allows the delivery of high doses of radiation to tumors while keeping the exposure of the healty liver at a minimum. SIRT with SIR‐Spheres microspheres is a promising treatment modality for those patients suffering inoperabl liver cancer.
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significantly related to histological grading and histological subtypes .The mean and standard error of the SUVmax was lower for well differentiated tumours (G1: 2.2 ± 0.3 with a 95% CI of 1.5 and 2.9) than moderate tumours (G2: 5.1 ± 0.7 with a 95% CI of 3.6 and 6.6) and poorly differentiated tumours (G3: 5.2 ± 0.3 with a 95% CI of 4.4 and 6.0) (p<0.001). Adenocarcinomas showed a mean and standard error of SUVmax of 5.2 ± 0.3 with a 95% CI of 4.4 and 6.0. This value was significantly lower than the other NSCLC subtypes: squamous cell carcinoma 10.5 ± 0.9 with a 95% CI of 8.7 and 10.4; large cell carcinoma 10.4 ± 0.3 with a 95% CI of 9.9 and 11.7 and pleomorphic carcinoma 13.2 ± 2.3 with a 95% CI of 7.5 and 18.9 (p<0.001). According to ROC curve analysis the optimal cut‐off value of SUVmax to discriminate adenocarcinoma from other histological subtypes was 5. When we used a cut‐off value of <5 to identify adenocarcinoma, the diagnostic performance of the SUVmax were as follows: sensitivity, 59.4%; specificity 93.7%; PPV 93.2%; NPV 61.6%. The area under the curve (AUC) of the maximal SUV was 0.839 (95% CI, 0.759‐ 0.900; p = 0.039). The SUV max evaluation seems to be also a good predictive marker to establish the pre‐surgical adjuvant chemotherapy
PW066 Correlation of SUV on 18F-FDG PET Uptake polymorphonuclear in Non-small Cell Lung Cancer
with
M. Simo1, A. Mestre-Fusco1, L. Pijoan2, T. Baro2, B. Casado2, C. Trampal1, A. Rodriguez3; 1CRC Mar, Barcelona, SPAIN, 2Hospital del Mar. Pathology Department, IMIM, Barcelona, SPAIN, 3Hospital del Mar.Surgery Department., Barcelona, SPAIN. Abstract : The aim of this study was to assess the correlation between SUV values on 18F‐FDG PET/CT studies with histophatological findings as polymorphonuclear (PMN) in patients with suspected non‐small cell lung cancer (NSCLC). Material and methods: 58 patients with suspected NSCLC (43 male) were studied. All had complete surgical resection and were diagnosed based on the WHO classification of NSCLC. PET imaging was performed with hybrid PET/CT scanner 60 min after 370 Mbq 18F‐FDG administrations. Tumour lesions were identified as areas of focally increased uptake in the lungs. For semi‐quantitative analysis, the maximum standardized uptake value (SUV) was calculated. Histopathological findings as polymorphonuclear, tumour infiltrating lymphocites, necrosis and vascular invasion were examinated in a section of surgically resected lung lesion. We compared SUV with these histophatological findings with two subgroups defined as the presence or not of every of these findings. Results: PET/CT showed focal uptake in primary tumour in all cases. Vascular invasion were observed in 21 patients (36,2%), PMN in 14 (24,1 %), infiltrating lymphocites in 51 (88 %) and necrosis in 34 (58,6 %). Non significant correlation was observed with 18F‐FDG PET SUV value with tumour infiltrating lymphocites, necrosis or vascular invasion. On the other hand, significant correlation was observed between SUV values with polymorphonuclear analysis (p < 0,001). PMN subgroup showed a higher SUV values (mean 14, standard error 6,3) than the non PMN subgroup (mean 9, standard error 6,7). Conclusion: We observed significant differences between SUV values on 18F‐FDG PET with the presence of PMN in NSCLC. Surgically resected lung lesion with PMN showed higher SUV in all the cases studied.
PW067 Correlation of SUV on 18F-FDG PET Uptake with Ki-67/MIB-1 index in Non-small Cell Lung Cancer A. Mestre-Fusco1, M. Simo1, L. Pijoan2, T. Baro3, B. Casado4, S. Mojal5, A. Rodriguez6; 1CRC Mar, Barcelona, SPAIN, 2Hospital del Mar. Pathology Department, IMIM, Barcelona, SPAIN, 3Hospital del Mar. Pathology Department, IMIM, Barcelona, SPAIN, 4Hospital del Mar. Pathology Department, IMIM, Barcelona, SPAIN, 5Hospital del Mar. AMIB, Barcelona, SPAIN, 6Hospital del Mar. Surgery department., Barcelona, SPAIN. Introduction: The aim of this study was to assess the correlation between SUV values on 18F‐FDG PET/CT studies with proliferative activity by the Ki‐67/MIB‐1 index in patients with suspected non‐small cell lung cancer (NSCLC). Material and methods: 58 patients with suspected NSCLC (43 male) were studied. All had complete surgical resection and were diagnosed based on the WHO classification of NSCLC ( adenocarcinomas n=29, bronchioloalveolar carcinomas n=2, squamous cell carcinomas n=16, large cell carcinomas n=7, carcinoid n=3 and mucoepidermoid carcinoma n=1). PET imaging was performed with hybrid PET/CT scanner 60 min after 370 Mbq 18F‐FDG administrations. Tumour lesions were identified as areas of focally increased uptake in the lungs. For semi‐quantitative analysis, the maximum standardized uptake value (SUV) was calculated. Proliferating cell activity as indicated by the Ki‐67 index was estimated in a section of surgically resected lung lesion. We compared SUV with their corresponding Ki‐67 using linear regression analysis, in the total group and in small subgroups: With tumour lesions size at least 2 cm, in squamous carcinoma and adenocarcinoma subgroups. Results: PET/CT showed focal uptake in primary tumour in all cases. A low correlation was observed between SUV and Ki‐67 (r=0,6; p=0.001) in the total group. A high correlation coefficient was observed in the tumour size at least 2 cm (n=35, r=0,73; p=0.001), similar to previous reports. In patients with benign pathology Ki‐67 was < 1% and SUV <2.5 showing perfect correlation. Large cell carcinomas showed high SUV and high Ki67. No correlation was observed in adenocarcinomas subgroup (n=29; r=0,30) and low correlation in squamous subgroup (r= 0,58, p=0,01). Conclusion: The results of this prospective study demonstrated significant correlation between degree of semi‐ quantitative uptake by SUV on 18F‐FDG PET with proliferative activity by the Ki‐67/MIB‐1 index in the primary tumour only in the subgroup of patients with tumour size above 2 cm in diameter.
PW068 Inmunohistochemical expression of the epidermal growth factor receptor (EGFR) in patients with non-small cell lung carcinomas. Correlation with other biological parameters and the values SUV-18F-FDG-PET A. Sanchez-Salmon, M. Garrido, M. Pombo, I. Abdulkader, F. Gude, L. Leon, A. Ruibal; Hospital Clinico Santiago, Santiago de Compostela, SPAIN. The EGFR is a tyrosinekinase transmembrane receptor involved in the physiopathology of the non‐small cell lung carcinomas (NSCLC). In order to study its behaviour, we have analyzed EGFR's
expression in 98 NSCLC patients (59 squamous cell type and 39 adenocarcinoma) by means of tissue‐arrays (Kit phamDX (K‐1494) of DAKO (Denmark) prediluted) and have compared it to the expression of HIF‐1alfa, p16 and p53. EGFR's expression (> 10 % positive cells) was observed in 19 adenocarcinomas and 39 squamous carcinomas (p 0,087) and there was no differences in relation to the clinical stage (I‐II: 28/46 vs III‐IV: 30/52). EGFR's expression was correlated positively (p: <0,000) with that of HIF1alfa and negatively with that of p16 (p:0,027). After multivariant analysis, the clinical stage was an outcome prediction factor (I‐II vs III‐IV; RR 2,3), but EGFR's expression was not. In 42 patients we compared EGFR's expression with the values SUV in the 18F‐FDG‐PET. These were of 9,4 +/‐5,4 in 6 cases negative EGFR; 13,9 +/‐6,3 in 11 EGFR +, 16,5 +/‐3,9 in 8 EGFR ++ and 19,6 +/‐9,7 in 17 EGFR +++, existing statistically significant differences (p:0,034). This direct correlation between both parameters could be explained by the functional relationship between the EGFR and the Na/glucose transporter (Engelman JA et to. Cancer Cell 2008; 13:375‐6) and by the relation with the HIF1a, which associates also to SUV's higher value (Ruibal A, et al. Eur J Nucl Med Mol Imaging 2008; (Suppl 2): S221). The previous results induce us to the following considerations: 1) the expression of EGFR is higher in the squamous cell carcinomas that in the adenocarcinoma and does not correlate with the clinical stage, but it does positively with the HIF1alfa and negatively with p16; 2) in the squamous cell carcinomas, EGFR's expression is correlated positively with the SUV values; 3) EGFR's expression was not a prognostic factor, but it was the clinical stage.
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Two-phase F-FDG PET study does not improve diagnostic accuracy in the differentiation of malignant from benign solitary pulmonary nodules T. K. Au-Yong, M. O. Kong, C. M. Tong; Nuclear Medicine Unit and PDY Clinical PET Centre, Queen Elizabeth Hospital, Kowloon, HONG KONG. Aim: To evaluate whether two‐phase FDG PET imaging improves the diagnostic accuracy in differentiating malignant from benign solitary pulmonary nodules (SPN) comparing with 1‐hour imaging. Methods: a retrospective study on patients who were referred to us for the evaluation of SPN. FDG PET studies were performed using a hybrid PET/CT scanner. Imaging was taken at 1 hour with or without delayed imaging at 3.5 hours after injection of the tracer. The maximum SUV pixel value (SUVmax) of the lung lesion in 1‐hour and delayed imaging was designated as SUVe and SUVd respectively. SUVe > 2.5 and an interval increase in SUV value (i.e. SUVd‐SUVe > 0) were considered as positive findings. Results were correlated with final diagnoses, either histologically or clinically. Results: 81 patients (46 male, 35 female, mean age 64 years) were recruited. 41 patients had two‐phase study performed. All were followed up with mean duration of 38.4 months (range 12‐72 months). 53 patients were diagnosed to have malignant SPN and 28 patients had benign nodules. The malignant nodules had significantly higher SUVe (mean 6.5 + 4.1 vs. 3.2 + 2.9; median 5.5 vs. 2.1; Mann‐Whitney test, p = 0.000). 42/53 patients with malignant SPN and 11/28 patients with benign nodules had SUVe > 2.5. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy was 79.2 %, 60.7 %, 79.2 %, 60.7 % and 72.8 % respectively. 13/22 of patients with malignant nodules and 6/19 patients with benign nodules had delayed increase in SUVmax. These gave sensitivity, specificity, PPV, NPV and accuracy of 59.1 %, 68.4 %, 68.4 %, 59.1 % and 63.4 % respectively. If combining SUVmax > 2.5 AND change in SUVmax of > 0 as positive finding, the sensitivity was decreased to 50 %, while the specificity was increased to 77.3 %. The PPV, NPV and accuracy became 68.8 %, 60.7 % and 63.0 % respectively. If the diagnostic criteria of either SUVe > 2.5 OR change of SUVmax > 0 was used, the sensitivity, specificity, PPV, NPV and accuracy was 72.7 %, 62.5 %, 64 %, 62.5 % and 63.4 % respectively. Conclusions: SUVmax value at 1 hour post‐injection gives the highest sensitivity and accuracy in the diagnosis of malignant SPN. Two‐phase FDG PET provides little value in the selection of patients with SPN for further evaluation.
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The value of dual-phase F-FDG PET/CT in the assessment of single pulmonary nodules with an initial standard uptake value≥2.5. Z. Wu, Y. Zhang, Q. Jia, X. Sun; The PET Center of Union Hospital,Tongji Medical College,Huazhong University of Science&Technology, Wuhan, CHINA. [Aim] A cutoff standard uptake value (SUV) of 2.5 has been commonly adopted for 18F‐FDG PET to evaluate single pulmonary lesions(SPN),but false‐positive results can occur in nodules with an initial maximum SUV≥2.5.Studies have shown that delayed PET is useful to improve accuracy.This study was designed to assess the valve of delayed PET in the differentiation of SPN with an initial maximum SUV≥2.5. [Material and Methods] Fifty‐six patients with SPN(diameter,7‐30 mm) with an initial maximum SUV≥2.5 were retrospectively investigated.Dual‐phase FDG PET images were obtained 1 and 2.5 hours after FDG injection,and SPN with an initial maximum SUV≥2.5 were identified.Nodules were confirmed to be malignant lesions(n=33) or benign lesions(n=23) by histopathologic findings or clinical follow‐up(lasting 12~33months).The differences in retention index(RI) between benign and malignant pulmonary lesions were analyzed,and a cutoff of RI greater than 0% or 10% was adopted to evaluate SPN.[Results] A RI≤0% was observed in 12.1%(4/33) of the malignant lesions,and 8.7%(2/23) of the benign lesions had a RI≤0%(χ2=0.1663,P value=0.6835).18.2% (6/33) of the malignant lesions had a RI<10%,and 17.4%(4/23) of the benign lesions had a RI<10%(χ2=0.0058,P value=0.9394).No significant differences in retention index between benign and malignant lesions were found.[Conclusion] It is suggested that delayed 18F‐FDG PET be not useful for differentiating benign and malignant single pulmonary nodules with an initial maximum SUV≥2.5.
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Poster
walking
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gastrointestinal
cancer
diagnosis
PW071
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Usefulness of F-FDG-PET/CT for a Post-surgical Follow-up Study in Gastrointestinal Tract Cancer H. Munechika, H. Shinjo, K. Kawakura, Y. Miura, Y. Miura, T. Abe, T. Saginoya, K. Watanabe; Southern Tohoku General Hospital, Koriyama, Fukushima, JAPAN. Purpose/Introduction The aim of this study was to see that 18F‐FDG‐PET/CT (PET/CT) was useful for a post‐surgical follow‐up study in gastrointestinal tract cancer because metastasis or recurrence of cancer could be found more easily in PET/CT than in contrast‐enhanced CT (CE‐CT). Materials and Methods Recurrent or metastatic lesions were found by post‐surgical PET/CT in 39 patients. The primary malignant tumor included 12 esophageal cancers, 7 gastric cancers and 20 colorectal cancers. Metastasis and recurrence of cancer were confirmed by clinical follow‐up studies or histological examinations. The findings of whole body CE‐CT that was obtained shortly before or after PET/CT were compared retrospectively with the findings of PET/CT to see whether the lesions could be found by CE‐CT alone without knowledge of PET/CT findings in 47 lesions of 39 patients. The 47 lesions included 22 in lymph node, 5 in the peritoneum, 2 in primary cancer recurrence, 8 in the lung and 10 in the liver. Results 73 % (16/22) of lymph node metastasis, 40 % (2/5) of peritoneal metastasis, 0% (0/2) of primary cancer recurrence, 100% (8/8) of pulmonary metastasis and 90% (9/10) of hepatic metastasis were found by CE‐CT alone when compared with PET/CT. Only 17% (1/6) of the lesions could be found by CE‐CT when the lesion was located at post‐surgical regions. Conclusion/Discussion PET/CT was useful for a post‐surgical follow‐up study in gastrointestinal tract cancer. CE‐CT should be performed for further evaluation. However, CE‐CT was suited for evaluation in the lung or liver because detectable size of the lesion was limited in PET/CT.
PW072 Incicental finding of FDG-AVID HOT SPOT in the colon at WB PET/CT: Clinical significance and diagnostic work-up E. Banti1, L. Rampin1, G. Grassetto1, M. Marzola1, S. Cittadin1, A. Massaro1, G. Del Favero2, D. Rubello1; 1Nuclear Medicine Service - PET Centre Hospital Rovigo, Rovigo, ITALY, 2Gastroenterology Unit - Hospital Rovigo, Rovigo, ITALY. Aim: To evaluate clinical significance and management of incidental finding of FDG‐avid hot spot in the colon at WB PET/CT scan. Methods: In the period from Jan. 2008 to Dec. 2008, 2247 pts were scanned by a hybrid PET/CT system (GE, Discovery STE). Pts were examined in fasting condition. Serum glucose levels were systematically measured before low dose (2.2 MBq/Kg b.w.) FDG administration (only pts with glucose levels < 180 mg/dL were injected) . WB acquisition started 1 hr after FDG injection by 3D method. 189 pts referred to us to investigate an intestinal tumour were excluded from the present analysis. Pts with a finding at PET/CT of an incidental solitary FDG‐avid hot spot in the colon underwent further diagnostic work‐up by colonoscopy performed within a 4‐week period from PET/CT. Results: in 97 of 2058 pts (4.7%) a solitary FDG‐ avid hot spot in the colon was found. At subsequent colonoscopy, in 64 pts (66% of cases) no pathologic findings were detected and the FDG PET/CT was interpreted as an unspecific radio‐ tracer accumulation in the bowel. In the remaining 33 pts a polyp was edoscopically removed (size ranging 8 mm to 4 cm, median 1.6 cm; SUVmax ranging 7.3 to 20.9, median 13.6): at subsequent E&E histological examination 20 polyps were diagnosed as benign adenomas, low‐ grade dysplasia in 5 cases, medium‐high grade dysplasia in 4, adecarcinoma in 4. These latest pts underwent surgery and, of note, no loco‐regional or distant metastases were found intra‐ operatively. Conclusion: the prevalence of incidental finding of FDG‐avid hot spot at WB PET/CT scan is not a rare condition accounting for about 5% of cases in our series. Despite of in more than half of these pts an unspecific FDG accumulation is found at colonoscopy, in more than one third of cases a polyp is detected and in a fraction of these patients a low to high‐grade dysplasia or an adenocarcinoma is diagnosed. It’s recommended to perform colonoscopy in pts with focal FDG uptake in the colon showed at WB PET/CT scan with the main purpose to early diagnose and treat malignant polyps.
PW073 Is the CEA-test of benefit in the interpretation of F18-FDG PET-CT-scans in the postoperative follow-up of rectal cancer? B. Intriago1, M. Danus1, C. Trampal2, N. Calvo1, E. Rebenaque1, L. Milla1; Dimatge-CRC-University Hospital San Joan Reus, Reus, SPAIN, 2IAT-CRC, Barcelona, SPAIN.
1
Objetives: The aim of this study was to assess whether the carcinoembryonic antigen (CEA)‐test may be of benefit in the interpretation of F18‐FDG‐PET‐scans in the postoperative screening for recurrence of rectal cancer and to find out if a particular pattern of association was present. Methods: We performed a retrospective study including patients referred to our institution during the last 18 months. The patients underwent a F18‐FDG‐PET‐scan as postoperative screening modality for recurrence of rectal cancer. All patients presented pathological levels of CEA at the time of first diagnosis and were referred either based on pathological increased CEA serial blood‐test or because of suspected recurrence at conventional imaging (CT, RM) or physical examination. A CEA‐test cut‐off of 5ng/ml was established. Outcomes were confirmed either through biopsy or based on clinical follow up (minimum 6 months). Results 42 patients with treated rectal cancer underwent a F18‐FDG‐PET/CT‐scan because of suspected tumor recurrence: 27 cases showed increased CEA levels and 15 normal CEA‐test. F18‐FDG‐PET‐scan showed 3 false positives in patients with normal CEA‐test due to granulomatous tissue uptake. In two cases of positive CEA‐test, no recurrence of rectal cancer was found, but in both cases medullary thyroid carcinoma was detected instead at PET‐CT‐scans. However, in 6/11 patients, metastatic
pulmonary nodules < 1cm were present, without pathological FDG‐uptake and with negative CEA‐test. Considering that F18‐FDG‐PET‐CT‐scan was able to correctly detect all metastatic pulmonary nodules even the ones without FDG‐uptake (based upon the lowdose‐CT images), the overall results for this modality were: 100 % sensitivity, 88% specificity, 90% PPV, 100% NPV , 21.4% FP and 0% FN, (diagnostic OR 2). CEA‐test showed the following results: 60% sensitivity, 70% specificity, 29% FP, 36% FN, (diagnostic OR 1.47). CONCLUSIONS: Despite the small sample, this study discloses the potential benefit of CEA‐test as an additional diagnostic tool in the interpretation of F18‐FDG‐PET‐CT‐scans in the surveillance of rectal cancer: • CEA‐test seems not to be altered in PET‐CT‐scans depicting areas of granulomatous disease mimicking recurrence. • CEA‐test combined to PET/CT studies may be helpful in disclosing unexpected primary tumors. • CEA‐test resulted negative in cases of pulmonary metastatic nodules <1cm.
PW074 F-18 FDG PET/CT in the assessment of patients with unexplained CEA rise after surgical curative resection for colorectal cancer. G. Storto1, S. Ippolito2, S. De Luca2, M. Lancellotti1, A. Nappi1, A. Cammarota1, V. Suriano1, A. Venetucci1, A. Nardelli3, G. Ortosecco3, A. Di Leo1, A. Tempone1, R. Pace1, L. Pace2; 1IRCCS CROB, Rionero in Vulture, ITALY, 2Dept. of Biomorphological and Functional Sciences, Univ. “Federico II”, Naples, ITALY, 3Inst.of Biostructures & Bioimages, CNR, Naples, ITALY. Aim: Postoperative follow‐up for asymptomatic patients with rising serum CEA levels after curative colorectal cancer resection represents a clinical challenge. We evaluated the role of the quantitative assessment by SUVmax on F‐18 FDG PET/CT for stratifying patients with unexplained CEA rise after surgical curative resection. Material and Methods: Twenty‐three asymptomatic patients (mean age, 63±14 years) with previous colorectal cancer presenting serum CEA levels >10 ng/ml underwent F‐18 FDG PET/CT 13±3 months after the complete surgical intervention. All patients had adjuvant chemotherapy, none received radiotherapy recently. The maximum standardized uptake value (SUVmax) was registered on anastomosis and peri‐anastomotic tissue lesions, if any (i. e. pericolic fat thickening and/or n. 1 lymph nodes >1cm or n. 3 in cluster). Patients were followed up 24±13 months thereafter. Main events such as re‐intervention, evidence of newly discovered distant metastases or death constituted surrogate end‐points. Receiver‐operator‐curve (ROC) analysis was performed to estimate the optimal cut‐off of SUVmax for differentiating patients at high risk of main events. PET/CT results were then compared to the disease outcome (overall survival; OS).Results: Mean SUVmax at the anastomotic site was 6.2±3 (range 2.5‐15). 8/23 patients (35%) had evidence of peri‐anastomotic involvement at F‐18 FDG PET/CT as per pericolic fat thickening or lymph nodes showing increased uptake (SUVmax 9.2±4). 4/23 patients (17%) had biopsy confirmation of recurrence and further underwent re‐intervention whereas 5/23 (22%) showed newly discovered distant metastases and 3/23 (13%) died. The remaining 11 patients (48%) were fully active without signs of relapse. ROC analysis recognized that the optimal threshold of SUVmax for differentiating patients at high risk of main events was 5.2. A worse OS was observed for patients with a SUVmax greater than 5.2 as compared to those with SUVmax values lesser (median survival: 13 vs 29 months; p< 0.001).Conclusion: the quantitative assessment by SUVmax on F‐18 FDG PET/CT may be helpful for stratifying patients presenting unexplained CEA rise after curative resection at risk of main events. A better OS was observed in patients with SUVmax values < 5.2 at the anastomotic site.
PW075 The Value of F-18 FDG PET/CT in Restaging of Recurrent Colorectal Cancer Patients with Elevated Serum Tumor Markers and Unclarified by Conventional Imaging Modalities A. Küçüköz Uzun, T. Özülker, F. Özülker, Ö. Eker, T. Özpaçacı, M. Mülazımoğlu; Okmeydanı Training and Research Hospital, Department of Nuclear Medicine, Istanbul, TURKEY. Aim The objective of this study was to determine the efficacy of F‐18 FDG PET/CT in restaging of previously operated colorectal cancer patients whose tumor markers are elevated and findings of conventional imaging modalities (CIM) like USG, CT, MR are nondiagnostic or equivocal. Materials and Methods This is a retrospective study performed in 49 patients (25 males, 24 females) with colorectal cancer with a mean age of 61,3 years (range between 28‐82). All patients had undergone low anterior resection or hemicolectomy. All of them had elevated serum tumor markers (CEA and/or Ca 19‐9) during follow up. In all patients exploration with 18‐F FDG PET/CT scan were undertaken and PET/CT findings were compared with other conventional imaging methods (CT, MR, USG). In case of any abnormality on PET/CT, follow up after treatment were performed with PET/CT, conventional imaging methods and serum tumor marker levels. Results In 19 patients (38,7%) metastases or recurrences were detected by both PET/CT and conventional imaging methods. 13 patients (26,5%) with no radiologic evidence of relapse or metastases had positive findings on PET/CT studies. In 2 out of these 13 patients PET/CT reported the lesions as suspicious for malignancy, and on follow of both of them turned out to be metastases. In 8 patients (16,3%) PET/CT detected new metastatic foci in addition to lesions detected by CT, MR and PET/CT. These lesions were mostly lymphadenopathies which are not reported on CT since their dimensions were not at pathological levels. In 7 patients (14,2%) the lesions which were equivocal on CIM were found to be malignant in PET/CT studies. In 2 patients (4%) lesions which were thought to be malignant on CT, were reported as benign reactive hyperplasia in lymph nodes. Conclusion In nearly two‐thirds of patients with colorectal carcinoma, serum carcinoembryonic antigen levels are elevated with a sensitivity of 70‐80%. CIM can detect relapses only in 3‐9 months following the rise in CEA. Staging is important in colorectal cancer patients because of its impact on the management of the patients. In our study PET/CT has changed the management of the disease in 61,2% of the patients and its sensitivity is found to be higher than CT, MR and USG.
Poster Presentation
PW08 ‐ Monday, October 12, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
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PW076 Evolving role of PET scan in colorectal cancer patients with rising CEA and negative CT scans M. A. Shimpi, B. A. Krishna; P.D.National Hinduja Hosp & MRC, Mumbai, INDIA. INTRODUCTION: The rising CEA level with negative CT scans is a diagnostic dilemma in colorectal carcinoma patients during follow up. The FDG‐PET scan is prooving to be useful in this context. Hence we undertook a study to determine the sensitivity of FDG‐PET in this clinical context. MATERIALS AND METHOD: Total of 36 patients were included in the study. All of them had rising CEA levels with negative CT scan. The FDG PET/CT scans were performed using the standard protocol .The SUV values were calculated using body weight criteria. These patients were grouped into five categories depending upon the CEA level. RESULTS: Of the total 36 patients, PET/CT demonstrated recurrence in 27(75%) patients, while in 9 (25%) patients the PET/CT was negative. In Group I (CEA<5ng/ml) FDG‐ PET was positive in 4/10( 40%) patients, Group II (CEA 5‐ 10ng/ml) PET was positive in 2/3(66%), Group III (CEA10‐20ng/ml) in 5/6 (83% ), Group IV (CEA 20‐50ng/ml) 9/10 (90%) patients and Group V (CEA >50ng/ml) 7/7(100%) patients. There were local recurrence in 9 patients, nodal disease in 9 metastasic lung lesions in 4, liver disease in and skeletal metastasis in 2 patients. All these patients underwent further treatment in the form of surgery, RFA, chemotherapy, radiotherapy. CONCLUSION: Our study demonstrates overall sensitivity of 75 % for FDG PET scan in this clinical context, highlighting the superior role of FDG‐ PET scan over CT scan. The sensitivity appears to be directly related to the CEA levels with sensitivity of above 80% in patients with CEA>10 ng/ml and 40 % in less than 5 ng/ml which would also be clinically useful
PW077 PET/CT Detection of Incidental Colorectal Foci of FDG Uptake : Correlation With Colonoscopy Results M. Nouira1, I. Sobhani1, H. Hagège2, E. Evangelista1, M. Meignan1, E. Itti1; Henri Mondor Hosp., Créteil, FR, 2Intercommunal Hosp., Créteil, FRANCE.
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Purpose: FDG‐PET is an established tool for the diagnosis of recurrent or metastatic colorectal carcinoma. Several case series suggest that FDG‐PET often detects incidental adenomatous polyps which are cancer precursors. The aim of this study was to correlate unexpected colorectal foci of FDG uptake to pathology findings after systematic colonoscopy. Patients and Methods: We reviewed the records of more than 3500 patients who underwent FDG PET/CT in our institution over a 2‐year period for the assessment of a known or suspected malignancy. In 85 of them, incidental, nodular shaped and well‐circumscribed foci of abnormal uptake were identified in the area of the colon or rectum. Patients with segmental or diffuse abnormal colorectal uptake were excluded, as well as patients with known benign or malignant colorectal disease. Colonoscopy and complete pathology report was available in 29 patients. Maximal Standardized uptake value (SUVmax) was measured in all lesions. Results: Unexpected colorectal foci of FDG uptake were associated with colonoscopic abnormalities in 23 patients (true positive rate 79%). Adenocarcinomas were found in 6 patients (SUVmax = 7.3±2.6), tubulous adenomas in 4 patients (SUVmax = 7.3±4.9) and tubulovillous adenomas in 12 patients (SUVmax = 4.2±1.1). Hyperplasic polyps with no sign of dysplasia were found in the last patient (SUVmax = 3.3). Concomitant CT abnormalities were found on PET/CT fusion in 8 patients and consisted of wall thickening (n=5) or nodular mass (n=3). Conversely, PET was falsely positive in 6 patients (21%), with no concomitant CT abnormalities and no abnormal findings at endoscopy (SUVmax = 6.2±2.8, no significant difference with true positive lesions). Conclusion: Our findings emphasize the need for systematic colonoscopy in front of incidental colorectal foci of FDG uptake because malignant or pre‐malignant neoplasms, which are not clinically apparent, are found in more than 3/4 of cases.
PW078 The Clinical Value of Dual Time Point F-18 FDG PET/CT Imaging for the Differentiation of the Colonic Focal Uptake Lesions J. Kim1, S. T. Lim2, Y. J. Jeong1, D. W. Kim2, H. Jeong2, M. Sohn2; Department of Nuclear Medicine, Chonbuk National University Medical School & Hospital, Jeonju, REPUBLIC OF KOREA, 2Department of Nuclear Medicine, Research Institute of Clinical Medicine, Cyclotron Reasearch Center, Chonbuk National University Medical School & Hospital, Jeonju, REPUBLIC OF KOREA. 1
Aim: F‐18 FDG can accumulate in the liver, bowel, kidney, urinary tract, and muscles physiologically. The aim of this study was to evaluate the clinical value of dual time F‐18 FDG PET/CT imaging for the differentiation of the colonic focal uptake lesions. Materials and Methods: One hundred thirty two patients (M:F=77:55, Age: 62.8±11.6 years) underwent F‐18 FDG PET/CT at two time points, prospectively: early image at 50‐60 min and delayed image at 4‐4.5 hours after the intravenous injection of F‐18 FDG. Focally increased uptake lesions on early images but disappeared or shifted on delayed images defined a physiological uptake. For the differential evaluation of persistent focal uptake lesions on delayed images, colonoscopy and histopathologic examination were performed. SUVmax changes between early and delayed images were also compared. Results: Among the 132 patients, 153 lesions of focal colonic uptake were detected on early images of F‐18 FDG PET/CT. Of these, 72 (47.1%) lesions were able to judge with physiological uptake because the focal increased uptake disappeared from delayed image. Among 81 lesions that persistent increased uptake in delayed image, 61 (75.3%) lesions were confirmed as the malignant tumor and 14 (17.3%) lesions were confirmed as the benign lesions including adenoma and inflammatory disease. Remaining 6 (7.4%) lesions were confirmed as the physiological uptake because there was no particular lesion in the colonoscopy. In the malignant lesions, the calculated dual time point change for SUVmax (Δ%SUVmax) was 20.8%±18.7%, indicating a significant increase in SUVmax between the two point (p<0.01). In contrast, the change in SUVmax for the non‐malignant lesions including benign lesions and physiological uptake was ‐13.7%±24.2%. For the differentiation of the malignant and non‐malignant focal colonic uptake lesions, Δ%SUVmax was the most effective parameter, and the cut‐off value using ‐5% provided the best sensitivity, specificity, and accuracy. Conclusion: The dual time F‐18 FDG
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 PET/CT imaging using SUVmax change could be an important noninvasive method for the differentiation of malignant and benign focal colonic uptake lesions including physiologic uptake.
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Impact of F-FDG-PET/CT scan on clinical management in patients with potentially operable oesophageal adenocarcinoma L. Iordanidou1, S. Vyas2, M. Hashemi2, D. Stoker2, I. Mitchell2, S. Read3, A. Almuhaideb1, N. Papathanasiou1, J. Bomanji1; 1Institute of Nuclear Medicine UCLH, London, UNITED KINGDOM, 2Division of Oesophageal Surgery UCLH, London, UNITED KINGDOM, 3Radiology Department UCLH, London, UNITED KINGDOM. Aim In the western world, oesophageal adenocarcinoma has replaced squamous cell carcinoma as the most frequent variety of oesophageal cancer. The TNM stage of the disease at presentation is the single most important prognostic determinant of survival. The aim of this study was retrospectively to evaluate the role of routine 18FDG‐PET/CT scanning in the staging of oesphageal adenocarcinoma , particularly with its ability to detect incidental occult synchronous neoplasms in this group of patients. Patients and Methods Staging data (EUS, CT and PETscans) on 104 patients with non‐metastatic (as on initial CT scan) oesophageal adenocarcinoma ( Siewert Types 1,2,3 ) were reviewed. Subject to their TNM staging on EUS / CT scanning patients were offered primary surgery ( T1/2,N0) or neoadjuvant chemotherapy ( T3/4 and N1 diease ) followed by oesophagectomy. Prior to initiation of treatment all patients underwent an 18F‐FDG PET/CT scan for delineation of metastatic disease. FDG‐avid hot spots detected were further investigated to rule out metastatic disease or coexisting malignancies ‐ conditions that would 18 significantly alter primary treatment plans. Results F‐FDG PET/CT re‐classified 14 of 104 patients (13.5 %). Eight patients were upstaged as M1b disease, missed by CT/EUS (3 with distant nodal disease; 5 distant organ metastases) leading to change of treatment plan from potentially curative to palliative chemotherapy. The remaining 6 patients were found to have unsuspected synchronous primary cancers (SPC) (6/104; 5.76%).Three of them had early stage colorectal adenocarcinomas; and 3 had SPC in the pancreas, lung and prostate respectively. The patients with colorectal adenocarcinomas, lung and pancreatic tumours were treated with curative intent alongside their oesophageal cancer. However the patient with prostate cancer had locally advanced lymph nodal disease in the pelvis from his prostatic primary , thereby precluding potentially curative treatment for the oesophageal cancer . He was treated with palliative chemotherapy and radiation. Compared with pathology the positive predictive value of PET‐CT was 73.6 % and negative predictive value was 92.2% with an overall accuracy 93.2 %. Conclusions 18 F‐FDG PET/CT in patients with esophageal adenocarcinoma shows high accuracy in the detection of occult distal malignancies and alters the clinical management by avoiding futile surgery and modifying the chemotherapy treatment plan from curative to palliative one.
PW080 The role of F-18 FDG PET/CT staging in the management of Oesophageal Cancers S. Han1, M. F. Dempsey1, S. Ballantyne2; 1West of Scotland PET Centre, Gartnavel General Hospital, Glasgow, UNITED KINGDOM, 2Radiology Department, Gartnavel General Hospital, Glasgow, UNITED KINGDOM. Background & Aim Oesophageal cancer is the 5th most common cause of cancer deaths in the UK.1 Accurate staging of oesophageal cancer is crucial in selecting appropriate patients for curative surgery or radical radiotherapy, and in avoiding futile operation. The main staging tests have been CT, endoscopic ultrasound (EUS) and laparoscopy. 2 Since the arrival of a new PET/CT scanner at Glasgow Beatson Oncology Centre in November 2007, PET/CT has been increasingly used in the oesophageal cancer staging in the West of Scotland. This study is to determine the diagnostic accuracy of PET/CT in defining regional nodal status (N stage) and distant metastases (M stage), and the impact on patient management. Methods 54 patients with known oesophageal cancers attended the West of Scotland PET Centre for an F‐18 FDG PET/CT scan between December 2007 and November 2008 for preoperative staging. Pathology staging information, follow up imaging results and case records were available in 43 patients (34 males, 9 females, ages 63 ± 10.5 years) for retrospective review. PET/CT reports were compared with gold standard pathological staging when available (n=31; radical surgery 21, biopsy/cytology 10). For the remaining 12 patients, follow up imaging (CT, MRI, isotope bone scan) and clinical notes were used to assess the nodal/metastatic disease. Results Sensitivity, specificity and accuracy of PET/CT staging for N stage were 66%, 90% and 72% respectively, and for M stage were 83%, 92% and 88% respectively. PET/CT demonstrated true positive metastases in lungs (3), bone (3), non‐ regional nodes (9). The use of PET/CT for preoperative staging altered clinical management in 13/43 patients (30%). Of these 13 patients, radical surgery was decided unsuitable in 12 patients because of distant metastases detected by PET/CT and in 1 patient because of no active residual disease on PET/CT following neoadjuvant therapy and comorbidity. Within the follow up period of 2‐12months from diagnoses 9/17 patients with PET/CT M1 stage died (53%) compared to 2/26 with M0 (8%). Conclusions F‐18 FDG PET/CT imaging is highly accurate in the assessment of M stage, a strong prognostic marker and a reliable test to identify appropriate patients for radical surgery in oesophageal carcinoma. References: 1. UK Cancer Mortality Rates 2006 (Cancer Research UK) 2. Management of oesophageal and gastric cancer (SIGN guidelines 87) June 2006
PW09 ‐ Monday, October 12, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 9: cardiovascular - myocardial perfusion scintigraphy
PW081 Assessment of Frequency of SPECT and CT Misalignment in Myocardial Perfusion Studies
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Purpose Attenuation correction of myocardial perfusion scintigrams enables differentiation between artifacts caused by attenuation of gamma rays in a patient body and actual deficits of radiopharmaceutical uptake (perfusion defects). The aim of the work was to assess the frequency of misalignment of SPECT and CT images and its impact on attenuation corrected scintigrams. Methods 102 patients (mean BMI=28) were studied according to a two day study protocol, using a Hawkeye gamma camera (GE). Seventy seven stress and 101 rest (together 177) studies were analyzed (several patients did not show up for a second study; 6 studies were rejected from analysis: 1 because of a significant sub‐diaphragmatic activity and additional 5 because of serious CT image artifacts). Check of alignment of CT and SPECT images was made visually. Cases of misalignment were corrected by shifting CT slices in proper directions. For every shifted CT study a length of a shift vector was calculated as a square root of sums of squares of shifts along 3 axes: x (lateral), y (ventrodorsal) and z (craniocaudal). Shifts have been divided into 3 groups: A. less than 1 pixel (6.9mm), B. between 1 and 2 pixels and C. larger than 2 pixels. Next, two observers compared visually, by method of consensus, attenuation corrected scintigrams before and after CT realignment. Results Misalignment was observed in 38 out of 177 (22%) studies; in rest as well as in stress studies in 19 cases (20% and 25%, resp.). In group A 20 (19%) studies were found, in group B ‐ 15 (9%), whereas in group C ‐ 3 (2%) studies. The largest number of shifts were made in a lateral plane, the smallest one in a ventrodorsal direction. A visual comparison of myocardial scintigrams attenuation corrected before and after CT realignment revealed an impact of realignment on all 3 (100%) studies in group A, 7 (47%) studies in group B and 7 (35%) studies in group C. This impact in 34% was observable in the anterior, in 18% in the septal, in 11% in the lateral and in 11% in the inferior walls, and in 13% of cases in the apex. Conclusion Application of CT‐derived attenuation correction to myocardial perfusion scintigrams requires a routine control of SPECT and CT studies alignment. Misalignments can be observed in over 20% of cases and can introduce artifacts in all locations in myocardium.
PW082 Feasibility and validation of 10 min post-stress tetrofosmin myocardial gated SPECT in CAD patients S. Costo1, A. Manrique2, V. Dunet1, F. Besson1, G. Grollier1, J. Parienti1, G. Bouvard1, D. Agostini1; 1CHU Côte de Nacre, Caen, FRANCE, 2CYCERON, Caen, FRANCE. The aim of this prospective study was to compare tetrofosmin SPECT imaging performed 10 and 30 min after the injection at stress in order to detect CAD and myocardial stunning. Methods : 134 patients (G0) (108 M, 26F, age: 62+/‐10), suspected or known from CAD, enrolled the study and underwent 123 pharmacological stress (120 diprydamole, 3 dobutamine) and 11 treadmill tests. Acquisitions were done at 10min (T1), 30 min (T2) and 4 hrs after tetrofosmin injection on a double‐head camera (LEHR, 8 bins, 40s per image). Image quality was assessed using a 4‐point visual scale. Myocardial perfusion was analyzed on a 17‐LV‐segment model using 0 to 4 scale visual scoring system to determine summed difference score (SDS) at T1 and T2. Function (EDV (ml), ESV (ml), LVEF (%)) parameters were automatically analyzed using QGS software. Stunning was defined by a decrease of 5% between post‐stress and rest LEVF with myocardial ischemia patterns (SDS>0). Results: 38 normal (G1) and 96 abnormal (G2) scan (ischemia and/or infarction) were identified. Images quality was suitable for interpretation for 86% (116/134) at T1 and 91% (122/134) at T2; scans were discordant in quality for 6% (p=0.034), mostly because of high sub‐ diaphragmatic activity. Lung to heart and liver to heart ratios were significantly higher at T1 than at T2 (p<0.001). Perfusion scores SDS (T1 vs. T2) were significantly correlated for G0 (r=0.77), G1 (r=0.43), G2 (r=0.77) (p10. Logistic regression curves representing the probability of ischemia function of SDS in G0 showed excellent c index values, 0.97 and 0.96, at T1 and T2 respectively. LVEF (T1 vs. T2) were significantly correlated for G0 (r=0.9), G1 (r=0.84), G2 (r=0.91) (p<0.001). LVEF increased significantly between T1 and T2: G0 (58.9±12.7% vs. 55.7±11.2%), G1 (64.5±11.9% vs. 62±10.7%), G2 (56.5±12.4% vs. 53.1±10.4%) (p<0,02). Stunning in ischemic patients (67) was detected in 11 cases (16%) at T1, 21 cases (31%) at T2 (p=0.0003). Scans were concordant in 79% (53/67). Conclusion: Early tetrofosmin gated SPECT is a feasible, reproducible and reliable method to determine perfusion and function measurements in patients with CAD. However, quality of images is slightly worse and myocardial stunning can be underestimated at T1. Key words: tetrofosmin, myocardial gated SPECT, early acquisition, myocardial stunning, coronary artery disease
PW083
or a partially reversible defect was considered a sing of stent restenosis. Results: The quality of GSPECT images was rated as optimal in 34 patients, good in 17 patients and poor in 1 patient. The only patient with poor‐quality images showed very high liver uptake, low hepatobiliary clearance and was with obesity. In MP SPECT, 21/65 (32%) vascular stented territories showed stress induced ischemia (18 of them were partially reversible, 3 were completely reversible) and were classified as restenoused; 44/65(68%) territories were with normal Tf uptake. Restenosis was found in 11 LAD, 9 RCA and 1 RCx that were stented. As compared to the coronary angiography results, there were 15 true positive, 39 true negative, 6 false positive and 5 false negative findings. The sensitivity, specificity and accuracy of 99mTc‐Tf fast imaging were: 75%, 87% and 83% respectively. Conclusion: 99mTc‐Tf fast‐imaging MS GSPECT is a sensitive method for detection of restenosis after PTCA. Our data confirm that it can provide clinical information the same as that, provided by the standard protocols, reducing total imaging time and improving the logistics of nuclear medicine laboratory.
PW084 Pre-Risk Assessment of CHD: Coronary Artery Calcium Score compared with Framingham Score and Copenhagen Risk Score in a Danish Population (Preliminary Results). K. F. Andersen1, L. Alslev1, B. Zerahn1, P. Hasbak2; 1Dept. of Clinical Physiology & Nuc. Med., Herlev Hospital, Herlev, DENMARK, 2Dept. of Clinical Physiology & Nuc. Med., Rigshospitalet, Copenhagen, DENMARK. Aim This study compares three different coronary heart disease (CHD) risk assessment tools (Coronary Artery Calcium (CAC) score, Framingham Score (FS) and Copenhagen Risk Score (CRS)) with the outcome of myocardial perfusion imaging (MPI) in Danish patients with suspected or known CHD. Materials & Methods Out of 147 consecutive patients referred to MPI at our department, full clinical data were available in 77 (42 female; 35 male) of the cases, of which 17 were known with prior heart disease. All patients underwent a one‐day 99mTc‐sestamibi stress myocardial perfusion imaging protocol, performed either as symptom‐limited bicycle exercise (n = 42) or with dipyridamol/dobutamine for pharmacological stress (n = 35). The subjects were categorised with CAC score and risk assessment of hard CHD (FS and CRS ‐ 10‐year predictions). Outcome of MPI was considered the gold standard. The included patients were divided into three groups (all patients and ± known heart disease), for which correlation analyses with MPI outcome were performed using Spearman’s rho. Results 16 of the 77 MPI’s were pathological (≥ 2 segments with reduced perfusion (≥ 2.5 SD) of the left ventricle myocardium on 20‐segment bull’s eye maps). CAC score turned out to be significantly correlated with the outcome of MPI in all three patient groups. CRS and FS were only significantly correlated with MPI outcome when analysing the group with all patients and the group including the patients with no prior heart disease, respectively. Conclusions When looking at patients with a mixed medical history of heart disease, the results expose weaknesses of both CRS and FS as risk assessment tools for CHD, as the correlation with left ventricle myocardial perfusion on MPI shows a lack of consistency. It is known that geographical variances could result in misinterpretation of risk scores, and this fact neither can nor should be ignored. The strong, consistent correlation between CAC score and MPI could turn out to be helpful, both as a screening tool prior to a potential referral to MPI, but also as an applicable risk estimator of CHD, especially when planning international multi‐centre studies. Further inclusion of patients is awaited to provide estimates of sensitivity and specificity. Assessment tool
n Spearman’s rho P
All patients CAC score CRS (AMI) CRS (Fatal event) FS (Hard CHD)
77
0.57 0.33 0.31 0.21
< 0.001* 0.003* 0.006* 0.07
No known heart disease 0.38 CAC score 0.14 CRS (AMI) 60 0.15 CRS (Fatal event) 0.27 FS (Hard CHD)
0.003* N.S. N.S. 0.04*
Known heart disease CAC score CRS (AMI) CRS (Fatal event) FS (Hard CHD)
0.01* N.S. N.S. N.S.
17
0.60 0.27 0.11 0.08
AMI ‐ acute myocardial infarction; N.S.:Non‐significant. Significant results (P < 0.05) marked with *
Usefulness of 99mTc Tetrofosmin myocardial perfusion (MP) GSPECT fast-imaging protocol after percutaneous transluminal coronary angioplasty (PTCA) and stent implantation
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A. Tzonevska, K. Tzvetkov, M. Dimitrova, E. Piperkova; National Oncology Hospital, Sofia, BULGARIA.
S. Lucic1, K. Nikoletic1, A. Peter1, S. Tadic2, M. Stefanovic2, J. KmezicGrujic2, J. Stojiljkovic2; 1Insitute of Oncology of Vojvodina, Sremska Kamenica, SERBIA, 2Insitute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, SERBIA.
The present study was performed to determine the use of 99mTc‐ Tetrofosmin(Tf) fast‐imaging protocol MP GSPECT for detection of restenosis after PTCA and stent implantation . Material and methods: Fifty‐two patients ( 41 male, 11 female; mean age 59,2 ± 3,9 ) with successful PTCA and stent implantation were included in the study. There were 31 LAD, 9 LCx and 25 RCA stenosed vessels,varied from 75% to 95% before stent implantation. The median time interval between MS GSPECT and PTCA was 8 months. In all patients control coronary angiography was performed. Each patient underwent stress/rest Tf MS GSPECT in a 1‐d protocol. Tf (300 MBq) was administered intravenously at peak stress. Immediately after the end of the stress, the patients received a glass of could water to accelerate hepatobiliary clearance of the tracer. Within 15 min, GSPECT was performed. Immediately after completion of the stress study, the study was repeated under rest conditions (Tf 740 MBq). Evaluation of overall quality of GSPECT images was done. Analysis of scintigraphic data was performed using QGS and QPS. 99mTc‐Tf uptake in vascular territory of stented arteries were classified in individual cases as: (a) normal; (b) stress‐ induced perfusion defect with complete normalization at rest; (c) stress‐induced perfusion defect with incomplete normalization at rest; (d) persistent defect. Either a completely reversible defect
Can myocardial perfusion Tc-99m MIBI SPECT imaging influence further revascularization strategy in patients after PTCA with additional borderline coronary artery stenosis
Introduction: Clinical dilemma whether the patients (pts) with percutaneous transluminal coronary angioplasty (PTCA) and additional borderline hemodynamic stenosis on other non‐ stented coronary arteries should have further conservative or invasive treatment is always present. Therefore the aim of this study was to determine the possible contribution of myocardial perfusion technique (MPS) based diagnostic information in the clinical decision making process if only the significantly stenotic coronary arteries are to be stented, or the patient should underwent multiple stenting. Methods and material: In 109 pts (35 women (32.1%) and 74 man (67.9%), mean age 58.82±8.33 years) who underwent coronary angiography (CA) after acute coronary event resulting with PTCA and with additional borderline stenosis (50‐70%) of at least one other coronary artery, one to three months after CA we performed ECG‐gated pharmacological stress Tc‐99m MIBI SPECT imaging using a two day protocol in order to evaluate the perfusion of the myocardium in the irrigation regions of the borderline stenotic arteries. The MPS was processed visually and evaluated by use of 4DMSPECT processing algorithms (SSS, SRS
Poster Presentation
J. Siennicki1, K. Kovacevic-Kusmierek1, J. Kusmierek2, A. Plachcinska1; Department of Quality Control and Radiological Protection, Medical University of Lodz, Lodz, POLAND, 2Department of Nuclear Medicine, Medical University of Lodz, Lodz, POLAND. 1
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and SDS). Regarding the localization of the borderline stenosis all pts were divided in three groups ‐ 58 pts (53.21%) with LAD, 27 pts (24.77%) with RCx and 24 pts (22.02%) with RCA borderline stenosis. Results: In 95/109 pts (87.16%) MPS showed normal perfusion of the myocardial region irrigated by borderline stenotic artery (SSS=0, SDS=0) while in 14 (12.84%) pts perfusion indicated stress induced ischemia of the irrigated region of myocardium (SDS>2); within this group 6/14 pts (42.86%) had a borderline stenosis in LAD, 5/14 (35.71%) in RCx and 3/14 (21.43%) in RCA artery region. Consequently, 8/14 (57.14%) pts from this group with positive MPS results underwent additional PTCA of the borderline stenotic coronary artery and 6/14 pts (42.86%) received further medicamentous treatment. Contol MPS was performed after 6‐9 months in all 14 pts with initial stress related perfusion defects, indicating normalisation of myocardial perfusion in 5/8 (62.5%) stented pts, while unchanged results were found in 3/8 (37.5%) stented and in all 6 pts treated with drug therapy only. Conclusion: Although the investigation will be continued on a larger group of patients with longer patient follow‐up, already it is possible to claim that MPS may improve clinical decision in the process of optimizing the therapy for individual patient by providing valuable information on the myocardial perfusion in irrigation regions of borderline stenotic arteries.
PW086 Assessment of left ventricular function and myocardial perfusion before and after cardiac resynchronization therapy V. Chernov, S. Minin, K. Zavadovskiy, D. Lebedev, G. Savenkova; Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. Background: Cardiac resynchronization therapy (CRT) reduced symptoms and improves left ventricular function in patients with a wide QRS complex and advanced heart failure. However, not all patients respond to CRT, have positive haemodynamic and contractility effects. Aim: To evaluate of chronic CRT effect on left ventricular function and on myocardial perfusion in patients with severe heart failure. Material and methods: We studied 20 patients (M/F: 16/4, mean age: 62.17±7.9 years) scheduled for implantation of a CRT device based on conventional criteria (NYHA class III or IV, ejection fraction (LVEF) <35%, left bundle‐branch block and QRS duration >120 ms). Six patients had ischemic and 14 patients had idiopathic dilated cardiomyopathy. The equilibrium‐gated angiography (MUGA) and 99mTc‐tetrofosmine SPECT were performed before and 6 month after CRT. Results: It was shown a significant clinical benefit of CRT after 6 month (NYHA class change from 3.3+0.6 to 2.1+0.7; p=0.01). We found significant increase in cardiac output from 3.7±1.2 to 4.3±1.1 ml/min (p=0.004), stroke volume from 52.1±18.8 to 64.4±17.6 ml (p=0.02), cardiac index from 1.9±0.6 to 2.2±0.5 ml/min/m2 (p=0.009) and stroke index from 26.8±9.8 to 32.1±9.9 ml/m2 (p=0.03). After CRT, left ventricular ejection fraction improved from 22 ± 5% to 29 ± 13%, p=0.04. There was a significant reduction of intraventricular asynchrony in ischemic patients. It was shown positive effects of CRT on myocardial perfusion after 6 months: the summed rest score (SRS) decreased from 33±14 to 21±12 (p=0.004). Conclusion: Results of this study indicated, that CRT improved left ventricular function as well as myocardial perfusion in patients with severe heart failure.
PW087 Reliability of ejection fraction calculated with gated myocardial perfusion SPECT in patients with extensive perfusion defect C. N. B. Harisankar, K. K. Kamaleshwaran, S. Sarika, M. Parmar, A. Bhattacharya, B. Singh, B. R. Mittal; Postgraduate Institute of Medical Education & Research, Chandigarh, INDIA. Introduction: Gated myocardial perfusion scintigraphy (MPS) provides functional information of the left ventricle (LV) apart from the perfusion status. Software based LV ejection fraction (EF) calculated has been found to be reliable in patients with normal perfusion. However, its role in patients with extensive perfusion defects is not clear. Aim: To find the reliability of LVEF calculated from resting gated MPS in patients with extensive perfusion defects (> 25% of LV myocardium) and to correlate it with echocardiography (ECHO) and multigated radionuclide ventriculography (RNV). Materials and methods: 17 patients with fixed perfusion defect of size ≥25% of LV myocardium on rest gated MPS study were studied. EF was calculated using three softwares: Emory cardiac toolbox (ECT), Myometrix (Myo) and QGS/QPS. LVEF was recorded using ECHO and RNV within one week of Gated SPECT. RNV was performed after in‐vivo labeling of RBCs with 99mTc. Images were acquired in best septal view. Images were processed by two experienced nuclear medicine physicians such that variability in LVEF was <3%. Correlation among the EF values determined was examined. Results: 17 patients (15 Males; 2 Females; Mean age 51 yrs, Range 32yrs‐70yrs) were prospectively included. The average size of perfusion defect was 38% of the LV myocardium (Range 25%‐56% of LV). The average ejection fraction values were 33% for ECT (Range 11%‐50%), 28% for Myometrix (range 18% to 46%) and 33% for QGS/QPS (Range 17% to 49%). The mean EF on Echo was 36% (Range 22%‐60%) while that of RNV was 32% (Range 10% to 50%). The data was normally distributed. There was statistically significant positive correlation between software based EF measured and that of Echo and RNV (Results in the table 1). Conclusion: This study suggests that EF calculations, from gated SPECT MPS data using different software, in patients with extensive perfusion defects has high correlation with the gold standard RNV. Any of the software may be used interchangeably in EF calculation. RNV for the sole purpose of EF measurement may be unnecessary. Table 1. Table showing the correlation among different software based left ventricular ejection fraction measured during rest gated SPECT study, with echocardiography and with RNV. There is statistically significant positive correlation among the values measured.
EF ECT EF Myo EF Qgs RNV
Correlation Coefficient 1.000 EF ECT Sig. (2‐tailed) N Spearman''s rho
.
.001
.000
.003
.023
17
17
17
17
17
Correlation Coefficient .750(**) 1.000 EF Myo Sig. (2‐tailed) N
Echo
.750(**) .779(**) .671(**) .549(*)
.870(**) .628(**) .479
.001
.
.000
.007
.052
17
17
17
17
17
EF Qgs Correlation Coefficient .779(**) .870(**) 1.000
.703(**) .566(*)
Sig. (2‐tailed)
.000
.000
.
.002
.018
N
17
17
17
17
17
Correlation Coefficient .671(**) .628(**) .703(**) 1.000 ERNA Sig. (2‐tailed) N Echo
.776(**)
.003
.007
.002
.
.000
17
17
17
17
17
Correlation Coefficient .549(*) .479
.566(*) .776(**) 1.000
Sig. (2‐tailed)
.023
.052
.018
.000
.
N
17
17
17
17
17
** Correlation is significant at the 0.01 level (2‐tailed). * Correlation is significant at the 0.05 level (2‐tailed).
PW088 Attenuation & Scatter Correction (ASC) on Tl-201 myocardial perfusion imaging (MPI): physician’s level of experience or patient’s gender depended method? A. Velidaki1, J. Koutsikos2, S. Koukouraki1, K. Perisinakis1, N. Karkavitsas1; Nuclear Medicine Department, Heraklion University Hospital, Heraklion, GREECE, 2401 General Military Hospital, Nuclear Medicine Department, Athens, GREECE. 1
AIM: To evaluate the clinical usefulness of ASC on Tl‐201 SPECT studies according to physician’s level of experience and patient’s gender. METHODS: We studied 76 males and 26 females who were subjected to coronary angiography (CA) prior to or after the scintigraphic examination. A Tl‐ 201 one day protocol was used. Simultaneous transmission‐emission images were obtained by a γ‐camera equipped with an AS correction system based on two moving collimated 153Gd rod sources. Stress and delay reconstructed images, uncorrected for AS, were diagnosed from less experienced (fellows in training ‐ interpretation A) and experienced physicians (interpretation B). One month later, the same images corrected for AS were diagnosed by the same readers (interpretations C and D respectively). The results were compared using as reference the CA findings. A stenosis >50% was considered significant. The areas under ROC curves (Az) were compared for each interpretation. A probability P<0.05 (two‐tailed) was considered statistical significant. RESULTS: The aggregate Az values for detecting arterial defects in males and females are shown in Table. C and D interpretations were concordant. The trend was for an increase in the Az for the progression from inexperienced readers to experienced without ASC, and to ASC readings independently the level of experience. In males either ASC or experienced interpretations demonstrated statistical significant difference to interpretation A for LAD and RCA territories, while in females statistical significant differences were observed only for ASC interpretations also for LAD and RCA territories.CONCLUSION: ASC is a method not influenced from the level of physician's experience and provides the highest detection accuracy, particularly in females. Defect location
Mean+/‐SD Az (P value) for: Interpretation A Interpretation B Interpretations C & D
MEN LAD
0.711+/‐0.077
0.859+/‐0.066 (0.028)
0.859+/‐0.066 (0.028)
LCx
0.777+/‐0.083
0.892+/‐0.067 (0.088)
0.9+/‐0.067 (0.07)
RCA
0.63+/‐0.03
0.797+/‐0.048 (0.0005)
0.89+/‐0.039 (0.0001)
LAD
0.71+/‐0.058
0.85+/‐0.686 (0.193)
0.929+/‐0.071 (0.018)
LCx
0.978+/‐0.008
1+/‐0.006 (0.317)
1+/‐0.006 (0.317)
RCA
0.817+/‐0.095
0.892+/‐0.087 (0.067)
0.917+/‐0.083 (0.029)
WOMEN
PW089 99m
Tc-MIBI redistribution in myocardial perfusion SPECT of the patients with coronary artery disease
D. Beiki1, B. Fallahi1, Z. Mohseni2, M. Bostani1, A. Khalaj2, A. FardEsfahani1, M. Eftekhari1, K. Ansari Gilani1, A. Gholamrezanezhad1, V. R. Dabbagh Kakhki3, M. Saghari1; 1Research Institute for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF, 2Department of Nuclear Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF, 3 Department of Nuclear Medicine, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, IRAN, ISLAMIC REPUBLIC OF. Aims: There are some evidences in favor of 99mTc‐MIBI redistribution in ischemic myocardium that may have potential role in assessment of viability on delayed 99mTc‐MIBI images. On the other hand, some reports suggested that infusion of low dose dobutamine during delayed 99m imaging may augment the value of Tc‐MIBI for evaluation of viability. A study was designed to determine whether the observed changes of perfusion defects on delayed images are due to early radiotracer redistribution or as a result of reversal partial volume effect in response to inotropic stimulation. Methods: Eighty‐nine cases with angiographically proven coronary artery disease (CAD) entered in this study. The stress gated‐SPECT images were obtained 1.5 hours after dipyridamole injection. Subsequently, the patients were randomly allocated in two groups and the delayed 2.5‐hour images were obtained during low dose dobutamine (dobutamine group; 45 cases) or placebo infusion (placebo group; 44 cases). Difference between summed stress score of
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PW090 Selection prognostic criteria for asymptomatic Diabetics type 2, candidates for Myocardial Perfusion SPECT Studies I. Kotsalou1, C. Kotsalos2, N. Zakopoulos3, M. Dimopoulos4; 1NIMTS Hospital, Nuclear Medicine Dept., Athens, GREECE, 2NIMTS Hospital, Cardiothoracic Surgery Dept., Athens, GREECE, 3Alexandras Hospital. University Dept. of Internal Therapy, Athens, GREECE, 4Alexandras Hospital, University Dept. of Internal Therapy, Athens, GREECE. Aim It is known that Autonomic Dysfunction is common in patients with Diabetes Mellitus type 2 (DB) causing Silent Coronary Disease and reviewing the literature it is proven that almost 22‐39% of diabetics with not known or suspected CAD have silent myocardial ischaemia. Therefore the authors aim to conclude which asymptomatic diabetics should preventively undergo Myocardial Perfusion Studies. Materials ‐ Methods In this study we included 96 diabetics type 2 mean age 62 years, 78,6% male and 21,4% female and DM duration 1‐35 years, which were asymptomatic or had atypical or nonspecific angina symptoms. Inclusion criteria were: HbA1C ≤ 7,0% and LDL < 206 mmol/L. 50 (52%) and Blood Pressure controlled (≤ 140/90 mmHg) using appropriate medication or not. 37 out of 96 diabetics had also history of Hypertension (38,5%‐ Group A), 20 were smokers (20,8% Group B), 26 (27% Group C) had hyperlipidemia, 32 (33,3% Group D) were overweight, whereas 46 (48%‐Group E) had no additional risk factors, but Diabetes. All patients were subjected to a rest and stress Technetium‐99m tetrofosmin myocardial perfusion SPECT study. The images were interpreted as fixed perfusion defects, reversible ischemia findings and normal perfusion studies. Results Significant perfusion abnormalities were found in 37 (74%) out of the 50 diabetics with more than two cardiovascular risk factors, and in 33 (71%) out of 46 diabetics (Group E). On the other hand, there were totally 26 (27%) normal myocardial perfusion SPECT studies. Conclusions Coronary Artery Disease (CAD) is a common complication of Diabetes Mellitus type 2 and very often lacks diagnosis, due to silent ischemia. Diabetics with more than 2 risk factors even asymptomatic, should preventively undergo Myocardial perfusion SPECT studies to estimate their specific cardiovascular risk profile, which is proved to be heavy. Research data suggest that 41% of abnormal MPS results come from asymptomatic diabetics with ≥ 2 risk factors. The high incidence of ischemia findings in our study, may be explained by the long diabetic history and the heavy cardiovascular profile of our patients.
PW10 ‐ Monday, October 12, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 10: lung, lympho, bone and endocrinology
PW091 Tc99m-MIBI dual phase parathyroid scintigraphy and radioguided minimally invasive parathyroidectomy without using QPTH measure and frozen section biopsy in patients with solitary parathyroid adenoma S. Karyagar1, O. Yalcın1, S. S. Karyagar1, T. Ozpacacı1, M. Mulazımoglu1, Y. Ozdenkaya1, E. Uyanık1, S. Ergur2; 1Okmeydanı Training and Research Hospital, İstanbul, TURKEY, 2Denizli Training and Research Hospital, Denizli, TURKEY. Purpose: Evaluate the efficieny of radio‐guided minimally invasive parathyroidectomy (MIP) without using QPTH (quick parathormone) measure and frozen section biopsy for the solitary parathyroid adenoma (SPA) treatment. Material and Method: 26 female primary hyperparathyroidism (PHPT) patients in whom SPA was determined by dual‐phase parathyroid scintigraphy (PT) taken by 20 mCi Tc99m‐MIBI injection were included in this study. Radio‐guided MIP operation had been applied under local anestesia 90‐120 minutes (min) after 20 mCi Tc99m‐ MIBI injection. In the case that the counting taken from exvivo lesion by gamma probe is more than 20 % of the counting taken from the lesion bed; the 20 % rule that accepts lesion excised is SPA. Results: Mean operation time was 39,4 ± 8 (30 ‐ 60) min. Exvivo counting value measured on the SPA’s by gamma probe was 860 ± 462 count/second on the average. Lesion bed counting value was found to be 561 ± 256 count/second. The % ratio of exvivo SPA counting to the lesion bed was % 155,8 ± 46,4.The counting of exvivo SPA, found to be more than 20 % of the lesion bed’s in all patients (lowest 83,5 %, highest 265,9 %). There was more than 50 % decrease on serum PTH level in the postoperative 1st day compared to the preoperative level and serum calcium (Ca+2) levels decreased to normal level postoperatively in all patients. There was significant difference between preoperative and postoperative serum PTH levels (P=0,001). There was significant difference between preoperative and postoperative serum Ca+2 levels (P=0,001). It was detected in the histopathological search that the excised lesions in all patients were SPA. Positive correlation was detected between preoperative serum PTH and SPA weight (P=0,029). But, no relation detected between preoperative serum Ca+2 level and SPA weight (P=0,39).
Conclusion: In the PHPT patients having apparent uptake in favour of SPA in dual‐phase Tc99m‐ MIBI PT scintigraphy and those having no paternal HPT and MEN sendrome story and also having no thyroid nodule on their neck USG; the MIP operation under local anestesia without using intraoperative QPTH measure and frozen section biopsy is a safe method for the SPA’s intraoperatory diagnosis and treatment. In the evaluations of countings made by gamma probe, the 20 % rule was determined to be the a intraoperative useful criterion on detecting the excised lesion to be SPA.
PW092 Clinical Outcome in Patients with Differentiated Thyroid Cancer: Preliminary Results of the MSDS-Trial B. Riemann, J. Krämer, T. Frankewitsch, O. Schober; University Hospital, Münster, GERMANY. Aim. The prospective Multicentre Study Differentiated Thyroid Cancer (MSDS) was initiated in 2000 in order to investigate the benefit of adjuvant radiotherapy in patients with locally invasive differentiated thyroid carcinoma (pT4; UICC 1997) with or without lymph node metastases and no known distant metastases. In 04/2003 the trial became a prospective cohort study. It was the aim to evaluate the recurrence‐free and overall survival in these “high‐risk” patients 8 years after the start of the study. Methods. As yet, the follow‐up data of 300 out of 397 patients have been available for the analysis. The survey addressed the following parameters: permanent laryngeal nerve palsy, permanent hypocalcaemia, complete or partial remission, stable or progressive disease, leucaemia, Karnofsky‐index, cumulative radioiodine activity, cause and date of death if applicable, locoregional recurrence and distant metastases. Results. Median follow‐up was 5.8 years (range 0.4‐8.8 years). Permanent unilateral and bilateral recurrent laryngeal nerve pareses occurred in 41 (14 %) and 2 (< 1 %) of patients, respectively. Permanent hypocalcaemia was found in 58 (19 %) of cases. There were 27 (5 %) recurrences in the thyroid bed (n = 6), in locoregional lymph nodes (n = 14) and/or in the lungs (n = 14). 273 (91 %) patients reached complete remission. 7 patients had partial remissions, 18 progressive diseases and 2 stable diseases. 7 (2 %) patients died during the time studied, 2 of them due to extrathyroidal disease. Conclusion. The patients in the MSDS‐trial showed an excellent recurrence‐free and overall survival. However, the relatively high complication rates of permanent recurrent nerve paresis and hypocalcaemia may be due to the high‐risk profile of the MSDS‐patients in a multi‐centre setting.
PW093 Detection of Neuroendocrine Tumors with 1
1
99m
Tc-Tektrotyd
1
V. Artiko , S. Novosel , N. Petrovic , D. Sobic-Saranovic1, S. Pavlovic1, E. Jaksic1, D. Macut2, M. Petakov2, B. Popovic2, S. Damjanovic2, V. Obradovic1, A. Koljevic-Markovic3; 1Centre for Nuclear Medicine CCS, Belgrade, SERBIA, 2Clinic for Endocrinology, Diabetes and Metabolic Diseases CCS, Belgrade, SERBIA, 3Institute for Oncology, Belgrade, SERBIA. Aim: The aim of the study is detection of neuroendocrine tumors with 99mTc‐Tektrotyd, radiopharmaceutical indicated for diagnosis of tumors with overexpression of somatostatin receptors. Patients and Methods: Whole body scintigraphy was performed in 107 patients, 2h‐ 24h after i.v. administration of 740MBq 99mTc‐Tektrotyd, as well as SPECT of particular regions.Results: From 26 patients with neuroendocrine tumors of unknown origin there were 21 true positive findings (TP) (9 with liver metastases, 6 with lung metastases, 4 with bone metastases and one with mediastinal gland metastases), 3 false negative findings (FN) (two with poorly differentiated liver metastases and one with very small lung metastases < 1 cm), one FP (vague uptake in lung inflammation) and one TN. In 17 patients scintigraphy contributed to the further management of the patients. In the group of 38 patients with gut carcinoids there were 16 TP (16 with liver metastases), 17 true negative findings (TN) (after surgery), 4 FN (in 2 small metastases < 1cm, necrosis) and 1 FP (physiological accumulation of the activity in the bowel). In 8 patients scintigraphy contributed to the further management of the patients. In the group of 23 patients with neuroendocrine pancreatic carcinomas there were 16 TP (6 with liver metastases and one with metastases in paraortal lymph nodes), one FP (physiological activity in the bowel), 3 TN (somatostatinoma, insulinoma and carcinoid after surgery) and 3 FN (poorly differentiated). In 11 patients scintigraphy contributed to the further management of the patients. In the group of 14 lung neuroendocrine tumors (10 carcinoids and 4 lung neuroendocrine tumors) there were 11 TP (6 with liver, 3 with lung metastases and 2 with bone metastases), two FP (inflammation) and one TN (after surgery). In 9 patients scintigraphy contributed to the further management of the patients. In the group of 6 patients with gastrinomas (jejunal, paraduodenal and pancreatic) there were 3 TP findings, 2 TN and one FN (poorly differentiated). In 4 patients scintigraphy contributed to the further management of the patients. Overall sensitivity of the method is 86%, specificity 83%, positive predictive value 93% and negative predictive value 69%. Conclusion: Scintigraphy of neuroendocrine tumors with 99mTc‐Tektrotyd is a useful method in diagnosis, staging and follow up of the patients suspected to have neuroendocrine tumors. It is also helpful in the appropriate choice and monitoring of the therapy, including the radionuclide one.
PW094 Lung reactions depending on radioiodine treatment in the differentiated thyroid carcinoma with lung metastasis S. Ergur, T. Ozpacaci, M. Mulazimoglu, E. Uyanik, D. Ozcan, M. Tamam; Okmeydani Training and Research Hospital, Istanbul, TURKEY. AIM: The prognosis of differentiated thyroid carcinoma (DTC) is generally good. The lungs are the most frequent sites of distant metastases in DTC. The treatment protocol includes periodical application of a high dose of radioiodine treatment (RIT), that may cause pneumonitis on early period and fibrosis in long term. The aim of the study to evaluate the lung reaction depending on radiation after RIT in the lung metastases (LM). METHODS: Out of 1500 patients who were followed up for DTC in Okmeydani Training and Research Hospital Nuclear Medicine Department between 2003 and 2005, 60 patients (8M,56F, mean age:43,8 ±15) who had LM were included to the study. Lung metastases are classified as milier‐micro‐noduler(<10mm) and macro‐ noduler(>10mm).In order to determine the LM, I‐131 whole‐body scintigraphy (WBS), chest X‐ ray, high‐resolution computed tomography (HRCT) results are used. In evaluation of lung
Poster Presentation
the first (SSS1) and second (SSS2) stress images (ΔSSS) was considered as a marker of reversibility in single‐injection double‐acquisition (SIDA) method. Also summed difference score (SDS) was recorded as a marker of reversibility in stress/rest, double‐injection double‐acquisition (DIDA) method. ΔSSS of the two studied groups were compared. Also the correlation between ΔSSS and SDS was analyzed in total and each separate group of patients. Results: A significant difference was found between SSS1 (Median=15, range=0‐48) and SSS2 (Median=11, range=0‐42) in total patients (p<0.0001). A significant correlation was noted between ΔSSS and SDS in dobutamine group (r=0.58, p=0.002) as well as in placebo group (r=0.57, p<0.0001). When the DIDA protocol was considered as a reference study, the influence of dobutamine infusion on the SIDA protocol was not significantly different from the influence of placebo in showing the magnitude of fixed or reversible perfusion defects. Conclusion: The changes in the magnitude of the perfusion defects may occur in the first hours of 99mTc‐MIBI injection in the stress phase imaging. These changes correlate well with perfusion improvement on the rest images. This phenomenon may be independent of improvement in myocardial function, in more delayed imaging or following inotropic augmentation. Thus, the early detectable redistribution of 99mTc‐MIBI may result in decrease of the perfusion defect magnitude in the SIDA protocol.
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reactions depending on RIT, 99mTc‐DTPA radioaerosol transalveolar clearance (RTC) scintigraphy, transbronsial biopsy (TBB), histopathologic observations and Pulmonary Function Tests (PFT), are used. Clearance half‐time (t1/2) of RTC was measured in two terms. The first term was 60‐90days after RIT, considered as probable pre‐pneumonitis term, second term: 91‐300days, considered as probable pneumonitis term.Statistical analysis was performed using Mann‐Whitney U test. RESULTS: Out of 60 patients who had DTC (38 papillary‐22 follicular carcinoma), 27 had macronoduler metastases and 33 had milier‐micronoduler metastases. While only lung metastases was found in the 70%patients, the other distant metastases were found in 30% of the patients. The number of the patients, radioaerosol transalveolar clearance were measured in each group was 8. In both groups no meaningful differences were found out between RTC half‐ time results(p>0,05).In the first term, the patient with a longer clearance time(t1/2:103,5min) the radiation pneumonitis finding didn’t developed. In the second term, one of the patient whose clearance half‐time shorter than normal limitation (t1/2:41min) was thought to have stage 1 toxic pneumonitis along with minimal restrictive lung disease. None of the 10 patients who were applied TBB was observed to have thickening of alveolar septa based on fibrosis of the radiation in the biopsy material (~487mCi).PFT was evaluated after RIT on 18 patients who have milier‐ micronoduler lung metastases.1 patient (~850mCi) was thought to have minimal restrictive lung disease. The measurement were found normal in the other 17 patients( ~557mCi). CONCLUSION:Lung reactions to RIT are very rare based on RIT in the DTC with lung metastases. Milier‐micronoduler lung metastases, pneumonitis risk can be tolerated in the repeating RIT.
PW095 68Ga-DOTA-NOC PET clinical neuroendocrine tumours
impact
in
patients
with
V. Ambrosini1, D. Campana2, L. Bodei3, C. Nanni1, A. Musto1, P. Castellucci1, A. Lambertini1, F. Ceci1, M. Celli1, A. Maffione1, P. Tomassetti2, G. Paganelli3, S. Fanti1; 1Nuclear Medicine, Azienda OspedalieroUniversitaria di Bologna, S.Orsola-Malpighi University Hospital, Bologna, ITALY, 2Internal Medicine, Azienda Ospedaliero-Universitaria di Bologna, S.Orsola-Malpighi University Hospital, Bologna, ITALY, 3Division of Nuclear Medicine, European Institute of Oncology, Milano, ITALY. Aim : to evaluate the role of 68Ga‐DOTA‐NOC PET on the clinical management of patients with neuroendocrine tumours (NET). Methods: 41 pts (mean age: 55.5 ys [26‐80], M:F= 24:17) with pathology proven NET were studied by 68Ga‐DOTA‐NOC PET. Indications to perform PET included staging (9), re‐staging (17), equivocal conventional imaging findings (6), interim PET evaluation (4), follow‐up (4), unknown primary (1). In 28 cases the primary tumour was excised before PET evaluation. PET results were compared with CI (conventional imaging including CT in all cases, MRI in 10 paraganglioma cases), and with follow up data (10 months [2‐22]). Results: Concordance of PET and CI findings was observed in 11/44 cases and PET had an impact on the clinical management of only two pts: in one case both PET and CT showed liver metastasis and PET demonstrated the initial response to the on‐going peptide receptor radionuclide therapy that was therefore continued. In the other case, PET was performed to exclude the presence of ssr‐ expressing lesions, other that at liver level, that would have prevented the patient to be candidated to liver transplant. PET findings were discordant with CT in 29 cases. In 24/29 PET findings were relevant to influence the patients clinical management: PET excluded the presence of malignancy in 6, in 6 cases up‐staged the disease, in 3 pts down‐staged the disease, in two cases identified the presence of relapse (retroperitoneal disease and at the periphery of the surgical area), in 3 cases identified the primary tumour (pancreas in 2, duodenum in 1), in one case addressed the patient to surgical treatment (revealing a paraganglioma lesion close to the superior caval vein undetected on CT). In 5/29 cases PET findings did not influence the pts management: in 2 cases PET detected a higher number of lesions and in 2 cases a lower number of lesions but this did not change the disease stage, in the remaining case PET failed to identify a primary lesion of the pancreas (false negative PET result). Overall PET findings were determinant for the management of 26/44 cases. Conclusions: Our preliminary data showed that PET with 68Ga‐DOTA‐NOC provided determinant information for the clinical management of 26/44 NET patients.
PW096 Lung SPECT Perfusion Scintigraphy: Can CT substitute for Ventilation imaging? D. Gradinscak, P. J. Roach, G. Schembri, D. Bailey; Royal North Shore Hospital, Sydney, AUSTRALIA. OBJECTIVE: To determine whether CT could be used as an alternative to ventilation tomography in SPECT V/Q. METHODS: The studies of 30 patients with suspected PE (pulmonary embolism) who underwent both CTPA and SPECT V/Q within 48 hours were retrospectively reviewed. In patients considered to have PE on V/Q SPECT scintigraphy, the perfusion SPECT study was fused to the CTPA and reviewed. Perfusion defects with corresponding parenchymal lung abnormalities on CTPA were reported as “matched” whereas perfusion defects in the absence of parenchymal change on CT were considered “mismatched”. The fused CTPA/Q study results were then compared to the SPECT V/Q results. RESULTS: A total 96 mismatched defects were reported on V/Q SPECT. Eighty four of these (87%) were correctly identified as “mismatched” on CTPA/Q fusion. The remaining 12 (13%) V/Q mismatched perfusion abnormalities were considered “matched” on CTPA/Q due to underlying parenchymal lung abnormality. An additional 27 “mismatched” abnormalities were identified on CTPA/Q, 15 of which were present in retrospect on VQ. Twelve were identified as false positives (matched on the V/Q). CONCLUSION: The majority of mismatched perfusion defects on SPECT VQ can be identified as mismatched on SPECT Q‐CT. False negatives (matched defects with CT) were mostly due to atelectasis, usually less extensive than the associated perfusion defect. False positives (mismatch on CT/Q but matched on V/Q) were seen in asthmatic patients, presumably related to air trapping which has a similar CT appearance to hypoattenuation from hypoperfused lung distal to PE. In the absence of an adequate ventilation imaging agent, SPECT‐CT Q may be a potential alternative technique for assessment of PE although some false positive cases should be expected.
PW097 Technetium-99m Hexamethylpropylene Amine Oxime Lung
Clearance Rate in Patients with Behçet’s Disease G. Gumuser1, T. Pirildar2, S. Tarhan3, M. Kararmaz1, A. Sakar4, E. Sayit1; Celal Bayar University, Medical Faculty, Nuclear Medicine, Manisa, TURKEY, 2Celal Bayar University, Medical Faculty, Internal Medicine, Manisa, TURKEY, 3Celal Bayar University, Medical Faculty, Radiology, Manisa, TURKEY, 4Celal Bayar University, Medical Faculty, Chest Disease, Manisa, TURKEY.
1
Aim: Behçet’s disease (BD) is a multisystem disorder characterized by vasculitis, and consists of a triad of recurrent ulcers of the oral and genital mucosa with relapsing uveitis. The prevalance of pulmonary involvement varies in the range of 1‐10% in various studies and its complications are severe and life‐threatening. To objectively assess the degree of pulmonary vascular endothelial damage in BD, the lung the clearance rate of Technetium‐99m hexamethylpropylene amine oxime (Tc‐99m HMPAO) was determined. Methods: Twenty‐three non‐smoking patients with BD (10 females, 13 males; mean age: 39.17±8.62 years) and 11 (6 females, 5 males; mean age: 50.27±8.78 years) healthy non‐smoking controls underwent Tc‐99m HMPAO dynamic lung scans, pulmonary function tests (PFT), chest x‐ray examination (CXR), contrast enhanced spiral chest computed tomography (CT), and high‐resolution computed tomography (HRCT) examinations. For dynamic imaging, after intravenous (iv) injection of 740 MBq Tc‐99m HMPAO posterior sequential images were collected at 1‐second intervals for 150 seconds. Subsequent images were obtained at 60 sec/frame for 10 frames using a double headed gamma camera (Infinia, GE, Tirat Hacarmel, Israel) interfaced with a Xeleris computer and were filtered with a low‐energy all purpose parallel hole colimator (LEAP) in 64x64 matrices. Time activity curves were acquired by setting irregular regions of interest in the right lung. Radioactivity was corrected for Tc‐99m decay. The clearance rate was expressed as the half‐time (T1/2) for the activity to decrease 50% of the peak value. Results: Chest x‐ray, HRCT and CT findings in BD patients were nonspecific for BD. There was also a statistically significant difference between patients with BD (30.26±10.55 seconds) and normal controls (19.53±6.24 seconds) on their T1/2 values (p=0.0004). No correlation was found between the T1/2 values and pulmonary function tests (PFTs) of BD patients. Conclusion: The degree of pulmonary vascular endothelium damage was represented as slower lung clearance rate measured on 99mTc‐HMPAO lung scan in patients with BD. Our results indicated that determining the T1/2 values onTc‐99m HMPAO lung imaging should be an objective method to assess subclinical pulmonary damage in the early stages of BD patients.
PW098 Can the dynamic phase of the lymphoscintigraphy be avoided for the detection of sentinel lymph node in breast cancer? I. Martinez-Rodriguez, I. Banzo, R. Quirce, J. Jiménez-Bonilla, H. PortillaQuattrociocchi, A. Sainz-Esteban, J. Barragán, P. Medina-Quiroz, J. Carril Carril; H.U. Marques de Valdecilla, Santander, SPAIN. Aim: To evaluate if the dynamic phase (DP) of the lymphoscintigraphy (LS) can be avoided without any decrease in the detection of the sentinel node (SN) in breast cancer (BC) patients. Material and Methods: This retrospective study included 161 patients with BC (160 women and 1 man, mean age 57.5±11.2 years) and 164 breast lesions (3 patients had bilateral cancer). Average tumor size was 16.4±8.3 mm. Patients with tumor > 5 cm, multicentric, palpable nodes, axillary involvement and previous history of surgery, lymphadenectomy, radio or chemotherapy were not included. All patients underwent preoperative LS 18‐20 hours before surgery. 99mTc‐ Nanocolloid 40 MBq was peritumorally (guided by ultrasonography in non‐palpable lesions) or periareolary injected. DP (45 sec image/15 min) was immediately acquired after the injection. It was followed by early (at 15 min) and delayed (at 2‐4 hours and 20 hours if necessary) planar images. Images were blindly evaluated by 2 expert observers. A score from 0 to 3 according to the intensity of uptake was used. Results: SN was visualized in 47 of the 164 cases (29%) by DP, in 100 cases (61%) by early images and in 162 cases (99%) by delayed images. Critical analysis of the studies showed that DP contributed to the interpretation of lymphatic drainage patterns and identified the SN in 17 of 164 cases (10.4%). Of these 17 cases, in 11 DP was essential to identify the SN in axilla; additional SN in the internal mammary chain were identified in 5 cases, and intramammary location in 1 case. Thus, DP was crucial to the detection of axillary or intramammary SN in 12 cases (7.3%). In 147 cases (89.6%) DP did not give additional information to that provided by early and delayed planar images. Conclusions: DP was crucial to achieve the lymphatic drainage pattern and improved the detection of the SN in 10.4% of cases. In 7.3% of cases DP identified additional axillary or intramammary SN being a direct impact on surgical procedure. Thus, DP should be performed as routine prior to the early and delayed planar images.
PW099 Is sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy reliable? D. Balkose1, A. Mudun1, B. Ozcınar2, V. Ozmen2, M. Muslumanoglu2, T. Dagoglu2, H. Dongel2, E. Yavuz3, S. Cantez1; 1Istanbul University Istanbul Medical Faculty Department of Nuclear Medicine, Istanbul, TURKEY, 2 Istanbul University Istanbul Medical Faculty Department of Surgery, Istanbul, TURKEY, 3Istanbul University Istanbul Medical Faculty Department of Pathology, Istanbul, TURKEY. AIM: There has been increased use of sentinel lenf node biopsy (SLNB) in breast cancer patients treated with neoadjuvant chemotherapy (NAC) previous to surgery. However there are contraversial results. In this study, we present our results of SLNB in patients who have been treated with NAC previous to surgery. METHODS: Twenty three women who have been treated with NAC and have been operated between March 2006 and February 2008 were enrolled for this study. Mean age of patients was 51. Lymphoscintigraphy (LS), perioperative blue dye injection, intrasurgical gamma probe and axillary lymph node dissection (AxLND) were performed in all patients. With AxLND, 3 to 20 lymph nodes were removed in all patients. Seven of 23 (30.4%) patients had negative axillary lymph nodes clinically before NAC. RESULTS: In 16 of 23 patients (69.5 %) SLN were vizualized with LS. The mean number of SLN visualised in axilla was 2 . In one patient , in addition to axillary lymph node ( AxLN), one internal mammaria lymph node ( IMLN) was vizualized. Also in another patient who did not show AxLN, IMLN was seen on LS. Of
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PW100 Uptake and biodistribution of 99mTc-chondroitin sulfate in degenerated cartilage. Potential for imaging of osteoarthritis G. Sobal, R. Dorotka, J. Menzel, H. Sinzinger; Medical University of Vienna, Vienna, AUSTRIA. Aim: Chondroitin sulfate (CS) is an endogenous component of cartilage and could allow the monitoring of osteoarthritic cartilage degeneration after radiolabeling. It is also used in the treatment of human osteoarthritis. Material and methods: Radiolabeling was performed by 99mTcO4‐/tin method at pH 5.0 in 0.5 M Na acetate. For uptake studies human articular cartilage (n=4, 65‐79a), from individuals for knee replacement (pieces of 3‐5 mg wet weight) was used, or frozen tissue sections (5‐20µm) for autoradiography (3‐10µCi). The uptake was monitored from 10 minutes to 120h to achieve saturation. As the commercially available drug Condrosulf (IBSA, Lugano) contains magnesium stearate as additive (to improve its resorption), we investigated the uptake ± additive. The wash‐out of the tracer was examined by tissue incubation after uptake experiments (3h and 24h) with PBS‐buffer for different time from 10 minutes to 3h. Results: Using human articular cartilage the maximal uptake of 99mTcCS (specific activity of 4.1‐ 6.1mCi/µM) was continuously increasing with time amounting to a maximum of 81.1%±6.1%, with additive, versus 51.8%±4.2%, (n=6) without additive, at 120h of incubation. Additive increased the resorption of the drug and consecutively its uptake. The wash‐out of the tracer from cartilage after 3h uptake amounted to 1.5±0.2% with additive, versus 2.6±0.5%, without. After 24h wash‐out was lower amounting to 1.1±0.1% versus, 2.1±0.3%, respectively. Autoradiography reveals also a permanently increasing uptake of 99mTcCS with time. Starting at 10 minutes of incubation the increase in uptake was proportional to the incubation time, reaching the maximum at 48‐72h. Enhanced uptake in the surface (superficial zone), as compared to the subchondral part (deep zone) of slices was observed. The non‐specific uptake in the presence of 50‐fold excess of cold CS was increasing with time up to a maximum of 15% (tissue) and 10% (autoradiography), at saturation. Conclusions: The uptake studies indicate, that 99mTcCS accumulates in articular cartilage and proved the chondrotrophic effects. Therefore, due to its high uptake, 99mTcCS could be a promising agent for osteoarthritis imaging.
PW11 ‐ Tuesday, October 13, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 11: pediatric - nephrourology miscellaneous
PW101 Diagnostic potential of renal clearance parametric images for detection of kidney scars in juveniles with chronic infections of the urinary tract E. Pietrzak-Stelmasiak1, I. Frieske1, M. Bieńkiewicz2, W. Woźnicki1, M. Surma1, M. Kowalewska-Pietrzak3, K. Bubińska4, W. Młynarski5, J. Kuśmierek1; 1Department of Nuclear Medicine, Medical University of Lodz, Lodz, POLAND, 2Department of Quality Control and Radilogical Protection, Medical University of Lodz, Lodz, POLAND, 3Department of Pediatric Oncology, Hematology and Diabetology, Medical University of Lodz, Lodz, POLAND, 4J. Korczak Children’s Hospital; M.Copernicus Center of Lodz, Lodz, POLAND, 5Department of Pediatric Oncology, Hematology and Diabetology, Med. University of Lodz, Lodz, POLAND. Introduction: Infections of urinary system in children and adolescents form difficult problem in pediatrics. Chronic and recurrent inflammatory syndrome, accompanied by renal malformations lead to scarring of kidneys. A static scintigraphy of kidneys is acknowledged as "gold standard" for detection of focal defects of uptake of 99mTc‐DMSA, which results from underlying destruction of renal parenchyma. This procedure enables detection and assessment of renal scarring. A dynamic renogram in these patients is also commonly applied for diagnosis of functional state of urinary system. By selecting early dynamic images (0‐4 min) post administration of radiopharmaceutical and by their summation one can also obtain image of renal parenchyma. Another variant of dynamic procedure, elaborated by Surma and Anderson, utilizes parametric imaging of clearance function of parenchyma and this enables visualization of local defects. Aim of the study: Reported study aimed at evaluation which of variant of dynamic renography should be preferend for assessment of renal damage(scarring) using static scintigraphy as standard. Material of the study: 25 patients (age 4‐19 years) with diagnosed chronic infection of urinary system were studied, in 7 only 1 kidney (lack, dysplasia of second organ); total of 43 kidneys were studied. Methods: In each patients there were performed: ‐static scintigraphy using 99mTc‐DMSA. ‐dynamic renogram 99m using Tc‐EC. Summation and parametric clearance images were generated. Each kidney was divided into 3 segments (upper, middle, lower) and altoegether 129 segments were evaluated by 3 procedures. For quantifying observation a modified Goldraich and Howard scale was used: 0‐ undefected, 1‐one defect, 2‐more than one defect in segment. Images were evaluated blank by 2 physicians; final decision were achieved at by consensus. Principal evaluation included: comparison of static with summation and parametric images. Results: 1.Sensivity and accuracy of parametric images amounted to 93 and 89% respectively. 2.Sensivity and accuracy of summation images was 51 and 65%, resp.(p<0,001). 3.Speciticity of parametric‐84%, of summation images‐ 88%, NS. 4.Positive predictive value of parametric and summation images amountied to 87 and
52 %, (p<0,001). 5.Agreement kappa reached 0,66 and 0,33 for respective dynamic imaging versions, (p<0,005). Conclusion: 1.Using static scintygraphy images as standard, parametric clearance images proved more accurate and sensifive than those from simple summation of early images from renogram. 2.Preliminary conclusion could be postulated that dynamic renogram with generated parametric clearance images could substitute for 2 examination: static and dynamic scintigraphy, for diagnosis and assessment of function and damage in patients with chronic inflammation of the urinary tract.
PW102 Parametric kidney scintigrams and conventional summation images - reproducibility of semiquantitative image evaluation. I. Frieske1, E. Pietrzak-Stelmasiak1, M. Bieńkiewicz2, M. Surma1, J. Kuśmierek1; 1Department of Nuclear Medicine, Medical University, Lodz, POLAND, 2Department of Quality Management and Radiological Protection, Medical University, Lodz, POLAND. Parametric kidney scintigraphy provides a possibility for regional function distribution assessment of these organs. The aim of the present study was assessment of the reproducibility of visual evaluation of parametric kidney clearance images as well as of conventional summation images from dynamic scintigraphy of the urinary system, in patients with varying degree of kidney function impairment, in course of different diseases. Material and methods: Results of 141 dynamic kidney scintigraphic series (after i.v. administration of99mTc‐ethylenedicysteine) were evaluated, obtained from examination of 87 patients with diabetes, reccurent infections of urinary system and nephrolithiasis, who had been treated by means of lithotripsy. Altogether 277 kidney images were evaluated. The semiquantitative assessment involved conventional renoscintigraphic images, obtained from summation of scintigraphic serial records in the secretory phase, and parametric clearance images. The analysis was performed in two ways. Images of the kidneys were divided into three regions: upper, middle and lower. Each region was evaluated for the presence or absence of defects. Moreover, for assessment a whole kidneys, a 5 level Howard score was applied , based upon presence of defects in kidneys regions. The blank assessment was performed independently by 2 observers: A‐ an experienced specialist in nuclear medicine, who has evaluated the images twice. B ‐ a resident physician with limited experience in the field. Results: While evaluating the images of 277 kidneys the more frequent defects were noted in parametric images 73% vs. 33% in summation images . Results of the analysis of concordance of evaluations for three regions are presented in tables 1 Intraobserver concordance of two evaluations of one observer and interobserver concordance
REGIONS % (number of fully concordant results) % (number of fully concordant results) (n=277)
Conventional images
Parametric images
Upper INTRA Middle Lower
96 (267) 99 (275) 98 (272)
95 (263) 99 (274) 97 (269)
Upper INTER Middle Lower
87 (242) 97 (268) 91 (253)
83 (229) 95 (264) 87 (240)
For the whole kidneys ,the agreement between two evaluations by the specialist (intraobserver test) reached the level of 94% for conventional images and 91% for the parametric ones. In interobserver test a full agreement reached the level of 81% and 70% for conventional and parametric images (respectively‐p<0,05). Conclusions: Inter and intraobserver concordance of kidney parenchyma imaging by conventional summation of renoscintigraphic scanning and clearance parametric images, is satisfactory. A little less fully concordance was observed for the regions of upper and lower than for the middle segments, which is likely to be related to difficulties in interpretation of anatomical variations of kidneys. In both concordance studies a better agreement was obtained for conventional than for parametric images. This observation may be explained by the fact that number of details seen in parametric images is higher than that in summation images what probably makes interpretation more difficult.
PW103 Performance of the Modification of Diet in Renal Disease Formula in Turkish Population T. Erselcan, P. Duman, Z. Hasbek, A. Ozdal, P. Kelkit, S. Gul; Cumhuriyet University School of Medicine, Sivas, TURKEY. The estimation of glomerular filtration rate (GFR) by a regression formula has become a popular issue in recent years due to the known difficulties of GFR measurement by classical renal clearance methods. Nowadays, the most widely used and recommended formula by many associations of nephrology is the “Modification of Diet in Renal Disease” formula (MDRD). Moreover, it is recommended that the calculated GFR (cGFR) through this formula should be supplied by each laboratory, along with the serum creatinine values. On the other hand, different degrees of deviation of cGFR by the MDRD formula from measured GFR (mGFR) values were reported in some populations. The aim of the present study was to evaluate the consistency of the MDRD formula (Or‐MDRD) in Turkish population. Materials and methods: mGFR, obtained using slope‐intercept method by two plasma sample and Tc‐99m‐DTPA were compared with the calculated ones by Or‐MDRD formula [186*(creatinine**‐1.154)*(age**‐0.203)*(0.742 if women)] in 292 adult patients (155 women, 137 men, mean age±SD=57±17). When mGFR was chosen as a dependent variable in the stepwise regression analysis only creatinine and age were remained in the equation, while height, weight and body mass index were excluded. The coefficients of each variable in the Or‐MDRD formula, in agreement with Turkish population were calculated by the non‐linear regression analysis. The new MDRD formula (TR‐MDRD) being consistent with the Turkish population was assessed for the accuracy. Results; correlation was high between cGFR (by Or‐MDRD) and mGFR (Table 1). The average difference was ‐6.8, and the limits of agreements were ‐50 to 37 ml/min in the Bland&Altman analysis. The new MDRD formula, adapted to Turkish population was TR‐MDRD=306*(creatinine **‐0.928)*(age**‐ 0.392)*(0.84 if female). Significant improvements were noticed in parameters of correlation, difference and bias as compared to Or‐MDRD (Table 1). However, cGFR (by Or‐MDRD) of 54% of patients showed more than 30% deviation from the mGFR values in the accuracy analysis. This
Poster Presentation
sixteen patients in whom LNs were detected on LS, 9 had axillary metastasis by pathological examination ( 56.2 %) and 3 of them were clinically N0. Of seven patients who did not show lymph nodes on LS , 3 had axillary metastasis by pathological examination (42.8 %) and 1 of these 3 patients (14.2 %) were clinically N0. CONCLUSION: In 69.5 % of patients following NAC, AxLN was detected by LS . When compared to pathologic results after AxLND, although these patients were clinically negative , they might have AxLN metastasis. Thus, the right surgical method must be carefully choosen for the these patients. On the other hand, in patients with lymph nodes not visualized by LS, axillary metastasis is not always the rule. Therefore with all these findings in this small group of patiens, we did not find SLNB as a reliable tool for predicting the axillary lymph node status in patients who received NAC.
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rate was decreased to only 47% with the TR‐MDRD formula. Moreover, the mean difference between Or‐MDRD and TR‐MDRD was 10 ml/min and it was statistically significant (P <0.001). Conclusion: Although Or‐MDRD formula seemed acceptable consistency in the Turkish population by regression analysis, further analysis revealed that even adapted TR‐MDRD formula carries a high risk of error in the GFR estimation. Table 1. Performance parameters of MDRD formula Parameters
Or‐MDRD
Intercept (95% CI) Slope (95% CI)
6.59 (3.41‐9.78) ‐1.04 (‐4.0‐1.1) 0.71 (0.66‐0.76) 1.13 (1.06‐1.19)
TR‐MDRD
R R2
0.85 0.72
0.89 0.80
Mean of difference (limits of agreement) ‐6.8 (‐50 ile 37) 3.4 (‐28 ile 35) Bias (unit area) 2231 203
PW104 99mTc -DMSA scintigraphy in children with vesicoureteral reflux Y. B. Lishmanov, K. W. Zavadovskiy, Y. A. Ermolaeva; Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. Aim: To assess the value of dimercaptosuccinic acid scintigraphy (DMSA) in detecting and grading of the renal scar, comparing its results with those of intravenous urography in patients with vesicoureteral reflux (VUR). Patients and methods: We investigated 28 patients aged 5‐16 with vesicoureteral reflux of any grade and 10 children with normal clinical status, laboratory results and absence reflux. VUR was diagnosed by voiding cystourethrography. The following examinations were performed in all patients: intravenous urography, renoscintigraphy with 99mTc‐DMSA in planar mode and single photon emission computed tomography (SPECT) with scanning 3 hours after intravenous injection. In all patients 99mTc ‐DMSA scintigraphy was performed after the conservative or surgical treatment. Renal scarring by DMSA scan was categorized into grades 1‐4 according to scale Smellie (1984). Mann‐Whitney and the chi‐square tests were used for the statistical analysis. Results: Renal defects were found in all patients with VUR by means of planar image and SPECT. The incidence renal scars were significantly higher (p<0,005) in SPECT: 16 affected kidneys were detected with intravenous urography, 47 affected kidneys were detected with planar mode, and 53 affected kidneys were detected with SPECT. The cortical defects were revealed even in the absence of VUR in 25% renal units. Prevalence of reflux‐nephropathy (RN) of the first type was in 2 children, RN of the second type was in 13 patients, RN of the third type ‐ 13, RN of the forth type was not detected. A good correlation was obtained between DMSA grading and VUR grade (r=0,49, p<0,03). All patients with VUR had a urinary tract infection (p<0,005). Renal size measuring with intravenous urography was similar to renoscintigraphy size (r=0.94, p<0.05). Proteinuria was found in 2 patients with RN of the third type having bilateral scarring. No statistically significant change was noted from scaring kidneys to patient age. Hypertension was diagnosed in 31% children with vesicoureteral reflux. The positive correlation was determined between diastolic indices and grades of RN (r=0,43, p<0,05). Conclusion: The data confirm that the scintigraphy with the DMSA is safe and essential in the investigation of patients with VUR and cannot be replaced by intravenous urography. SPECT detected post‐inflammatory changes in kidneys more than 99mTc‐DMSA in planar mode or intravenous urography. These results showed the close relation between the reflux grade, blood pressure, infection and the presence of renal scar.
PW105 A new technique for the quantitation of the absolute renal uptake of technetium-99m DMSA (ARU) in children M. Gorenberg1, L. Radan2; 1Bnai Zion Medical Center, Rappaport Faculty of Medicine, Technion,, Haifa, ISRAEL, 2Bnai Zion Medical Center, Haifa, ISRAEL. AIM: Dimercaptosuccinic acid chelate labeled with technetium‐99m (99mTc‐DMSA) is the radiopharmaceutical agent of choice for high‐resolution imaging of the renal cortex and estimation of the functional renal mass. The aim of this study was to evaluate a simplified new technique for determining the absolute renal uptake (ARU) of 99mTc‐DMSA , using the validated QDMSA SPECT measurements as the gold standard for comparison. MATERIALS &METHODS: Sixty one consecutive children, mean age 5.39±4.75 years, range (0.02‐18) were included in the study. There were 19 males (31.1%) and 42 females (68.9%). Patients were chosen iregardless their underling kidney pathology. The studies were performed 4 to 6 hours after intravenous injection of 1 to 3 mCi of the radiopharmaceutical. The exact dose delivered was determined by measuring the syringe in a dose calibrator before and after injection. Absolute uptake of the radiopharmaceutical by the kidneys was measured using previously described methods QDMSA SPECT (1). Studies were performed using a rotating gamma camera and an all‐purpose, low‐ energy collimator (SP‐6; Elscint, Haifa, Israel). For QDMSA SPECT data acquisition lasted 20 minutes. Kidney volumes and radioactivity‐concentration measurements were calculated on the reconstruction data using the threshold method (1). For ARU measurements a planar posterior view of the kidneys was acquired for one minute, at the end of the QDMSA SPECT study. RESULTS: The ARU measurements were very similar to those obtained using the validated QDMSA SPECT method, as determined by linear regression analysis (Pearson's r=0.924, p<<0.001), r squared = 0.854, regression equation: QDMSA‐SPECT=0.445+1.061ARU CONCLUSION: ARU estimation in children's using the newly proposed method was found to be nearly identical with the validated QDMSA SPECT method. 1. Iosilvsky G, Israel O, Frenkel A, et al. A practical SPECT technique for quantitation of drug delivery to human tumors and organ absorbed radiation dose. Semin Nucl Med 1989;19:33‐46.
PW106 The Contribution of 18F-FDG PET/CT Imaging in Management of Pediatric Lymphoma Patients N. Gökçora, Ü. Ö. Akdemir, T. Çakır, F. G. Pınarlı, C. Karadeniz, A. Oğuz; Gazi University Medical Hospital, Ankara, TURKEY.
Aim: To evaluate the usefulness of 18F‐FDG PET/CT in staging and chemotherapy response assessment in pediatric lymphoma patients. Methods: We retrospectively evaluated 39 18F‐FDG PET/CT examinations in 24 pediatric lymphoma patients with a mean (± SD) age of 10.2 (± 4.1). PET/CT scans were visually evaluated by a single observer blind to patients’ data. The findings of 18F‐FDG PET/CT and conventional staging were compared. Results: Twenty‐one patients had Hodgkin’s lymphoma (HL) and three patients had non‐Hodgkin’s lymphoma (NHL). 18F‐FDG PET/CT examinations were done for primary staging in 13, assessment of chemotherapy response in 17 and evaluation for suspected recurrence in 9 cases. When used for primary staging PET/CT upstaged 3 of 13 (23%) patients. Extranodal kidney, lung and bone involvement were detected in two patients. In 10 patients PET/CT was used to evaluate chemotherapy response after 3 cycles of chemotherapy (“interim PET”) and demonstrated remission in two patients who were non‐ responsive according to conventional staging. One of these patients had concordant negative results at the completion of chemotherapy. In 7 patients both PET/CT and conventional staging revealed remission at the end of chemotherapy. In 7 of 9 patients with suspected recurrences according to conventional methods PET/CT findings were negative. Conclusion: In pediatric lymphoma patients 18F‐FDG PET/CT provided important additional data in respect to staging, evaluation of early therapeutic response and suspected recurrence.
PW107 Clinical Usefulness and Safety of Lung Perfusion Scintigraphy with 99mTc-MAA in the Follow-up of Children Operated for Transposition of the Great Arteries P. Zucchetta1, R. Biffanti2, D. Cecchin1, O. Milanesi2, G. Stellin3, A. Sartorello1, S. Chondrogiannis1, F. Bui1; 1Nuclear Medicine, Padova, ITALY, 2 Paediatric Cardiology, Padova, ITALY, 3Paediatric cardiac surgery University Hospital, Padova, ITALY. Lung perfusion scintigraphy (LPS) can play a significant role during the follow‐up of congenital heart disease with peripheral pulmonary bed involvement, as in tetralogy of Fallot. After detecting by echocardiography sporadic lung perfusion disturbances in patients affected by transposition of the great arteries (TGA) we introduced LPS in the follow‐up of these patients. Materials and Methods: We have evaluated the clinical usefulness of 99mTc‐labeled macroaggregated albumin (99mTc‐MAA) LPS in 34 patients (age 0‐222 months, median 21; M 25, F 9) treated for TGA during the first weeks of life (median age at intervention 14 days). Only 2 patients had history of pulmonary artery stenosis corrected during surgery. All patients were asympomatic (NYHA class 1) and off therapy. The standard follow‐up included clinical examination, ECG and echocardiography. LPS was performed using a weight‐scaled dose of 99mTc‐MAA, accordingly to the EANM Paediatric Commitee guidelines. The number of injected particles was similarly adjusted, using an adult reference dose of 300000. Patients were positioned on a gamma‐camera equipped with a high‐resolution parallel‐hole collimator, without sedation, using only mild physical constraint (Velcro straps, sand bags, etc.) when necessary. Each image was stored in a 256x256 matrix with 500 Kcounts at least. The right/left distribution was calculated as percentage of total lung activity, drawing lung ROIs on the posterior view. Definite hypoperfusion was defined as <40% and severe hypoperfusion < 30%. Results: A total of 52 scans were performed (9 patients had 2 or more studies), whithout adverse reactions. A definite (<40%) lung hypoperfusion was detetcted in 16/34 (47%) patients (left lung 11, right lung 5). Five out of 16 had a severe hypoperfusion (40%) after percutaneous angioplasty. Scintigraphic data modified the clinical management in 10/34 patients. Conclusions: The data confirm the safety of 99mTc‐MAA LPS in the follow‐up of congenital heart disease. The prevalence of lung perfusion unbalance is quite high (47%) in this group of TGA patients and the severity threshold (<30%) has beeen reached in 1/3 of the affected subjects. Based on echocardiography and surgical history only a minority of them was suspected of having impaired lung perfusion, therefore it seems appropriate to introduce the LPS in the routine follow‐up. Further studies are needed to elucidate the pathogenesis and the long‐term clinical significance of pulmonary blood flow abnormalities in these patients.
PW108 Radioiodine Therapy in Differantial Thyroid Carcinoma in Childhood E. Ceylan Gunay1, P. Ozgen Kiratli2, M. Buyukpamukcu3; 1Mersin University Faculty of Medicine, Department of Nuclear Medicine, Mersin, TURKEY, 2 Hacettepe University Faculty of Medicine, Department of Nuclear Medicine, Ankara, TURKEY, 3HacettepeUniversity Institute of Oncology, Department of Pediatric Oncolgy, Ankara, TURKEY. Introduction: Thyroid cancer is among rare childhood head and neck tumours. In this study, the course of 25 chidren with differantial thyroid carcinoma (DTC) who were radioactive iodine (RAI) therapy given, was reviewed. Subjects and Methods:Twenty‐five children (9 male, 16 female) aged between 5‐19 years (median:13.5) with DTC, treated with RAI after appropiate surgery followed up for 97 months were retrospectively evaluated. All were referred to the hospital for cervical mass except one with the symptom of hoarseness. Physical examination revealed diffuse goitre in 9, nodular goitre in 12, cervical lymphadenopathy in 4 patients. Seventeen patients underwent total thyroidectomy with lymph node excision or neck dissection, 6 patients underwent total and 2 patients had subtotal thyroidectomy. Histological diagnosis confirmed papillary carcinoma in 16, papillary carcinoma with follicular variant in 7, pure follicular carcinoma in 2 patients. At the time of diagnosis 15 patients had lymph node metastases, 1 patient showed lymph node and tymus, and 4 patients had bone or lung metastases. Results:Fifteen patients were treated with RAI once, 8 patients received multiple doses of RAI therapy. The total amount of received dose was between 2775‐33300 MBq (median:5550 MBq). Dose of the therapy was given after a consensus between the oncologists and nuclear medicine on an ampiric dosage where 2775 MBq was given to 1 patient, 3700 MBq to 12 patient, 5550 MBq to 11 patients and 6845 MBq to one patient. Side effects were minimal nause and vomitting and pansitopenia in one patient who received a total dose of 9250 MBq.Patients were followed‐ up by I‐131 whole body scan, neck USG, and serum Tg levels. Five of the 25 patients received additional RAI therapy because of the recurrence of the disease (2 patients lung, 1 patient bone and 2 patients lymph node metastases). One of the patients died because of the complications of another malignancy on the 64th month of her follow‐up. All of the patients Tg levels showed significant decrease or reached to undetectable values. Two of the female patients gave birth to
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PW109 Nuclear dacryoscintigraphy: Will it replace traditional SAC syringing method? M. A. Shimpi, B. A. Krishna; P.D.National Hinduja Hosp & MRC, Mumbai, INDIA. Introduction: Epiphora is the most common reason one might consider to image the lacrimal drainage system. The relatively simple, cheap, and physiological modality of nuclear dacryoscintigrapghy (DSG) which is presently underutilized, allows the examiner to visualize the movement of tear out of the lacrimal drainage system from start to finish. Thus it is important to consider dacryoscintigraphy as a method to determine the location and type of obstruction so that appropriate management decision can be taken. Materiala and Method: This is a retrospective study of 50 eyes of 36 patients (M: 12, F: 24, Age: 3 to 79 years) with complains of epiphora who had not received any treatment in past. Patients underwent sac syringing (S/S) followed by (DSG). The DSG was done by standard method by putting a drop (100uci) of diluted Pertechntate solution in lateral fornix of lower lid and acquired images immediately and 10 minutes of interval till 3 hours. After a mean follow up of 2 +0.3 years, all patients were reassessed clinically. The diagnostic value of DSG was determined by comparing scan results with clinical symptoms and findings of S/S. Patients were classified into four categories depending on S/S findings. Category I consist of eyes with patent nasolacrimal passage on S/S. Category II consists of eyes with partial obstruction on S/S. Category III consist of eyes with total obstruction and category IV consist of eyes with inconclusive finding on S/S. Results: In category (I (20 eyes), DSG was normal in 10 (50%) and showed obstruction in 10 (50%). In category II (6 eyes), DSG revealed obstruction in 5(83.3%) and was normal in one (16.7%) In category III (22 eyes), DSG was normal in 3 (18%) and obstructed in 19 (82%) eyes. In category IV (2 eyes), DSG showed obstruction in one eye (50%). In follow up of these patients, we found that patients with normal S/S but obstruction on DSG did not improve after medical management and required surgery. Whereas patients with obstruction on S/S and normal DSG improved after medical management. Patients with obstruction on both methods required surgery. Conclusion: The use of nuclear DSG confirms and localizes the obstruction in the lacrimal drainage pathway of patients with epiphora . Thus DSG facilitates diagnosis of epiphora and changes management in 30 % of cases. Our study concludes that nuclear dacryoscintigraphy is NOT only complimentary to sac syringing method but can replace this modality.
PW110 Effect of ivabradin on myocardial perfusion and clinical evidences in patients with coronary heart diseases S. Minin, V. Chernov, A. Garganeeva, S. Bagreeva; Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. The aim of the study was to evaluate the anti‐ishemic effect and influences of if‐canals inhibitor ‐ Ivabradin on clinical evidences and myocardial perfusion in patients with coronary heart diseases (CHD) mixed with chronic obstructive pulmonary disease (COPD). Materials and methods. The study involved 20 patients (M/F: 11/9, mean age: 52,3±1.12 years). Eleven patients had stable angina and 9 patients had CHD mixed with COPD. The results evaluated are 12‐weeks therapy with if‐canals inhibitor ‐ Ivabradin (Koraksan, Servier, France) with the average dose of 5,2±0,7 mg/day. All patients were studied before and after Ivabradin administration general medical examination, spirography, veloergometric and 6‐minutes walk test. Pharmacological stress was performed by use of adenosine infusion (140 µg ∙ kg‐1 ∙ min‐1 for 6 minutes). The 99mTc‐ tetrofosmine was injected at the end of the third minute of infusion, and single photon emission computed tomography (SPECT) was initiated 60 minutes after the end of the adenosine infusion. Results. As the result of the Ivabradin therapy the reduction of coronary insufficiency clinical implications were noticed ‐ the decrease of episodes and heart stroke disappearance in some cases (3 patients). The number of angina patients with II and III class reduced and the number of patients with I degree and without angina episodes increased statistically‐valid p<0,05) in both groups. The reliable average increase of physical tolerance in both groups is 18,4±5,3% according to veloergometric tests and 14,8±6,2% according to 6‐minutes walk test. After 12‐weeks Ivabradin therapy was expressed antianginal efficiency caused by reliable decrease of heart attacks (to 15,7%; p<0,001) and daily requirement of nitroglycerine decreased to 16,0%; p<0,05. Mean baseline summed rest score (SRS) before Ivabradin therapy was 7,3±14%and the mean number of affected segments per patient was 2. After 12‐weeks myocardial perfusion significantly improved Ivabradin therapy: the SRS decreased from 7,3±14 to 3,2±12 p<0,001) and the mean number of affected segments was 1. Conclusion. The if‐canals inhibitor Ivabradin therapy has a positive effect on myocardial perfusion, clinical evidences of coronary insufficiency and physical tolerance in patients with CHD mixed with stable angina of II‐III class, also in patients with CHD mixed with COPD.
PW12 ‐ Tuesday, October 13, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 12: oncology - radioguided surgery
PW111 Non palpable breast cancer lesion excision: a comparison between radioguide occult lesion locatization (ROLL) vs wire guide lumpectomy (WGL). P. C. Notta1, M. Bajén Lázaro1, A. Benítez Segura1, J. Mora1, Y. Ricart1, A. Domènech1, I. Romero Zayas1, A. Gumà1, J. Climent2, A. García3, J. MartínComín1; 1S. Medicina Nuclear - Hospital Universitari de Bellvitge-IDIBELL, L'Hopsitalet de Llobregat, SPAIN, 2S. Anatomía Patológica - Hospital
Universitari de Bellvitge-IDIBELL, L'Hopsitalet de Llobregat, SPAIN, 3S. Ginecología - Hospital Universitari de Bellvitge-IDIBELL, L'Hopsitalet de Llobregat, SPAIN. Aim. To compare ROLL technique vs standard wire guide method in excision of non palpable breast cancer lesions. Materials and methods. 200 patients (p) (cT1N0) out of 843 p with occult breast cancer operated on conservative breast surgery and sentinel node biopsy during the period from June 2000 to december 2008 were retrospectively analysed. Two groups of patients were analyzed depending on the method that had been used to localized the occult lesion. Group A (ROLL method): 100p. Group B (wire guide method): 100p. The following factors were analysed: total tumor excision, maximun diameter of excised tissue and the number of patients who needed re‐excision of involved margins in the same operation because of positive intraoperative anatomopathological exam and the number of patients who need second therapeutic operation because of persistence of involved margins in the definitive anatomopathological exam. Statistical analysis: chi‐square method was performed and it was considered significative at p < 0,05. Results. All tumors were successfully localised and excised with ROLL and WGL method. The mean maximun diameter of tissue excised was 6,31 cm in group A and 6,73 cm in group B. There were no significant differences (p < 0,05) in re‐excision of involved margins in the same operation (49p group A and 44p group B). Involved margin who needed a second therapeutic operation occured only in 1 p from group B Conclusion. ROLL method is as effective as wire guide method for excision of non palpable breast lesion without increasing surgical length. Nevertheless, ROLL technique is easier, quicker and simplier than WGL method, not only for patients but also for surgeons, radiologists and pathologists.
PW112 Radio-Guided Occult Lesion Localizaton For Non Palpable Breast Lesions H. A. Ayan, O. A. Karacalioglu, E. Ozturk, R. Yildiz, S. llgan, T. Tufan, M. A. Ozguven; Gülhane Military Medical Academy, Ankara, TURKEY. Radio‐guided occult lesion localization is a new technique which allows identification of nonpalpable breast lesion. The aim of this study was to evaluate the effectiveness of radio guided occult lesion localization (ROLL) for non palpable breast lesions. MATERIAL AND METHOD 62 patients (80 lesions) who have nonpalpabl breast lesions > 1cm in diameter, underwent ROLL and tumor excision via 10‐12 MBq mCi intratumoral injection of Tc99m‐labelled macro‐aggregate albumin on the day of surgery . Image guidance was done either by ultrasound or mammography. In case of mammography guidance a control mammogram was taken a few minutes later to verify the correct localization of contrast within the lesions. Also lateral and anterior scintigraphic images were acquired and evaluated for migration and contamination.Intraoperative detection was performed with a handheld gamma probe. The area of maximum radioactivity was excised according to the radiological size of the lesion. Frozen‐section histological examination was performed immediately to determine whether the lesion was malignant or not. RESULTS Mean age was 41.07 years (range 23‐61 years). 56 (75%) cases tumor marking completed with sonographic guidance and in 7 (25%) cases with mammography. Localization of the lesions was successful in all cases. 10 patients had a cancer diagnosis. Clear margins were achieved in all cases. Most frequent benign diagnosis was fibrocystic changes and sclerosing adenosis. Patient preparation and radionuclide lesion localization last less than 10 minutes. CONCLUSION The frequency of non palpable lesions has increased due to the widespread use of mammography, and ultrasonography. The main problem with non‐palpable lesions is that of precise preoperative localization to make easy complete excision with free margins. Radioguided occult lesion localization is a preferred method for our institute when compared to guide‐wire localization. It provides better centering of the lesion and it is time and cost effective . Roll is a practical and reliable localization technique.
PW113 Radioguided localization of malignant non-palpable breast tumours in combination with selective sentinel node biopsy (SNOLL); experience in our hospital P. De La Riva, T. Cambil, C. Calvo, P. Fernández, P. Yañez, J. Ibañez, M. La Calle, J. Castro; Hospital Virgen Macarena, Sevilla, SPAIN. Aim: To describe the methodology of SNOLL technique carried out in our Hospital. Materials and methods: 34 patients were included (mean age=57,6) diagnosed with non‐palpable breast cancer (mean size=13,2mm) that fulfilled the indications for selective sentinel lymph node biopsy(SLNB) as stated per consensus(Spain). The day before surgery, 148MBq of nanocoloids were administered intratumoraly under ecographic control, obtaining conventional gammagraphy images, and skin marking the tumour and sentinel node (SN). During surgery a mixed technique was used (radiotracer + blue dye) using a detector gammaprobe (Navigator) in all the cases and a portable minigammacamera (Sentinella) in 16 cases. The nodes with an activity index >3:1 in‐ vivo, >10:1 ex‐vivo and/or dyed blue, were considered sentinel nodes. The lumpectomy was addressed and extracted according to the activity counts. In the cases with Sentinella, ex‐vivo images were taken having outlined contours and borders with a 99mTc pointer. Finalizing the process, images were acquired with Sentinella to check the surgical field was clear of any focal activity. Results: Identification rate of SN=97%, with a mean 2,2 SN extracted per patient in axillary area. And in one case an intrammamary SN was localized. S.N.
activity
No activity
Byed blue 80% (n=27) 8.8% (n=3) Not dyed 8.8% (n=3) 2,9% (n=1) Complete lymphadenectomy was performed in 14,7% of the patients (n=5/34). In 38,2% (n=13/34) internal mammary drainage was observed in the gammagraphy the day previous to surgery, tackling them when technically feasible. The mean size of the lesion lumpectomy was 70mm, margins were widened in 22 patients being negative in 81%(n=18/22); 27,7%(n=6/22) in contact with the borders, 13,6%(n=3/22) too small a border, 40,9% (n=9/22) persistent activity and in 4,4%(n=4/22) a combination of the above. Sentinella proved absence of activity in the surgical field after SN and tumour extraction, allowing conclusion of the procedure. Conclusion: SNOLL technique enables lumpectomy to be performed without a harpoon and SLNB in the same surgical act, reducing the amount of resected healthy tissue and centering the lesion. In our
Poster Presentation
a healthy baby during their follow‐up after a healty gestational period. Conclusion: Although the number of the patients is relatively small, and presentation is with mostly lymph node and sometimes wih distant metastasis, the fairly long follow‐up period in this study confirms that DTC in childhood could succesfully be treated by RAI after surgical treatment and shows good overall prognosis.
S304 group, we are most probably overrating the margins as we are still in the learning phase. It has a better acceptance by the patient, requiring <48 hours of hospital admittance. It is a unique procedure, but also multidisciplinary, so the availability of equipments and theatres must be assured and organised beforehand. The portable minigammacamera generates images of high sensibility that allows the progression of the intervention to be monitored invivo and exvivo.
PW114 Abdominal Para-Aortic Sentinel Lymph Nodes: towards Optimal Detection and Intra-Operative Localization using SPECT/CT and Intra-Operative Real-Time Imaging L. Vermeeren, R. Valdés Olmos, W. Meinhardt, W. Vogel, K. Hoefnagel, A. Bex, S. Horenblas; Netherlands Cancer Institute, Amsterdam, NETHERLANDS. Aim: Para‐aortic sentinel node biopsy may be a challenging procedure due to retroperitoneal localisation of the sentinel nodes, in close proximity to vital structures. The purpose of this study was to describe and evaluate the value of SPECT/CT for lymphatic mapping and a portable gamma camera for intra‐operative radioguidance, in patients with para‐aortic sentinel nodes. Material and methods: We evaluated our practise in 18 patients, who were treated at the Netherlands Cancer Institute with sentinel lymphadenectomy for different urological malignancies, and showed para‐aortic drainage on pre‐operative images. After injection of 99mTechnetium‐nanocolloid, patients received planar lymphoscintigraphy at 15 minutes and 2 hours, hybrid SPECT/CT, and afterwards proceeded to sentinel lymphadenectomy. Intra‐ operative node detection and localisation was guided by a (laparoscopic) gamma probe and a portable gamma camera. This gamma camera was set to display both the 99mTechnetium‐signal and a 125Iodine‐seed signal. The 125Iodine‐seed was placed on top of the gamma probe, functioning as a pointer on screen, thus enabling real‐time sentinel node localisation with the gamma camera. Results: In 16 patients with mid‐abdominal drainage on planar imaging and in 2 patients with non‐visualisation on planar imaging, SPECT/CT showed clear localisation of para‐ aortic sentinel nodes in relation to the abdominal vessels. In all patients para‐aortic sentinel nodes were successfully localised and removed with help of a gamma probe; through open surgery in 5 patients and with laparoscopy in 11 patients. In 16 patients the portable gamma camera was additionally used, enabling more efficient localisation of the sentinel nodes as well as post‐excision monitoring of remaining radioactivity. In one patient the para‐aortic sentinel node showed a metastasis. Conclusion: If retroperitoneal drainage is expected, SPECT/CT, in contrast to planar lymphoscintigraphy, can provide clear localisation of sentinel nodes in relation to anatomic structures. Detection and removal of para‐aortic sentinel nodes by means of a (laparoscopic) gamma probe and real‐time imaging with a portable gamma camera has shown to be a successful method with high intra‐operative detection rates.
PW115 Laparoscopic sentinel lymph node (SLN) dissection for clinically localized prostate carcinoma: preliminary results C. Rousseau1, A. Pallardy1, T. Rousseau2, G. Aillet3, J. Lacoste2, G. Le Coguic2, F. Kraeber-Bodéré4, C. Curtet5; 1Cancer Center, Nuclear Medicine, Nantes-saint herblain, FRANCE, 2Urologic Clinic Nantes-Atlantis, Urology, Nantes-saint herblain, FRANCE, 3IHP, Pathology, Nantes, FRANCE, 4 University Hospital, Nuclear Medicine, Nantes, FRANCE, 5CRCNA INSERM U892, Nantes, FRANCE. Aim. Positive lymph node is clearly established as prognostic factor of disease recurrence in prostate cancer (PC). High morbidity rate is reported with extended pelvic lymph node dissection (PLND) and limited dissection leads to a decrease of PLND sensitivity. The purpose of this prospective study was to assess the results and the relevance of laparoscopic radioisotope guided sentinel node dissection in loco‐regional staging in patients (pts) with clinically localized PC. Materials and methods. Pts were selected with organ‐confined prostate cancer, injected under transrectal ultrasound guidance 24 hours prior to surgery into each lobe of the prostate with 0.3ml/100MBq 99mTc‐rhenium sulfur colloid. Two hours after injection, SPECT/CT images were acquired. The laparoscopic surgery radiodetection and dissection of SLNs with a specially designed laparoscopic γ probe (CLERAD Gamma Sup) was performed followed by extended PLND. All nodes were analysed by histopathology and negative SLN with additional anticytokeratin antibodies analysis. Results. 21 pts were enrolled, (mean age 69 years, range 57‐76), with clinical stage T1 (5pts) and T2 (11pts) N0, M0 with mean PSA level ng/ml of 11 (3‐33) and a Gleason score sum ≥6 (6‐8). Four pts were excluded owing to prior prostate resection. SLN were visualized by lymphoscintigraphy in 16/17 pts (94%), with a mean of 4.3 SLN/pt (2‐9). The number of SLN removed by intraoperative radiodetection was mean 6 (1‐11), in 16/17 pts (94%), with ex vivo mean counting (cps) 893 (168‐3160). Background count was recorded in peritoneum 21 cps (5‐ 50), vesical area 127 cps (17‐236), psoas 127 cps (17‐236) and prostate 945 cps (168‐3180). A patient with no SLN on lymphoscintigraphy was not radiodetected and had a very low prostate probe counting (168 cps) corresponding to a missed injection. The most predominant site of SLNs was the obturator fossa 42%, followed by internal iliac 32.2%, common and external iliac 12.9% each. 11 pts (65%) were free of metastases, and 6 pts (35%) positive (2 pts with metastases only in SLN of whom for one only a micrometastasis, 3 pts with SLN and NSLN, and 1 false negative). Metastatic nodes were located in obturator fossa (45%), internal iliac (25%), common iliac (20%) and external iliac (10%) areas. Conclusion. Laparoscopic radioisotope guided SLN is an accurate method for assessing nodal involvement with a low morbidity. SLN dissection is a tool for staging intermediate risk PC and a combination of SLN and extended PLND in pts with high‐risk PC could prove worthwhile.
PW116 Radioisotope guided sentinel lymph node dissection in patients with localized prostate cancer: Results of the First 140 cases C. Bastide1, I. Brenot-Rossi2, S. Garcia1, D. Rossi1; 1Hopital Nord, Marseille, FRANCE, 2Institut Paoli-Calmettes, Marseille, FRANCE.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 OBJECTIVES The purpose of this prospective study was to assess the results and the relevance of radioisotope guided pelvic lymph node dissection (PLND) in loco‐regional staging in patients with clinically localized prostate cancer. MATERIALS AND METHODS A total of 140 patients with prostate cancer underwent radioisotope guided PLND. 127 patients were candidates for retropubic radical prostatectomy and 13 underwent radiotherapy. The 72 first patients received 2x 0.3ml‐30 MBq‐nanocolloid‐99mTc and the next 68 patients received 2 x 0.3‐100 MBq. Sentinel lymph nodes (SLNs) were detected intraoperatively with a gamma probe. RESULTS A median number of 3 SLNs was removed per patient. SLN were located outside obturator fossa in more than two thirds of patients. Lymph node involvement was observed in 11,4 % of patients. 62,5% of the LNM were outside obturator fossa. 43,7% of lymph node metastases (LNM) were lying at the first centimeters of the hypogastric artery. Fourteen of the sixteen LNM were detected in the SLN. The two non‐SLN (NSLN) involved nodes were found in 2 patients who failed the sentinel lymph node procedure. Each of twelve patients had pre‐operative PSA above to 10ng/mL and/or Gleason score ≥ 7. CONCLUSIONS Limited PLND to obturator fossa is clearly insufficient for accurate lymph node staging in patients with prostate cancer. SLN procedure could be an alternative for pelvic lymph node staging with an excellent sensitivity in patients with unfavorable prognostic factors (PSA > 10 ng/mL; biopsy Gleason score > 6).
PW117 Radio-guided sentinel lymph node detection in laryngeal and laryngopharyngeal cancer patients E. Cherdynceva1, V. Novikov1, V. Chernov2, I. Sinilkin1, O. Cheremisina1, S. Chizhevskaya1; 1Cancer Research Institute, Tomsk, RUSSIAN FEDERATION, 2Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. The purpose of the study was to determine a feasibility of radio‐guided sentinel lymph node detection for patients with laryngeal and laryngopharyngeal cancers. Materials and Methods: 11 patients with laryngeal cancer (2‐T1, 3‐T2, 5‐T3 and 1‐T4 and 2 patients with laryngopharyngeal cancer (1‐T2 and 1‐T4) were studied. The mean age of the patients was 58.7 years (range: 41 to 64). All patients underwent surgery. To localize SLNs, during the conventional fibrolaryngoscopy, 1 ml of 99mTc‐“Nanocis” at a dose of 80 MBq was injected peritumorally into 2‐4 sports (depending on the size and localization of the tumor) using 0.6‐0.7 diameter needle. Planar scintigraphy and SPECT was performed 20 minutes, 2 and 18 hours after radiotracer injection. During surgery, a gamma‐probe was used to identify SLNs in the operating wound. Lymph nodes with increased radiotracer uptake were removed for subsequent histological examination. All patients underwent regional lymph node dissection after a positive SLN was detected. Results: SPECT revealed from 1 (10 patients) to 3 (1 patient) SLNs. A total of 17 SLNs were visualized (average 1.3). Localization of SLNs was as follows: in the upper third of jugular vein (level IIA) (6 SLNs), lower third of jugular vein (IV) (1 SLN), prelaryngeal lymph node (VI) (4), paratracheal lymph node (VI) (3 SLNs) and paralaryngeal lymph node (VI) (3 SLNs). All 17 SLNs were localized using intraoperative gamma‐probe guidance technique. Hematoxylin‐eosin histological study of SLNs showed metastatic involvement in 2 SLNs, inflammatory infiltration in 7, fibrosis in 3 and normal lymphatic tissue in 5. One patient with SLN metastasis had no additional regional lymph node metastases. Metastases in both SLN and remaining regional lymph nodes were detected in 1 case. Conclusion: Radio‐guided SLN detection is a promising technique in the assessment of the extent of surgery for patients with laryngeal and laryngopharyngeal cancers.
PW118 Detection of sentinel lymph nodes in patients with gastric cancer I. Sinilkin1, V. Chernov2, S. Afanasyev1, A. Avgustinovich1, A. Titskaya1, M. Karakishisheva1; 1Cancer Research Institute, Tomsk, RUSSIAN FEDERATION, 2Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. Purpose: to study the accuracy of sentinel lymph node (SLN) detection and the value of the technique in the assessment of lymph node involvement. Materials and Methods: The study included 32 gastric cancer patients. There were 28 male and 4 female patients with ages ranging from 40 to 73 years. Distribution of the patients according to T‐criterion was as follows: 8 patients with T1, 13 with T2, 9 with T3 and 2 with T4. Radioactive colloid (99mTc‐“Nanocis”) at a dose of 80 MBq was injected endoscopically 24 hours before surgery. SPECT was performed using E.CAM gamma‐camera (Simens, Germany) 20 minutes, 2 and 18 hours after injection of the radioactive colloid. All patients underwent gastrectomy with D2 lymphodissection. Sentinel lymph nodes were identified using RAICAL gamma‐probe (“Amplituda”, Russia) and labeled for histological examination. Results: By SPECT 23 SLNs were found in 17 patients. According to radioguided detection, 74 SLNs had been labeled in 32 patients. The relationship between the number of SLNs and the diameter of the primary tumor was found (1‐3 lymph nodes: tumor size <3 cm in diameter, tumor size 2‐4 nodes: 3‐5 cm in diameter and 3‐4 nodes: tumor size >5 cm in diameter. Histological examination revealed metastasis in SLN and in the remaining dissected lymph nodes in 17 patients. In 14 patients, SLNs as well as other lymph nodes were found to be negative for metastatic disease. In 1 patient, SLN contains no tumor cells, whereas other lymph nodes were involved with metastasis. The number of metastatic lymph nodes was related to the tumor diameter metastasis was revealed in 2 (11%) patients with tumor size < 3 cm in diameter, in 6 (60%) patients with tumor size 3‐5 cm and in 9 (83%) patients with tumor size >5 cm. The relationship between metastatic involvement of lymph nodes and T‐criterion was also studied. Metastasis in SLN was revealed in 2 (25%) patients with T1, in 7 (54%) with T2, in 7 (77%) with T3 and in 2 (100%) with T4. Conclusion: The study of sentinel lymph nodes using radioactive colloid in gastric adenocarcinoma provides high sensitivity and accuracy. Risk for metastatic involvement of abdominal lymph modes increases with the tumor growth and it invasion into the gastric wall.
PW119 Gamma probe-guided surgery for completition thyroidectomy H. Kaya1, C. Can Karahan1, S. Altindag1, E. Gedik2, O. Cetinkaya1; 1Dicle University School of Medicine the Department of Nuclear Medicine, Diyarbakir, TURKEY, 2Dicle University School of Medicine the Department of General Surgery, Diyarbakir, TURKEY.
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PW120 Use of portable gammacamera in selective biopsy of sentinel node in cutaneus melanoma P. De La Riva, T. Cambil, D. Moreno, C. Calvo, J. J. Ríos, J. Castro; Hospital Virgen Macarena, Sevilla, SPAIN. Aim: Describe the technique of selective sentinel lymph node biopsy (SLNB) in cutaneous melanoma, in those patients where we used a portable gammacammera (Sentinella) for the first time in combination with a gammaprobe (Navigator). Materials and methods: 10 patients were included (mean age:56,9) diagnosed with cutaneos melanoma, with Breslow>1mm or <1mm with ulceration‐regression, and in all cases N0. With the diagnosis, 4 patients presented Breslow<1mm, 5 Breslow 1‐4mm and 1 Breslow>4mm. The localization of the melanomas where: inferior limbs (n=5), trunk (n=3), upper limbs (n=1) and supraclavicular (n=1). The day before the surgical intervention, 111 MBq of nanocoloids was administered intradermaly pericicatricialy distributed in 4 points; obtaining dynamic and static images with a conventional gammacamera, once the SN was observed we proceeded to mark the skin on the different planes. During surgery a gammaprobe detector was used along with a portable gammacamera (Sentinella) which allowed us to take pre‐incision images to find the SN and decide the most adequate approach. Those with an activity >3:1 in‐vivo/>10:1 ex‐vivo were considered SN. Once extracted, images of the SN were taken ex‐vivo, and of the surgical site to assure no focal point compatible with being a SN remained. Results: In all cases the objective with conventional gammagraphy showed lymphatic drainage of the lesion, in 90% of the cases it was a lymph node basin: in 4 patients to ipsilateral axillary region to the lesion and in 5 to ipsilateral inguinal region. In 1 case only was there migration to bilateral axillary basins. SN identification rate: 100% (n=10/10), with a mean 2,7 SN extracted per patient. In the surgical site search after SN extraction, Sentinella proved persistent activity compatible with SN in two patients; the rest of the patients presented a clear image. The anatomicophatological study gave absence of metastasis in all patients. Conclusion: With the combined use of Navigator and Sentinella we obtained a SN identification rate of 100%. We believe the use of Sentinella aids the SN detection, can identify in real time possible aberrant SN or in transit and so would improve melanoma staging. Although we only have a small sample, we believe the results are very hopeful, and the potential advantages of Sentinella should be proven versus the conventional mixed technique (radioisotope + colouring) through controlled randomized study.
PW13 ‐ Tuesday, October 13, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 13: oncology - breast cancer (single photon)
PW121
99m
Evaluating the role of Tc-MIBI scintimammography with MRI and histology correlation in predicting and assessing tumour response to neoadjuvant chemotherapy in locally advanced/metastatic breast cancer S. J. Lu, A. Sinha, S. Wang, E. M. Ong, V. Reynolds, T. Putti, P. T. Iau, T. Han; National University Hospital, Singapore, SINGAPORE. Aim This study evaluated the role of 99mTc‐MIBI scintimammography in predicting and assessing tumour response to neoadjuvant chemotherapy in locally advanced/metastatic breast cancer and also explored the correlation and concordance between scintimammography, MRI and histology in assessing tumour response. Materials and methods Twenty‐seven women with locally advanced/metastatic breast cancer were prospectively recruited and underwent both scintimammography and MRI pre‐ and post‐neoadjuvant chemotherapy before undergoing surgery (mastectomy or lumpectomy). Twenty‐eight breast tumours were imaged (one patient had bilateral breast cancer). Scintimammographic images were acquired 10 minutes, 1 hour, 2 hours and 4 hours after radioisotope administration. Tumour‐to‐normal tissue ratios (T/N) were calculated from the early 10‐minute and delayed 4‐hour images. Tumour response on scintimammography was assessed using early T/N. MRI included routine and dynamic contrast‐ enhanced sequences. Early and delayed T/N pre‐neoadjuvant chemotherapy as well as mean percentage decrease in early and delayed T/N after neoadjuvant chemotherapy were compared between responders and non‐responders to neoadjuvant chemotherapy. Correlations and comparisons were made between scintimammography, MRI and histology findings in assessing tumour response. Results There were 19/28 responders and 9/28 non‐responders. Pre‐ neoadjuvant chemotherapy, the early and delayed T/N of responders were higher than those of non‐responders (early T/N: 2.88 ± 1.76 vs 2.17 ± 0.78, p=0.15, and delayed T/N: 2.33 ± 1.15 vs 1.92 ± 0.80, p=0.29) which, although statistically not significant possibly due to small numbers, suggested that greater MIBI uptake by tumours predicts response. Post‐neoadjuvant
chemotherapy, the mean percentage decrease in early and delayed T/N of responders were significantly greater than those of non‐responders (mean percentage change in early T/N: ‐43.53 ± 19.90% vs 0.58 ± 33.66%, p<0.05, and mean percentage change in delayed T/N: ‐35.91 ± 22.15% vs ‐1.02 ± 27.85%, p<0.05), suggesting that scintimammography is able to assess response. In assessing tumour response, there was good scintimammography‐MRI agreement (Cohen's kappa, κ=0.73, p<0.05), good scintimammography‐histology agreement (κ=0.73, p<0.05) and good MRI‐histology agreement (κ=0.84, p<0.05). There is significant correlation between residual tumour size measured by MRI and that determined by histology (Spearman’s rho, ρ=0.64, p<0.05). Scintimammography has 100% sensitivity, 66.7% specificity and 89.3% accuracy while MRI has 94.7% sensitivity, 88.9% specificity and 92.9% accuracy in assessing tumour response. Conclusion 99mTc‐MIBI scintimammography is able to predict and assess tumour response to neoadjuvant chemotherapy in locally advanced/metastatic breast cancer. In assessing tumour response, there is good metabolic‐anatomic‐pathologic concordance between scintimammography, MRI and histology.
PW122 99m
Tc-MIBI mammoscintigraphy in assessment and prognosis chemotherapy response
A. Titskaya1, V. Chernov2, E. Slonimskaya1, I. Sinilkin1; 1Cancer Research Institute, Tomsk, RUSSIAN FEDERATION, 2Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. Purpose: to determine the most significant quantitative parameters of 99mTc‐MIBI mammoscintigraphy allowing the assessment of changes in tumor tissue during pre‐operative treatment and the prognosis of neoadjuvant chemotherapy for breast cancer. Materials and Methods: The study comprised 27 patients with stage T1‐4 N1‐2M0 breast cancer. All patients underwent single photon emission computed tomography (SPECT) of the chest using 99mTc‐MIBI before and after 2 courses of neoadjuvant chemotherapy. The scintigrams were quantitatively assessed using L/N (lesion/non‐lesion ratio) and RI (retention index) calculated by the formula: early LN and delayed LN/early LN. Results: All patients were divided into 2 groups according to RESIST scale: Group I included 17 patients with chemotherapy response rate of more than 30% and Group II (10 patients) ‐ chemotherapy response rate of less than 30%. No complete response was found in any of the case. The initial L/N index appeared to be significantly lower in Group I than in Group II (3.5±1.7 versus 7.6±4.01; p=0.0005). RI was also lower in Group I compared to Group II (0.1±0.3 versus 0.3±0.2; p=0.04). The individual analysis of results showed that pre‐ therapy L/N index was under 5.5 in 16 out of the 17 patients (94%) of Group I and above 5.5 in 8 out of the 10 patients (80%) of Group II. Similar results were obtained when analyzing initial RI. Pre‐therapy RI was less than 0.3 in 11 out of the 17 patients (65%) of Group I and more than 0.3 in 6 out of the 10 patients (60%) of Group II. Conclusion: The results obtained show that quantitative parameters of 99mTc‐MIBI mammoscintigraphy (L/N and RI) are useful in prediction and assessment of neoadjuvant chemotherapy response.
PW123 Radionuclide evaluation of response chemotherapy in breast cancer patients
to
neoadjuvant
O. Solodyannikova, N. Voit, D. Dzhuzha, G. Sukach; National Institute of Cancer, Kyiv, UKRAINE. Introduction. Searching of most informative and clinical based methods of estimation and prediction of chemotherapy treatment and monitoring among breast cancer (BC) patients is very acute medical problem, limiting advanced breast cancer treatment. The aim of present study was to evaluate whether tumor clearance of 99mTc‐MIBI is capable to assess tumor response to neoadjuvant chemotherapy in patients with locally advanced BC. Material and methods. 40 BC patients planning for undergoing neoadjuvant chemotherapy were investigated 2‐8 days prior to chemotherapy using scintimammography (SMG) with 99mTc‐MIBI. Static scintimammography was performed 10 and 60 min after intravenous injection of 400‐550 MBq of 99mTc‐MIBI. Time to half clearance (T1/2) of 99mTc‐MIBI was calculated for each patient from decay‐corrected time‐activity curves using monoexponential fitting. Chemotherapy was given as either standard AC (doxorubicin, cyclophosphamide) courses (n=20 patients), as CEF (cyclophosphamide, epirubicin, 5‐fluorouracil) courses (n=15 patients), or as FEC (5‐fluorouracil, epirubicin, cyclophosphamide) courses (n=5 patients). Patients were assessed and tumor size was measured by mammography and ultrasonography before and at the end of the treatment. Due to the clinical results after chemotherapy patients were assessed as complete and partial responders (34 patients), non‐responders (4 patients) and disease progressions (2 patients). Results and discussion. Among non‐responders T1/2 was significantly high (average value 159.8 min) than among patients with complete answer to chemotherapy (average value of T1/2 ‐ 122.1 min). In 2 cases of BC progression we observed rapid tumor clearance of 99mTc‐MIBI (≥ 113 min). Conclusion. The efflux rate of 99mTc‐MIBI may be used for the in vivo identification of chemotherapy prediction to neoadjuvant chemotherapy in patients with locally advanced breast cancer. A rapid tumor clearance of 99mTc‐MIBI may predict the lack of tumor response to chemotherapy.
PW124 The usefulness of 99mTc-tetrofosmin SPECT/CT in the assessment of breast cancer (BC) response to neoadjuvant therapy A. Spanu1, F. Chessa1, D. Sanna1, A. Farris2, A. Manca3, M. Pittalis2, P. Cottu4, S. Nuvoli1, G. Madeddu1; 1Department of Nuclear Medicine. University of Sassari, Sassari, ITALY, 2Department of Oncology. University of Sassari, Sassari, ITALY, 3Department of Pathology. University of Sassari, Sassari, ITALY, 4Department of Surgery. University of Sassari, Sassari, ITALY. Aim: Conventional diagnostic procedures proved of limited value in the assessment of response to neoadjuvant therapy in patients with large or locally advanced BC. In the present study, we evaluated 99mTc‐tetrofosmin SPECT/CT usefulness in the assessment of BC response to neoadjuvant chemo or hormonotherapy. Methods: A consecutive series of 42 BC patients (33‐82
Poster Presentation
Introduction: Reoperative thyroid surgery may be required in patients who undergo any procedure less than total or near total thyroidectomy. Aim: The aim of this study was to investigate advantages of gamma probe guided revision thyroidectomy in patients with differentiated thyroid carcinoma. Material‐Method: 17 patients with differentiated thyroid carcinoma who had previously undergone surgery were included in this study. Before radioguided surgery, all patients showed significant degree of uptake in the thyroid bed with Tc99m perthecnetate schintigraphy. Reoperative thyroid surgery was planned for all the patients. One day before operation 1 mci dose of I‐131 was given orally. İn the morning of operation day, all patients had been performed thyroid scan . All operations had been performed using hand held gamma probe. One day after the surgery, a postoperative thyroid scan was performed using the remaining radioactivity to evaluate the success of the surgery. Results: There were 13 women and 4 men, ranging in age from 26 to 48 years.(mean 37.1 years) Residual tissue was visualized with thyroid scan and USG in all patients after the initial operation. The intraoperative mean ratio of thyroid activity to background activity was detected as 15.5/1 and the mean ratio of thyroid bed activity to background activity after excision was 1.9/1(p<0.001). Minimal residual tissue was visualized in 4 patients in postoperative thyroid scan after the second operation. Conclusions: These results indicate that intraoperative gamma probe application may be beneficial to detect and remove residual thyroid tissue in revision thyroidectomy.
S306 yrs) with large or locally advanced BC scheduled to neoadjuvant chemo (31 cases) or hormonal (11 cases) therapy underwent 99mTc‐tetrofosmin SPECT/CT in addition to conventional diagnostic methods before and after neoadjuvant treatment. SPECT/CT studies were acquired using a dual head gamma camera integrated with a X‐ray tube for low dose CT, including both breasts and axillary regions in the field of view. SPECT images were corrected for attenuation and scattering, reconstructed with iterative method and fused with CT images. Following neoadjuvant therapy, all 42 patients had breast surgery and 36/42 also axillary lymph node dissection, with histopathological evaluation. According this, the patients were classified as completely (n=6), partially (n=32) or non responders (n=4). Results: 99mTc‐tetrofosmin SPECT/CT was true negative in 6/6 completely responder patients (specificity: 100%) and true positive in 32/36 patients with residual tumors (sensitivity: 89%), including 28/32 partially responder and 4/4 non responder patients; of the 32 residues positive at SPECT/CT, 2 were ascertained only at microscopic evaluation, while 30 were macroscopic (size: 1.2‐7 cm). A high correlation between radiotracer uptake and tumor site and extension found at surgery was observed in all 32 positive cases. SPECT/CT was false negative in the remaining 4 partially responder patients, missing microscopic residues scattered in a fibrotic area in 2 cases and macroscopic residues (a 18 mm mucinous BC and a multifocal lobular BC) in the other 2 cases. Moreover, SPECT/CT ascertained axillary lymph node metastases in 12/26 affected patients (sensitivity: 46%) and missed metastases in 14/26 cases who had micrometastasis or small deposits of metastases scattered in lymph nodes with fibrotic changes. No false positive findings were observed in the remaining patients without metastases (specificity: 100%). Conclusions: 99mTc‐tetrofosmin SPECT/CT proved a useful diagnostic tool in the assessment of BC response to neoadjuvant chemo/hormonotherapy. In particular, a positive study is highly predictive of the presence of residual tumors, although false negative findings can occur in patients with microscopic residues and in those with low‐cellularity histotype tumors. Moreover, like all the others diagnostic imaging procedure, SPECT/CT proved of limited value in identifying small metastases scattered in fibrotic lymph nodes.
PW125 Ibuprofen use reduces the proliferation seeking agent 99m Tc(V)DMSA uptake in severe breast epithelial hyperplasia without atypia V. Papantoniou1, E. Sotiropoulou2, A. Tsaroucha1, S. Marinopoulos1, P. Valsamaki1, S. Tsiouris3, N. Ptohis4, A. Fothiadaki1, T. Karianos1, K. Stipsanelli1, E. Kounadi1, M. Sotiropoulou1, K. Dimitrakakis1, A. Antsaklis1; 1 "Alexandra" University Hospital, Athens, GREECE, 2"Sotira" General Hospital, Athens, GREECE, 3Ioannina University Hospital, Ioannina, GREECE, 4"Attikon" University Hospital, Athens, GREECE. Purpose: To investigate if ibuprofen intake can influence 99mTc(V) DMSA uptake in patients with severe epithelial and atypical breast epithelial hyperplasia Methods: 8 patients with histologically confirmed severe epithelial hyperplasia with (NAEY= 4) and without atypia (NEY= 4) were submitted to 99mTc(V) DMSA scintimammography, before and after a 3‐4 week period of 400 mg ibuprofen intake daily. Lesion /Background ratio were calculated and compared (t‐ test) 60 min post injection before and after ibuprofen administration Results: The patients with severe epithelial hyperplasia showed a significant higher uptake ratio as compared with the patients with atypical epithelial hyperplasia pro ibuprofen intake (2,47±0,54 vs 1,68±0,14, respectively p=0,029). These patients were also found to exhibit a significant decreased percentage of 99mTc(V) DMSA ratio as compared to women with atypical epithelial hyperplasia after administration of ibuprofen (52,75±9,28 vs 9,7±3,76 respectively, p=0.001) Conclusion: Ibuprofen induces significant reduction of 99mTc(V) DMSA uptake in severe breast epithelial hyperplasia without atypia and thus it could reflect a substantial tool in the chemoprophylactic strategy of women in the early state of malignant transformation
PW126 Breast density, scintimammoraphic 99m Tc(V)DMSA uptake and calcitonin gene related peptide(CGRP) expression in mixed invasive ductal associated with extensive in situ ductal carcinoma (DCIS +IDC) and pure invasive ductal carcinoma (IDC).Correlation with ER status and proliferation index (Ki67). V. Papantoniou1, E. Sotiropoulou2, A. Tsaroucha1, S. Marinopoulos1, P. Valsamaki1, S. Tsiouris3, N. Ptohis4, A. Fothiadaki1, T. Karianos1, K. Stipsanelli1, E. Kounadi1, M. Sotiropoulou1, K. Dimitrakakis1, A. Antsaklis1; 1 "Alexandra" University Hospital, Athens, GREECE, 2"Sotiria" University Hospital, Athens, GREECE, 3Ioanninia University Hospital, Athens, GREECE, 4"Attikon" University Hospital, Athens, GREECE. Purpose: The aim of our study was to assess the variation of CGRP expression in patients with IDC and in patients with IDC+DCIS in relation with % mammographic breast density (BD), the uptake of the cell proliferation seeking radiotracer 99mTc‐(V)DMSA (SMM uptake), the proliferation index (Ki ‐67) and the estrogen receptors (ER) status. Methods: We studied retrospectively 24 women who referred to our department with suspicious findings on palpation and/or mammography and were evaluated preoperatively with 99mTc‐(V)DMSA scintimammography. Histology revealed 12 IDC (mean age±SD= 66,5±13,1) and 12 IDC+DCIS (mean age±SD = 58,5±15,1). Immunohistochemical staining for CGRP, Ki‐67 and ER status was performed in all 24 surgical specimens. BD and SMM uptake were calculated by computer assisted methods and were correlated with CGRP expression by linear regression analysis. CGRP values were compared (Mann Whitney test) between patients with >25% and <25% BD. BD and SMM uptake were compared between CGPR(‐) and CGRP(+) patients and between IDC and IDC+DCIS. Ki‐67 and ER were compared between IDC and IDC+DCIS. Ki‐67 was also compared between patients with BD >25% and <25%, whereas ER was correlated with CGRP Results: Overall positive correlation was found between BD and CGRP expression (r=0,577 p<0,001) [rBD(IDC)‐CGRP = O,765 p<0,001, rBD(IDC+DCIS)‐CGRP = 0,746 p<0,001]. Positive correlation was found between SMM uptake and CGRP only in IDC+DCIS [rSMM(IDC+DCIS)‐CGRP= 0,634 p<0,05] CGRP expression was significantly higher in patients with >25% BD compared to the ones with <25% (23,18±7,5 vs 9±5,1 , p=0,00008). BD and SMM uptake was significantly higher in CGRP(+) than in CGRP(‐) patients (30,68±11,24 vs 18,01±4,5 , p=0,001 and 22,63±10,61 vs 11,92±4,79, p= 0,012, respectively) as well as in IDC+DCIS
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 as compared to pure IDC (31,38±8,19 vs 21,67±11,6 , p= 0,044 and 27,94±8,04 vs 13,19±6,84 , p=0,0002 , respectively). Ki ‐67 was significantly higher in IDC+DCIS than in pure IDC (27,91±13,8 vs 12,8±9,44) as well as in patients with BD>25% than in patients with BD<25% (26±15,44 vs 10±1,63). On the contrary, ER was significantly lower in IDC+DCIS compared to pure IDC (71,81±95,45 vs 162,17±55,49) and strongly inversely correlated with CGRP in pure IDC (r=‐0,742, p<0.01). Conclusion: ΒD, SMM, CGRP and Ki‐67 expression were significantly increased and ER status significantly decreased in DCIS+IDC as compared to IDC, indicating that the two groups are different entities, the DCIS+IC being more aggressive and ER independent and possibly associated with a pathway linked to stromal involvement and CGRP activity.
PW127 The Feasibility of Simultaneous Radinuclide Occult Lesion Localization and Sentinel Lymph Node Biopsy. U. Yararbas1, B. Zengel2, Z. Adıbelli2, A. G. Deneçli2; 1Ege University Hospital, Izmir, TURKEY, 2Bozyaka Training and Research Hospital, Izmir, TURKEY. Aim: Radionuclide occult lesion localization (ROLL) has become an alternative to wire localization technique in non‐palpable breast lesions. It can be performed either by ultrasound or mammagraphic guidance. The aim of our study is to test the feasibility of simultaneous ROLL and sentinel lymph node biopsy (SLNB). Material and Method: Twenty‐two female patients with non‐ palpable breast lesion were included in the study. Age range was 35±12. All patients underwent lymphatic mapping using Tc‐99m nanocolloid and isosulphan blue to make SLNB available in case of malignant frozen section result of the breast lesion. A total of 1 mCi activity was injected at 4 quadrants of periareolar region intradermally the day before surgery and isosulphan blue was injected at subareolar space after the induction of general anesthesia. The day of the surgery in 7 patients using ultrasound and in 15 patients using mammography 0.5 mCi of Tc‐99m MAA in 0.2 ml volume was injected into the lesion. MAA injection was followed by 0.2 ml saline. Excision material was evaluated radiologically to verify the removal of the lesion and then evaluated by frozen section analysis. Results: In all patients ROLL technique could successfully localize the occult lesion. Mean lesion/background count ratio was 4250. In none of the patients SLN activity interfered with ROLL injection. On intraoperative frozen section analysis of the breast lesions 10 patients had benign and 12 patients had malignant result. Successful SLN detection was reached in all patients. In SLNB of the patients with malignant breast lesions mean count rates obtained on skin was 27. On frozen section analysis of SLNs in 4 patients SLNs were found to be malignant. Conclusion: Although both ROLL and SLNB techniques use Tc‐99m labeled radiocolloids, since target/background count ratio in ROLL is very high when compared with SLNs interference did not occur even in upper outer quadrant tumors. Simultaneous ROLL and SLNB avoids a second operation in patients with malignant lesions.
PW128 Positive molecular sentinel node (pNmol+) in breast cancer patients. A follow-up study up to 7 years. A. Benítez Segura1, M. Bajén Lázaro1, L. Rodriguez-Bel1, J. Mora1, Y. Ricart1, M. Roca1, M. Varela2, J. Climent2, A. Urruticoechea2, M. Plà2, C. Masuet3, J. Martín-Comín1; 1S. Medicina Nuclear Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, SPAIN, 2Unidad Funcional de Mama-Hospital Universitari de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, SPAIN, 3S. Preventiva y Estadística-Hospital Universitari de BellvitgeIDIBELL, L'Hospitalet de Llobregat, SPAIN. Aim: To analyze the global survival and free survival disease in breast cancer patients (p) with positive molecular sentinel node without histopathological traduction (pN0 (mol+)). Materials and methods: 702p operated on breast cancer (cT<3cm) and SLN biopsy from the period June 2000 to December 2004 were retrospectively analysed from a prospective data base. 76 out of 702p (10,8%) with pN0(mol+) without axillary lymph node dissection were analyzed. Mean aged: 57 y (32‐87y). Follow‐up was done up to 7y. 5p were excluded because of lack of follow‐up. SN pathologycal analysis: intraoperatively cytological imprint (Diff‐Quick); delayed evaluation with hematoxylin and eosin staining, immunohistochemistry and molecular analysis (RT‐PCR). After surgery all patients underwent a clinical examination (the first 3 years at 4 monthly interval, every 6 months for 2 more years and annually afterwards). Adyuvant treatment was indicated according the hospital protocol. Axillary recurrence, distant disease and free survival disease (Kaplan‐Meier method) was analyzed. Results: After a median follow‐up of 4, 83 y (0,8 ‐ 7,20 y), 1p developed an axillary recurrence because of a contralateral breast cancer, but any patient developed axillary recurrence in the same side of breast cancer. The 7‐year overall survival rate was 100%. Conclusion: The positivitly molecular sentinel node (pNmol+) seems not to have any influence on breast cancer patients evolution.
PW129 Internal mammary sentinel node biopsy for breast cancer. P. Liévano, T. Baringo, P. Navarro, L. De la Cueva, E. Arroyo, M. Añaños, M. González, M. Abós; Servicio de Medicina Nuclear. Hospital Universitario Miguel Servet, Zaragoza, SPAIN. AIM To review our data obtained of the identification of internal mammary sentinel node biopsy in order to determine the value changing staging and treatment. METHODS A retrospective analysis was made in 374 patients from our database, between May 2005 and June 2008 (underwent lymphatic mapping with preoperative lymphoscintigraphy and intraoperative use of a gamma‐ray detection probe). In most patients, Tc‐99m albumin colloid were injected intra and peri tumoral for sentinel node biopsy. RESULTS Internal mammary sentinel node was detected in 62 patients (15.3%). In 18 patients (29%) mammary lymph nodes were not removed due to technical surgery difficulties or comorbidity associated. Internal mammary sentinel node was negative in 36 patients (81.8%) and was positive in 8 cases (18.2%), whereas 4 patients revealed positive axilar lymph nodes, 2 negatives axilar lymph nodes and 2 only migrate to internal mammary nodes. CONCLUSIONS It is valuable to explore internal mammary sentinel node, has changed the staging and treatment of 4 patients. However, a greater number of cases and randomized studies are required to determine protocols consensus to follow.
S307
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 99m
PW130 Autoevaluation of the clinical practice of Sentinel Lymph Node Biopsy in the breast cancer J. M. Freire, M. Pajares, A. Utor, P. Paredes, M. J. Palomo, E. Alonso; University Hospital Puerta del Mar, Cadiz, SPAIN. The procedure of the Sentinel Lymph Node Biopsy (SLNB) has demonstrated to be a safe alternative to the traditional complete axillary lymph node dissection in the staging and surgical treatment of the breast cancer. The multidisciplinary team: surgeons, pathologists and nuclear medicine physicians must do it with rigor and demonstrating to fulfill a few essential criteria. Aim: Evaluating the quality of the procedure in the Unit of Breast Pathology of the University Hospital Puerta del Mar (Cadiz), using the guide of autoevaluation that in March 2007 was presented by the Spanish Society of Breast Pathology Material and Method: The above mentioned guide establishes a few objective and measurable criteria of evaluation related to the different aspects that intervene in the practical application of the procedure SLNB. Every criterion is associated to 4 levels of standard quality. In addition there are established 3 essential criteria of forced fulfillment to implement SLNB in the clinical practice. The guide consists of 3 parts: Experience of the team with 6 Criteria of evaluation, Operative Aspects with 18 criteria (3 essentials) and Scientific Activity with 8 standard indicators. The procedures were initiated in April 2006 like validation phase that includes 50 patients, and from November 2007 in application phase 120 patients. Results: The team fulfills with three essential criteria related to the technical efficiency in the detection of the sentinel node (96 %), sensibility accredited in phase of validation (90 %), and media of axilar sentinels (2,1) Criteria Punctuation
Experience
6
Level of Standard I
II
III
12/25
1
4
1
Operative Aspects 18
24/26
1
14
3
Scientific Activity 8
4/20
0
6
2
Total
40/71
2
24
6
32
Management system focused on quality with reference to medical services with application of ionizing radiation A. Wyszomirska, J. Sowiński; Poznan University of Medical Sciences Clinic of Endocrinology, Metabolism and Internal Diseases, Poznań, POLAND.
The application of the autoevaluation guide in our Unit has turned out to be a global punctuation of 40 on a maximum of 71 points. Being the level II the quality level most prevalent (24/32). Conclusion: Our teams fulfilled during the validation phase the criteria established to implement the procedure. The utilization of the guide published by the Spanish Society of Breast Pathology credits the good practice of SLNB's procedure for our Unit and allows to identify the areas of improvement, in our case the related ones to the scientific and formative activities
PW14 ‐ Tuesday, October 13, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 14: general topics - quality and regulations
PW131
PW133
18
Comparison of Imaging Protocol of F-FDG PET/CT for Overweight Patients: Optimizing Scan Duration vs. Administration Dose Y. Masuda1, C. Kondo1, Y. Matsuo1, K. Kusakabe1, M. Uetani2; 1Tokyo Women's Medical University, Sinjuku, JAPAN, 2Nagasaki University, Nagasaki, JAPAN. The quality of 18F‐FDG PET/CT images of overweight patients can often be degraded. We evaluated the effects of optimizing injected dose or scan acquisition time on the quality of images of overweight patients using lutetium oxyorthosilicate (LSO) PET/CT with high‐ performance detector electronics. Methods: We initially retrospectively measured radioactivity concentrations and signal‐to‐noise ratios (SNR) in the liver relative to body weight of 80 patients 18 who had undergone F‐FDG PET/CT according to our standard protocol (injected dose, 3.7 MBq/kg; acquisition time, 2 min/bed position). The patients were sub‐grouped (n = 20 per group) according to baseline body weight as G1 (≤59 kg), G2 (60‐69 kg), G3 (70‐84 kg), and G4 (≥85 kg), respectively. We compared the SNR of the G1 with those of G2, G3, and G4, and calculated the ratio squared as a factor to correct the acquisition parameters for overweight patients. We then prospectively enrolled 120 patients according to the same body weight criteria. We multiplied the correction factors to optimize injected doses or acquisition times, and defined dose‐adjusted groups (n = 20 per group) as G2dose (5.59±0.19 MBq/kg), G3dose (7.29±0.33 MBq/kg), and G4dose (8.88±0.43 MBq/kg), and time‐adjusted groups (n = 20 per group) as G2time (3 min/bed position), G3time (4 min/bed position), and G4time (5 min/bed position), respectively. Results: Although liver activities did not significantly differ among the G1through G4 irrespective of patient weight, the SNR progressively decreased as patient weight increased. The liver activities of G2dose, G3dose, and G4dose were 1.4, 1.9, and 2.5‐fold higher than that of the baseline counterparts, respectively. Nevertheless, the increased liver activities of G2dose, G3dose, and G4dose did not significantly affect SNR compared with the baseline groups. In contrast, the SNR of G4time was significantly higher than that of G4. Conclusions: Our findings suggest that quality of images acquired from heavier patients can be maintained only by scanning for longer periods. Increasing the dose per kg of body weight did not improve the quality of LSO PET/CT images.
PW132 Labelling and quality control procedure of the albumin nanocolloid Kit
99m
Tc-Human
C. Dumas1, A. Llamazares1, P. Koch2, G. Westera1; 1University Hospital Zurich, Zürich, SWITZERLAND, 2Municipal Hospital Triemli, Zürich, SWITZERLAND.
Aim In medical applications of ionizing radiation the quality of services is a very complex notion. With regard to the specific character of this activity, the quality aren't only an excellent medical attention, a comfort of patients, but above all an accuracy of calculations, a reliability and credibility of readings of used medical devices. Creating the universal model of management system which would find application and would meet requirements concerning all medical applications of ionizing radiation was a purpose of this abstract. Materials & methods In the creation of the system model a process approach was used what enabled to distinguish all significent processes (managing, crucial and support) having the influence on the quality of medical procedures with application of ionizing radiation. At this doctoral thesis legal bases and norms are included (ISO series norms being applicable, legal requirements which concern specific activity in exposure to ionizing radiation, recommendations of UEMS / EBNM CME Accreditation Committee and other requirements being applicable), on the basis of which the system model was created and it was proved that these bases for creating the system were just appropriate. Results and conclusion The created model of management system allowed for concentrating in one place all most important requirements, thanks to that comparing amounts concerning requirements of individual kinds of activity was possible. The model of the system contains requirements concerning the specificity of medical activity with applying the ionizing radiation, therefore it is prevailing above different systems implemented in medical facilities. Implementation of the system can contribute for raising the quality of provided services and assure the appropriate anti‐radiation protection, not only for a patient, but also the staff and persons from the whole of the population. Implementing the system can however be time‐ consuming and require the considerable financial outlays. The model of the system could serve as the base for creating accreditation criteria for medical facilities providing medical services with applying the ionizing radiation.
PW134 Kurchatovio program. Patient safety and quality assurance. Devised and utilized by the Nuclear Medicine Unit of San Cecilio Universitary Hospital in Granada R. Nieto-Serrano1, E. Pérez-Maldonado2, J. Ortigosa-García*3, L. MartínNavas2, E. García-Peinado2, C. Rubiols-Maluenda2, M. Marín-Melgarejo2, C. Sánchez-García2; 1UGC Medicina Nuclear. H.U. San Cecilio., Granada, SPAIN, 2UGC Medicina Nuclear. H.U. San Cecilio, Granada, SPAIN, 3* Servicio de Informática. H.U. San Cecilio, Granada, SPAIN. The aim of this work is to present the program Kurchatovio, devised by our Unit and developed in collaboration with the Informatics Department of our Hospital, which provides Quality Assurance and safety of the patient attended in our Nuclear Medicine Unit. It is based on Real Decreto 1841/1997, by means of which quality standards in nuclear medicine are set. The first version of the program came out in January 1998, and has undergone several updates from then on, in order to adapt it to the quality and safety standards of our Unit. Also, it is integrated with the Patient Appointment Software and with the Electronic Medical Record of the patients, where our records and images are stored. Kurchatovio accurately records and displays the attention provided to the patient in our Unit, since their arrival for a diagnostic test until the moment they leave, when the Electronical report of the examination is given. This is made in a comprehensive and integrated way, with the participation of doctors, nursing personnel and imaging technicians. Briefly, this process consists of: ‐ Patient appointment. ‐ Consent or Non‐consent, on the part of the doctor in charge of examining the patient, in view of the referral from the consultant (indicating examination, radiopharmaceuticals to be administered, radiation dose, administration route, date and time of the administration, date when the images were taken, etc.). Motivations for non‐consent are also stated. ‐ Displaying of the list of patients that have been confirmed in our radiopharmacy, in order to prepare monodoses, dispensed with the patient’s personal details, radioactive pharmaceutical and its activity. ‐ Outpatient admission at our Unit (nurse in charge of the patient, time of arrival, information provided, basic history…). ‐ Administration of radiopharmaceuticals (nurse in charge of the patient, radiopharmaceutical administered, dose, route of administration, noting of incidents…). ‐ Data acquisition from images (nurse and/or technician responsible, incidents…). ‐ Record output (date, time, doctor…). ‐ Exploitation of the application.
Poster Presentation
Tc‐Nanocoll® (human albumin nanocolloid) is a radiotracer kit used for bone marrow, inflammation and sentinel lymph node scintigraphy. The kits are labelled with 99mTc pertechnetate according to the supplier recommendation in the package insert. The measurement of the radiochemical purity (RCP) serves as the process control to assure that at least 95% of the 99mTc pertechnetate is bound to protein. Different kit.‐ batches were labelled with different 99mTc generators. Labelling was performed at different days, by different persons, in different laboratories and using different radioactivity concentrations. The RCP of the kits was measured 10, 20, 30 and 60 minutes after labelling. Two methods were used in parallel to perform the quality control (QC): the supplier method (ITLC‐SG, methanol (MeOH):water 85:15) and the Ph. Eur. (EP) and WHO method (Silica gel on glass fibre sheet, methylethylketone (MEK)). The different QC methods do not give equivalent results: the EP/WHO method shows quantitative labelling after a short reaction time (5 to 10 minutes, as prescribed by the supplier), whereas the supplier method by that time shows varying (insufficient) labelling yields. The supplier method shows that a reaction time of 40 to 60 minutes are necessary to ensure an RCP of at least 95%. This means that the labelling reaction proceeds over at least two steps. In a first rapid step a complex is formed in which the Tc is bound to the protein in such a way that it is stable against separation by an organic solvent (MEK), but water/MeOH can still remove a small Tc‐containing entity from the protein. In a slower process a rearrangement takes place the product of which is also stable against water/MeOH. It seems possible that the first complex may not be stable in the blood as this is mainly a watery solvent and thus resembles more the water/MeOH eluent. In conclusion: the supplier package insert should be changed in respect to the reaction time and the Ph. Eur. and WHO monographs should be changed regarding the quality control method.
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PW135 Quality control of pre-examination procedures and impact of a standardized medical pre-examination evaluation in a Nuclear Medicine department P. Oliveira, A. M. Brazão, T. Faria, A. Oliveira, M. B. Perez, H. Fernandes, J. P. Patrício, J. G. Pereira; Hospital S. João, Porto, PORTUGAL. Aim. Nuclear medicine examinations (NMEs) are simple and non‐invasive but imply ionizing radiation and the patient’s permanence in the department, sometimes for long hours. It is essential to guarantee the suitability of the examination and the reliability of the results obtained, as well as to ascertain the allocation benefit of technical and human resources for those purposes. The aim of this study was to assess the quality of the requests’ triage and of the transmission of the preparation instructions (PIs) to patients, as well as to determine the impact of a standardized medical pre‐examination evaluation (PEE). Materials and Methods. Specific forms were created for all NMEs and completed by the physician when the patient arrived, during the PEE. They focused on the confirmation of compliance with the PIs and on relevant data not mentioned on the examination request. From Jan‐2008 to Feb‐2009, a query sheet was attached to each patient file and its questions answered by the physicians that executed the triage, the PEE and the final report. We evaluated: suitability of the exam requested, clinical information provided, need for protocol adjustments, for additional radiation protection instructions, and global impact of the PEE. Results. A total of 1226 queries were answered. At triage, 30 (2.4%) examination requests were refused and in 34 (2.8%) the protocol was adjusted to better answer the clinical question. In 43 (3.5%) cases the attending physician was contacted to further elucidate the clinical context. A total of 1198 patients attended the PEE on the day of the scheduled examination. As a result, 8 (0.7%) were postponed and 5 (0.4%) were canceled, the protocol was adjusted in 16 (1.3%) and 14 (1.2%) were given additional radiation protection instructions besides the ones specific for the exam. Of the 1193 NMEs concluded, the PEE had a significant impact on the final report in 227 (19.1%). Conclusions. As expected, at our university hospital, most (94.8%) of the requests were suitable for the clinical question. The PEE corroborated the triage decisions, demonstrated the effectiveness of the PIs’s transmission and had an impact on nearly 20% of the NMEs executed. At our department, pre‐examination procedures proved effective in their purpose. Nevertheless, we underline the importance of always checking PIs compliance before a NME and of having the maximum clinical information available. Whether the PEE should be performed only by physicians remains a question to be answered when alternative methods are implemented.
PW136 Austrian Modification of Diagnostic Reference Levels in Nuclear Medicine A. Stemberger1, A. Hefner2, H. Duan3, A. Staudenherz3; 1Rudolfstiftung Hospital, Vienna, AUSTRIA, 2ARC Seibersdorf research GmbH, Seibersdorf, AUSTRIA, 3Univ. Clinic of Nuclear Medicine, AKH, Vienna, AUSTRIA. Aim Diagnostic reference levels (DRLs) are implemented to optimize diagnostic medical examinations using ionizing radiation. In Austria DRLs were established for the first time 2005 by the Austrian medical radiation protection regulation. In the context of quality assurance nuclear medicine departments have to compare the administered activity used for standard procedures with the DRLs. In a nation wide survey we asked for daily routine patient details (i.e. used device, applied activity, body height and weight). The aim was to adjust the DRLs in Austria, considering new device developments as well as modified acquisition protocols. Materials and Methods Using pooled data of 5320 patients from the survey, descriptive statistics was done. Frequency, age distribution and mean applied activities were determined, whereby we estimated also an individual effective dose for particular examinations. An extrapolation concerning the cumulative exposure of the population were also taken into consideration. Results In Austria the most frequent examination was thyroid scintigraphy using 99mTc‐pertechnetate (23.2%), followed by heart (19.7%), bone (18.7%), renal (8.6%), PET‐FDG (7.7%) and lung (7.5%) scintigraphy. About 150000 nuclear medicine procedures in 71 nuclear medicine facilities were performed 2008. An extrapolation revealed 35000 thyroid, 28000 bone, 29500 myocardial 12900 renal, 11500 PET‐ FDG, 11200 lung and 21900 miscellaneous scintigraphies. Regarding the number of nuclear medicine examinations per 1000 Austrian residents, Austria is located on the fourth place in comparison with 8 other European countries. The average effective dose for a nuclear medicine procedure was 4.7 mSv (range: 0.2 ‐ 22.2 mSv). A mean effective dose of 0.07 mSv per year and resident was estimated. The additive part of the nuclear examinations compared to the total natural effective dose of 3.8 mSv per year could be stated as marginal. In 33% the DRLs were exceeded and this was due to insufficient data, which were used, in the first implementation. Conclusion Due to our survey results we suggested a modification of the DRLs in 73%. These alterations will be presented and implemented in a revised version of the forthcoming amendment of the Austrian medical radiation protection regulation.
PW137 Color and grayscale display performance of off-the-shelf versus medical grade color displays for Nuclear Medicine A. M. Bolderdijk1, A. J. P. Reijnders1, M. A. L. Edelbroek2, N. A. M. De Beer1, A. J. Arends1; 1Catharina Hospital, dept. of Medical Physics, Eindhoven, NETHERLANDS, 2Catharina Hospital, dept. of Nuclear Medicine, Eindhoven, NETHERLANDS. Aim: The medical image display is typically the last stage of a medical imaging chain. Color displays of diagnostic nuclear medicine (NM) workstations however are often non‐DICOM‐ compliant off‐the‐shelf office displays. Recently modestly‐priced 1‐Megapixel medical grade color displays have become available for clinical reviewing tasks such as in NM. They are calibrated to match the DICOM Grayscale Standard Display Function (GSDF), for consistent representation of grayscale images, and employ backlight stabilization to compensate for luminance instability and decay over time. AAPM‐TG18 provided a guideline for grayscale performance evaluation. Unfortunately a similar standard for color performance evaluation is not available. Considering the extensive use of color lookup tables, consistent color representation by NM review displays is highly relevant too. Goals of this study were to select new displays for our NM department, and
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 to define and apply a protocol for acceptance testing and constancy evaluation of color displays, including their color performance. Methods: Office displays evaluated were 5 ViewSonic’s VX912: four used ones (4 yrs) and, for fair comparison, 1 new monitor. ‘Med‐grade’ displays were 6 new Barco MDRC1119’s. Grayscale section of our proposed protocol involves determining luminance range and setting it to 180 cd/m2 (or at max if lower). Visual assessment of contrast using AAPM‐TG18 5% and 95% patterns. Comparison of measured luminance response with GSDF. Measurement of luminance uniformity (expressed in %luminance and in number of Just Noticable Differences (JND)) and its variation with viewing angle. Color section involves measurement of color temperature, color uniformity and gamut. Results: Luminance of office displays dropped 48% (15% /yr) during 4 years of use. Gamut of med‐grade displays appeared smaller than that of office displays. Display
Max. % deviation luminance from GSDF nonuniformity % (JND’s)
Office (1 >50% new)
21% (42)
Max. color* nonuniformity
Contrast: 5% vs. 95% patterns visible?
Color % luminance temp. loss at 20° off‐ range [K] axis
0.0040
yes / yes
6820
19% n.a. 21%
Office (4 >50% old)
17% (29)
0.0052
no / no
6120 ‐ 6930
Med‐ grade <10% (6 new)
13% (27)
0.0059
yes / yes
6510 ‐ 7210
*) CIE‐space Euclidean distance Conclusion: A protocol for acceptance testing and constancy evaluation has been developed and successfully applied. As expected grayscale performance of the medical grade display tested is superior. Its color gamut however appears smaller. In both display types grayscale luminance nonuniformities cover a large number of JND’s. Quantitative acceptance criteria for displays in NM applications are lacking. Future observer studies could help determine the impact of display quality on detectability of subtle lesions.
PW138 Development of PET in Western Europe A. N. Stevens; Medical Options, London, UNITED KINGDOM. AIMS To track the development of PET in Europe. The provision of PET and PET/CT in Europe is extremely heterogeneous with a large variation in scans per head of population between countries; while within countries workload varies widely between different providers. The high level of variation between facilities, the number of new installations and the rapid growth in workload at existing sites precluded a sampling approach and required identification of all European PET providers. MATERIALS AND METHODS Facilities with PET, PET/CT and or cyclotron(s) were identified from a number of sources including records of the IAEA, manufacturers of diagnostic equipment and sites providing diagnostic PET services. These sites were invited to confirm details of their equipment profile, to provide details of workload and where a cyclotron was not present to identify the source of radiopharmaceuticals. We were able to identify over 95% of the PET, PET/CT and cyclotrons operating in Western Europe. 71.9% of these sites provided workload numbers. To improve workload projections we developed a segmentation scheme which identified ten types of facility. Additionally the operation of the unit was described as ‘routine clinical’, ‘research’ or both. Sites carrying out examinations which are reimbursed in Europe or the US were classified as ‘routine clinical’ even if they were carried out under a research protocol. RESULTS In 2008 there were 398 providers of PET and/or PET/CT in Western Europe of which 22 were mobile. PET/CT accounted for 72% of the installed scanners up from 57% in 2006. Fig 1 illustrates that the growth in scan numbers varies markedly between the type of facility and the country. The prime determinants governing throughput are the availability of reimbursement, equipment type and the number of months that the imaging service has been provided. Fig 1: Patients per million population Region
2006 2008 CAGR
Northern Europe FIN,S,N,DK,GB,Ire 533 1,002 37.0% Western Europe NL,B,F,D,A,CH
1,222 1,619 15.1%
Southern Europe E,P,I
1,718 2,412 18.5%
Growth in western Europe has been lowered by Germany where patient numbers have risen annually by 12.4% from 416 per million population in 2002 to 841 in 2008 versus 32.3% for Western Europe. In the period 2006 ‐ 2008 Iberia, Scandinavia and the UK showed the largest rise in patient numbers. CONCLUSIONS PET imaging has moved from research to a routine clinical service. University hospitals and specialist hospitals, primarily oncology centres, carry out the majority of scans. In recent years activity has shifted to general hospitals and private providers but numbers are lower as referral patterns need to be established.
PW139 Multidisciplinar approach to mediastinal and thoracic neoplasm: G.I.P.O (INTERDISCIPLINAR PNEUMO-ONCOLOGY GROUP) experience. A. Moretti1, R. Galassi1, F. Matteucci1, A. Marzullo1, G. Genestreti2, N. Giovannini2, D. Dell'amore1, F. Fiorentini1, V. Poletti1, L. Serra1, M. Bertocco1, R. Polico1; 1Pierantoni Morgagni Hospital, Forlì, ITALY, 2I.R.S.T., Meldola, ITALY. Aim: pulmonary cancer is the principal cause of deadth in industrialized countries. Moreover provides expensive examinations and therapies without a clear clinical indication and often a waste of time. Our aim is direct to guide resources for this disease through active comparison between specialists of different disciplines all dedicated to Non Small Cell Lung Cancer (NSCLC), Small Cell Lung Cancer (SCLC), mesothelioma, and thymoma. Materials and methods: from may 2007 to may 2008 weekly we registered in our multidisciplinar department GIPO (Interdisciplinar Pneumo‐Oncology Group) all first visit concerning thoracic diseases. Results: we overall visited 286 patients (243 NSCLC, 33 SCLC, 8 mesotheliomas, 2 Thymomas). 175 out of 286 patients came
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PW140 Radiation protection rules applied for the treatment of thyroid diseases using I-131 S. Pellet1, O. Turák2, A. Konrády3, F. Giczi4, A. Temesi1; 1National Centre for Healthcare Audit and Inspection, Budapest, HUNGARY, 2National Research Institute for Radiobiology and Radiohygiene, Budapest, HUNGARY, 3 Jávorszky Ödön Hospital, Vác, HUNGARY, 42Széchenyi István University, Department of Physics and Chemistry, Győr, HUNGARY. Related regulation and professional directives and standard: • Decree No. 16/2000. of Ministry of Health • Methodological guide for the treatment of thyroid hyper function with radioiodine, 1993 • Guiding principle of MH Treatment of thyroid diseases with I‐131, 2008 • Hungarian Standard: MSZ 62‐7 (Radiation protection in use of unsealed sources) In Hungary the 131I examinations and treatments have an increasing tendency. The method of treatment can be out‐ patients or in‐patients. The way of treatments is decided by the medical practitioner who has to be a specialist in nuclear medicine and trained in radiation protection. In ambulatory treatment (hyperthyroidism) the highest activity is 550 MBq of 131I. Above this level the method of treatment is in‐patients (treatment for cancer) in three special units. At both ambulatory and in‐ patients treatments there are some special rules of releasing the patients: the level of 131I activity has to be lower than 500 MBq, the level of external dose rate have to be below 25 µSv/h in 1 m distance from patient, also good physical and mental capability of the patient, living under acceptable hygienic conditions. Both of these rules are very important. If the patient doesn’t meet these requirements, it can’t be released. At release the patient gets a written instruction that involves the instructions outlining the suitable behavior rules for living and the administrative data about treatment. There are so many rules for the environment of patient. Dose constraints are established for release: maximum external effective dose for children is 1 mSv and for adults 3 mSv. in case of adults the dose can be higher if the adult is the tender of patient.
PW15 ‐ Tuesday, October 13, 2009, 08:30 ‐ 09:30, Poster Exh. Hall
Poster walking tour 15: radiopharmaceuticals
PW142 99m
Tc(N)-DBODC(5) from cardiology to oncology. Preliminary in vitro study
C. Bolzati1, M. Cavazza-Ceccato2, V. Gandini2, C. Marzano2, F. Refosco1, A. Dolmella2, N. A. Colabufo3, F. Berardi3, R. Perrone3, G. Bandoli2; 1ICISCNR, Padua, ITALY, 2Department of Pharmaceutical Sciences, University of Padua, Padua, ITALY, 3Dipartimento Farmacochimico, Universita` degli Studi di Bari, Bari, ITALY. Aim: [99mTc(N)(DBODC)(PNP5)]+, abbreviated to 99mTc(N)‐DBODC(5) is a new lipophilic cationic mixed compound currently under clinical investigation as potential myocardial imaging agents. The findings that this complex accumulates in mitochondrial structures through a mechanism mediated by the negative mitochondrial membrane potential, and that the rapid efflux of 99m Tc(N)‐DBODC(5) from non‐target tissues seams correlated to the Pgp/MDR‐Pgp transport function opens the possibility to extend the clinical applications of this new class of complexes to tumor imaging and non invasive multidrug resistance studies. Standing on these grounds, the 99m goal of this work is evaluating the feasibility to extend the diagnostic application of Tc(N)‐ DBODC(5), to the imaging and monitoring of some neoplastic forms, characterized by high mitochondrial density, as well as to assess cell resistance mediated or not by Pgps. Method: The kinetic uptake at 4 and 37 °C of 99mTc(N)‐DBODC(5) was evaluated in vitro in suitable human cancer cell lines, such us MCF7 (human breast cancer) and 2008 (human ovarian cancer) and in the corresponding resistant MCF7/Adr cells, before and after MDR‐modulator treatment, using 99m Tc‐Sestamibi as reference. Results: Each experiment compare the uptake of the 99mTc(N)‐ tracer with those of the commercially available complex 99mTc‐sestamibi. In MCF7 cells line, 99m Tc‐sestamibi with respect to 99mTc(N)DBODC(5) presents a higher cellular uptake (8.43 ± 1.34 % uptake of 99mTc‐sestamibi vs 6.47 ± 1.45 % uptake of 99mTc(N)DBODC(5) at 60 min at 37 °C). On the contrary the uptake of 99mTc(N)DBODC(5) was higher in 2008 cells (11.15 ± 1.46 % uptake of 99m Tc(N)DBODC(5) vs 10.69 ± 1.77 % uptake of 99mTc‐sestamibi at 60 min at 37 °C). At 4 °C the percentage of non specific uptake was assessed around 2% after 60 min. A slight increment was observed, for all tracers, during the time ( 3% at 120 min). A significant reduction of the net cell uptake between drug sensitive cells and MDR tumor cell was observed for 99mTc(N)‐DBODC(5) and 99mTc‐sestamibi compounds. In both cases an enhancement of uptake in resistant cells after treatment with a MDR modulator, indicating selective blockade of Pgp‐mediate efflux of the tracers. In particular an interesting variation of the net uptake was observed in cells MDCK‐MRP1 overexpressing MRP1 protein before and after treatment with MK‐571 MRP‐1 inhibitor. Conclusion: This study gave a preliminary indications on the applicability of 99mTc(N)‐DBODC(5) in tumor imaging and for detecting MRD‐mediate drug resistance in human cancer.
PW143 Synthesis and Biological Evaluation of 99mTc-Labelled Aminoethylbenzenesulfonamide Conjugate for In vivo Visualisation of Carbonic Anhydrase IX (CAIX) Expression in Tumor Hypoxia
V. Akurathi1, L. Dubois2, N. G. Lieuwes2, S. K. Chitneni1, B. J. Cleynhens1, A. M. Verbruggen1, P. Lambin2, G. Bormans1; 1Katholieke Universiteit Leuven, Leuven, BELGIUM, 2University of Maastricht, Maastricht, NETHERLANDS. Objectives: In vivo visualization of tumor hypoxia‐related markers, such as endogenous transmembrane protein CAIX, may lead to novel therapeutic and diagnostic applications in management of solid tumors. We report here the synthesis and first evaluation of a 99mTc(CO)3‐ labelled complex with a conjugate of 4‐(2‐aminoethyl)benzene sulfonamide (AEBS) ( Ki=33nM for CAIX) and N‐(2‐picolylamine)‐N‐acetic acid (2). The corresponding rhenium analogue (3) was also synthesized. Methods: N‐(2‐pyridylmethyl)aminoethyl acetate (a) was prepared from 2‐ aminomethylpyridine and BrCH2COOEt. 2‐N‐chloroacetyl‐4‐benzene sulfonamide (b) was obtained from AEBS and chloroacetyl chloride under Schotten‐Baumann conditions. Intermediates (a) and (b) were conjugated in the presence of Et3N/CH3CN yielding N‐(pyridin‐2‐yl‐ methyl)‐N[2‐(4‐sulfamoylphenyl)‐ethyl]aminoethyl acetate (1). 99mTc‐tricarbonyl precursor [99mTc(CO)3(H2O)3]+ was obtained using an IsoLinkTM kit and reacted with (1) at pH 12, 70 °C for 20 min, followed by RP‐HPLC purification. The rhenium analogue (3) was synthesized in a similar way from [NEt4]2[fac‐Re(CO)3(Br)3] using (1). Rhenium analogue (3) was evaluated in vitro by assessing the inhibition of CA IX mediated extracellular acidification in a colorectal HT‐29 cell line. Biodistribution of (2) was studied in NMRI‐nu (nu/nu) mice bearing CAIX expressing HT‐29 tumors at 0.5, 1, 2 and 4 h after intravenous injection. Results: Compound (1) was synthesized with a chemical yield of 31%, compound (2) with 35% radiochemical yield and a radiochemical purity >99% after HPLC separation. The rhenium analogue (3) was obtained with a chemical yield of 17% and its identity confirmed by high resolution mass spectrometry. Identity of (2) was supported by co‐elution with (3) after co‐injection on RP‐HPLC. In vitro affinity studies showed that rhenium congener (3) efficiently reduces CAIX induced extracellular pH acidification at 1 mM concentration. Biodistribution studies in mice indicated a maximum tumor uptake of 0.1 % ID/g at 0.5 h. Plasma clearance of tracer was mainly through the hepatobiliary pathway (7 and 73 %ID in liver and intestines, respectively, at 4 h p.i.) and to some extent through the renal pathway (11 99m %ID in urine at 4 h p.i.). Conclusion: A Tc(CO)3+ labelled 4‐(2‐aminoethyl)benzenesulfonamide derivative and its rhenium congener were successfully synthesized. In vitro studies showed that the rhenium analogue efficiently reduces CAIX induced extracellular acidification. In vivo studies revealed that the tumor uptake of the tracer is minimal. However, the new tracer can be explored for its potential in in vitro studies to understand the behavior of CAIX in tumor hypoxia.
PW144 44
68
90
177
Sc and Ga versus Y and Lu labelled DOTA-Bombesin and its in vitro evaluation in PC-3 cells
E. Koumarianou1, R. Mikolajczak1, D. Pawlak1, F. Roesch2, N. Laktionova2, X. Zikos3, S. C. Archimandritis3; 1IAE Radioisotope Centre Polatom, Otwock, POLAND, 2Institute of Nuclear Chemistry, University of Mainz, Mainz, GERMANY, 3Institute R-RP, N.C.S.R “Demokritos”, Athens, GREECE. Introduction: DOTA‐derivatized peptides have been successfully labeled with 90Y, 177Lu for therapy and 68Ga for PET imaging. DOTA itself was proved to be a good chelator for scandium. However, so far published data on 44Sc labeled DOTA‐biomolecules are very limited. 44Sc has a potential for PET imaging as an alternative to 68Ga, especially when its longer half‐life may play a role. Previously we have studied the labeling of DOTA‐BN[2‐14]NH2 (DOTA‐QRLGNQWAVGHLM‐ NH2) with 90Y and 177Lu and their in vitro and in vivo characteristics were well established. Differences between the 90Y and 177Lu labeled peptide in terms of its internalization/efflux rate and binding affinity to PC3 cells could be attributed to the influence of metal ion coupled to peptide. Therefore, we extended this in vitro evaluation to 44Sc and 68Ga labeled DOTA‐BN[2‐ 14]NH2. Materials and Method: The 44Sc and 68Ga were eluted from semi‐automated generators 68 Ge/68Ga and 44Ti/44Sc respectively provided at the Institute of Nuclear Chemistry, University of Mainz. The 68Ga and 44Sc labeling conditions were investigated in relation to the final specific activity of the radiolabelled peptide. ITLC SG and solid phase extraction on mini columns were involved in QC. Cold complexes natSc‐DOTA‐BN[2‐14]NH2 and natGa‐DOTA‐BN[2‐14]NH2 where synthesized and characterized by HPLC and MS analysis to confirm their suitability for binding nat nat affinity assays. The in vitro assays: binding affinity of Sc‐DOTA‐BN[2‐14]NH2 and Ga‐DOTA‐ BN[2‐14]NH2 in competition to [125I‐Tyr4]‐Bombesin(2‐14) (Perkin‐Elmer) and an 68 internalization/efflux study of Ga‐DOTA‐BN[2‐14]NH2 were carried out in Human Prostate Cancer cell line PC‐3. In vitro assays were carried out according to standard protocols. Results: The specific activity achieved for 68Ga‐DOTA‐BN[2‐14]NH2 was 7.5 GBq 68Ga/μmol DOTA‐BN[2‐ 14]NH2 when incubated at 950C for 10‐15 min (labeling yield >95%). The internalization of 68Ga‐ 90 177 DOTA‐BN[2‐14]NH2 as compared to that obtained for the Y and Lu respective analogues showed lower internalization rate but similar percentage of internalization at the end of 68 90 incubation. Ga‐DOTA‐BN[2‐14]NH2 was externalized faster than Y‐DOTA‐BN[2‐14]NH2 and 177 Lu‐DOTA‐BN[2‐14]NH2. IC50 value for Ga‐DOTA‐BN[2‐14]NH2 was 0.85 nM and for Sc‐DOTA‐ BN[2‐14]NH2 was 6.50 nM, considering previously obtained values 1.99 nM and 1.34nM for Y and Lu labelled DOTA‐BN[2‐14]NH2 respectively, the DOTA‐BN[2‐14]NH2 receptor affinity in PC3 cells was decreasing in the order Ga>Lu>Y>Sc. Conclusions: All four investigated M+3 radiometals form stable complexes with DOTA‐BN[2‐14]NH2, the observed differences in the in vitro behavior of radiolabelled peptide in the same cell‐line can be attributed to the metal‐mediated receptor affinity. We acknowledge support by COST BM0607 and COST D38 (COST‐STSM‐D38‐3604)
PW145 Renal accumulation of two somatostatin analogs labeled with lutetium-177 in vitro F. Trejtnar, Z. Novy, J. Mandikova, A. Laznickova, M. Laznicek; Charles University in Prague, Faculty of Pharmacy, Hradec Kralove, CZECH REPUBLIC. Aim: Receptor‐specific somatostatin analogs labeled with gamma‐ or beta‐emitting radionuclides are useful for scintigraphic imaging and/or therapy of selected neuroendocrine tumors. However, significant renal uptake may result in radiotoxicological injury of the kidney and can limit clinical application of the agents. Lutetium‐177 represents one of the radionuclides convenient to label peptides useful in receptor‐targeted radionuclide cancer therapy. The aim of the study was to compare the rate and mechanism of renal accumulation of two somatostatin receptor‐targeted peptides, [DOTA0, Tyr3, Thr8]‐octreotide (DOTA‐TATE) and [DOTA0, 1‐Nal3]‐
Poster Presentation
from our local health service of Forlì, 77 patients came from other healt services of different towns and 34 patients came from other local health’s districts. From the examination to the start of therapies on average 23 days are elapsed in particular 22 days (range 8 ‐ 33) before surgery, 10 days (range 4 ‐ 29) before chemotherapy and 36 days (range 18 ‐ 81) before radiotherapy. Conclusions: thoracic diseases need, for their intrinsic complexity, a multidisciplinar approach to optimize the diasgnostic and therapeutic iter, and to better direct economic resources. Our experience shows that this objective is feasibility.
S310 octreotide (DOTA‐NOC), labeled with lutetium‐177, using an in vitro method at the cellular level. Methods: Freshly isolated rat renal cells were used as the experimental in vitro model. The renal cells were isolated from rat kidneys by two‐phase collagenase perfusion. Accumulation studies were used to evaluate the renal uptake of the peptides and to study of the mechanism of renal accumulation. The influence of selected inhibitors of receptor‐mediated endocytosis (albumin, simvastatin) and the inhibition of active transport processes were investigated. We also compared the renal cellular uptake of 177Lu‐DOTA‐TATE and 177Lu‐DOTA‐NOC with that of the same peptides labeled with 111In. Results: 177Lu‐DOTA‐NOC renal uptake in the isolated renal rat cells was several times higher than that of 177Lu‐DOTA‐TATE. Both used inhibitors of receptor‐ mediated endocytosis, albumin and simvastatin, inhibited the renal accumulation of the radiolabeled peptides only partly. The inhibitory potency of simvastatin was lower than that of albumin. An inhibitor of renal organic transporters does not decrease the renal accumulation significantly. The uptake of the evaluated radiopeptides in the rat renal cells was significantly inhibited under lower incubation temperature. The renal accumulation of the 177Lu‐labeled peptides in vitro was lower than that of the peptides labelled with 111In. Conclusions: Using a cellular experimental model, a significant difference in renal uptake of the studied radiopeptides was demonstrated. A significant participation of active transport processes in renal accumulation of the peptides was observed. The results found in 177Lu‐labeled peptides were in good agreement with the previous published results in the same peptides labeled with indium‐111. The investigation was supported by grant NR/9208‐3 of the Internal Grant Agency of the Ministry of Health, Czech Republic, and by grant No. 124409/FaF/C‐LEK of the Grant Agency of Charles University.
PW146 Experimental therapy of leukemia cells with [At-211]anti-CD33 antibodies in vitro overcomes resistance to gemtuzumab ozogamicin T. Petrich, Z. Korkmaz, D. Krull, C. Frömke, G. J. Meyer, W. H. Knapp; Medizinische Hochschule, Hannover, GERMANY. Aim Conjugation of monoclonal anti‐CD33 antibodies with toxic calicheamicin derivate (gemtuzumab ozogamicin, GO) is a novel therapy for acute myeloid leukemia (AML). Key prognostic factors for patients with AML are high CD33‐expression of leukemic cells and the ability to overcome mechanisms of resistance to cytotoxic chemotherapies, including drug efflux and other mechanisms decreasing apoptosis. Alpha particle‐emitting radionuclides overwhelm such anti‐apoptotic mechanisms by producing numerous DNA double strand breaks (DSB). We therefore labeled monoclonal CD33‐antibodies with the alpha‐emitting radionuclide At‐211 (half life: 7.2h) and evaluated in vitro cytotoxicity and survival of CD33‐expressing leukemic cell lines HL‐60 and K‐562 relative to those observed with GO. Material and Methods CD33‐positive myeloid cell line HL‐60 and the weakly CD33‐positive myeloid cell line K‐562 were grown in suspension. For cell binding experiments, 1x106 cells were incubated with 0.4kBq (18.1ng) [At‐ 211]‐antiCD33 over 30min. As a blocking control, unlabeled anti‐CD33 was added (5µg/5µl). For survival analysis, cells were incubated with cold CD33‐antibody, [At‐211]‐labeled CD33‐antibodies (mean labeling ratio: 1:1106), GO (MylotargTM) and GO diluted 1:1000. At‐211 was produced in our cyclotron following the Bi‐209(α,2n)At‐211 reaction. DNA damage (DSB) was measured by DNA fragmentation using gel electrophoresis. Cell viability was determined after 48 and 72h by adding 20µl Alamar‐BlueTM. Fluorescence was detected using FLUOstar optima. Results Mean ratio of labeled/unlabeled antiCD33 antibodies was 1:1106 (range 1:642 ‐ 1:3728). Specific activity was 9.8MBq (range: 2.9‐16.8MBq) At‐211/nmol antibodies. Cell binding of [At‐211]‐ antiCD33 to HL‐60 (K‐562) was 28.0% (7.5%) of the applied activity. DNA‐damage (DSB) in HL‐60 cells was high after [At‐211]‐antiCD33 (500kBq/ml, 4.29µg/ml) and equal to that caused by GO (4.29µg/ml) although [At‐211]‐antiCD33 despite the low astatination. GO diluted 1:1000 (4.29µg/ml) produced no DSB, similarly to unlabeled CD33, untreated HL‐60 or free [At‐211]‐ solution (500kBq/ml) as controls. In both cell lines, cytotoxic effects for cell survival became relevant in concentrations from 10‐1000 ng/ml [At‐211]‐antiCD33/GO (1:1106/1:1) without significant difference between both antibodies. No influence on survival was observed after application of GO (1:1000) or unlabeled antiCD33 as control. Conclusions Our data suggest that [At‐211]‐antiCD33 may cause sufficient DNA‐DSB to overcome to a clinically relevant degree anti‐ cytotoxic resistance such as that seen against calicheamicin‐conjugated antibodies. Therefore these astatinated antibodies may potentially be a highly effective antileukemic therapy. Higher‐ yield astatination procedures must be developed for therapy of tumors with reduced tumor‐ specific epitope expression.
PW147 Quality of n.c.a. Lutetium-177 S. Wohlfahrt1, L. Nikula1, P. Juntunen1, S. Marx1, D. Dautzenberg2, O. Leib1, K. Zhernosekov3, T. Nikula3; 1ITG Isotope Technologies Garching GmbH, Garching, GERMANY, 2Lehrsthul für Radiochemie, TU München, Garching, GERMANY, 3ITM Isotopen Technologien Muenchen AG, Garching, GERMANY. Lutetium‐177 can be produced through two ways: either by direct irradiation with neutrons from enriched Lutetium‐176 or by indirect route from enriched ytterbium‐176. The advance of the direct route is relative easy target handling and chemistry after irradiation to produce final lutetium‐177 labelling solution. To produce lutetium‐177 through indirect route is relative demanding task on the reason that lutetium and ytterbium are most nearby elements by both chemical and physical properties in the periodic system and hundreds milligrams highly enriched ytterbium‐176 (>99%) target is required to produce in the Ci ‐ levels of lutetium‐177. A separation factor of 10‐5 ‐ 10‐6 is required. On the other hand lutetium‐177 from indirect route 177 177 (n.c.a Lu) has several advantages over lutetium from the direct route (c.a. Lu): Higher specific activity: n.c.a 177Lu can be produced up to 104 Ci/mg lutetium which gives for the product long using time 1 to 2 week with good labelling result compared to c.a. 177Lu which typically has specific activity 20 ‐ 25 Ci/mg at the end of the irradiation. High radioactivity purity: During neutron irradiation of ytterbium‐176 no lutetium‐177m is produced or extreme minute amount from the lutetium‐176 in the target material. Typically at the calibration time 177mLu/177Lu ratio is << 10‐7. During separation process of lutetium from ytterbium other radioactive impurities can be removed or reduced remarkably. For the labelling peptides or antibodies small amount metal impurities might strongly affect labelling results. We have studied several metal impurities effect to n.c.a lutetium‐177 labelling yield of DOTA and DOTA‐peptides. Based on metal impurities
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 which we have found from the lutetium solution by ICP‐OES (values μg/Ci) in three different sample: Al
4,09
8,28
Ca
7,12
30,82 48,93
6,18
Cd
< 0,008 < 0,16 < 0,25
Cu
< 0,03 < 0,49 < 0,74
Fe
0,278 ≤ 0,33 ≤ 0,15
cold Lu 0,379 0,365 0,69 Ni
< 0,03 < 0,33 < 0,49
Y
< 0,006 ≤ 0,15 ≤ 0,072
Yb
0,597 ≤ 0,082 1,00
Zn
0,486 0,56
1,27
We have also developed new method to estimate acid concentration of lutetium‐177 solution from minute amount sample by spectrophotometric method.
PW148 18
[ F]FTIDC: a new PET radioligand for metabotropic glutamate receptor 1 M. Ohgami1, T. Haradahira1, N. Takai1, M. Zhang2, K. Kawamura2, T. Yamasaki2, K. Yanagimoto2; 1Nagasaki International University, Sasebo, JAPAN, 2National Institute of Radiological Sciences, Chiba, JAPAN. Aim: Metabotropic glutamate receptors (mGluRs) are classified into three subgroups (Group I, II, III), in which the group I subgroup includes subtype 1 (mGluR1) and subtype 5 (mGluR5). Pharmacologic blockade of the group I receptors produces neuroprotection in a variety of in vitro or in vivo models. mGluR1 antagonists are promising drugs for the treatment of brain ischemia or for the prophylaxis of neuronal damage induced by synaptic hyperactivation. To explore the physiological and pharmacological characteristics of the group I receptors, as well as to generate novel therapeutic drugs targeted to mGluRs, Developments of the PET/SPECT radioligands for imaging of the group I receptors in living brain are desirable. Various PET radioligands for mGluR5 have already been developed. Radioligands for mGluR1, however, are still unavailable due to the lack of antagonists suitable for in vivo imaging. In this study, we have synthesized a positron‐ emitter labeled mGluR1 antagonist and evaluated its potential as a radioligand for use in mGluR1 imaging with PET. Subjects & methods: Very recently, a novel mGluR1 antagonist, 4‐[1‐(2‐ fluoropyridin‐3‐yl)‐5‐methyl‐1H‐1,2,3‐triazol‐4‐yl]‐N‐isopropyl‐N‐methyl‐3,6‐dihydropyridine‐ 1(2H)‐carboxamide (FTIDC), has been developed (JPET, 321: 1114, 2007). FTIDC (IC50= 5.8 nM) was successfully labeled with F‐18 by a halogen exchange reaction with the corresponding bromine derivative. C‐11 labeling at the amide moiety of FTIDC was unsuccessful (very low yield). HPLC purification after the fluorination gave a radiochemically pure [18F]FTIDC in an aqueous solution, which was subsequently used for in vitro and in vivo experiments. In vitro binding was evaluated on rat brain cryosections in Tris HCl buffer. In vivo binding was evaluated with animal PET in mice and rats. Results: In vitro studies, [18F]FTIDC showed high accumulations and specific bindings (>98%) in the thalamus, cerebellum and hippocampus, the regional distribution of which was very similar to that of mGluR1 immunoreactivity in rat adult brain. After intravenous injections in mice, [18F]FTIDC showed the highest accumulation in the cerebellum, which was strongly reduced to the non‐specific revel by co‐injection with FTIDC. Animal PET studies also showed the similar results in mice and rats. Brain uptake of radioactivity was high and displayed the highest accumulation into the mGluR1‐rich cerebellum, which was about 2‐3 times that of other regions. The maximum uptake of radioactivity in the cerebellum was observed at 10 min post injection followed by decreased with time. Conclusion: The present studies indicated that 18 [ F]FTIDC may be a promising radioligand for visualizing the mGluR1 by PET.
PW149 Synthesis and Metabolic Stability of 11C-Labelled SU11248 Derivative as Inhibitor of Tyrosine Kinases T. Kniess, R. Bergmann, J. Steinbach; Forschungszentrum DresdenRossendorf, Dresden, GERMANY. Aim: SU11248 is a novel inhibitor of receptor tyrosine kinases (RTKs) targeting vascular endothelial growth factor (VEGF) and plated‐derived growth factor (PDGF) [1]. Due to the fact that RTKs are overexpressed in some tumour entities, they might be a suitable target for cancer imaging by positron emission tomography (PET). A tyrosine kinase inhibitor labelled with a positron emitting isotope could represent a useful tool for monitoring levels of RTKs in tumour tissue by giving valuable information for anti‐angiogenic therapy. For this purpose we synthesized a methoxy substituted derivative of SU11248 and performed the radiosynthesis with the PET radionuclide carbon‐11 to the corresponding 11C‐labelled radiotracer. First investigations on the 11 in vivo metabolic stability of the new C‐labelled SU11248 derivative are reported. Materials and methods: The radiolabelling was performed via 11C‐methylation reaction of the corresponding desmethyl precursor with [11C]MeI in a TRACERLab FXC gas phase synthesizer (GE). After purification by semi‐preparative HPLC and solid phase extraction the radiotracer was dispensed with E153 electrolyte solution and injected intravenously into male Wistar rats. For metabolite analysis blood samples were taken from the arteria femoralis at 1.5; 3; 5; 10, 20, 30 and 60 minutes past injection. After centrifuging blood samples 5 min 13.000 rpm at 4°C plasma was analyzed by radio HPLC. Results: The synthesis of the non‐radioactive methoxy‐substituted SU11248 as well as the desmethyl precursor was accomplished by reacting 5‐methoxy‐ and 5‐ hydroxyl‐oxindole with 5‐formyl‐2,4‐dimethyl‐1H‐pyrrole‐3‐carboxylic‐acid‐(2‐ diethylaminoethyl)‐amide. Radiolabelling was achieved by reaction of the 5‐hydroxy‐substituted 11 SU11248 derivative with [ C]CH3I in DMF/aqueous NaOH at 80°C. After semi‐preparative HPLC purification the 11C‐labelled radiotracer was obtained in 14‐17% decay corrected radiochemical yield at a specific activity of 162‐198 GBq/µmol at the end of synthesis in 94‐99% radiochemical purity. Metabolism analysis in rat plasma showed 96% of intact compound 3 min and 73% 60 min 11 p.i., together with three more polar metabolites. Conclusion: The new C‐labelled derivative of SU11248 can be synthesized in good radiochemical yield, sufficient purity and high specific activity. The found metabolic stability in rat plasma showing 73% of intact radiotracer 60 min p.i.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
PW150 11
C NS8880 a new ligand targeting the norepinephrine (NET) transporter
K. H. Vase1, D. Peters2, E. Ø. Nielsen2, A. K. Olsen1, D. Bender1; 1Aarhus University Hospital, PET-Center, Aarhus C., DENMARK, 2NeuroSearch A/S, Ballerup, DENMARK. Introduction: Currently 11C (S,S)‐MeNER is the most widely used tracer for imaging NET, despite its rather slow kinetics in human. We report here the radiolabeling and preliminary in vivo evaluation (rat and pig) of NS8880, a novel compound with high affinity (IC50: NET: 5 nmol; SERT: 260 nmol; DAT: 2000 nmol) towards NET. NS8880 is structurally not related to reboxetine. Methods: NS8880 was radiolabeled by substituting fluorine in a BOC protected precursor using C‐ 11 methanolate, followed by prep. HPLC and deprotection. In vivo evaluation was performed a) in a µPET study using a rat model and b) in a PET study in a pig model. In both studies the species were scanned under baseline conditions and after desipramine block (1 mg kg‐1). Results: The radiolabeling procedure yielded sufficient amounts of radiolabeled NS8880 in high purity and specific radioactivity to perform the in vivo evaluation. It is noteworthy that the first attempt, namely the substitution reaction with a pyridinyl chlorine containing precursor, did not yield any product at all. Even for the easier substitutable fluorine this labeling approach is quite slow and requires drastic reaction conditions. In both animal models radiolabeled NS8880 was rapidly metabolized (5% parent after 30 minutes). Both rat and pig showed a rapid brain uptake with a highest uptake in thalamus, followed by cortex and striatal uptake and the equilibrium was reached after approx. 20 minutes. Binding in all regions was blocked by desipramine. The volume of distribution (Vd), calculated according to method of Logan, was reduced in thalamus from around 4 ‐ 5 ml g‐1 to around 2 ml g‐1 after administration of 1 mg kg‐1 desipramine. We did not observe such high binding in striatum when using radiolabeled (S,S)‐MeNER and are currently investigating, if striatal binding is due to binding to SERT. Conclusion: Radiolabeled NS8880 might serve as a NET ligand with fast kinetics. In any case this compound might serve as a new lead compound in the further development of PET radiotracers targeting NET.
POSTER PRESENTATIONS
P01 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Cardiovascular: diagnosis-perfusion
P001 Comparison of Gated Blood Pool SPECT with cardiac ultrasound for quantification of left ventricular volumes and ejection fraction. M. Bugriy, N. Rogunova, M. Saidova, V. Sergienko; Cardiology Research Complex of Ministry of Health of Russian Federation, Moscow, Russia, Moscow, RUSSIAN FEDERATION. Aim: The main aim of this study was to validate the accuracy of Gated Blood Pool SPECT (GBPS) in the assessment of left ventricular (LV) end‐diastolic/end‐systolic volumes (EDV, ESV) and ejection fraction (LVEF), using cardiac ultrasound (US) as the reference method. Materials and methods: Sixty one patients (54 male) with ischemic heart disease, dilated cardiomyopathy and decompensated arterial hypertension in chronic heart failure underwent 99mTc‐in vivo labeled red blood cells GBPS (16 images/cycle) using gamma camera SKYLight® (Philips) than in 1 week patients underwent cardiac US. LV EDV, ESV and LVEF in GBPS were calculated by count‐based volume‐derived values in GBPS and using Simpson’s method in US. Results: LV parameter GBPS
US
correlation, r p
EDV, ml
194.8±113.8 144.5±82.4 0.91
p<0.0001
ESV, ml
125.1±101.8 90±73.1
0.93
p<0.0001
EF, %
44.5±20.4
45.1±16.3 0.93
p<0.0001
Correlation between GBPS and US was high for EDV, ESV and for EF. Conclusion: Our study show very good agreement between GBPS and US in the estimation of major hemodynamic parameters of LV. GBPS is safe, non‐invased method for precise estimation of heart volumes and EF in patients with reduced contractility function.
P002 The value of myocardial perfusion scintigraphy in screening patients for liver transplantation D. E. Oprea, M. P. M. Stokkel; LUMC, Leiden, NETHERLANDS. Introduction Liver failure can be subdivided into an acute en chronic form. The chronic form generally leads to the question whether a patient should be prepared for liver transplantation (OLTx). The whole workup for such a major surgery consists of a thorough evaluation of exclusion and inclusion criteria. One of the diagnostic tests that has to be performed as part of a screening protocol is myocardial perfusion scintigraphy (MPS). The aim of the present study was to evaluate the value of MPS in this screenings protocol. Materials and methods: All patients who had been referred for MPS related to the screening for OLTx between April 1998 and February 2008 were included, revealing 202 patients (mean age 50.4 yrs). The census date was 1‐03‐2009.
All general data (date of transplantation and death), risk factors and factors related to the liver failure were gathered. Causes of death were subdivided into cardiac and non‐cardiac. Finally, all MPS were reassessed and scored using a 17‐segmental model. Results: In the 202 patients screened for OLTx, the follow‐up between MPS and OLTX was 16.8 mo (0,10 ‐ 120,99), whereas the overall follow‐up from MPS to census date was 46.7 mo (0,13 ‐ 129,67). In this cohort, 122 patients finally underwent OLTX, whereas 45 patients died during the follow‐up: 41 non‐cardiac and 4 cardiac. MPS showed in 25 patients’ in ≥ 3 segments perfusion abnormalities: 23 patients had persistent defects and 2 (1%) patients had reversible ischemia. CAG in these 2 patients revealed no abnormalities in 1 and significant stenosis and the other. Three factors were significantly related to survival: OLTx (HR 0.295: p<0.001), smoking (HR 0.264: p=0.003) and Hepatocellular carcinoma as cause of liver failure (HR 2.547: p=0.047). The 5‐year survival rate for patients with an OLTx (85%) was significantly better than without an OLTx (62%) (p<0.001). There was no correlation between the MPS results and survival, but the number of patients with reversibility was too small. Conclusion: The role of myocardial perfusion scintigraphy in the screening of patients for liver transplantation is very limited. The cause of death in most of the patients is non‐cardiac. In this specific population, patients’ selection for MPS should be based on symptoms and risk factors to avoid unnecessary performed studies.
P003 Gated myocardial perfusion SPECT: Effect of patient position on left ventricular functional indices. V. Dabbagh Kakhki1, D. Beiki2, B. Fallahi2; 1Mashhad University of Medical Sciences, Emam Reza Hospital, Mashhad, IRAN, ISLAMIC REPUBLIC OF, 2 Research Institute for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF. Introduction & Aims: Gated myocardial perfusion SPECT is used for assessment of myocardial perfusion and left ventricular functional indices by reference to left ventricular end‐diastolic volume(EDV), end‐systolic volume(ESV) and ejection fraction (EF). Usually myocardial perfusion imaging has been performed in supine position. However imaging in the prone position markedly improved the specificity by identifying and reducing artifacts. For computation of left ventricular functional indices different algorithms such as commercially available automated Quantitative Gated SPECT algorithm (QGS) has frequently been validated using the currently established gold standard: cardiac magnetic resonance imaging. These validation studies have dealt with SPECT data acquired in the supine position. Prone positioning affects intraabdominal pressure and sympathetic nerve activity and arterial filling. The aim of this study was to investigate the effect of prone vs. supine positioning of the patient on left ventricular functional indices acquired on Gated SPECT. Methods: We studied 60 patients (40 men and 20 women, mean age 52.1±8.8 years), who all underwent rest Tc99m‐sestamibi gated myocardial perfusion SPECT at in both prone and supine positions. All images were analyzed s using QGS software for calculation EDV, ESV, SV and EF. Results: Of the 60 patients, 15(25%) had normal tomogram, 14 (23.3%) had reversible defects, 14(23.3%) had fixed defects and 17 (28.3%) patients had partially reversible defects. EDV, ESV and SV were significantly lower for prone acquisitions (EDV: 78.05 ±32.89 ml, ESV: 36.22±28.04 ml, SV: 41.83±11.78 ml) than for supine acquisitions (EDV: 86.37±37.70 ml, ESV: 41.40±33.28 ml, SV: 44.97±11.38 ml), but EF did not differ significantly between supine and prone acquisitions. Heart rate was significantly higher for prone acquisitions [71.87±9.56, (51‐ 93)] than for supine acquisitions [67.30±9.54, (51‐96), P<.001) with an average increase of 6.8% Conclusion: Our study showed that heart rate as well as EDV, ESV and SV are significantly different between prone and supine positions. Therefore comparison of prone gated SPECT data with reference values that usually were obtained on supine position is unsuitable. In another words, reference data that usually acquired on supine position should not be used to classify the results of prone gated SPECT acquisitions.
P004 Prevalence of Coronary Artery Disease (CAD) in Diabetics Type 2, identified by Myocardial Perfusion Studies I. Kotsalou1, C. Kotsalos2, N. Zakopoulos3, M. Dimopoulos3; 1NIMTS Hospital, Nuclear Medicine Dept., Athens, GREECE, 2NIMTS Hospital, Cardiothoracic Surgery Dept., Athens, GREECE, 3Alexandras Hospital, University Dept. of Internal Therapy, Athens, GREECE. AIM : Cardiovascular disease is one of the commonest complications of diabetes mellitus (DM) type 2 which very often lacks of diagnosis, because it is frequently asymptomatic. This study aims to stress the need of early detection of CAD via Myocardial Perfusion Scan in diabetic population to prevent acute cardiovascular events. MATERIALS ‐METHODS: We retrospectively studied 78 diabetics type2, of both sexes, DM duration 1‐15 years (64% Group 1) and 16‐25years (36 Group 2). The 22 of the patients (28%‐ Group A) were referred for angina symptoms, 23 of them (29%‐ Group B) mentioned atypical angina symptoms, whereas 33 (43%‐ Group C) were asymptomatic. We excluded patients with known CAD. All patients were subjected to gated‐ single photon emission tomography, using a one‐day stress/rest protocol with Tc‐99m tetrofosmin (n=65:physical exercise, n=13:adenosine). Multiple risk factors and clinical predictors like duration of DM, presence of peripheral vascular disease, dyslipidemia, hypertension, smoking, family history of CAD and obesity were analyzed. RESULTS : We used the 20‐segment scoring model for SPECT analysis and found that 77% of perfusion studies in Group A were positive for CAD (scar and/or ischemia) and 48%, 73% for Group B and Group C respectively. Finally, there was no statistically significant difference in Incidence of Ischemia between the groups 1 and 2 (Duration of Diabetes Mellitus). CONCLUSIONS : Diabetes Mellitus is widely considered as a Coronary Artery Disease risk equivalent, because of the high incidence of coronary ischemia and high cardiovascular mortality rates of this population. Myocardial Perfusion Scintigraphy Study is a simple, non invasive and sensitive mean of screening for subclinical Coronary Heart Disease in patients with Diabetes type 2.
Poster Presentation
suggests that the 11C‐methoxy labelling group is preserved under in vivo conditions. These findings are encouraging for further investigation with this radiotracer on RTK expressing cells and tumour tissue to answer the question if this radiotracer would be a useful tool for monitoring angiogenic processes by PET. [1] Sun L., Liang C. et al., J. Med. Chem., 46, (2003), 1116
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P005 A Comparative Regional Analysis of coronary artery disease on multislice CT with Myocardial Perfusion SPECT. V. Sergienko, A. Ansheles, M. Bugriy; Cardiology Research Complex of Ministry of Health of Russian Federation, Moscow, RUSSIAN FEDERATION. Aim: For the noninvasive evaluation of coronary artery disease (CAD), both multislice CT and gated SPECT are available. How these 2 methods relate, however, is yet unclear. The purpose of this study was to comparison of multislice CT and gated SPECT on a regional basis in patients with known or suspected CAD. Materials and methods: Twenty one patients (14 male) with ischemic heart disease, underwent multislice CT for coronary angiography and gated SPECT for myocardial perfusion imaging in 1 week period. Coronary arteries on multislice CT angiography were classified as having no CAD, insignificant stenosis (<50% luminal narrowing), significant stenosis (50‐90%), or total or subtotal occlusion (≥90% luminal narrowing). Gated SPECT findings were classified as normal or abnormal (reversible or fixed defects) and were allocated to the territory of the various coronary arteries. Results: In most of the normal coronary arteries on multislice CT angiography, the corresponding myocardial perfusion was normal on SPECT (12/14, or 86%). In contrast, the percentage of normal SPECT findings was significantly lower in coronary arteries with obstructive lesions (32%) or with total or subtotal occlusions (4%) (P < 0.01). Conclusion: Relationship between the severity of CAD on multislice CT and myocardial perfusion abnormalities on SPECT, analysis on a regional basis showed good agreement between observed atherosclerosis and abnormal perfusion. Further studies should address how these 2 modalities can be integrated to optimize patient management.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 I. Kotsalou, I. Karfis, A. Zoumboulidis, N. Dimakopoulos; NIMTS Hospital, Athens, GREECE. AIM : Increased Lung/ Heart Ratio (LHR) is commonly associated with invasively determined measures of ventriclular dysfunction, extent of coronary artery disease and perfusion abnormalities. In this study we aimed to study the degree of correlation between the Lung/ Heart Ratio and the extent of coronary heart disease defined by 99mTc‐ tetrofosmin myocardial perfusion imaging. METHODS ‐ MATERIALS : We correlated the clinical characteristics and quantitative lung/heart ratio in 50 patients undergoing stress (treadmill or adenosine) 99mTc‐ tetrofosmin perfusion testing. LHR was defined by the ratio of the mean pulmonary counts and the mean myocardial counts assessed from corresponding regions of interest (ROI’s) positioned over the left lung and the heart, respectively in the anterior view of the tomographic data acquisition procedure. Normal values were stress LHR ≤ 0,49 and S
SPECT (no. vessels)
Normal
5 (45%) 7 (28%) 2 (14%) 14 (28%)
1
2
3
Total
P006
Abnormal 6 (55%) 18 (72%) 12 (86%) 36 (72%)
Feasibility and diagnostic accuracy of ECG-gated spect myocardial perfusion imaging by a two hours protocol: The myofast study
Total
V. Dunet, S. Costro, R. Sabatier, G. Grollier, G. Bouvard, D. Agostini; CHU de Caen, Caen, FRANCE.
Diagnostic efficacy of myocardial perfusion SPECT in diabetic women in detection of coronary artery disease.
AIM OF THE STUDY: To assess the feasibility of early stress and rest myocardial perfusion and function study using a fast 99mTc‐Tetrofosmin gated‐SPECT protocol in patients with known coronary artery disease. METHOD: 46 pts (40 M, 6 F, mean age 63.7 ± 9.8 years) underwent a 99mTc‐Tetrofosmin gated‐SPECT (Picker‐Philips®) myocardial study and a coronary angiography (CA) within 3 month. Images were acquired (LEHR, 8 bins, 40 sec per image) after injection of 99mTc‐Tetrofosmin (200 to 380 MBq) early (15 minutes) post‐stress (39 dipyridamole, 2 dobutamine and 5 ergometric stress), and at rest after 99mTc‐Tetrofosmin reinjection (600 to 1150 MBq), in a total time not exceeding 2 hours. Quality of images was analyzed by a 3 scale scoring. Processing was performed with QGS® software using the 17‐segment model. Pathological study was defined as a summed difference score (SDS) ≥ 4, a fixed defect with summed rest score ≥ 4 and/or LV dysfunction defined as myocardial stunning (variation between stress and rest LVEF > 5%), stress LVEF ≤ 45% or rest LVEF ≤ 40%. Results were compared with CA, and stenosis ≥ 50% was considered as significant. RESULTS: For 100% the quality of SPECT imaging was good or excellent. For 6 patients gating was unrealizable because of arrhythmia. The overall sensitivity, specificity and accuracy were 95 %, 66.7% and 91.3%, respectively. The concordance between gated SPECT and CA was good (Cohen’s kappa index= 0.62, se= 0.15). Interestingly, early gated acquisition permitted to underline left ventricular dysfunction in 12 cases (20%) whom 8 cases of polyvascular disease. Stunning was detected in 7 of 40 cases (17.5%), whom 6 with polyvascular disease. CONCLUSION: A one day two‐hours 99mTc‐ Tetrofosmin gated‐SPECT protocol to assess left ventricular perfusion and function is feasible and accurate. Early gated acquisition help for detecting post‐stress stunning which is well known to be a crucial prognostic factor of major cardiac events. We conclude that fast protocol could help to speed up clinical management while improving prognosis assessment.
M. Pombo Pasín, V. Pubul Núñez, M. Garrido, S. Argibay Vázquez, C. Peña Gil, A. Ciobotaru, A. Sánchez Salmón, J. Cortés Hernández, E. Abu Assi, J. Gómez Buela, R. Rey Carreira, Á. Ruibal Morell; Complejo Hospitalario Universitario, Santiago de Compostela, SPAIN.
P007 The use of Computer-Aided Diagnosis to influence the interobserver variability when interpreting Myocardial Perfusion Imaging. K. A. Tägil1, S. Aguadé2, A. Crespo3, A. Flotats4, I. Martinez-Rodriguez5, Á. Muxí6, L. Edenbrandt1; 1Department of clinical science, Malmo, SWEDEN, 2 Hospital Central de la Vall d'Hebron, Barcelona, SPAIN, 3Hospital Ramon y Cajal, Madrid, SPAIN, 4Hospital de la Santa Creu, Madrid, SPAIN, 5Hospital Universitario Marqués de Valdecilla, Santander, SPAIN, 6Hospital Universitari Clinic Barcelona, Barcelona, SPAIN. The aim of this study was to investigate the variation in interobserver variability using a computer assisted diagnosis (CAD) system when interpreting myocardial perfusion imaging. Method: 14 physicians independently interpreted 50 myocardial perfusion scintigraphy studies (MPS), without and with the advice of a CAD system. The physicians experience of interpretation of MPS varied. Each study was interpreted regarding myocardial ischemia and infarction in nine myocardial regions. Each physician interpreted the patients before and after receiving an advice of a CAD program. The patients had undergone a gated MPS using a two‐day 99mTc‐sestamibi protocol. Result: The interobserver variability regarding the interpretation of infarction was reduced in 24 cases and increased in 7 cases (p=0.003, McNemar test) when the physicians had access to the advice of the CAD system. There was a similar but not significant tendency for the interpretation of ischemia, with a reduction of the variability in 21 cases and an increase in 12 cases. Conclusion: This study shows that a CAD system can be used to reduce interobserver variability when interpreting myocardial perfusion imaging.
P008 Relationship of stress Lung/ Heart Ratio and Multivessel 99m Tc- tetrofosmin myocardial Coronary Disease defined by perfusion imaging
11 (22%) 25 (50%) 14 (28%) 50
P009
AIM: To assess the usefulness of myocardial perfusion imaging by means SPECT in diabetic women for the detection of coronary artery disease (CAD). Secondly, to determine the prognostic value for occurrence of cardiovascular events in these patients. PATIENTS AND METHODS: Of 2.935 consecutive patients who underwent SPECT from September 2004 to February 2008, 1.546 diagnostic studies and 777 female patients, we realize a retrospective study in 102 female patients diagnosed of diabetes mellitus (DM) and 102 female patients without DM, all of them without known CAD. All patients underwent stress‐rest SPECT which was classified as negative or positive. The cardiovascular risk factors (CVRF) registered were: age, smoking, diabetes (DM), hypertension (HT), dyslipidemia (DL), peripheral arterial disease and body mass index (BMI). Clinical follow‐up was conducted during a period of time between 6 months and 4 years. Were considered future cardiovascular events and the results of the coronary angiography (if it was realized) were also analyzed. RESULTS: The mean age was significantly higher in the group of diabetic women (67.75 ± 7.5 vs 62.62 ±11.29) p<0.0002 and the distribution of CVRF in relation with the HT (84.31 % vs 56.86 % p <0.0001), DL (75.49% vs 50 % p <0.0002) and mean BMI (30.28 ± 4.9 vs 28.23 ± 6.07 p <0.009). Of the 102 diabetic patients, 24 patients had a SPECT + (23.53%) vs 11 (10.78 %) of the control group (p <0.01). In diabetic women with SPECT +, 11 patients underwent cardiac catheterization (10.78%) presenting 8 significant coronary disease (7.84%). In the control group with SPECT +, 5 patients underwent hemodynamic study (4.90 %). Of these patients, 4 had significant coronary artery disease (3.92 %). In diabetic women with SPECT ‐ , 9 patients underwent cardiac catheterization (8.82 %) and only 2 (1.96%) had significant angiographically lesions. In the control group, 2 patients (1.96 %) underwent hemodynamic study, being the result of the study without lesions. The occurrence of coronary events was 9.31 % in the diabetic group opposite to 2.45 % in the control group (p <0.02). CONCLUSIONS: ‐ Diabetic women have a cardiovascular risk profile more atherogenic, higher proportion of positive SPECT and positive hemodynamic studies, as well as a greater proportion of coronary events during the follow‐up than non‐diabetic. ‐ SPECT may be a useful tool for the early CAD diagnosis in diabetic women and for selecting those with a higher probability of coronary events.
P010 Myoview Imaging Optimization (MIO) study, part 2: the pathophysiological substrata of early and fast myocardial imaging in nuclear cardiology A. Giorgetti, A. Kush, M. Casagranda, I. D'Aragona Tagliavia, P. Marzullo; "Monasterio" Foundation - CNR, Pisa, ITALY. AIM Recently, we demonstrated early and fast myocardial GSPECT using 99mTc‐Tetrofosmin to be more accurate than standard delayed acquisitions in more than 44% of studied patients, because of differences in post‐stress scans. The pathophysiological explanations of this so called “see before see more” effect are still to be clarified. METHODS The patients population (100 male, 20 female, mean age 61+/‐10 yrs) previously studied with both early (T1, 15’) and standard Tetrofosmin gated SPECT imaging (T2, 45’) was analyzed in terms of regional myocardial count statistics and semiquantitative wall motion indexes. Regional myocardial counts and perfusion/wall motion analysis was performed on a 20‐segment model using the available softwares (QPS/QGS and 4DMSPECT). The study population was divided into two groups: group 1 (G1, 53/120 pts) with differences between T1 and T2 imaging; group 2 (G2, 67/120 pts) with similar results between the two condition of acquisitions. In each patient, myocardial areas were categorized as control, ischemic and scarred on the basis of perfusion/contraction properties. RESULTS In G1 patients, post‐stress 99mTc‐Tetrofosmin decay corrected wash‐out resulted 15±8%, 7±10% and 2.9±8.9% in control, ischemic and infarcted regions, respectively, (p<0.0001 among all categories). In G2 patients, post‐stress radiotracer wash‐out resulted 13.6±9.6%, 12.2±9.5% and 4.3±8.1% in control, ischemic and infarcted regions, respectively, (control and
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P011 Gated-spect, are the results with 128 matrix different than 64 matrix with or without special reconstruction algorithms? M. Barios, S. Aguade-Bruix, E. Mariscal, F. Dellepiane-Clarke, G. Cuberas, V. Aliaga, J. Castell-Conesa; Hospital Universitari Vall d'Hebron, Barcelona, SPAIN. Aim: The study aimed to detect an quantify possible differences in left ventricular volumes and EF measurements, obtained by myocardial perfusion Gated‐SPECT, applying different size acquisition matrix and reconstruction algorithms. Methods: The study consisted in a retrospective analysis of myocardial perfusion Gated‐SPECTs of 65 patients (39 females, age: 64,98±11,27 years). A one‐day stress/rest protocol with acquisition of stress images (370 MBq 99mTc‐Tetrofosmine) and rest gated‐SPECT images (888MBq 99mTc‐Tetrofosmine) with128x128 matrix (pixel size 3.40mm) were performed. Rest gated‐SPECT images were reconstructed with OSEM/MLEM (2 iterations, 10 subsets) and Butterworth 0.4/10 filter. All of them were minimized to 64x64 matrix (pixel size 6.8mm) and reconstructed, first with OSEM/MLEM (2/10) and Butterworth 0.4/10 filter, and finally with WBR. The three reconstructed studies were processed with QGS program to obtain ventricular volumes and EF. All quantitative values were analysed with SPSS 11 statistic software. Results:
Matrix 1282
EF 57.9±14.1 (17‐80)
Matrix 642
WBR (Matrix 642)
61.1±14.7 ( 19‐85) 58.6±13.1 ( 18‐77)
TDV 101.8±65.2 (37‐503) 94.5±64.5 (34‐482) 100.8±66.2 (39‐499) TSV 49.4±57.1 (7‐419)
43.2±54.3 (5‐391) 47.7 ±55.4 (9‐408)
Results show a good correlation (0.988 to 0.976 for EF, 0.997‐0.995 for EDV and 0.988 for all ESV). No significant differences with ANOVA test were found. Bland‐Altman plot shows in 128 matrix and WBR images higher volumes and lower EF than in 64 matrix images. Conclusions: EF obtained with 1282 matrix is slight lower (without significant difference) and the ventricular volumes are higher (without significant difference) than 642 matrix images. The results obtained with WBR (Matrix 642) are not different than results obtained with 1282 matrix.
P012 The value of stress gated 99mTc-MIBI SPECT in evaluation of perfusion abnormalities and left ventricular function in patients with previous anterior myocardial infarction D. P. Sobic-Saranovic1, L. Bojic1, S. Pavlovic1, N. Kozarevic1, V. Artiko1, B. Beleslin2, E. Jaksic1, M. Todorovic-Tirnanic1, V. Obradovic1; 1Institute of Nuclear Medicine, CCS, Belgrade, SERBIA, 2Institute for Cardiovascular Diseases, CCS, Belgrade, SERBIA. Background and Aim: Myocardial gated SPECT (MGS) gives usefull information about the extent and severity of perfusion defects (PD) and global left ventricular (LV) dysfunction in patients with coronary artery disease.The aim of this study was to evaluate PD and LV function in patients with previous anterior myocardial infarction (AMI) with MGS. Material and methods: This study included 45 patients (age 55±10, 35 males) with AMI, Q‐wave on ECG and single‐vessel coronary disease of left anterior descending coronary artery on coronary angiography. All patients underwent a 2‐day stress‐rest GSM imaging with 99m‐tehnetium metoxy‐isobutile‐isonitrile (MIBI). The assesment of PD was performed by polar maps.End‐diastolic LV volume (EDV), end‐ systolic volume (ESV) and ejection fraction (EF) were determined by 4D‐MSPECT software. Results: In all enrolled patients with AMI, LV function parameters (EF, EDV, ESV) were not statistically different between rest and post‐stress (EFr: 51±9% vs. EFps: 50±8%, EDVr: 137±29 ml vs. EDVps: 139±29 ml, ESVr: 65±20 ml vs. ESVps: 66±22 ml, p>0.05 respectively), while stress‐PD value was higher but did not reach statistical significance (21±10% vs. 24±10%, p>0.05). In the subgroup with additonal ischemia to the fixed defect (n=22), post‐stress PD value was statistically higher in comparison with PD value in rest study (PDr:14±4% vs. PDps: 23±11%, p<0.01). EFps was significantly decreased (EFr: 54±8% vs. EFps: 50±7%, p<0.05) while ESVps was increased (ESVr: 61±20 ml vs. ESVps:71±22 ml, p<0.05) in comaprison to the rest value. There was not statistical differance between EDVr and EDVps (142±29 ml vs. 144±29 ml, p>0.05). In the subgroup with fixed perfusion defect (n=23), there was not statistical significance between post‐stress and rest parameters (EFr: 48±8% vs. EFps: 50±9%, EDVr: 138±43 ml vs. EDVps: 136±41 ml, ESVr: 68±30 ml vs. ESVps: 66±28 ml, p>0.05) as well as between PDr and PDps (23±11% vs. 24±10%, p>0.05). Conclusion: MGS has important role in evaluation of PD and LV function in patients with AMI especially in patients with additional ischemia and transient post‐ischemic LV dysfunction in whom significantly decreased post stress EF is probably due to significantly increased ESV.
P013 Left Ventricular Ejection Fraction From Gated-Spect-CT Myocardial Perfusion. QGS And Emory Cardiac Toolbox. Correlation In Between Both Methods.
P. Paredes Rodríguez, J. Castro Beiras, V. Castillo Morales, M. Orduña Díez, Á. Crespo Díez; Hospital Ramón y Cajal, Madrid, SPAIN. PURPOSE To evaluate relationship between values obtained by each software package QGS and ECTb, taking in account that these methods are both the most widely distributed analysis packages for myocardial perfusion gated SPECT MATERIAL AND METHOD 71 gated‐SPECT 99mTc‐ tetrofosmine rest myocardial perfusion studies, in patients studied because coronary artery disease, all of them with end‐systolic volume >35 ml, using a double‐headed gamma camera (Infinia, GE). QGS and ECTb values of ejection fraction (LVEF) were calculated in a Xeleris workstation. Linear regression analysis was used to compare calculations of LVEF between QGS and ECTb, and Bland Altman plots of differences versus means. RESULTS Linear regression correlation between QGS and ECTb of LVEF has been strong (p<0.0001) with Pearson correlation coefficient r = 0.894 Ejection fraction values (LVEF) correlated linearly, but were lower for QGS compared with ECTb (37.49% , SD = 12.45 versus 46.43%, SD = 12.80). Linear regression curves for ECTb versus QGS were Y=11.9+0.91X, statistically significant. Bland Altman analysis revealed that the slope of LVEF differences versus means was 0.023, not statistically significant, with a constant offset of 7.4%. CONCLUSIONS Correlation was strong between the two methods, in patients with end‐systolic volume >35 ml, but evident differences and trends were observed. In patients with lower volumes (≤35ml), the correlations possibly is not so strong. Values of LVEF are lower with QGS compared to ECTb, it is important to take notice of these differences when both software packages are used.
P014 Are ventricular functional parameters, obtained by gated spect, influenced by patient size? L. Tagliabue, L. Gilardi, S. Seghezzi, A. Del Sole, G. Lucignani; University Hospital "S.Paolo", Milan, ITALY. INTRODUCTION: althought myocardial Gated SPET studies allow an easy measurement of both ventricular volumes and ejection fraction, very little is known about how Patients size can affect the assesment of cardiac functional parameters. The aim of this study was to estabilish how End‐ diastolic Volume (EDV), End‐Systolic volume (ESV), Stroke Volume (SV)and Ejection Fraction (EF) can be influenced by Patients dimensional variables.MATERIAL AND METHODS: we studied 200 consecutive Patients undergoing diagnostic stress‐rest perfusion Gated‐Spect imaging : 100 Patients had Body Mass Index (BMI) >30 and both positive scintigraphy and cardiac stress test (Group A); 50 Patients had BMI>30, low pre‐test probability (<5%) and both negative scintigraphy and cardiac stress test (Group B); 50 Patients with BMI<30,presented low pre‐test probability (<5%) and both negative scintigraphy and cardiac stress test (Group C). Ventricular volumes (VV) and EF were calculated by using a commercial semi quantitative software (Autoquant ®).In all Patients Body Surface Area (BSA) and BMI were calculated.For statistical analysis a Pearson’s correlation coefficient (r) and Student’s t test (p<0.01) was used. RESULTS: Group A: EDV: 119 mL (±46); ESV: 61 ml (± 38); SV: 55 ml(± 18);Ejection Fraction (EF): 53% (±11%); Group B: EDV: 77.1 ml (± 27); ESV: 28.2ml (± 16); SV: 45 ml (± 17); EF: 66% (± 6%); Group C: EDV: 72,6 ml (± 20);ESV: 27 ml (± 12); SV: 45,6 ml (±9): EF: 66% (± 8%). In normal people (groupB and C) we found no correlation between ventricular volumes and BMI,whereas we found a significant positive correlation between ventricular volumes and BSA for the same groups (r=0.7; p<0.01). EF doesn’t correlates neither with BMI nor with body surface area. In Group A we found no correlation between EDV, ESV, SV, EF and BMI or BSA whereas we found a significant reduction in SV and EF with increase in VV when compared to Groups B and C Patients. (p<0.01) CONCLUSIONS: in Patients with low pre‐test probability of CAD, VV (EDV, ESV, SV) not EF show a linear correlation with BSA but not with BMI,suggesting that data should be normalized to the former in clinical practice; moreover, in Patients with perfusion defects, this phenomenon is not observed, probably because ventricular volumes are most likely altered due to loss in contractility and ventricular remodelling.
P015 The assessment of relation between presence of side effects resulting from dipyridamole injection during myocardial perfusion imaging with hemodynamic changes, electrocardiographic and scan findings H. Javadi1, M. Shariati1, S. Jalallat2, M. Mogharrabi1, I. Neshandar Asli2, N. Bahafar2, M. Shiroodi2, M. Assadi3; 1Department of Nuclear Medicine, 5 Azar Hospital , Golestan University of Medical Science, Gorgan, IRAN, ISLAMIC REPUBLIC OF, 2Department of Nuclear Medicine, Taleghani Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Science, Tehran, IRAN, ISLAMIC REPUBLIC OF, 3The Persian Gulf Health Research Center, Bushehr University of Medical Sciences, Bushehr, IRAN, ISLAMIC REPUBLIC OF. Aim: Evaluation the prevalence of side effects due to dipyridamole injection, during myocardial perfusion imaging, and their correlation with hemodynamic changes and scan findings . Materials & Methods: Before starting the stress phase myocardial perfusion imaging , electrocardiogram, blood pressure and heart rate of all the patients were registered and then, dilute dipyridamole amounting to 0.568 mg/kg in 10 ml of normal saline was infused within 4 minutes . Within the period of infusion, the patient s electrocardiogram, HR, SBP, DBP, and any complaint of them was recorded. Results: In this study, we examined 590 patients (Mean ± SD; 57 ± 11 year old), who performed myocardial perfusion scan with intravenous dipyridamole in stress phase. In order to assessment the relation between side effects, hemodynamic response to dipyridamole infusion, myocardial perfusion imaging , and electrocardiographic findings , we evaluated resting and post‐infusion changes of HR, SBP, DBP. There is no significant difference in mean ± SD of resting HR (82 ± 12 beat/minute, vs 82 ± 10 beat/minute; p > 0.05), resting DBP (79 ± 9 mmHg ,vs 79 ± 10 mmHg; p> 0.05), and stress SBP (132 ± 20 mmHg vs 131 ± 23 mmHg ; p > 0.05) in patients without and with symptoms. However, significant difference in mean ± SD of post‐infusion HR (88 ± 13 beat/minute, vs 92 ± 10 beat/minute ; p = 0.016), rest SBP (139 ± 20 mmHg, vs 133 ± 23 mmHg ; p = 0.024), stress DBP (76 ± 9 mmHg ,vs 72 ± 10 mmHg ; p = 0.003), were noted in patients with and without symptoms. Conclusion: Our data demonstrated that most of side effects are self limiting and occur in patients with basic abnormalities in their ECG and scan findings.
Poster Presentation
ischemic vs. infarcted areas: p<0.0001). Therefore, post‐stress radiotracer wash‐out was significantly higher in control regions of G1 pts than in the same areas of G2 pts (p<0.02), significantly lower in ischemic regions of G1 pts than in the same areas of G2 pts (p<0.0001), and comparable between infarcted areas of the two patients groups (p=NS). In G1 pts delta post‐ stress regional wall thickening (T1‐T2) was 0.17±9.68, ‐4.5±9.15, 1.66±7.37% in control, ischemic and infarcted regions, respectively, (control vs. ischemic areas p<0.001; ischemic vs. infarcted regions p<008; control vs. infarcted area p=NS). In G2 pts delta post‐stress regional wall thickening resulted ‐0.33±10, ‐1.90±7.0, 0.56±5.80% in control, ischemic and infarcted regions, respectively, (control vs. ischemic areas p<0.04; control and ischemic vs. infarcted regions p=NS). Thus,delta post‐stress regional wall thickening was lower in ischemic regions of G1 than in the same areas of G2 pts (p<0.001). CONCLUSIONS Differential radiotracer wash‐out and ischemic‐ induced alterations in regional wall motion and wall thickening are the pathophysiological background of the increased accuracy of early Tetrofosmin imaging. Since these phenomena are inversely related to the time of the ischemic event, delayed imaging could miss informations, reducing the potential diagnostic power of GSPECT.
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P016 An investigation of myocardial perfusion measurement with Tc-99m MIBI through a mathematical compartment model analysis. A. Okizaki1, Y. Urano2, M. Nakayama1, M. Odashima1, Y. Sasagawa2, T. Aburano1; 1Asahikawa Medical College, Asahikawa, JAPAN, 2Rumoi City Hospital, Rumoi, JAPAN.
Absolute myocardial perfusion measurement with PET is useful for diagnosis of ischemic heart disease (IHD). However, it is available in only a limited number of institutions because PET scanner and cyclotron are necessary. These devices are expensive and not yet widely available. If the quantitative measurement could be performed with gamma‐camera system using single‐ photon radionuclides, the quantitative data might be obtained easily. We hypothesised that quantitative myocardial perfusion (QMP) might be estimated by an influx rate constant from blood to myocardium, which calculated through a compartment model analysis, and left ventricular (LV) volume. The purpose of this study was to investigate QMP which obtained with gammma‐camera system through a compartment model analysis in normal subjects and patients with IHD. The mean rate of change of QMP were compared between IHD and normal, to evaluate the usefulness of this method for diagnosis of IHD. A total of 30 subjects, including 19 normal subjects and 11 patients with IHD, were studied. Tc‐99m MIBI dynamic scintigraphy was performed during vasodilation with adenosine (120 microgram/kg/min). Two hours after the imaging, a scintigraphy without pharmacologic provocation was also performed. By using the time‐activity curves, we analyzed Tc‐99m MIBI pharmacokinetics through a 3‐ compartment model. We calculated QMP by an influx rate constant and LV volume, which was derived from the compartment model analysis and quantitative perfusion SPECT. Additionally, each of QMP was corrected by myocardial mass that was obtained with the Emory cardiac toolbox, to minimize an effect of myocardial mass differences among each subjects. After QMP was obtained, the mean rate of increase of QMP were calculated as: QMP with pharmacologic provocation / QMP without pharmacologic provocation. Finally, the mean rate of increase of QMP were compared between in normal and IHD. The QMP of Tc‐99m MIBI, which corrected by myocardial mass was increased with pharmacologic provocation in normal subjects. The mean rate of increase of QMP in all subjects was 1.53 ± 0.39, in normal subjects was 1.65 ± 0.41 and in IHD was 1.31 ± 0.26. The mean rate of increase of QMP was statistically significant lower in IHD than in normal (p < 0.01). The the mean rate of increase of QMP was lower in IHD than in normal. This quantitative approach might be useful for diagnosis of IHD.
P017 Role of myocardial perfusion scintigraphy following coronary angiography in patients with myocardial infarction C. N. B. Harisankar, B. R. Mittal, K. Kamaleshwaran, A. Bhattacharya, B. Singh; Postgraduate Institute of Medical Education & Research, Chandigarh, INDIA. INTRODUCTION: In developing countries, patients with acute myocardial infarction (AMI) often present late and have severe coronary artery disease. Presence of severe hypokinesia or akinesia and near complete stenotic lesions on coronary angiography raises question of viability in the involved territory and its response to revascularization. The decision on revascularization can be effectively taken after myocardial perfusion scintigraphy (MPS). AIMS: To evaluate the role of MPS in patients with acute or recent myocardial infarction after invasive coronary angiography. MATERIALS AND METHODS: 35 patients (27 Males, 8 Females; Mean age 54 yrs) with AMI, who underwent invasive angiography, were included prospectively. Invasive angiography without prior MPS was performed either due to ongoing chest pain at presentation (20/35 patients) or non‐availability of MPS at the time of initial presentation in the referring hospital (15/35 patients). The reason for not stenting the involved coronary artery during angiography were complete/near complete block of artery with hypokinesia/akinesia of the corresponding LV segments in 32/35 patients, 50% to 70% block (hemodynamically equivocal plaque) in 3/35. The distribution of lesions in individual coronary arteries were 28 in LAD, 12 in LCx, 12 in RCA. On patient by patient basis 17 had single vessel disease, 10 had double vessel disease while 5 had triple vessel disease. Only 3 patients had stenosis <70% in all the three coronaries. 14 had complete occlusion of the LAD with hypo/akinesia of the territory supplied. Physical exercise using treadmill (TMT) was performed whenever feasible. Nitrate augmented rest redistribution (RR) study was performed when contra‐indications to stress study, i.e LV aneurysm, LVEF<25%, LV clot. 19/35 underwent TMT, 1 underwent adenosine stress and 15/35 underwent RR study. None had any life threatening complications. Imaging was performed using hybrid SPECT/CT along with attenuation and scatter correction. The average defect size of perfusion defect was 34% (5%‐57% range). 16 patients (46%) had fixed perfusion defects. Reversible ischemia was present 19 (54%). Nine (26%) underwent an invasive revascularization procedure due to demonstration of significant amount of ischemic myocardium. Eight of these 9 patients had 100% occlusion with severe hypokinesia of the LV angiography. CONCLUSION: MPS is invaluable in patients who have total/near total occlusion of coronary artery and distal segment hypokinesia or akinesia on invasive angiography. 26% patients who would benefit from revascularization were identified with MPS. Further, MPS prevented unnecessary stenting in 74% of these patients by demonstrating absence of viable myocardium in the involved territory.
P018
99m
Results analysis of gated Tc-MIBI SPECT myocardial perfusion scintigraphy in patients with systemic sclerosis (SSc). A. Parfieńczyk, F. Rogowski, O. Kowal-Bielecka, P. Szumowski, J. Kita, S. Abdelrazek, S. Sierakowski; Medical University of Białystok, Białystok, POLAND. Aim: Cardiac involvement is considered a poor prognostic sign in systemic sclerosis (scleroderma, SSc), however it is often underdignosed untill clinically evident. The purpose of the study was to investigate the changes in left ventricular perfusion and function by the rest / stress study imaging using 99mTc‐MIBI Gated SPECT in asymptomatic patients with SSc. Material and methods:
The study was performed on 38 patients (all female aged 40‐65) with SSc diagnosed according to the ACR classification criteria. None of the subjects have any symptomatic ischemic heart diseases. The patients were examined with GSPECT at rest ‐ 1 hr and 24 hr after on stress after the injection of 800 MBq activity 99mTc‐MIBI. Myocardial perfusion was performed using one‐ head rotating gamma camera (Nucline X‐Ring/R) equipped with a low‐energy, parallel‐hole collimator and connected with a dedicated Interviev computer system. End‐ diastolic (EDV), end‐ systolic volumes (EVS) and left ventricular ejection fraction (LVEF) were automatically calculated. Visual interpretation of GSPECT was performed using a 14 ‐ region model and a five‐point scoring system (1= normal perfusion, 2 = mildly reduced, 3 = moderately reduced, 4 = severely reduced, 5 = absent). Results: None of SSc patients had ischemic changes in exercise Ecg, however 30/38 (79%) of SSc patients were unable to achieve submaximal heart rate due to fatigue and/or musculoskeletal complaints. In GSPECT, all SSc patients had segmental LV perfusion impairment, which were reversible in 70% and irreversible in 30% of segments during stress study. In the majority of patients mildly (36%) or moderately (18,5%) reduced perfusion impairments were found in both rest and stress studies. Accordingly, using SDS, we found multiple, partly reversible perfusion defects in all patients. The largest areas of hypoperfusion were observed in inferior wall of LV. In the SSc patients LVEF was normal at rest (median 60%) and did not deteriorate during stress. Also there was no correlation between the size of changes in GSPECT scintigrams and Ecg.. Conclusions: ‐ Clinically silent impairment of myocardial GSPECT perfusion is a generalized feature in patients with SSc. ‐ Decreased perfusion by GSPECT does not correlate with the results of rest ecg and impairment of LV function. ‐ Since the musculosceletal involvement restricts peroformance of exercise ecg testing in the majority of SSc patients, the GSPECT appears to be preferable method of evaluation of myocardial ischemia in SSc. ‐ Further studies are required to evaluate clinical significance of ischemic changes in GSPECT
P019 The place of combining ischemia modified albumin (IMA) levels to myocardial perfusion scintigraphy (MPS) in diagnosis of coronary artery disease Z. P. Koc1, I. Basaraci2, N. Deger2, O. Saka3, M. Erkilic4; 1Fırat University Faculty of Medicine Nuclear Medicine Department, Elazığ, TURKEY, 2 Akdeniz University Faculty of Medicine Cardiology Department, Antalya, TURKEY, 3Akdeniz University Faculty of Medicine Bioistatistics Department, Antalya, TURKEY, 4Akdeniz University Faculty of Medicine Nuclear Medicine Department, Antalya, TURKEY. Improving Tc‐99m MIBI MPS’ diagnostic efficiency is an important issue in follow up of coronary artery disease patients. IMA, which is known as an acute coronary syndrome marker can be helpful in differentiating acute coronary syndrome from other coronary artery patients thus can improve nuclear imaging methods diagnostic efficiency. Aim: Aim of this study is evaluating IMA and other diagnostic parameters’ (TID, scores) influence on improving diagnostic efficiency of Tc‐ 99m MIBI MPS. Materials and Methods: 62 patients (25F, 37M; 55,56 ±8,52) were included in our study. Stress‐rest Tc99m MIBI MPS was performed to 54 patients. IMA levels from the blood samples which was taken before and after the treadmill test were measured. 30 patients underwent coronary angiography and results were evaluated according to gold standard angiography. Results: There was a difference between IMA levels of ischemia positive and negative groups but the difference was not statistically important. Also there wasn’t statistically important difference between IMA levels of patients who have narrowing in the coronary arteries and not. Conclusion: Although there is a difference between IMA levels of Tc‐99m MIBI MPS ischemia positive and negative groups, it seems that IMA levels do not improve tests’ diagnostic efficiency.
P020 Quantitative parameters of gated myocardial perfusion SPECT acquired in patients in sitting and supine position. O. Lang1, I. Komorousova2; 1Charles Univ., 3rd Medical Faculty and Center for Nuclear Medicine, Prague, CZECH REPUBLIC, 2Center for Nuclear Medicine, Prague, CZECH REPUBLIC. Aim: Gated myocardial perfusion scans are usually acquired supine. However, some newer gamma cameras are designed for imaging pts in the sitting position. Our goal was to compare data derived from quantitative analysis in both types of acquisition and to test possible relation to the gender and body mass index. Material and Methods: We analyzed 32 pts (20 male, 12 female, avg age 61 y) evaluated for suspected or known ischemic heart disease. Standardized protocol with Tc99m‐MIBI was used. Data were acquired twice on all pts, using dual‐head gamma cameras equipped with high‐resolution collimators. Nucline™ Spirit DHV was used for supine pts and Nucline™ CardioDesk for sitting pts. Emory Cardiac Tool Box™ was used for quantitative analysis; quantitative parameters were compared with paired t‐test. Supine and sitting groups were also analyzed according to a gender and a body mass index (BMI). Results: The respective quantitative parameters for supine and sitting positions were: mean SSS 6.7 vs. 10.9, total perfusion defect 12.7% vs. 23.4%, LAD defect 3.8% vs. 16.7%, LCx defect 16.8% vs. 19.5%, RCA defect 24.6% vs. 26.5%, EF 0.69 vs 0.71. Total perfusion defect size and SSS differed significantly (p=0.019 and p=0.040). Analysis of individual vascular territories revealed only LAD defect size to be significantly different (p<0.001), defect sizes in other two areas were similar (p=0.669 for LCx and p=0.785 for RCA) as well as EF (p=0.515). As to gender, only LAD defect and EF differed significantly (p=0.036 and 0.004; both are higher in female) in the supine group; but in the sitting group, all parameters differed significantly (p from 0.0001 to 0.005). As to BMI, no significant differences were detected in both groups (p from 0.328 to 0.968). Conclusions: Image patterns of myocardial perfusion are different depending on whether the data are acquired in the supine versus the sitting position. Some quantitative parameters differ significantly; therefore, current commercially available normal databases should not be used for quantitative analysis of perfusion images acquired in the sitting patients. The differences depend probably on the gender and not on the BMI, but the group of pts is too small for generalization.
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Comparison of Tc-99m MIBI myocardial perfusion SPECT imaging on supine and prone position. S. Sağlam1, S. S. Çerçi1, M. Yıldız1, A. İçli2; 1Süleyman Demirel University Department of Nuclear Medicine, Isparta, TURKEY, 2Süleyman Demirel University Department of Cardiology, Isparta, TURKEY. Aim: Aim of the study was to compare the diagnostic accuracy of prone quantification to supine quantification for detection of coronary artery disease. Methods: We performed Tc‐99m MIBI gated‐SPECT in both supine and prone position with two days protocol to 27 patients (10 women, 17 men) who had suspected coronary artery disease. All patients were also evaluated with coroner angiography. Semiquantitative visual interpretation of myocardial perfusion images was done in both supine and prone position. Myocardial perfusion was scored using a 17‐segment model. A summed stress score (SSS) and a summed rest score (SRS) were calculated by adding all 17 individual segment scores. A summed difference score (SDS), a measure of stress‐induced myocardial ischemia, was also calculated by subtracting the SRS from SSS. Fix defect score with the same segment at both stress and rest images was determined. MPS was classified as normal (SSS <4), mildly abnormal (SSS 4‐8), moderately abnormal (SSS 9‐13), or severely abnormal (SSS>13). Sensitivity, specificity, positive predictive, negative predictive values and accuracy of SPECT were defined for both supine and prone position images by assuming coronary angiography as gold standard. Coronary ectasia and obstruction of vessels higher than %50 were accepted significant. Results: Coronary artery ectasia was found on eight patients, serious obstruction of vessels was found fifteen patients and normal coronary arteries for four patients. On quantative analysis of supine position images, three patients had mild defect , six patients had moderate defect and thirteen patients had severe defect. On quantative analysis of prone position images, nine patients had mild, four patients had moderate and seven patients had severe defects.
Supine position Prone position
Sensitivity % 95.60
% 82.60
Specificity % 75
% 75
PPV
% 95.60
% 95
NPV
% 75
% 42.85
Accuracy %92.59
%81.48
Conclusion: In this preliminary study, we found that prone MPS did not reduce the false positive rate associated with supine position for the diagnosis of coronary artery disease.
P022 The Role of Myocardial Perfusion Scintigraphy in The Evaluation of Female Patients with Cardiac Metabolic Syndrome O. Yaylali, S. Kirac, E. N. Akalin, D. Yuksel, D. Dursunoglu; Pamukkale University Medical School, Denizli, TURKEY. The development of myocardial microvascular pathology (metabolic syndrome, cardiac syndrome X) depending on risk factors such as hypertension, hyperlipidemia, diabetes mellitus, obesity, smoking increases with aging in females. Metabolic syndrome is observed in 41 % of females and 29 % of males, and sudden cardiac death in women without a known coronary artery disease has been reported as 64 %. There are limited study about the significancy of MPS SPECT study in the diagnosis of micro/macro vascular pathology for the special risk group of females. We aimed to evaluate the performance of MPS SPECT study for diagnosing of the metabolic syndrome in symptomatic women with normal coronary angiography. Material‐Method: The study group consisted of 30 women (mean age 59.60 ± 9.34 years) with metabolic syndrome depending on the presence of typical angina pectoris, positive exercise test, normal coronary angiography and other clinical risk factors. Informed consent form was signed by all patients. In the case of a coronary lumen narrowing is below 50 % or absent, the coronary angiography has been accepted as normal. Then, all cases underwent exercise / rest MPS SPECT imagings which have been obtained by circular CamStar AC/T gamma camera. Results: Myocardial ischemia in one or more segments have been detected in the MPS SPECT images in all cases. The obesity in 16 (53 %) patients, menopause in 28 (93 %) patients, hyperlipidemia in 20 (67 %) patients, DM in 13 (43 %) patients and hypertension in 23 (77 %) patients were detected. In the evaluation of the MPS SPECT images for all patients, ischemia has been observed in apical segment (n=3), in anterior wall (n=10), in inferior wall (n=9) and in septum (n=7). Additionally, apical aneurysm (n=2) and anterior infarct (n=1) have also been detected. When evaluating their angiographic results, myocardial bridging in LAD vessel and 30 % narrowing of LCX, 1. OM vessel, and 30 % narrowing of LAD vessel were present. Any of the mammary and / or diaphragmatic attenuation were not detected by MPS SPECT raw images and LBBB was present in none of the patients. Conclusion: MPS SPECT imaging is a valuable noninvasive diagnostic method for the assessment of myocardial perfusion abnormalities while coronary angiography is inadequate to show the microvascular pathology. Therefore, we suggest to perform MPS SPECT study in women under the risk of metabolic syndrome, before coronary angiography procedure.
P023 Radiation therapy involving left chest: perfusion findings in patients with breast cancer G. Storto, A. Nappi, G. Gallucci, M. Coccaro, A. Venetucci, V. Suriano, M. Aieta, M. Botte, L. Labella, V. Fusco; IRCCS CROB, Rionero in Vulture, ITALY. Aim: breast cancer is the most common malignancy in Italian women, with approximately 70.000 new cases diagnosed in 2006. Radiation Therapy (RT) to the breast region plays a crucial role in the multimodality management of patients presenting breast cancer. Although, modern RT techniques have reduced radiation exposure to the heart, they may not have eliminated cardiotoxicity. In particular, undue cardiac irradiation could deliver significant damage to the heart generating diffuse myocardial interstitial fibrosis and microcirculatory damage and as a
result accelerated atherosclerosis. To evaluate myocardial perfusion abnormalities and LV function by Tc99m‐tetrofosmin Gated‐SPECT (GSPECT) as well as epicardial vessels by Cardiac Multi Slice Computed Tomography angiography (C‐MSCT) in patients undergoing radiation treatment involving the left chest because of breast cancer. Materials and methods: we enrolled 15 patients (Pts) with breast cancer and low likelihood of coronary artery disease (mean age 53.8 ± 12 yrs) who underwent quadrantectomy and subsequent RT (total dose 40Gy). A single day stress‐rest protocol by GSPECT was carried out among 4 months later. No attenuation correction was done. C‐MSCT was performed within one week in those having myocardial perfusion defects to rule out epicardial vessels abnormalities. Patients were also scheduled for a medium term cardiologic and scintigraphic follow up. Results: Pts were asymptomatic.10 pts (67%) had normal perfusion, 5 (23%) shown reversible, stress‐induced perfusion defects (mean Summed Stress Score 7 ± 2; A) and 12‐lead ECG significant abnormalities of ventricular repolarization mimicking myocardial ischemia (ST elevation and negative T waves) lacking at baseline. None had left ventricular ejection fraction impairment but mild segmental dysfunctions were detected in the coronary territories with perfusion defects. C‐MSCT revealed normal coronary arteries in the latter subset. Pts were followed‐up until 16 months and those presenting transient perfusion defects at beginning continued to show altered stress‐induced perfusion and ECGraphic patterns (mean Summed Stress Score 6 ± 2; B ; A vs B: p=ns). Conclusions: in patient with breast cancer who underwent RT involving left chest the normality of C‐MSCT substantiates the hypothesis that RT‐induced cardiotoxicity is due mainly to microvascular damage. The early detection of reversible perfusion defects by GSPECT may aid to implement more aggressive cardiologic therapy in order to reduce the clinical impact of RT‐induced cardiotoxicity.
P024 The added value of rest gated-SPECT myocardial perfusion imaging for detection of patients with 3-vessel coronary disease P. Oliveira, E. Martins, A. Oliveira, H. Fernandes, J. P. Patrício, T. Faria, J. C. Silva, J. G. Pereira; Hospital S. João, Porto, PORTUGAL. Aim. From July 2008, in our department, we acquire gated SPECT myocardial perfusion imaging (gMPI) for both stress and rest exams. The aim of this study was to determine the added diagnostic value of left ventricle (LV) functional performance at rest in patients with angiographic 3‐vessel disease (3VD) and to compare it with the findings in pts with angiographically insignificant coronary artery disease (ICD). Material and Methods. From all pts with 3VD (359) and ICD (1080), detected by coronary catheterisms (CC) from May/2008 to February/2009, we selected those with previous gMPI (maximum 6 months interval), and excluded those with CABG, severe valvular disease, heart transplant and cardiac events between studies. 3VD was defined as: >70% AD, Cx and RCA stenosis, or >50% LMA stenosis with either left dominance or >70% RCA stenosis (or its branches). ICD was defined as: <50% LMA stenosis and/or <70% stenosis at any other main coronary artery. Perfusion SPECT scans were processed with QGS/QPS (20 segment heart display). We calculated the stress/rest ratios for end‐systolic volumes (ESVr), end‐diastolic volumes (EDVr) and Ejection Fractions (EFr), for both groups. Results. We reviewed data from the 15 pts with 3VD and from the 30 pts with ICD selected. Eleven (73.3%) pts with 3VD and 12 (40%) with ICD were male, mean age was 69±10.1 and 59±10.8 years and the interval gMPI‐CC was 0.85±1.5 and 1.64±1,6 months, for 3VD and ICD groups, respectively. The difference between parameters concerning perfusion, motility and wall thickening for both groups, in stress and in rest, were statistically significant. The results for stress and rest EF, ESVr, EDVr and EFr are presented in the table below.
3VD
ICD
p value
Stress EF 39.87±13.40 55.47±14.59 p=0.001 Rest EF 39.77±14.18 54.64±15.52 p=0.008 EFr
0.95±0.11
0.97±0.15
p=0.68
ESVr
1.08±0.19
0.49±0.14
p<0.001
EDVr
1.03±0.12
2.57±9.98
p<0.001
Conclusions. This study showed that rest‐gated parameters of LV perfusion, segmental motility, wall thickening and global function were significantly different between the 3VD and the ICD groups. Importantly, we also obtained very significant differences in ESVr and EDVr, between both groups, which could prove (once we increase our sample of pts) that rest gMPI is a valuable tool in the detection of some stress‐induced abnormalities not related to perfusion, but with known diagnostic and prognostic impact, and can help select pts without significant perfusion defects that may have important coronary artery disease and should be further evaluated.
P025 Myocardial perfusion imaging in diabetic patients A. Guensi, M. Aitidir, A. Matrane, F. Chabraoui, M. Kebbou; Ibn Rochd UH, Casablanca, MOROCCO. Background: Stress MPI is used for diagnosis, prognostic purposes and monitoring after therapeutic interventions in patients with CAD. Contribution of MPI to patient care has been well studied in general population. CAD is more severe, more prevalent, and occurs at a younger age in diabetic patients. The aim of this study was to assess cardiac events occurrence in diabetic patients compared SPECT results. Patients and Methods This retrospective study included 42 type 2 diabetic patients (21 men) investigated between May 2005 and May 2008 (42 % of MPI performed in this period). Ten of them had a typical angina and none had a known history of myocardial infraction (MI). Patients were 47 to 80 years old (mean 59). Diabetes was known 1 to 30 years before (average: 7.71). Cardiovascular risk factors other than diabetes were smoking in 15 patients, hypertension in 13, dyslipidemia in 15 and CAD inheritance in 12. Twenty two patients had 3 risk factors or more, 11 had 2 risk factors, and 8 had only diabetes. Thallium 201 (26 patients) or Sestamibi‐Tc SPECT (16) was performed for diagnosis (36 patients) and for monitoring of known ischemia (6). Ten patients underwent pharmacological stress and the 32 exercise. Two to 36 months (average14.5) after MPI, occurrence of Cardiac events including acute instable angina, MI and heart disease related death were evaluated. Recorded events were compared to MPI results. Results: MPI was abnormal in 23 patients (55 %) with non reversible defect in 2. Frequency and extent of uptake decrease were the same in female and male patients. Uptake decrease was more frequently observed in patients with sixty to 70 years (66 % versus 43
Poster Presentation
P021
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%), with three risk factors or more (87 % versus 16 % for patients with less than 3). Impact of diabetes duration was not demontrated in this series (55 % with duration > 5 years versus 53 % under 5 years). Cardiac events occured 4 to 24 months after MPI in four cases (MI: 2; instable angina: 2). All events occured in patients with decreased uptake involving more than 20 % of left ventricular wall. After MPI SPECT, 12 patients had angiography, 7 dilatation and 5 angioplasty. Conclusion CAD was found more frequently in patients with more than 3 risk factors. Frequency of CAD seems not linked to gender or presence of typical angina. Risk of cardiac events seems related to extent of uptake decrease.
P026 Is BMI related to a higher incidence of ischemic cardiopathy? L. Tagliabue, L. Gilardi, S. Seghezzi, L. R. Setti, A. Del Sole, G. Lucignani; University Hospital "S.Paolo", Milan, ITALY. INTRODUCTION: Although the main risk factors for developing coronary artery disease (CAD) are well known, it has recently been suggested that obesity can be an additional factor. The aim of this study is to establish how a high body mass index (BMI) can predict the presence of coronary artery disease. MATERIAL AND METHODS: We studied 200 consecutive patients undergoing diagnostic stress‐rest perfusion gated SPECT imaging: 50 patients with a BMI<30, presenting with low pre‐test probability (<5%) and both normal perfusion and ergometric stress test (Group A), 50 patients with a BMI>30, low pre‐test probability (<5%) and both normal perfusion and ergometric stress test (Group B), and 100 patients with a BMI>30 and both perfusion defects and a positive ergometric stress test (Group C). The presence of perfusion defects, major risk factors for CAD (diabetes, hypertension, dyslypidemia, smoking and a family history of CAD) were recorded. Student’s t test and the χ2 test were used for statistical analysis. A p value < 0.05 was considered significant. RESULTS:
Group A (%) Group B (%) Group C (%)
Smoker
38
21
42
Former smoker
6
27
34
Non smoker
56
52
24
Diabetes
9
28
46
Hypertension
56
76
86
Dyslipidemia
49
45
71
Family history of CAD 52
42
55
Aim of the study: It was previously reported that anteroseptal defect can occur on MPS in patients with LBBB and in the absence of significant LAD coronary artery disease. Aim of this study was to determine the role of myocardial perfusion scintigraphy for accurate assessment of anteroseptal ischemia in patients with LBBB. Materials and methods: Sixty patients (39 man, 21 women; aged 31‐73; mean 61,08 ± 7)) with LBBB on ECG without previously known CAD were included in the study (January 2006 to January 2009). Two‐day stress/rest protocol MPS with 99mTc‐MIBI was performed starting with stress dipyridamole study followed by rest study the next day. Images were interpreted as normal anteroseptal perfusion (group 1); irreversible anteroseptal defect (group 2) and reversible anteroseptal ischemia (group 3). All patients undergo coronarography within six months after MPS. The results of MPS of anteroseptal wall and coronarography findings of LAD were compared to assess diagnostic accuracy of MPS in detecting anteroseptal ischemia. Stenosis of 75% on LAD was concerned to be significant. Results: Of the 60 patients, 23 (38%) had normal anteroseptal perfusion scan, 21 (35%) were interpreted as irreversible anteroseptal defect and 16 (27%) had reversible anteroseptal ischemia. Coronarography findings of LAD were normal or insignificant in 39 (65%) patients (20 (51%) in first group, 15 (39%) in second and 4 (10%) in third group). Significant LAD stenosis was found in 21 (35%) patients: 3 (14%) in group 1, 6 (29%) in group 2 and 12 (57%) in group 3. Conclusion: MPS is useful diagnostic method in the assessment of patients with LBBB and clinical indications requiring coronarography assessment. Visual anteroseptal reversibility is highly indicative of existing significant LAD stenosis in patients with LBBB. High percent of normal LAD findings in group 2 can be explained by reduced septal perfusion due to abnormal systolic phase in the septum.
P029 Differences observed in the diagnosys of coronary heart diasease with myocardial perfusion SPECT in patients with implanted pacemakers. M. Garrido Pumar, V. Pubul, C. Peña, S. Argibay, A. Sánchez-Salmón, A. Martínez-Monzonis, A. Ciobotaru, M. Pombo, P. Arce, A. Ruibal; Hospital Clinico Univ. de Santiago de Compostela, Santiago de Compostela, SPAIN.
No differences in family history of CAD were found between the three groups; there were an higher incidence of smoker in Group C than in Group B and Group A and of non smokers in Group B than in Group C whereas the incidence of former smokers was lower in Group A than in Groups B+C put together (p<0.05). Group C showed a higher incidence of diabetes and dyslipidemia compared with Group B (p<0.05) and Group A (p<0.01) and a higher incidence of hypertension compared to Group A (p<0.01). Group B showed a higher incidence only of diabetes (p<.001), but not of hypertension or dyslipidemia, compared to Group A, and a lower incidence of diabetes and dyslipidemia compared to Group C (p<0.01). Conclusion: It seems that obesity per se isn’t a major risk factor for CAD; rather, it appears to favor the onset of major risk factors, mainly of diabetes,the most important component of the metabolic syndrome. Smoking, when present, plays an additional role. The presence of a high proportion of former smokers among obese patients is an indication that giving up smoking might be a factor contributing to weight gain.
P027 The Role of Stress Myocard Perfusion SPECT Study in the Women With Cardiac Symptoms S. Kirac1, O. Yaylali2, N. Akalin3, D. Yuksel3, M. Kilic4; 1Pamukkale University Medical Faculty, Dept of Nuclear Medicine, Denizli, TURKEY, 2Pamukkale University Medical Faculty,Dept. of Nuclear Medicine, Denizli, TURKEY, 3 Pamukkale University Medical Faculty, Dept. of Nuclear Medicine, Denizli, TURKEY, 4Pamukkale University Medical Faculty, Dept. of Cardiology, Denizli, TURKEY. INTRODUCTION: The incidence of heart and vascular diseases in women rises due to the extended mean life time. Obstructive coronary lesions leading to severe myocardial perfusion abnormality may not be detected by coronary angiography (CAG) in women because anatomic structures of coronary arteries and morphologic characters of atherosclerotic plaques are different from men. Myocard perfusion SPECT study (MPS) provides to detect myocardial perfusion abnormalities. This retrospective study was planned to evaluate the role of noninvasive MPS study comparing to CAG in the diagnosis of coronary artery disease (CAD) in women. MATERIAL&METHOD: Study group consisted of 97 women (mean age of 61.46 ± 9.88 yrs) with abnormal stress MPS which was acquired for proven or suspected CAD. Within two weeks, all patients underwent CAG. Presence of equal to or greater than 50% narrowing in one or more coronary arteries was accepted as CAD. Accordance between ischemic segments on the MPS SPECT images and the territories supplying by arteries with obructive lesions on coronary angiography was evaluated. RESULTS: There was severe lesion in one or more vessels in 51/97 female having abnormal MPS. Although 37 of 46 pts had luminal obstruction at the level of 30 % and 50%, true ischemic findings on MPS SPECT were detected in the myocardial segments supplied by these obstructive vessels. Any artefacts on cine view of raw data was not present in them. However, 9 pts with normal CAG had breast or diaphragma attenuation artefact mimicking myocardial ischemia in anterior wall in 8 cases and inferior wall in one case. CONCLUSION: Alone coronary angiography without performing MPS SPECT study was not sufficient in postmenopausal women who are under the high risk of CAD.Stres‐rest MPS SPECT study plays an important role in the early diagnosis and appropriate treatment of CAD in women with cardiac symptoms. To avoid attenuation effect, raw data should have always been evaluated.
P028 Assessment of Anteroseptal Ischemia Perfusion Scintigraphy in LBBB Patients
K. Nikoletic1, S. Lucic1, A. Peter1, J. Kmezic-Grujin2, J. Stojiljkovic2, M. Stefanovic2, S. Tadic2, R. Jung2; 1Institute of Oncology of Vojvodina, Sremska Kamenica, SERBIA, 2Institute of Cardiovascular Disease of Vojvodina, Sremska Kamenica, SERBIA.
with
Myocardial
The aim of this study was to evaluate the effect of having a pacemaker in the results of a myocardial perfusion spect (MPS). From 2116 patients remitted to perform a two‐day stress/rest MPS for diagnostic purposes, 50 consecutive patients with pacemaker were selected. A group of consecutive 180 patients without cardiac precedents were selected as control. Data registered included the presence of cardiovascular risk factors, evidence of fixed or reversible perfusion defects in the SPECT study suggesting myocardial necrosis or ischemia, and measure of the left ventricular ejection fraction (LVEF) and telesystolic/telediastolic ventricular volumes. Posterior follow‐up of cardiac events included the diagnostic of coronary heart disease by cardiac catheterism, revascularization procedures, acute coronary syndrome, cardiac insufficiency and myocardial infarction within the next 12 months after the study. RESULTS There were no significant differences in age, sex or other registered cardiovascular risk factors between pacemaker patients and control patients. There was a higher proportion of patients with a positive SPECT result in the pacemaker patients, though differences were not significant (20 pacemaker patients ( 40.0%) vs 49 control patients (27.2%); p 0.08). More fixed perfusion defects were observed in pacemaker patients (28% vs 10%; p 0.001). Pacemaker patients showed lower values of LVEF (45.2±15.5 vs 54.5±12.1; p 0.01), and an increment of telesystolic (45.9±26.3 vs 27.3±27.7; p 0.002) and telediastolic ventricular volumes (70.2±24.0 vs 55.9±21.8; p 0.02). Among the patients with a positive SPECT, 27 patients (9 pacemaker patients and 18 control patients) were submitted to cardiac catheterism. The value of the results in whole patients had no relevance. Catheterism confirmed coronary disease in 15 patients (51.85%), with no differences between the two groups (55.5% vs 50.0%; p 0.785). In the posterior 12 months follow‐up, the pacemaker patients showed more events (35.0% vs 6.1%; p 0.002), and events were more often observed in pacemaker patients who showed fixed defects in the SPECT (66.6% pacemaker patients with fixed defects vs 33,3% pacemaker patients with reversible defects; p 0.022). CONCLUSIONS ‐ Pacemaker patients showed no significant differences in global SPECT results compared with a similar group of non‐pacemaker patients, but showed more prevalence of fixed defects, lower LVEF values and an increase of the ventricular volumes. ‐ No differences were observed in the results of catheterism. ‐ Pacemakers patients showed a more cardiovascular events in the 12 months following the completion of SPECT. It seems advisable to maintain control over this group of patients.
P030 A Comparison of the LV Parameters between the Early and Standard GSPECT Acquisition among CAD Patients I. S. Bandong, J. Obaldo; Philippine Heart Center, Quezon City, PHILIPPINES. Background: Background: Gated single‐photon emission computed tomography (SPECT) sestamibi myocardial perfusion scintigraphy (MPS) provides information on both left ventricular wall perfusion and wall function. The delay between tracer injection and imaging may result in resolution of exercise‐induced ventricular dysfunction Objective: To compare the LV parameters between early and standard GSPECT acquisition among CAD patients Methodology: We had 36 CAD patients who underwent MPS‐SPECT at the Philippine Heart Center between May 2008 and April 2009. Standard rest and stress sestamibi gated SPECT MPS were performed. Images were ordinarily obtained 60 minutes after tracer injection. In addition, an early acquisition obtained 15 minutes after tracer injection was done immediately after stress tracer injection. Result: Of the 36 patients, 33 patients had abnormal MPI result (6 had stress‐induced ischemia, 8 had partial thickness fibrosis and 14 had transmural infarct). The mean values of LVEDV, LVESV and LVEF at 15 and 60 minute GSPECT acquisition showed no significant difference (p value >0.05).Conclusion: The early GSPECT acquisition can be used as an alternative to the standard GSPECT acquisition in detecting exercise induced ventricular dysfunction. Comparison of LV Parameters of Standard and Early GSPECT Acquisition among CAD Patients
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Early GSPECT Acquisition (15 minute)
p value
LVEDV Mean ± SD
144.69 ± 11.30
142.28 ± 11.30
0.26 (NS)
LVESV Mean ± SD
96.50 ± 10.88
94.86 ± 11.65
0.37 (NS)
LVEF Mean ± SD
40.47 ± 2.79
40.08 ± 2.80
0.75 (NS)
P031 Diagnostic usefulness of the early gated myocardial perfusion SPECT in patients with ischaemic heart disease I. Szilvasi, M. Toth, M. Moravszki, K. Buga, R. G. Kiss; State Health Centre, Budapest, HUNGARY. Aim: ECG‐gated myocardial perfusion SPECT (GSPECT) gives simultaneous information on myocardial perfusion and global/regional left‐ventricular (LV) function in ischemic heart disease (IHD). Ergometric stress can provoke myocardial stunning. We studied usefulness of early GSPECT (15‐G: 15‐minutes after excercise) compared to standard GSPECT (60‐G: 60‐minutes after exercise) in detecting exercise‐induced reversible LV dysfunction. Materials and methods: 23 patients with IHD were studied. 6 had decreased, 17 had normal LV‐EF at rest. We performed 15‐ G, 60‐G and resting GSPECT (R‐G). LV‐EF, segmental wall‐motion and systolic wall‐thickening of the three examinations were compared using QPS/QGS‐program. Results: from 6 patients with low EF at rest, EF was decreased by 15‐G in 5, by 60‐G in 3. From 17 patients with normal EF decreased EF was found in 3 by 15‐G and 60‐G as well. Decreasing was more prominent by 15‐G. In segments with normal perfusion (n=220) no significant changes of motion/thickening were found. By 15‐G decreasing motion in 23%, decreasing wall‐thickening in 19% of the segments with ischemia (n=105) were found ‐ compared to 60‐G and R‐G as well. In segments with fix perfusion defect (n=52) further decreasing of thickening was found in 25% by 15‐G and in 6% by 60‐G. (14 segments with ,,inverse redistribution” were not analysed.) Conclusions: 15‐G is useful in detecting exercise‐provoked LV‐dysfunction. It detect transient decreasing of LV‐EF more frequently than by 60‐G. Worsening of segmental motion/thickening occur in some ischemic segments. They can be detected by 15‐G only. Deterioration of wall‐thickening of segments wih fixed perfusion‐defect can be found more frequently by 15‐G. With aknowledgement of the IAEA (RP:14676).
P032 How can myocardial perfusion scintigraphy help the multislice coronary CT? I. Balogh1, G. Kerecsen2, E. Marosi2, I. Préda3; 1Uzsoki Hospital, Budapest, HUNGARY, 2Pozitron Diagnostic Centre, Budapest, HUNGARY, 3Pozitron Centre, Budapest, HUNGARY. Aim Even in the era of the state of the art coronary CT (64 slices dual sorce ‐ MSCT) some limitations still remained for accurate diagnosis of coronary stenosis. These cases ‐ among others‐ are as follows: the stenosis which can be found inside the artery with serious coronary calcification, some kind of stents. In questionable MSCT cases the stress myocardial perfusion scintigraphy (MPS) can help decide the significance of the stenosis. Patient, methods We performed MSCT and subsequent MPS in 10 patients. The result of MSCT was questionable in every case: in 1 case the patency of the LAD stent, in 9 case the severity of the calcifided, stenosed artery was questionable. At first 64 slices, dual sorce MSCT was made. The second examination was the MPS, using the ,,fast protocoll” with Tc99m tetrofosmin, and both stress and rest phases ECG gated examinations were performed as well. For the best localisation of lesions and matching the coronary arteries (anatomic information on MSCT) and perfusion pictures ( functional information on MPS) MEDISO Interview‐ fusion software was used, consructing 3D pictures as well. We analysed the MPS examinations ‐ both stress‐rest perfusion and ECG gated examinations ‐ by quantitative analyses ( QPS‐QGS ). Result In MSCT the accurate degree of stenosis was doubtful in 4 cases on proximal LAD, in 1 case the middle part of LAD, in 2 cases CX, in 2 cases RCA, and in 1 case the patency of LAD stent was questioned. On the basis of fitted pictures using the MSCT‐ MPS fusion, and perfusion and ECG gated pictures analysis using the score values (1‐4) of 17 segments of the left ventricle, we could find the following: 3 cases (among stenosed LAD) 2 fitted segments, in 1 case (stenosed CX) 1 segment, with 1 stress score (non significant), reversible perfusion abnormality was detected, without any wall motion abnormality and increasing level of EF during the stress (both stress and rest EF levels were normal). In the other 6 cases the results of MPS were normal. Conclusion In spite of using the most accurate techniques of MSCT there remain some doubtful cases. In this field of IHD diagnosis the supplementary value of MPS is very high, taking advantage the latest methods of MPS. The highest accuracy can be achieved by quantitative evaluation of MPS stress and rest perfusion‐ function, and by MSCT‐ MPS fused 3D pictures.
P02 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Cardiovascular: viability - metabolism
P033 11C-Methionine PET imaging of acute myocardial infarction M. Miyako1, K. Kubota1, K. Ito2, H. Kadowaki1, O. Okazaki1, M. Kamimura1, T. Mitsumoto1, T. Sato1, M. Kashida1, K. Hasuo1, K. Ohtomo3, T. Momose3, M. Hiroe1; 1Int. Med. Center of Japan, Shinjuku, Tokyo, JAPAN, 2Saitama Int. Med. Center, Saitama, JAPAN, 3The Univ. of Tokyo, Bunkyo, Tokyo, JAPAN Tissue uptake of L‐methyl‐11C‐methionine (11C‐Met) has been used to monitor amino acid metabolism and protein synthesis. We examined whether 11C‐Met was retained in areas of myocardial infarction after successful reperfusion. Methods: Nine patients with infarction in the
left anterior descendent (LAD) region underwent percutaneous transluminal coronary artery intervention within 24 hours and 201Tl SPECT, 18F‐FDG, and 11C‐Met PET within 2 weeks of infarction onset. The standardized uptake value (SUV) of the infarction area (SUVi) and the SUV of the normal area (SUVn) were calculated. Results: The 11C‐Met images showed increased uptake in the infarction area, whereas the 201Tl SPECT and 18F‐FDG PET images showed decreased uptake. The highest accumulation of 11C‐Met in the infarction area was observed in early phase of AMI. Conclusion: 11C‐Met uptake is elevated in infarction areas. It may reflect the early acute phase of damage healing, i.e., the initial process of remodeling.
P034 Using 18F-Fluorodeoxyglucose Positron Emission Tomography for Imaging Atherosclerotic Plaque Inflammation in cancer patients. V. Sergienko1, E. Panchkovskaya2, M. Bugriy1, M. Rudas2; 1Cardiology Research Complex of Ministry of Health of Russian Federation, Moscow, RUSSIAN FEDERATION, 2Central Clinical Hospital of Medical Center of Administration of President of Russian Federation, Moscow, RUSSIAN FEDERATION. Aim: Cancer disease sometimes combined with ischemic heart disease so noninvasive evaluation of plague inflammation in cancer patients can change approach of treatment. 18F‐ fluorodeoxyglucose (18FDG) can be used to image inflammatory cell activity non‐invasively by PET with whole body study in cancer patients. In this study we tested whether 18FDG‐PET imaging can identify inflammation within thoracic and abdomen aorta atherosclerotic plaques. Materials and methods: We made retrospective analyze of five hundred patients with cancer (245 male and 255 female). The patients' ages ranged from 49 to 81 years. All patients divided into 2 groups: group 1 ‐ patients with cancer and ischemic heart disease (395 patients: 234 male and 161 female); group 2 ‐ 105 patients without ischemic heart disease (36 male and 69 female). Whole body 18FDG‐PET images acquired 1 hour post‐18FDG injection. The presence of vascular FDG uptake was assessed in the thoracic and abdominal aorta Results: 54.6% (282 of 500) of the total population showed thoracic or abdominal aorta FDG uptake. 75.2% (297 of 395) of group 1 and 13.3% (15 of 105) of group 2 showed aorta uptake. Conclusion: This study demonstrates that atherosclerotic plaque inflammation in aorta can be imaged with 18FDG‐PET. Percent of patients in group 1 with aorta plague inflammation means more prevalence this disturbance in patients with ischemic heart disease.
P035 Particularities of Myocardium Perfusion and Metabolism in Dilated Cardiomyopathy Patients I. V. Shurupova, L. A. Bockeria, I. P. Aslanidis, T. A. Trifonova, O. V. Moukhortova, E. P. Derevyanko, I. V. Yekayeva; Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, RUSSIAN FEDERATION. Purpose: to investigate the particularities of myocardium perfusion and metabolism disorders in patients with dilated cardiomyopathy (DCM). Methods: 41 patients with DCM (from 26 to 65 years old) underwent standard diagnostic protocol: ECG, ech‐CG, catheter angiography. All the patients were performed single‐photon emission computed tomography (SPECT) with 99m Tc‐ technetril two‐detector gamma camera (“Vertex Plus”, ADAC) and positron emission tomography (PET) with 18F‐FDG (“ECAT EXACT 47”, SIEMENS). There were indentified the perfusion/metabolic (P/M) match and mismatch zones. Results: based on SPECT data the perfusion defects (PD) were found in 36/41 (88%) patients, including 20 cases of posterior wall PD (1 group), 6 cases of anterior‐posterior PD localization (2 group), and 10 cases of isolated PD in the intraventricular septum, anterior, apical and lateral localization (3 group). In 9/36 patients with PD the diffuse decrease of metabolism was noted which subsequently was not compared to PD. In 9/36 patients the P/M mismatch was noted (including 8 in posterior wall). In 18/36 patients was noted P/M match. Therefore, the areas of decrease of viable myocardial (VM) were found in 50% of DCM patients. When comparing patients from the three groups, in patients with anterior‐posterior PD localization there were more expressed deviations from the norm: PD area (15,1+8,4%) was not significantly but yet more than both in the 1 group (9,7+4,8%) and the 3 group (11,2+6,3%); severity of PD was higher (17,2+7,9) as compared to the 1 group (9,7+4,8, p<0,05) and the 3 group (12,4+9,5, p=NS). Clearly marked metabolic disorders were found in all 6 patients with anterior‐posterior PD: 2 cases of diffuse decrease, 4 cases of expressed DM which occupied at least 20% of the left ventricle. Functional indicators as per echo‐CG data were also lower: ejection fraction (25+4%) as compared to the 1 and 3 group (32+3%, 31+6%, p<0,05, respectively). Conclusions: In DCM patients local perfusion disorders is noted often. Carrying out of PET has allowed to confirm in 50% cases the decrease of VM volume in PD zones. The most clearly expressed deviations from the norm (as per perfusion‐metabolic and functional characteristics) were found in patients with anterior‐posterior PD.
P036 Evaluation of Myocardium Perfusion and Metabolism Using 99m 18 Tc-Technetril and PET with Fthe Methods of SPECT with FDG in Infant Patients with AOLCAPA I. V. Shurupova, L. A. Bockeria, I. P. Aslanidis, T. V. Rogova, O. V. Moukhortova, T. A. Trifonova, E. P. Derevyanko, T. A. Katunina; Bakoulev Scientific Center for Cardiov. Surgery, Moscow, RUSSIAN FEDERATION. Purpose: to investigate the particularities of myocardium perfusion and metabolism disorders in patients with the anomalous origin of left coronary artery from pulmonary artery (AOLCAPA). Material and Methods: 17 patients with AOLCAPA in the age from 1,5 to 12 months have been examined. All the patients in rest status were performed single‐photon emission computed tomography (SPECT) with 99m Tc‐Technetril using tow‐detector gamma camera (“Vertex Plus”, ADAC) in order to evaluate the myocardium perfusion and positron emission tomography (PET) 18 with F‐FDG (“ECAT EXACT 47”, SIEMENS) to evaluate myocardium metabolism. Based on the results of comparison of the SPECT and PET images (tomographic sections and polar diagrams) there were indentified the perfusion/metabolic (P/M) match zones (if the difference between
Poster Presentation
LV parameters
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uptakes 18F‐FDG and 99m Tc‐Technetril did not exceed 10%) and P/M mismatch zones (if uptake 18 F‐FDG exceeded uptake 99m Tc‐Technetril by more than 10%). Results: based on SPECT data the perfusion defects (PD) sized from 9% to 44% (23,4±11,8%) of the left ventricle (LV) area were found in all the patients. In 7 patients (41%) the P/M mismatch with distinctly expressed glucose hypermetabolism was noted in the PD area and the adjacent parts of myocardium. The average PD area in this group was 15,7+5,6%, P/M zones was 27,7+4,1%. The clearly expressed mismatch was the evidence of hibernating myocardium (HM) in the hypoperfused zones of the LV. In 10 patients (59%) both comparable decrease of perfusion and metabolism (irreversible scar deformations) and P/M mismatch in the hypoperfused zones periphery were noted in the PD area. The average scar area was 11,9+6,4%, HM area ‐ 27,3+9,3%, with the average PD area 30,1+9,1%. Conclusions: 1. SPECT and PET data showed that hypoperfusion of cardiac muscle was combined with hibernating myocardium without concomitant scar deformations in 41% of infant patients with AOLCAPA. 2. The irreversible myocardium damage of various manifestation and extension degrees developed in 59% patients. At the same time, besides scar deformations, there were hibernating myocardium areas which did not exceed 20% of the left ventricle area in the absolute majority of cases. 3. The complex perfusion‐metabolic analysis has allowed to determine the condition of dysfunctional hypoperfused myocardium in the above mentioned category of patients and to make more precise evaluation of gravity of the cardiac muscle damage at the stage of preoperational examination.
P037 Viability and functional recovery after revascularisation in patients with poor LV function S. Nukala1, S. Jayakrishnan2, D. Puri2; 1Fortis & Care Hospitals, Hyderabad, INDIA, 2Fortis Hospital, Mohali, INDIA. Introduction Patients with severe LV dysfunction may have a significant amount of jeopardized myocardium which can be rejuvenated resulting in prolonged survival, enhanced LV function, and improved NYHA functional class after revascularization. Post‐operative improvement in LVEF is related to the preoperative identification of viable myocardium.Patients with predominantly viable myocardium treated medically had a cardiac death rate of 16% per year whereas who underwent revascularization had an 80% lower mortality rate . Several techniques are used for identifying the viable/hibernating myocardium including FDG PET, SPECT rest‐redistribution Thallium myocardial perfusion scintigraphy (MPS) ,Rest‐Nitrate enhanced MPS using Technetium‐ 99m labeled MIBI or Tetrofosmin, dobutamine ECHO and MRI. The sensitivity of rest‐ redistribution thallium for the determination of viability and improvement in wall motion is slightly less than PET but the cost and less availability of PET presently limits its usefulness.Therefore, rest‐redistribution Thallium MPS is widely used to predict recovery of LV function after revascularization.MPS criteria are less subjective compared to ECHO and correlate well with more expensive MRI. Methods In the present study one hundred and nineteen patients with ECHO cardiographic evidence of LVEF less than 35% and angiographically documented CAD underwent rest‐redistribution Thallium MPS .These patients were administered 3 to 4 mCi Thallium‐201 at rest followed by tomographic imaging using SPECT gamma camera. The acquisition was done using sixty four projections of twenty five seconds .Analysis was performed using Emory cardiac tool Box and by seventeen segment model for quantifying extent of viable/hibernating myocardium. The threshold was 50% and cut off value three out of seventeen segments which is about fifteen percent of LV myocardium .Based on this ninety two patients were adjudged to have significant viability .Only those patients who had revscularisation within one month after nuclear scan and ECHO after three months were included the study. Results Data of fifty six patients who had revascularization and regular follow‐up with ECHO for LVEF has been analyzed and presented here. LVEF improved in forty nine but did not in seven. Ninety percent of them improved NYHA functional class. The preoperative mean LVEF was 26.53% and post operative mean LVEF was 35.04%.The mean increase in LVEF was 8.51% which is statistically significant (p <0.01) Conclusion Based on this study it can be concluded that there is definite symptomatic improvement as well as significant increase in LV function in patients with substantial viable myocardium.. This helps in reducing mortality and cutting health care costs .
P038 Characterization of infarct and edema zones in the acute and chronic phases of myocardial infarction using MRI K. K. Yamada1, S. Isobe2, K. Kinoshita1, S. Suzuki1, K. Yokouchi1, H. Iwata1, K. Sawada1; 1Gifu Social Insurace Hospital, Kani, JAPAN, 2Department of Cardiology, Nagoya Univ. Graduate School of Medicine, Nagoya, JAPAN. (Background) We characterized the infarct and edema zones using delayed‐enhancement (DE) and T2‐weighted (T2w) MRI in the acute and chronic phases of patients with myocardial infarction (MI). (Method) In 22 (20 men and 2 women, 66 ± 10 years) patients who underwent emergency coronary revascularization for the infarct‐related artery, short‐axis T2w and DE MRI were performed 6.8 ± 3.0 days and 125.0 ± 24.0 days after the onset of MI. Peak creatine kinase (CK) was 1848 ± 1638 U/L. The MRI was analyzed using a threshold method defining infarct size on DE MRI and edema on T2w MRI as areas with signal intensity larger than +2 SD above remote normal myocardium. (Result) The edema size on T2w MRI (15.9 ± 8.5 % of LV area) was significantly larger than the infarct size on DE MRI (8.9 ± 5.0% of LV area, p = 0.007) in the acute phase. A significant correlation in the acute phase was observed between infarct size on DE MRI and peak CK (r = 0.37, p = 0.01), and between edema size on T2w MRI and peak CK (r = 0.46, p = 0.01). The edema size on T2w MRI (6.7 ± 2.6 % of LV area) in the chronic phase was significantly smaller than that in acute phase (p = 0.03), but the infarct size on DE MRI (6.6 ± 2.9 % of LV area) in the chronic phase was comparable to that in the acute phase. (Conclusion) The edema size was significantly larger than the infarct size in the acute phase. Peak CK significantly correlated with both edema and infarct size. The edema size in the chronic phase was significantly smaller than that in the acute phase. These results suggest that the edema area, which is improved in the chronic phase, may reflect ischemically damaged but viable myocardium. *p<0.05; compared with edema size in the acute phase **p<0.05; compared with edema size in the acute phase Change of LV area
first study (acute phase) second study (chronic phase)
Infarct size (% LV area) 8.9 ± 5.0%*
6.6 ± 2.9 %
Edema size (% LV area) 15.9 ± 8.5 %
6.7 ± 2.6 %**
P039 Comparative evolutions of the perfusion of chronic myocardial infarction areas in patients randomly referred to coronary artery bypass grafting alone or in association with cell therapy N. Didot, W. Djaballah, P. Maureira, N. Tran, M. Angioï, D. Bensoussan, J. Stoltz, G. Karcher, E. Aliot, J. Villemot, P. Marie; University Hospital, Nancy, FRANCE. It is not known whether myocardial perfusion may be enhanced when bone marrow mononuclear cells (BMNCs) are injected within areas of sever chronic myocardial infarction (MI) in man. We have conducted a randomized comparative study to assess the effects of intramyocardial implantation of BMNCs in the chronic MI areas of patients routinely referred to coronary artery bypass grafting (CABG). Methods ‐ Fourteen patients referred to CABG, with a >2‐month old MI and for whom a screening nitrate‐enhanced Sestamibi gated‐SPECT had given evidence of irreversibly damaged myocardium (< 50% uptake) and a LV ejection fraction ranging from 30 to 50%, were randomized between a cell therapy group (n=7; CABG and 20‐40 injections of 500‐1000x106 BMNCs in MI areas) and a control group (n=7; CABG alone). Changes in perfusion, metabolism and function were assessed up to 6‐months by Sestamibi‐SPECT, FDG‐PET and MRI. Results ‐ A clear trend toward a post‐therapeutic enhancement in the perfusion of MI areas was documented in the cell therapy group (% of variation of Sestamibi uptake between baseline and 6‐months: +15±20%, P=0.05) and not in the control group (+3±10%), although this enhancement was clearly higher than that of control group in only 3 of the 4 cell therapy patients (+30±7%). Several characteristics were documented in each of these 3 patients and in none of the 4 others: their MI areas exhibited a higher uptake of FDG relative to that of Sestamibi at baseline (mismatch), they had significant increases in LVEF at 1‐month (from 38±4% to 49±8%) but no more at 6‐months (42±9%), and they had evidence of sever bypass dysfunctions at 6‐months. Conclusion ‐ When associated to CABG, cell therapy with BMNCs allows enhancing the perfusion of severely damaged chronic MI areas, especially when these areas still exhibit metabolic signs of residual ischemia at baseline (FDG/Sestamibi mismatch). However, these favorable effects are associated with a high rate of bypass dysfunction, possibly because of BMNCs‐related changes in the healing process at bypass grafting sites.
P040 Effect of metamizol induction on Thallium-201 myocardial perfusion scintigraphy for the detection perfusion reversibility E. L. Ergun1, T. Aksoy1, H. Ergun2; 1Hacettepe University Dep. of Nuclear Medicine, Ankara, TURKEY, 2Ankara University Dep. of Pharmacology, Ankara, TURKEY. Aim: Metamizol, a well‐known analgesic‐antipyretic drug, has also relaxing activity on vascular smooth muscle. In our previous study, we showed that metamizol enhances rest myocardial perfusion with the use of Tc‐99m sestamibi. The aim of this preliminary study is to investigate whether metamizol induction could also be used to increase the detectability of the ischemic/jeopardized myocardium during myocardial perfusion SPECT(MPS) with Thallium‐201. Methods: In 17 patients who had partially reversible/irreversible perfusion defects on their previous stress‐redistribution and ‐reinjection Thallium‐201 MPS, 111 MBq Thallium‐201 was injected i.v. 45 min after the oral administration of 1000 mg metamizol and MPS was acquired 10(MPS10), 60(MPS60) and 180(MPS180) min after the injection. Blood pressure was measured in all patients before and after metamizol administration at 15‐minute intervals till the imaging time. Stress, redistribution, reinjection, MPS10, MPS60 and MPS180 images were interpreted on the model of 17 segments using a visual uptake score (VUS) [0:normal; 1:mild, 2:moderate, 3:significant decreases; 4:no uptake]. Thallium‐201 uptake ratios (Tl‐UR; mean counts in the region of the perfusion defect/mean counts on the region of the normal‐perfused wall) were calculated on each MPS and compared with each other. Results: VUS and Tl‐UR results showed that metamizol enhanced MPS displayed the defect reversibility significantly better than redistribution and reinjection MPS. BP remained unaltered after metamizol administration. Conclusion: Metamizol‐enhanced rest MPS increases the detectability of ischemic/viable myocardium regions during MPS with Thallium‐201as previously shown with Tc‐99m sestamibi; helps to make a confident interpretation for defect reversibility. Metamizol should be discontinued like nitrates before stress MPS since it may mask the visualization of perfusion defects in ischemic regions. Usage of metamizol 45 min before redistribution MPS may eliminate the need for reinjection MPS and consequently can lead to lower patient radiation dosimetry, reduce patient stay in laboratory and the cost of extra Tl‐201 injection would be decreased. Metamizol has a scintigraphically and eventually clinically proven vascular smooth muscle relaxing effect.
P03 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Cardiovascular: prognosis
P041 Comparison of Scintigraphic and Angiographic findings of Coronary Artery Disease in Diabetic type 2 population I. Kotsalou1, A. Kotsalos2, N. Zakopoulos3, M. Dimopoulos3; 1NIMTS Hospital, Athens, GREECE, 2NIMTS Hospital, Cardiothoracic Surgery Dept., Athens, GREECE, 3Alexandras Hospital, University Dept. of Internal Therapy, Athens, GREECE. Aim Coronary angiography is considered as the gold standard method for detection of coronary artery disease. On the other hand, the myocardial perfusion scintigraphic study examines the effect of coronary flow at stress and may detect the pathophysiologic impact of coronary microangiopathy, which is frequent in diabetics and worsens the prognosis if ignored. Materials ‐ Methods In this retrospective study we examined the stress‐rest Myocardial Perfusion SPECT studies of 117 diabetics (men:92, women:25), mean age 62 years, 1‐35years duration of DM,
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 following the appropriate therapy, from whom 78 (66,6%) had no previous history of CAD and were referred either for claiming typical or atypical angina symptoms, either for check up for possible target‐organ damage. The 77% (n:90) of SPECT scans revealed diverse degree signs of coronary disease (45% reversible ischemia, 15%scar, 17% mixed filling defect). Patients (n:72) with positive studies underwent coronary angiography. Results Statistical analysis of coronary angiography and scintigraphic results, showed matched findings in 68% of the cases, and mismatching in 32% (+ Spect vs ‐ cor. angiog.). Conclusions Myocardial perfusion Scintigram is a reliable, sensitive, non invasive method of screening coronary artery disease in diabetics, as in adverse to the coronary angiography, it also diagnoses early the diabetic microangiopathy.
P044
Regional changes in systolic and diastolic function using ventricular volume curves analysis M. Zigman1, S. A. Rogan1, D. Planinc2, M. Punda1, Z. Kusic1; 1Dpt. of Oncology and Nuclear Medicine, U.H. "Sestre milosrdnice", Zagreb, CROATIA, 2Dpt. of Internal Medicine, U.H. "Sestre milosrdnice", Zagreb, CROATIA. Purpose of the study: detection of differences in systolic and diastolic function between myocardial segments with impaired and preserved myocardial contractility by scintigraphic parameters derived from second derivation of volume curves. Patients and methods: A total of 124 consecutive patients (pts) underwent myocardial perfusion scintigraphy and angiography for the evaluation of coronary artery disease. Seventy‐two of them had ischemic and 52 had non‐ ischemic cardiomyopathy. Between hypokinetic segments, 100 were ischemic and 87 were non‐ ischemic. Resting radionuclide ventriculography using labeled erythrocytes was performed in all pts. Global and regional volume curves were obtained from scintigraphic data and peak values of second derivation of the curves were used for estimation of early and late systolic and diastolic phase. Data was expressed as end diastolic volume curves ‐ EDV in mL/sec2, where S1 and S2 represented early and late systolic phase, D1 and D2 represented early and late diastolic phase. In 395 analyzed myocardial segments 170 were normokinetic, 38 segments were dyskinetic and 187 were hypokinetic. Results: The change in EDV in mL/sec2 according to segments contractility are given in Table. Normokinetic Dyskinetic Hypokinetic non‐ischemic Hypokinetic ischemic segments segments EDV L/sec2 EDV mL/sec2 2 EDV L/sec EDV mL/sec2 4.8±0.5 6.9±0.5
5.2±0.6 6.3±0.4
2.8±0.7 3.2±0.6
D1 12.6±2.0 5.9±0.7 D2 8.1±0.4 7.0±0.5
4.2±0.6 9.2±0.4
3.1±0.6 5.3±0.5
Among normokinetic segments all parameters (S1,S2,D1,D2) showed significantly higher EDV mL/sec2 values compared to other three groups (p<0,01), particularly D1 parameter. The group with dyskinetic segments revealed significant reduction of EDV mL/sec2 values of all parameters (p<0,01). Comparing the groups with hypokinetic ischemic segments EDV mL/sec2 were reduced in S1,S2 and D1 phase, but showed higher values of D2 parameter, even higher than normokinetic segments (p<0,05). Conclusions: Scintigraphic parameters derived by regional volume curve analysis allow better quantification of segmental ventricular contractibility in both systolic and diastolic function of the myocardium. Furthermore, this method better estimates not only the segments with impaired function, but also regions with preserved myocardium function which contributes the most to the global ventricular contractibility.As the study group of pts with hypokinetic myocardium showed heterogeneity according to etiology (ischemic vs. non‐ ischemic), the analysis of early and late systolic and diastolic phase by scintigraphic parameters can be used to determine different types of contractility dysfunction. According to our data scintigraphic parameters values in early diastolic phase were severely reduced in hypokinetic ischemic segments compared to non‐ischemic segments, but in late diastolic phase (atrial phase) scintigraphic parameters were even higher than in normokinetic segments. These findings could have important clinical implications for therapy monitoring in follow‐up of patient.
P043 Diagnostic Significance Of Electrocardiographic ST-Segment Depression During Vasodilator Stress In Patients With Normal Myocardial Perfusion Imaging Studies S. Alexiou, P. Davlouros, N. Patsouras, T. Spyridonidis, P. Barla, C. Savvopoulos, A. Paschali, D. Alexopoulos, P. J. Vassilakos, D. J. Apostopoulos; University Hospital of Patras, Patras, GREECE. Background: Patients with normal SPECT myocardial perfusion imaging (MPI) who develop ischemic electrocardiographic (ECG) changes during vasodilator stress are considered to be at an increased risk of future cardiac events. However, the relation of these ECG findings to flow‐ limiting coronary artery disease (CAD) is unknown, since coronary artery angiography (CANG) has been undertaken selectively, in a minority of patients enrolled in published series. In the present study we aimed at elucidating this issue. Patients and Methods: Eighty‐five consecutive patients unable to perform an adequate physical exercise and therefore subjected to vasodilator stress (dipyridamole, n=30; adenosine, n=55), demonstrated horizontal or down‐sloping ST‐segment depression ≥1 mm during stress and had normal MPI. Patients with already known CAD or baseline abnormalities impeding stress ECG interpretation were excluded. There were 80 females and 5 males, aged 37‐79 y.o. (average 65). The frequency of CAD predisposing factors was: diabetes mellitus 32%, peripheral artery disease 3%, smoking 5%, hypertension 87%, hyperlipidemia 70%, and family history of CAD 44%. Chest pain complaints and dyspnea on exertion were reported by 40% and 24% respectively. Fifty‐one percent were on beta‐blocker medication and 17% on nitrates. All patients were advised to proceed to CANG. A phone interview was undertaken at 6‐month intervals following initial presentation. A control group was formed by recruiting individuals with normal MPI and no ECG changes during stress from a contemporary patient pool, matching the type of stress and patients’ characteristics with the positive‐ECG group. Results: Forty patients refused to consent for CANG. Of the 45 catheterized 34 had no evidence of CAD; 8 had atheromatous lesions causing <50% arterial lumen stenosis; 3 females had obstructive CAD (in the left main, right coronary artery, and the diagonal branch, respectively). The latter three patients with subsequent revascularization were excluded from
Incremental prognostic value of Tc-99m tetrofosmin early post-stress lung uptake during gated-SPECT myocardial perfusion imaging. V. Valotassiou1, N. Demakoploulos2, C. Tzavara1, S. Giannakou1, I. Tsougos3, A. Orfanakis1, P. Georgoulias1; 1Dept. of Nuclear Medicine, Univ. Hospital of Larissa, Larissa, Greece, 2Department of Nucl. Medicine, NIMTS Hospital, Athens, Greece, 3Department of Medical Physics, University Hospital of Larissa, , Larissa, Greece. Aim. The aim of this study was to evaluate the incremental prognostic value of early post‐stress Tc‐99m tetrofosmin lung/heart ratio (LHR). Materials‐Methods. We studied 276 patients (aged 62.2±8.9 years, 168 men) with stress/rest Tc‐99m tetrofosmin myocardial SPECT and coronary angiography. Rest scans were obtained as gated‐SPECT and the left ventricular ejection fraction (LVEF) and end‐diastolic volume were calculated. To evaluate myocardial ischaemia, we calculated the summed stress score (SSS), summed rest score (SRS) and summed difference score (SDS) indices. For the LHR calculation, an anterior image, 4‐6 minutes after radiotracer injection at stress was acquired. LHR was defined as mean counts/pixel in the lung region of interest (ROI) divided by the mean counts/pixel in the myocardial ROI. Cardiovascular death and non‐fatal myocardial infarction were considered as hard cardiac events, while late revascularization (>3 months after myocardial SPECT) procedures as soft events. The mean follow‐up period was 2.7 years (SD=0.8) with median equal to 2.7 years (interquartile range 2.2 to 3.3 years). The incremental prognostic value of LHR was evaluated by a statistically significant increase in the global chi‐square of the Cox proportional‐hazard model that included clinical, exercise, angiographic and scintigraphic variables. Using ROC analysis, the optimal sensitivity and specificity of various LHR cut‐off values for the prediction of cardiac events, was determined. Results. During the follow‐up period hard cardiac events occurred in 28 (10.1%) patients and soft cardiac events in 32 (11.6%) patients. ROC curve analysis showed that the optimal‐cut off of LHR for the prediction of soft cardiac events was 0.527 with sensitivity equal to 78.1% and specificity equal to 80.7. Similarly, the LHR value of 0.530 represented the optimal cut‐off for the prediction of hard cardiac events (sensitivity 68% and specificity 78.6%). The area under the curve (AUC) was 0.80 (95% CI: 0.71‐0.88) and 0.76 (95% CI: 0.66‐0.86), for soft and hard cardiac events, respectively, which significantly differs from 0.5 (p<0.001). The addition of LHR in the Cox regression model, included clinical, exercise data and myocardial perfusion SSS, increased significantly the global chi‐square for both soft and hard cardiac events (p<0.001) declaring the significant incremental value of LHR. The adjusted hazard ratios for LHR more than 0.53 were 9.44 and 7.51 (95%CI: 3.13‐28.41, P<0.001) for soft and hard cardiac events, respectively. Conclusion. Early post‐stress LHR value greater than 0.53 added incremental value to clinical, exercise testing, angiographic and scintigraphic variables, for the prediction of cardiac events.
P045 Diagnostic Value of G/SPECT And MUGA For The Evaluation of The Patients With Cardiac Stem-Cell Implantation B. Talay, H. Ozer, S. Talay, B. Kutas, C. Turkay, O. Bayezid, M. Erkilic; Akdeniz University, Antalya, TURKEY. AIM: The aim of this study is to determine preoperatively the implantation site and to predict the outcome of patients using noninvasive nuclear techniques such as G/SPECT and MUGA MATERIAL AND METHOD: 28 patients ( 25 male,3 female ) were included to this study. Mean age of the patients was 57.8 ( 43‐72 ). 24 of the study group were ischemic cardiomyopathy, 4 were dilated cardiomyopathy. All of the patients had ejection fraction for the left ventricle lower than 40%. Preoperatively and postoperatively G/SPECT and MUGA were performed in all patients. For follow‐up these studies were repeated in 4., 8. and 12. months. Myocardial perfusion, left ventricular ejection fraction (LVEF), myocardial systolic thickness were evaluated by G/SPECT, wall‐motion, global/regional LVEF, amplitude and stroke volume parameters were determined by MUGA for all patients. Preoperative G/SPECT detailed the possible implantation locations with the local findings of hypoperfusion sites with systolic thickness, polar clock‐wise. RESULTS: In follow‐up period, we had 22 patients for postoperatively evaluation, 6 patients were not able to come follow‐up. In 7 patients (39%) perfusion improved, 3 patients (17%) showed partially improved perfusion, 8 patients (44%) no improvement. In all patients, we have preoperatively mean globally LVEF 23.4 %, in postoperatively period we have mean globally LVEF 33.6 % by MUGA (p<0.001). During follow‐up period, 4 patients died. We noticed that in this group, there is no LVEF changes on the contrary, remaining 18 patients have improved globally LVEF. CONCLUSION: Gated/SPECT and MUGA imaging methods are noninvasive nuclear techniques which can manifest important parameters for stem‐cell patients in determining either the implantation site and to predict the prognostic outcome of patients.
P046 Is heart rate a risk factor for coronary disease? H. Q. F. Fernandes, E. Martins, P. Oliveira, J. P. Patricio, A. Oliveira, T. Faria, J. C. Silva, J. G. Pereira; Hospital S.joão, Porto, PORTUGAL. Aim: Recent studies have shown that resting heart rate is an important prognostic factor for sudden cardiac death and heart failure among patients with known cardiac disease. The aim of our study was to evaluate if resting heart rate could also be a risk factor for the diagnosis of coronary artery disease (CAD). Materials and Methods: We conducted a retrospective study selecting patients submitted to adenosine MPS (Myocardial Perfusion Scintigraphy) for thoracic pain and/or pre‐operative cardiac risk assessment, without proven CAD diagnosis, who had had a
Poster Presentation
P042
S1 7.2±0.4 S2 11.8±1.5
follow‐up. Among 65 patients who have completed at least one‐year follow‐up by now (19 months on average), a single hard event (non‐fatal inferior myocardial infarction) and no soft events has been reported. In an equal number of controls, no events were reported. Conclusion: The frequency of obstructive CAD in patients with normal MPI and ischemic ECG signs during vasodilator stress is low (6.7% in this study), probably not different from what is expected from patients’ risk profile and the sensitivity of MPI. Regarding prognosis, data of the present work are not yet conclusive; however, preliminary results (1.5% had‐event rate) do not seem to confirm current attitudes.
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CA (Coronary Angiography) within a six month interval. For each patient we evaluated cardiovascular signs and symptoms, cardiovascular drugs use, ECG, including resting and maximal heart rate, the presence of Diabetes mellitus and of CAD on CA. Each MPS was analysed using QGS/QPS® software to determine the Summed Stress Score (SSS), Summed Rest Score (SRS), Summed Difference Score (SDS), defect extent and ejection fraction in the left ventricle. Results: A total of seventy (70) patients were evaluated, 36 female (51%), mean age of 65±11 years, 21% were diabetic and 20% had left bundle branch blockage. On MPS 67% (47) patients had no or mild defects and 33% (23) patients had moderate or severe defects. SSS was 7.3±5.0, SRS 2.5±3.6, SDS 5.6±2.2, stress defect extent 9.7±7.4%, rest defect extent 5.5±5.8% and the ejection fraction was 50±13%. On CA 33% had significant disease (coronary stenosis >50%). Resting mean heart rate was 75±13 beats per minute and maximal heart rate was 88±16 beats per minute. Basal heart rate was positively correlated with SSS (p=0.013) and defect stress extent (p=0.007), and negatively correlated to the ejection fraction (p=0.004). Conclusions: In our study patients showed a positive correlation between their resting heart rate and the presence of MPS abnormalities. If this finding is confirmed in larger series, heart rate should be taken into account in a CAD risk profile.
ventricular diastolic function), suggesting that the uptake is associated with not only left ventricular contractility, but also with left ventricular diastolic function. The findings of the study suggest the involvement of disturbed cardiac sympathetic nerve activity as a possible cause of compromised left ventricular diastolic function.
M. Kobylecka1, T. Mazurek2, J. Kochman2, K. Filipiak2, J. Maczewska1, J. Kunikowska1, M. T. Plazinska1, K. Fraczewska-Wieniawska1, G. Opolski2, L. Krolicki1; 1Nuclear Medicine Dep. Warsaw Medical University, Warsaw, POLAND, 2Chair and Department of Internal Medicine and Cardiology Warsaw Medical University, Warsaw, POLAND.
P04 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Cardiovascular: neuronal functions and receptors
P047 Influence of Continuous Positive Airway Pressure therapy on regional cerebral blood flow in patients with moderate hypertension and obesity with or without obstructive sleep apnoe syndrome M. Bugriy, A. Aksenova, P. Galitsin, A. Litvin, I. Chazova, V. Sergienko; Cardiology Research Complex of Ministry of Health of Russian Federation, Moscow, RUSSIAN FEDERATION. Objective: To investigate changes in regional cerebral blood flow (rCBF) in hypertensive and obesity patients with and without obstructive sleep apnea‐hypopnea syndrome (OSAHS) after 6 months therapy. Design and methods: The study sample consisted of 19 pts. They all arterial hypertension (SBP=160±10 mm Hg; DBP=93±9 mm Hg) and obesity (body mass index 34±4). All patients underwent overnight polysomnography (EMBLA Flaga (Iceland)). Than all patients divided into three groups. Group I and group II had severe OSAHS, apnea‐hypopnea index (AHI 56±23), group III without OSAHS. rCBF was analyzed in 8 regions of interests by single photon emission computer tomography (SPECT) with 99mTc ‐ Ceretec in initial phase and after 6 months of therapy. Continuous positive airway pressure therapy (CPAP) was administered to 8 patients of group I. Group II hadn’t received CPAP therapy. All patients had effective antihypertnension treatment Results (%): GR 1: initial phase and after 6 months of therapy. (p<0.05) Frontal lobe s.
Occipital lobe s.
Occipital lobe d.
Parietal lobe Parietal s. lobe d.
Temporal Temporal lobe s. lobe d.
71.1±4.0 70.7±6.36 68.3±7.1
69.3±7.1
81.6±4.8
74.07±2.6 75±4.1
92±9.6
Frontal lobe d.
83.3±2.5
89.32±6.7 82.5±11.1 81.2±12.3 101.6±10.24 103.9±9.2 100.7±4.6 97±6.1
GR 2: initial phase and after 6 months of therapy. (p>0.05) 70.3±7.4 68,1±6.4
69.6±7.6 68±10.5 76.4±4.8 80.5±7.9 77.9±3.4 77.6±4.5
78±13.84 76.8±13.78 69.5±4.8 70±8
84.6±10.2 87.5±12.6 85.7±10.2 86±10.7
GR 3: initial phase and after 6 months of therapy. * ‐ (p<0.001) 71.5±6.9 69.1±5.2 69±8.5 67.2±7.8 78.9±4.9 82.7±3.8 75.8±5.7* 77.2±5.2* 76.1±10.6 75.6±10 72.7±11 73.1±12.1 82.3±9.7 87.1±8.8 84.1±7.6* 85±6.2* Patients of first group had significantly increased cerebral blood flow in all regions of interests after 6 months of therapy (p<0.05). Patients of third gr. had increased rCBF only in temporal lobes. Conclusions: CPAP‐therapy improves regional cerebral blood flow in patients with moderate hypertension, obesity and severe OSAHS.
P048 Assessment of the Relationship between Cardiac Sympathetic Nerve Activity and E/E’ (a Doppler index of Diastolic Function) with I-123 MIBG Imaging in Patients with Heart Failure N. Fukuda, H. Shimoyama, K. Mano, T. Minamisaka, D. Nakagawa; Itami Hospital, Itami, JAPAN. Aim: I‐123 MIBG has been used to evaluate the cardiac sympathetic nerve activity in patients with heart failure. Previous studies have indicated that the heart‐to‐mediastinum (H/M) ratio and the myocardial washout rate (WOR) of I‐123 MIBG are correlated with the ejection fraction (EF), an index of heart contractility, in patients with heart failure. However, the relationship of these parameters to diastolic heart failure has not yet been established. Recent studies have suggested that E/E’ (a ratio of the early‐diastolic velocity of transmitral flow [E], as determined by pulsed Doppler echocardiography, to the early‐diastolic velocity of mitral annulus [E’], as determined by tissue Doppler echocardiography, is useful as an index of left ventricular diastolic function. The present study was undertaken to evaluate the relationship between the cardiac sympathetic nerve activity and the left ventricular diastolic function using I‐123 MIBG and pulsed Doppler echocardiography in patients with heart failure. Methods: Echocardiography and I‐123 MIBG scintigraphy were performed in 31 heart failure patients in sinus rhythm. H/M ratio and WOR were calculated after 20 minutes (on early images) and after 3 hours (on delayed images), and their correlations with the E/E’ were analyzed. Results: The E/E’ was negatively correlated with delayed H/M ratio and positively correlated with the WOR, while no significant correlation was noted between early H/M ratio and E/E’ (early H/M ratio: r=‐0.3135, P=‐0.086; delayed H/M ratio: r =‐0.4536, P=0.0104; WOR: r =0.396, P=0.0275). Conclusion: I‐123 MIBG uptake (an index of cardiac sympathetic nerve activity) was correlated negatively with the E/E’ (an index of left
P05 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Cardiovascular: molecular imaging
P049 Is SUV max of Fluorodeoxyglucose Detected by PET/CT a Reliable Method for Detection of Inflammatory Activity of Perivascular Tissue?
Maximal standarized uptake value (SUVmax) of 18F‐FDG is currently widely used for localization of sites with augmented inflammatory activity in different body locations. It has been shown previously, that its value is proportional to macrophage density. Interestingly there is a growing number of publications looking for “outside‐to‐inside” signaling as a potential etiological mechanism of atherosclerotic plaque in coronary arteries. Accordingly we examined the adipose tissue inflammatory activity in visceral, periarterial and subcutaneous fat locations in patients with and without CAD. 22 pts were included. The presence of CAD was assessed according to Ca Score results, measured by CT during the same study. The study population was divided in to 2 subgroups according to the presence or absence of significant calcifications in coronary arteries (Ca Scoring measured by CT >100 (Group1) or <10 (Group2) Both groups were matched for age and BMI. SUV max was measured in subcutaneous fat (SC) , visceral thoracic fat (VS), epicardial fat over right ventricle (EPI), and periarterial fat (PAT) in proximal part of coronary arteries (RCA, LCX, LAD, respectively). The circular ROI was used for each calculation. The ROI was placed in the areas confirmed by CT as a fat tissue ( mean HU ‐100 +/‐ 20). The associations of SUV values with gender, age, BMI, serum glucose were analyzed. SUVmax value in different adipose tissue locations was mean of three measurements taken by two researches blind to result. Results: SUV measurements in different adipose tissue locations were reproducible with inter‐ and intra‐ observer variability<10%. PAT SUV was not related to gender, age, BMI, or serum glucose. SUV max surrounding all three main coronary arteries was significantly greater than SUVmax in other fat locations, for both groups of patients (SC=0.21; VS= 0.4, EPI= 0.39; RCA=0.65, LCX=0.9, LAD=0.87; p<0.001). When compared Group1 and Group2, SUV surrounding all tree main coronary arteries was greater in patients with CAD (1.03 vs. 0.56; p<0.005). Conclusions: 1. maximal standardized uptake value of flurodeoxyglucose (FDG) detected by postitron emission tomography could be a useful method for detection of inflammatory activity in different location of fat tissue. 2. Our results showed that metabolic (probably inflammatory) activity of the pericardial fat tissue correlates with calcium scoring and might play a role in pathogenesis of CAD.
P050 [11C]Choline Accumulates in Atherosclerotic Plaques in Mice I. E. K. Laitinen1, P. Marjamäki1, K. Någren2, P. Virsu1, J. O. Laine3, S. YläHerttuala4, J. Knuuti1, A. Roivainen1; 1Turku PET Centre, University of Turku, Turku, FINLAND, 2Rigshospitalet, University of Copenhagen, Department of Clinical Physiology & Nuclear Medicine, PET & Cyclotron Unit, Copenhagen, DENMARK, 3Turku University Hospital, Turku, FINLAND, 4University of Kuopio, Kuopio, FINLAND. Aims: Purpose of this study was to explore the feasibility of [11C]choline in the assessment of the degree of inflammation and the vulnerability of atherosclerotic plaques in coronary artery disease. The high amount of inflammatory cells in the plaques indicates vulnerability in comparison to atherosclerotic lesions with few inflammatory cells. [18F]Fluorocholine uptake has been shown to correlate significantly with plaque macrophages in an ApoE‐/‐ mouse model. The enhanced uptake is thought to be caused by increased choline transport and phosphorylation by choline kinase in activated macrophages. [11C]Choline accumulates very rapidly in cells. We hypothesized that despite the fast blood metabolism of [11C]choline, the tracer could be used as a marker of activated macrophages in atherosclerotic plaques. Methods: Seven mice deficient for both LDLR and ApoB48 (LDLR‐/‐ApoB100/100, age 17 months) kept on western type diet for 2 months and five control mice (C57Bl/Bom, age 15 months) were studied. The mice were injected with 28±9 MBq of [11C]choline and sacrificed at 10 minutes after injection. The aorta was dissected, frozen and cryosectioned for analysis of biodistribution, autoradiography and histology. Serial sections were stained with antibodies against macrophages (Mac‐3) and proliferative cells (Ki‐67). Results: The %ID/g of [11C]choline was 2.2 folds higher in the atherosclerotic aorta of LDLR‐/‐ApoB100/100 mice compared to the control mice aortas (5.16±1.14 vs.2.34 ±1.39 %ID/g tissue, p=0.003). In the LDLR‐/‐ApoB100/100 mice the aorta‐to‐blood and aorta‐ to‐muscle ratios were 5.5 and 3.0, respectively. The autoradiography analysis showed significant accumulation of [11C] radioactivity in the plaques as compared to the normal wall (plaque‐to‐ normal wall ‐ ratio 2.3±0.6, p=0.006, n=6 LDLR‐/‐ApoB100/100 mice). The aortas of LDLR‐/‐ApoB100/100 mice contained extensive atherosclerotic plaques with a high density of Mac‐3 positive macrophages but only occasional Ki‐67 positive cells. Conclusions: Significantly higher [11C]choline uptake was found in the atherosclerotic mouse aorta as compared to control mice and the activity localized in the plaques. Our data suggests that macrophages may be responsible for the uptake of [11C]choline in the plaques. While accumulation of [11C]choline was very prominent in this model, further studies should elucidate its clinical value as a marker of plaque inflammation.
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P051 Myocardial washout rate of Tc-99m Sestamibi would be a useful index to predict the transition from left ventricular hypertrophy to congestive heart failure in Dahl salt-sensitive hypertensive rats
FDG-PET has a potential for predicting progression of acute aortic dissection K. Fukushima, A. Kono, Y. Ishida, H. Naito; National Cardiovascular Center, Suita, JAPAN. Aim: 18F‐Fluorodeoxyglucose (FDG) has been established to be useful for detecting inflammatory cells such as macrophages, so FDG‐PET can give us useful information in patients with vascular diseases which are related to inflammation in the vascular wall. Acute aortic dissection (AAD) has a high mortality rate and is closely associated with inflammation, because serologic inflammation marker such as C‐reactive protein (CRP) frequently elevate in patients with AAD. The aim of the present study was to assess vascular inflammation using FDG‐PET and to identify patients at high risk for disease progression in patients with AAD. Methods: Twenty‐two consecutive patients with AAD (7 double barrel (DB) type and 15 intramural hematoma (IMH) type) were included. FDG‐PET was performed 2 to 4 weeks after the onset of AAD. After at least 5 hours fasting, FDG‐ PET images were acquired 60 min after administration of FDG. Follow‐up CT was performed to detect disease progression. Results: Twelve (54.5%) of 22 patients, including all of 4 DB type and 8 IMH type, showed elevated FDG uptake within the aortic lesions. Eight (67.7%) of 12 FDG‐ positive patients had disease progression, whereas 9 (90.0%) of 10 FDG‐negative patients showed stable disease or regression during the follow up period. Conclusion: These results suggested that FDG‐PET could predict disease progression in patients with AAD.
P06 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Cardiovascular: hybrid imaging
P054 Discrepancies between physiology (stress myocardial perfusion gated spect) and coronary anatomy (CT angiography) G. Cuberas-Borrós, H. Cuellar-Calabria, V. Aliaga, F. Rueda, S. AguadéBruix, J. Castell-Conesa, J. Candell-Riera; Vall Hebron, Barcelona, SPAIN. Introduction Correlation between myocardial perfusion (physiology) and coronary tree (anatomy) is not as perfect as expected. Aim To describe discrepancies between myocardial perfusion SPECT and non‐invasive coronary CT angiography (CT Angiography). Methods One hundred patients with suspected or known coronary artery disease (38 women; mean age, ± years) were prospectively studied by means of stress myocardial perfusion gated SPECT and CT Angiography, within a 3‐month interval between both techniques. Gated SPECT variables were: presence of abnormality (categorized to presence or absence of defect) and severity by Summed Stress Score (SSS). CT‐Angiography variables were: 1. Severity of coronary stenosis. categorized in three groups: 1. absence of atherosclerotic lesion, 2. presence of non‐significant stenosis (<50% of lumen diameter) 3. presence of significant stenosis (≥ 50% of lumen diameter) 2. Coronary Calcium Score measured in Agatston Unit Equivalents for each patient as well as for each vessel. Results:
STRESS MYOCARDIAL PERFUSION GATED SPECT
Presence of Defect
Absence of Defect
SSS Mean ± SD ( Min ‐ Max ) [ N ]
CT ANGIOGRAPHY Lack of stenotic lesion
4.13±2.70(1.00‐11.00)[15] 0.43±0.85(0.00‐3.00)[14]
Presence of significant stenosis
12.29±7.80(1.00‐ 26.00)[36]
2.00±2.45(0.00‐6.00)[9]
Lack of stenotic lesion
8.78±22.28(0.00‐ 85.60)[15]
82.05±176.86(0.00‐ 625.00)[14]
Presence of non‐ significant stenosis
238.43±318.19(7.80‐ 1.174.00)[16]
150.05±187.93(0.00‐ 565.00)[10]
Presence of significant stenosis
836.97±950.62(0.00‐ 3.235.20)[36]
509.38±328.64(131.00‐ 837.20)[9]
Conclusions Although there’s a positive correlation between stenosis severity and defect degree, we have found a 24% of discrepancies, mainly in cases with presence of defect and lack of stenotic lesion (15%): CT Angiography’s false negative result or stress gated‐SPECT’s false positive result. In 9% of cases, absence of perfusion defect was not observed in a region of an angiographic significant stenosis.
P055 Attenuation correction myocardial perfusion SPECT in the assessment of ischemia in patients with high prevalence of coronary artery disease J. P. Pilkington Woll1, V. M. Poblete García1, J. M. Cordero García1, A. M. García Vicente1, A. Leon Martin2, I. Sanchez Perez3, M. P. Talavera Rubio1, F. Lozano Ruiz-Poveda3, A. M. Palomar Muñoz1, M. E. Bellon Guardia1, B. González García1, I. Cepedello Boiso1, V. Fernández Vallejo3, A. Soriano Castrejón1; 1Nuclear Medicine Department.. Hospital General, Ciudad Real, SPAIN, 2Investigation Department Hospital General, Ciudad Real, SPAIN, 3 Hemodinamics Department Hospital General, Ciudad Real, SPAIN. AIM: To evaluate the use of X‐ray attenuation correction myocardial perfusion SPECT in the assessment of ischemia in patients with high prevalence of coronary artery disease. MATERIAL AND METHOD: We studied a group of 89 patients (79 male, 10 female) with coronary artery disease, with mean age of 65 years (25‐85y), with a myocardial perfusion SPECT‐gated study in stress, ergometric (65 patients) or pharmacologic (24 patients), and rest, following a 2 day protocol and using a hybrid SPECT‐CT gammacamera. All patients underwent a catheterism study within 6 months time interval. Two experienced specialists evaluated qualitatively the images with (AC) and without attenuation correction (NAC). Sensitivity, specificity, PPV, NPV, and diagnostic efficacy were obtained after statistical analysis of the data; using the catheterism results as gold‐standard. Semiquantitative analysis of images was made by dividing the left ventricle in 20 segments and assigning a score (0=normal, to 4=no perfusion) to each of them. Scores obtained were compared using the T student statistical analysis. RESULTS: Significative lesions (obstruction>70%) of at least 1 coronary artery were found in 69 (69.9%) patients: 41 in the anterior descendant artery (ADA), 44 in the right coronary artery (RCA) and 28 in the circumflex artery (CXA). 26 (29%) were found to have lesion of 1 coronary artery, 23 (25.8%) of 2 coronary arteries and 13 (14.6%) of 3 coronary arteries. The results obtained for sensitivity, specificity, PPV, NPV and efficacy were:
ADA
RCA
CXA
NCA CA NCA CA NCA CA
SENSITIVITY 45% 50% 75% 62% 64% 46% SPECIFICITY 91% 89% 75% 95% 91% 92% PPV
82% 81% 75% 93% 78% 72%
NPV
65% 67% 75% 71% 84% 79%
EFFICACY
69% 71% 75% 79% 80% 74%
Decreased activity was observed in the attenuation correction images in the ADA territory, being the average difference between CA and NCA scores of 3,5 (range: 4,5‐2,8). It was slighter in the RCA territory, with an average of 1 (1,5‐0,5); both statistically significant (p<0.05). No difference was found in the CXA territory. CONCLUSIONS: In patients with high prevalence of coronary artery disease, the attenuation correction myocardial perfusion SPECT improves diagnostic accuracy in the RC artery territory, while it seems not to be useful in the other territories. In the AD territory, attenuation correction produced a false decrease in activity that must be taken into account for a correct evaluation of the study.
P056 Value of Contrast Enhanced CT in SPECT/CT for the Monitoring of Transplanted Stem Cells in a Canine Model E. Sabondjian1, A. Mitchell2, G. Wisenberg1, J. Sykes1, L. Deans1, R. Z. Stodilka1, F. S. Prato1; 1The Lawson Health Research Institute, London, ON, CANADA, 2The University of Western Ontario, London, ON, CANADA. INTRODUCTION: A major challenge to monitoring stem cell (SC) therapy is visualizing the anatomic location of transplanted radiolabeled SCs relative to the infarct. The investigator may wish to direct the SCs into the center or periphery of the infarct. Although the infarct can be seen via 99mTc perfusion SPECT, resolution is insufficient and high counts from 99mTc can obscure the low signals emitted from the radiolabeled SCs. Instead, we propose contrast‐enhanced diagnostic quality X‐ray CT for high‐resolution infarct delineation in the context of SPECT/CT. We evaluate the use of SPECT/[contrast enhanced CT] in tracking transplanted 111In radiolabeled SCs in a canine model of myocardial infarction over 10 days. METHODS: First, we did simple phantom experiments to determine the accuracy of our SPECT/CT system (Siemens, Symbia T‐6). SPECT/CT 99m images were acquired of capillary tubes filled with a mixture of CT contrast agent and Tc. Tubes were arranged to evaluate registration in all three dimensions, and accuracy was measured by comparing locations of tube centroids in SPECT and CT reconstructed images. Next, cardiac imaging was performed on three adult canines with infarcted myocardium induced by a
Poster Presentation
P053
6.75±5.11(1.00‐15.00)[16] 1.10±2.85(0.00‐9.00)[10]
CALCIUM SCORES Mean ± SD ( Min ‐ Max ) [ N ]
M. Yokoe1, K. Fukushima2, H. Kurosawa3, K. Sakurai3, H. Hasegawa3, N. Nose4, H. Watabe4, K. Sugimura1; 1Kobe Unversity, Gradaute School of Medicine, Kobe, JAPAN, 2National Cardiovascular Center, Suita, JAPAN, 3 FUJI FILM RI Pharma Co.,Ltd., Matsuo-cho, JAPAN, 4National Cardiovascular Center, Research Institute, Suita, JAPAN. Aim: In Dahl salt‐sensitive rats under a high salt diet, systemic hypertension induces left ventricular hypertrophy (LVH) and results in congestive heart failure (CHF). We previously reported that increased myocardial washout of Tc‐99m Sestamibi (MIBI) is associated with myocardial mitochondrial dysfunction at the CHF stage of Dahl salt‐sensitive hypertensive (DSH) rats. The aim of this study was to assess myocardial mitochondrial function serially in DSH rats using myocardial MIBI washout rate (WR). Materials and Methods: We used DSH and Dahl salt‐ sensitive normotensive (DSN) rats as the control in the three stages (at the age of 10 [LVH stage], 14 [Transition stage] and 17 weeks [CHF stage]), respectively. After 74 MBq of MIBI was administrated to 6 rats in each group, planar imaging data was acquired at the early (10 min) and delayed (180 min) phases. Myocardial MIBI WR was calculated from the couple of the data. Results: At the age of 10 weeks, there was no difference of myocardial MIBI WR in between DSH and DSN rats (8.3 ± 6.1 %, ‐0.4 ± 7.7 %, respectively). At the age of 14 and 17 weeks, myocardial MIBI WR in DSH rats significantly increased compared to that in DSN rats (14 weeks: 21.9 ± 3.5 %, ‐1.0 ± 2.5 %, respectively, p < 0.001; 17 weeks: 17.0 ± 8.4 %, ‐3.7 ± 7.1 %, respectively, p < 0.005). In DSN rats, there was no difference of myocardial MIBI WR among the three stages. In contrast, in DSH rats, myocardial MIBI WR at the age of 14 and 17 weeks significantly increased compared to that at the age of 10 weeks although there was no difference of myocardial MIBI WR between the age of 14 and 17 weeks. Conclusions: These data suggested that myocardial MIBI WR could detect myocardial mitochondrial dysfunction at earlier stage of DSH rats before DSH rats resulted in CHF. Myocardial MIBI WR would be a useful index to predict the transition from LVH to CHF in hypertensive heart disease.
Presence of non‐ significant stenosis
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surgical ligation of the left anterior descending artery. 111In tropolone (0.1Bq/cell, ~30x106 cells) was used to label autologous endothelial progenitor cells, which were then injected into the myocardium using a left ventricular catheter one‐week post infarction. SPECT/CT was acquired on injection day, followed by 4 and 10 days later. For each imaging session, a 30mL bolus of CT contrast (300mgI/mL) was administered, followed immediately by a cardiac gated CT acquisition (50 slices, 2.5mm slice thickness) at end expiration. RESULTS: The phantom studies indicate errors in the anterior/poster, left/right, and apical/caudal directions were 1.63mm, 0.24mm, 1.34mm respectively. In all three canines imaging sessions, the infarct boundary was delineated clearly on contrast enhanced CT, and the centre of the 111In focus was located within the infarct boundary. The 111In focus was visualized well even at 10 days post SC injection, despite a low 111In count rate on day 10. Further, from an examination of the registered SPECT and CT images, it was clear that the transplanted cells did not enter the infarct boarder up to 10 days post cell transplantation and also, the cells did not migrate from their initial location. CONCLUSION: This novel technique provides investigators with high quality infarct imaging and the clear ability to identify the site of SC injections in relation to the infarct.
P057 Comparative analysis of the left ventricular function with 64slices computed tomography and myocardial perfusion gated SPECT A. A. Yampara Gutiérrez1, G. López Milena2, M. Carrero Lérida1, C. Dávila Arias1, M. Mariscal Cerato1, M. Fernández Mayorga1, A. García Mendoza1, R. Nieto Serrano1, O. Padilla Bolívar1, J. Martinez Sampere1; 1Department of Nuclear Medicine, San Cecilio University Hospital, Granada, SPAIN, 2 Department of Radiology, Virgen de las Nieves University Hospital, Granada, SPAIN. OBJECTIVE To evaluate the left ventricular (LV) ejection fraction (EF), end‐diastolic volume (EDV), and end‐systolic volume (ESV) from electrocardiogram‐gated computed tomography (CT) and myocardial perfusion gated‐SPECT (MPS). MATERIAL AND METHOD Patients Thirty (56 years ± 10.5) patients of our hospital who underwent both MPS and CT examinations within a 2 weeks intervals, where were referred for the evaluation of known or suspected coronary artery disease (CAD). Acquisition and Data Processing Myocardial perfusion gated‐SPECT images were obtained using dual detector gamma‐camera (Picker Axis 2; Picker International Inc.). With 64x64 matrix, 180º circular orbit, 32 stops, time/projection 60 sec., 8 images/cardiac cycle and ECG 15%. The transaxial images were reconstructed using Filtered BackProjection, Butterworth filter, orders (5) and frequency cutoff (0.55). EF values were automatically calculated by using the Quantitative Gated SPECT (QGS) software. CT coronary angiography was performed using a 64‐slices multidetector CT scanner (Lightspeed VCT; GE Healthcare). All examinations were acquired during suspended respiration, 0.625 mm slice thickness, 120 kV tube voltage, maximum current ranging from 550 to 800 mA., tube current modulation and were performed using retrospective ECG gating. Image data were reconstructed in the short axis of the LV for the evaluation of chamber volume and function using the Card IQ function software (GE Healthcare). RESULTS For each modality of image (MPS and CT) the mean values ± SD of the functional parameters previously mentioned were used, that are LVEF, EDV and ESV. A 2‐tailed t test and Pearson correlation coefficient was used to compare the mean values and to obtain their respective correlation. Table 1 MULTIDETECTOR CT VERSUS MYOCARDIAL PERFUSION gated‐SPECT PARAMETERS CT
SPECT
CORRELATION P*
FE
55,76 ± 12,10 49,34 ± 12,97 0,724
0,002
ESV
69,56 ± 39,85 58,39 ± 39,47 0,913
0,004
EDV
147,26 ± 41,87 107,39 ± 40,37 0,818
<0,001
*P value from paired t test evaluating for the difference in mean values between CT and MPS CONCLUSION According to our initial experience, the main values of LVEF, ESV and EDV in MPS are lower than in CT, because possibly to relative low resolution of MPS images. In addition the values of the FE in women are higher in MPS than in CT, due to the partial volume effect. However, there is a good statistical correlation between the parameters of left ventricular function of both imaging methods.
P058 Clinical application of cardiac SPECT/CT fusion image in patients with severe myocardial ischemia Y. Fukushima, M. Toba, T. Kiriyama, H. Hayashi, K. Cho, S. Mizumura, S. Kumita; Nippon Medical School, Tokyo, JAPAN. Objective: 123‐I‐ BMIPP imaging can estimate myocardial ischemia at rest in patients with severe myocardial ischemia. Recently, cardiac SPECT/CT Fusion imaging by CardIQ FusionTM (GE Healthcare) is available for ischemic heart disease. The purpose of this study is to clarify the usefulness of SPECT/CT Fusion image using 123I‐BMIPP for patients with severe myocardial ischemia. Methods: Consecutive 41 patients (31 men and 10 women; mean age 66 ± 12 years) clinically diagnosed with severe myocardial ischemia were included in this study. The kinds of diagnosis are unstable angina (n = 10), acute myocardial infarction (n = 9), ischemic cardiomyopathy (n = 22). All patients underwent dual isotope SPECT using Tc‐99m‐sestamibi and I‐123‐BMIPP and CT coronary angiography (CTCA) by 64‐slice CT. Interval of both studies was within 3 months. Two experienced nuclear cardiologists analyzed the SPECT image only, non‐ fused SPECT‐MPI and CTCA images (side‐by‐side analysis), SPECT/CT Fusion image with regard to culprit coronary artery. Results: SPECT image revealed defect in 39 patients. Perfusion/Metabolism mismatch is detected in 36 patients. 27 patients had defect in multiple coronary artery territories. A stenosis ≥ 50% was found in 119/627 segments (19%), 38 patients (93%) on CTCA. The remaining 508 coronary segments (81%) were normal or showed only insignificant wall alterations. The fused SPECT/CT interpretation provided added information with regard to 20 lesions in 11 patients and allowed alternation of a relevant lesion in significantly more segments than the side‐by‐side analysis (P < 0.001). Conclusions: Cardiac SPECT/CT fusion imaging provides additional information about hemodynamic relevance lesion interpretation by allowing exact allocation of accumulation defects to its subtending coronary artery even in patients with severe myocardial ischemia.
P059 Comparison Between Coronary Artery Plaque Measures by Multidetector Computed Tomography and Myocardial Perfusion by Single-Photon Emission Computed Tomography in Patients With Suspected Coronary Artery Disease L. Evangelista1, S. Daniele2, W. Acampa1, M. Imbriaco1, T. Pellegrino1, G. Messalli2, E. Xhoxhi1, C. Pagano1, G. Fiumara1, E. Di Giorgio1, R. Simeone1, A. Cuocolo1; 1University Federico II, Napoli, ITALY, 2SDN Foundation, Institute of Diagnostic and Nuclear Development, Napoli, ITALY. Aim: Multidetector computed tomography (MDCT) is useful for the anatomic evaluation of coronary artery disease (CAD). Differently, single‐photon emission computed tomography (SPECT) imaging is indicated to assess the physiologic significance of the disease. The aim of this study was to compare anatomic plaque characterization by MDCT and myocardial perfusion by SPECT in patients with suspected CAD. Material and Methods: We enrolled 135 consecutive patients with suspected CAD who underwent both 64‐slice MDCT coronary angiography and stress/rest Tc‐99m sestamibi SPECT imaging. MDCT plaques distribution and extent were graded by segment involvement score (summation of segments exhibiting any plaque) and by segment stenosis score (summation of luminal obstruction in all coronary segments). MDCT plaque location was assessed with segments‐at‐risk score (plaque extent weighted by proximity) and a modified Duke CAD index. At SPECT, an automated program was used to calculate the variables incorporating both the extent and severity of perfusion defects: summed stress score (SSS), summed rest score (SRS) and summed difference score (SDS). Abnormal SPECT was defined in the presence of SSS>3. Results: SPECT was abnormal in 68 (50%) patients and normal in 67 (50%). In patients with abnormal SPECT, segment involvement score (3.4±2.7 vs. 2.1±2.1), segments‐at‐risk score (7.8±7.4 vs. 3.8±6.3), segment stenosis score (5.2±4.2 vs. 3.0±2.9), and modified Duke CAD index (1.6±1.3 vs. 0.9±0.9) were significantly higher (all P<0.005) compared to those with normal SPECT. At univariate analysis, segment involvement score, segment stenosis score, segments‐at‐ risk score, and modified Duke CAD index resulted significant predictors of presence of abnormal SPECT (P<0.01). At MDCT, 101 (75%) patients did not show severe coronary artery stenosis (<70% stenosis). Of these patients, 59 (58%) had normal SPECT and 42 (42%) abnormal SPECT. Of the 34 (25%) patients with severe coronary artery stenosis (>70% stenosis) at MDCT, 8 (24%) had normal SPECT and 26 (76%) abnormal SPECT. Presence or absence of severe coronary artery stenosis by MDCT correlated to presence or absence of myocardial perfusion defects by SPECT imaging (P<0.001). Conclusion: In patients with suspected CAD, anatomic 64‐slice MDTC measures, including plaque extent, location and composition, are significant predictors of abnormal SPECT findings. However, a substantial number of patients without severe coronary artery stenosis at MDTC has abnormal SPECT findings and, conversely, patients with severe stenosis at MDTC might have a normal SPECT study.
P060
Attenuation correction by CT in SPECT myocardial perfusion imaging: infarct size determination in patients with previous inferior infarct
S. V. Gabanelli1, S. Lucchini1, G. Merli1, E. Puta1, F. Bertagna2, G. Bosio2, B. Paghera3, C. Rodella4, A. Terzi2, A. De Agostini4, R. Giubbini5; 1Chair of Nuclear Medicine, University of Brescia, Brescia, ITALY, 2Nuclear Medicine Unit, Spedali Civili, Brescia, ITALY, 3Nuclear Medicine Unit, Spedali Civili, Brescia, ITALY, 4health physics unit, Spedali Civili, brescia, ITALY, 5Chair of Nuclear Medicine, University of Brescia and Nuclear Medicine Unit, Spedali Civili, brescia, ITALY. PURPOSE: Diaphragmatic attenuation determines artefacts that frequently affects the evaluation of the inferior wall, specially in male pts. Attenuation correction (ATC) has been shown to improve the accuracy of myocardial perfusion single photon emission computed tomography (SPECT) for the evaluation of patients with coronary artery disease. Aim of this study was to define the value of ATC for the assessment of infarct size in CAD patients with previous inferior infarct. MATERIALS AND METHODS: gated‐SPECT with ATC by hybrid SPECT/CT was performed in 59 patients (53 M, 6 F) with documented previous inferior MIs. SPECT images were reconstructed in two methods: corrected and uncorrected for attenuation. Both SPECT images were analyzed for regional perfusion using a 5‐point segmental scoring scale from 0 (normal) to 4 (absent). Summed Stress Score (SSS), Summed Rest Score (SRS) and Summed Difference Score (SDS) of the inferior LV wall (inferoseptal, inferior, infero‐apical and infero‐lateral segments) were determined and compared (corrected versus uncorrected images); SSS, SRS of the inferior wall and SDS were compared with the regional wall motion score as determined by uncorrected gated‐SPECT. RESULTS: The inferior wall SSS, SRS, SDS for ATN uncorrected and correct images were 14.02±7.9, 9.5±7, 4.5±3.2 and 9.4±7.1, 5.6±6.1, 3.8±2.8, respectively. Differences were statistically significant (p<0.0001) for SSS and SRS but not for SDS. The ATN corrected infarct size (SRS) showed a better correlation with the regional wall motion score R=0.71 in comparison to uncorrected SRS, R=0.68. CONCLUSIONS: Diaphragmatic attenuation determines an artifactual overestimation of infarct size in inferior infarcts, as shown by comparison between corrected and uncorrected SSS and SRS . ATN corrected infarct size (SRS) better correlates with regional wall motion score of the inferior wall in comparison to uncorrected SRS. ATC does’ not affect detection and size of residual peri‐infarctional ischemia (SDS).
P07 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Cardiovascular: miscellaneous
P061 Assessing the Adriamycin Induced Early Cardiotoxicity by Estimating Left Ventricular Ejection Fraction using Tc-99m Multi- Gated Acquisition and Echocardiography N. Fatima, M. Zaman, A. Hashmi, S. Kamal, A. Hameed; Karachi Institue of Radiotherapy and Nuclear Medicine, Karachi, PAKISTAN.
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P062 13
N-ammonia Enables Quantification of Left Ventricular Volume and Left Ventricular Ejection Fraction in Rats using ECG-gated micro-PET
S. Kruizinga1, R. H. J. A. Slart1, L. Stegger2, R. A. Tio1, M. K. Szymanski1, R. G. Schoemaker1, D. van Veldhuisen1, R. A. Dierckx1, M. A. Schäfers2, H. L. Hillege1; 1University Medical Center Groningen, Groningen, NETHERLANDS, 2University Hospital Münster, Münster, GERMANY. Aim: Measuring left ventricular volumes (EDV, ESV) and ejection fraction (LVEF) with gated positron emission tomography (PET) is a novel tool to monitor cardiac function in small animal models. 13N‐ammonia is mainly used for quantification of myocardial perfusion, but data on LV‐ function assessment in rats using gated 13N‐ammonia is lacking. The aim of this pilot study was to evaluate gated 13N‐ammonia for quantification of LV volumes and LVEF in rats, using 18F‐FDG as a reference. Materials & Methods: Both 13N‐ammonia and 18F‐FDG were injected intravenously into control Wistar rats (n=5) and Wistar rats with myocardial infarction (MI) (n=4). Scans were obtained using a small‐animal PET scanner. After acquisition scans were reconstructed into 8 ECG‐gated bins. A validated 3‐dimensional segmentation algorithm was used to identify the endocardial contours to calculate LV volumes. Bland‐Altman analyses were used to compare results obtained with the two tracers. Agreement was defined as mean difference ± 1.96 SD. LV volumes and LVEF of different groups for both tracers are shown as mean ± SD. Results: In control animals values for EDV were 0.44 ± 0.08 mL and 0.47 ± 0.12 mL, whereas ESV values were 0.09 ± 0.06 mL and 0.10 ± 0.04 mL for 13N‐ammonia and 18F‐FDG respectively. LVEF values of 13N‐ ammonia were 80.5 ± 7.7%, compared to 80.8 ± 6.6% as obtained with 18F‐FDG. In MI animals EDV values were 0.88 ± 0.20 mL and 0.84 ± 0.25 mL, whereas ESV values were 0.47 ± 0.12 mL and 13 18 13 0.41 ± 0.13 mL for N‐ammonia and F‐FDG respectively. Values of LVEF using N‐ammonia were 45.9 ± 5.5%, whereas 18F‐FDG rendered values of 51.2 ± 9.4%. Measures of 13N‐ammonia 18 and F‐FDG showed strong correlations for LV volumes (r=0.67 for EDV) (r= 0.70 for ESV) and LVEF (r= 0.81). In the complete group the Bland‐Altman analysis indicated that the 95% limits of agreement between 13N‐ammonia and 18F‐FDG for measuring EDV ranged from ‐0.31 to 0.32 mL with a difference of 0.001 ± 0.16 mL. For ESV these limits ranged from ‐0.26 to 0.21 mL with a difference of ‐0.02 ± 0.12 mL. For measures of LVEF agreement ranged from ‐14.1 to 19.2% with a difference of 2.6 ± 8.5%. Conclusions: In this pilot study quantification of LV volumes and LVEF in rats using 13N‐ammonia showed a high accuracy and acceptable agreement with 18F‐FDG.
P063 Comparison of angiographic Findings with scintigraphic and stress-electrocardiographic (ECG) tests in Cardiac Syndrome X (CSX): a three-year follow-up study 1
2
2
3
1
1
M. Assadi , M. Yaghoubi , S. Arefi , M. Saghari , I. Nabipour , M. Pourbehi , M. Eftekhari3; 1The Persian Gulf Biomedical sciences Institute, Bushehr University of Medical Sciences, Bushehr, IRAN, ISLAMIC REPUBLIC OF, 2 Department of Cardiology, Shariati Hospital, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF, 3 Research Institute for Nuclear Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF. Aim: Cardiac syndrome X (CSX) is defined by an angina‐like chest pain, a positive response to stress testing and normal or near normalcoronary angiogram. Limited studies with angiography on this syndrome have indicated some abnormal findings. We evaluated the angiographic findings in these patients. Material and methods: Fifty‐two CSX patients were enrolled in this study. By reviewing the angiographic film, some variables including stenosis (less than 40 % of vessel diameter), diminutive, delay run off, delay wash out, calcification and tortusity were evaluated. All have been undergone on MPI (myocardial perfusion imaging) and stress‐ ECG (electrocardiography ). The subjects were followed up for three years. Statistical analysis was carried out using Chi square and T tests. Results: The study included 39 females aged 40‐58 years (mean, 49.79 ± 4.69 [SD] y) and 13 males ranging from 40 to 54 years (mean, 47.54 ± 3.76 [SD] y) with CSX. The most frequent abnormal angiographic finding in three territories was stenosis item.
Twenty ‐two (42%) of all 52 CSX patients had ischemia on MPI and also 13 (25%) cases had positive stress ECG test. The results of the stress‐ ECG and myocardial perfusion imaging were not concordant with six angiographic findings. In three years follow up, there was no cardiac event. Conclusion: We suggest that the presence of angiographic coronary findings such as stenosis, diminutive, delay run off, delay wash out, calcification and tortusity are not invariably associated with atherosclerosis, and also seen in CSX patients. The absence of cardiac event for three years may indicate good prognosis in cases with and without angiographic, scintigraphic and stress ECG findings in this population .However, well designed studies are needed to confirm these results .
P064 Labelled Red cell Radionuclide Venography for detection of deep venous thrombosis: Does SPECT-CT improve the planar imaging interpretation? S. K. Gupta, Q. Chiam, H. Dixson, M. Dobson, M. Lee, C. Bui, K. Lee; Department of Nuclear Medicine and Ultrasound, Bankstown-Lidcombe Hospital, Sydney, NSW, AUSTRALIA. Introduction: Labelled‐red‐cell radionuclide venography (RNV) is a sensitive and specific non‐ invasive test for the diagnosis of deep venous thrombosis (DVT). However planar RNV has lower resolution and has been largely surpassed by duplex doppler ultrasound (US) and CT & MRI venography. With the emergence of SPECT‐CT co‐registration, improvement in accuracy and reporting confidence for nuclear medicine studies has been described. The aim of this study was to assess the effects of the addition of SPECT‐CT on interpretation, change of diagnosis and confidence of reporting in equivocal planar RNV images. Methods: Patients with either suboptimal US (large patients and in those with oedematous or painful limbs), or relative contraindications (suspected thrombus in pelvic vessels, limbs in cast) were selected. A total of 49 regions (seven regions in seven patients; Mean age 74 years) were assessed. The regions assessed for each patient were each calf, thigh and pelvis and the inferior vena cava (IVC). Anterior and posterior planar imaging and SPECT with low dose non‐contrast CT (Philips Precedence) of the equivocal regions on planar studies were performed after autologous 99m‐Tc labelled red cell (1GBq) administration. US results of nine regions, assessed within one day of RNV, were also available for comparison. Results: The planar studies were considered diagnostically suboptimal in 27% of the regions (calf: 14%; thigh: 0%; pelvis: 50%; IVC: 57%). With SPECT‐CT, these regions were considered sufficiently interpretable. SPECT‐CT changed the diagnosis made by planar imaging in 33% of the regions. The diagnostic confidence of reporting physicians improved for 96% of all studied regions; this was attributed to improved contrast resolution, more clearly delineated focal filling defects, removal of attenuation artefacts and anatomical localization of focal filling defects to the veins. The mean radiation dose from low dose CT of the pelvis measured 2.3 mSv. For the nine regions that were also assessed with US, an overall 78% agreement in RNV and US findings was found. Conclusion: Addition of SPECT‐CT to planar RNV eliminated equivocal studies, led to substantial changes in diagnosis and improved the confidence of reporting physicians. SPECT‐CT was found to be particularly useful in the assessment of pelvic veins and the IVC.
P065 Qp/Qs by First Pass Radionuclie Ventriculography in the evaluation of inter-auricular communication correction. M. Barios, S. Aguadé-Bruix, E. Galve, V. Aliaga, J. Candell-Riera, J. CastellConesa; Hospital Universitari Vall d'Hebron, Barcelona, SPAIN. Objective: Analyse the usefulness of First Pass Radionuclie Ventriculography (FPRV) in detection of persistent residual shunting in patients with Inter‐auricular Communication treated with percutaneous or surgical interauricular communication (IAC) closure. Methods: The study consisted in a retrospective analysis of 110 patients with IAC (79 females, age: 39.7±16.8 years). FPPAS was performed before and after IAC closure. At the diagnosis, the average of Qp/Qs ratio was 2.35±1.05 (1.3‐7.4). The IAC closure was done 1.2±0.8 years after the diagnosis. The post‐ treatment FPRV was performed 2.25±1.67 years after the diagnosis. A fast i.v. bolus of 99mTc‐ DTPA (370 MBq) was administered and simultaneous dynamic 4 frames/s, in 64x64 matrix, during 45 seconds were acquired. The Qp/Qs ratio was calculated using Maltz‐Treves methodology, with fitting a gamma function. Results In all patients, FPRV was useful to obtain QP/QS index, before and after treatment of the IAC. After IAC closure, the average of Qp/Qs ratio was 1.11± 0.13. In 6 patients the Qp/Qs ratio was greater than1.3 (indicative of shunt persistence). These diagnosis were confirmed with the Doppler echocardiography. In other 7 patients the Qp/Qs ratio was between 1.2 and 1.3, two of them (both with Qp/Qs greater than1.27) had persistent residual shunt by Doppler echocardiography . Conclusions: FPRV is a good technique to confirm a successful closure of IAC and to detect and quantify the persistence of residual shunting.
P066 First Pass radionuclide ventriculography for the assessment of Qp/Qs ratio in patients with corrected interauricular communication: normal limits and variabilty. M. Barios, S. Aguadé-Bruix, F. Dellepiane, G. Cuberas, E. Galve, V. Aliaga, J. Candell-Riera; Hospital Universitari Vall d'Hebron, Barcelona, SPAIN. ObjectIve: To establish the normal limits of Qp/Qs ratio and the inter‐assay variability of the first pass technique (FPASS), in patients with corrected inteauricular communication (IAC). Methods: this study consisted in a retrospective analysis of 38 patients (26 females, age: 39.4±15.3 years) treated with percutaneous or surgical closure of IAC. We performed two post‐treatment studies in the follow‐up. The first control with a FPASS was acquired 1.2±0.51 years after the treatment and the second control was performed 4.46±1.81 years after the first control. A fast i.v. bolus of 99mTc‐DTPA (370 MBq) was administered and simultaneous dynamic 4 frames/s, in 64x64 matrix, during 45 seconds were acquired. The Qp/Qs ratio was calculated using Maltz‐Treves methodology, with fitting a gamma function. Results: Any patient presented residual IAC by echocardiography or MRI. In the first control the average of Qp/Qs ratio was 1.075±0.047 (1‐ 1.19). In the second control the average was 1.070±0.051 (1‐1.25). The inter‐assay variability (coefficient of variation) of the Qp/Qs ratio was 2.99%. No statistical differences were found between the two series. The determination of the upper normal limit was 1.175 (percentile 95)
Poster Presentation
Introduction: Adriamycin cardiac toxicity begins with the first dose of therapy. The insult may be subclinical initially, but with continued treatment can result in clinical Congestive Heart Failure. Therefore a study was performed to evaluate sensitive marker for the detection of early cardiotoxicity of Adriamycin in order to prevent irreversible cardiomyopathy. Objectives: The study assessed the Adriamycin induced early cardiotoxicity by Left ventricular Ejection Fraction (LVEF) estimation using Tc‐99m Multi‐Gated Acquisition (Tc‐99m MUGA) scan and Echocardiography (ECHO); determined the comparison of ECHO with Tc‐99m MUGA. Setting and duration of study: The study was conducted at Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN) from November 2006 to July 2007. Subjects & Methods: The cardiac function was assessed on 42 patients (age range15‐60 yrs) suffered from different types of cancer and received Adriamycin in higher doses (average 95.2 ± 6.82 mg/m2) either alone or in combination with 5‐Flourouracil and Cyclophosphamide in each of six cycles. The %LVEF was determined as a baseline, after every successive cycle simultaneously by; (1) Tc‐99m MUGA scan; and (2) ECHO. Tc‐99m MUGA was chosen as reference method. Criteria for the early cardiotoxicity was defined as decline in %LVEF≥10 units from baseline, or absolute fall in %LVEF to a final value <50%. Results: There was a significant decline in %LVEF of 12.17± 5.01 and 9.26 ± 4.82 (p‐value<0.001) from baseline to the end of 6th cycle of Adriamycin therapy as estimated by Tc‐99m MUGA and ECHO respectively. The 13/42 (31%) patients developed protocol defined cardiotoxicity as determined by Tc‐99m MUGA scan while ECHO determined in 6/42 (14%) patients. The incidence of cardiotoxicity was 2.4%, 2.4%, 4.8%, 16%, and 31.2% at the median cumulative Adriamycin dose of 210 mg/m2, 380 mg/m2, 450 mg/m2, 550 mg/m2 and 615 mg/m2 respectively. The regression equation of the ECHO against the Tc‐99m MUGA was Y=0.638x + 24.784 (r = 0.78). Conclusions: Subclinical adriamycin cardiotoxicity was detectable from 3rd cycle and if not detected earlier continued therapy may progress to severe and irreversible. A decline of ≥5 units of %LVEF instead of 10% LVEF should be considered significant marker of subclinical cardiotoxicity. MUGA is more sensitive than ECHO for estimation of subtle changes in %LVEF. Ideally %LVEF must be determined at baseline and after every cycle, if not possible then preferably from 3rd cycle onward. Key Words: Cardiotoxicity, Adriamycin (Adriamycin), Left Ventricular Ejection Fraction (LVEF), Tc‐99m Multiple Gated Acquisitions (Tc‐99m MUGA).
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and 1.196 using the value average + 2.5SD. Conclusions: First pass ventriculography is a reproducible technique. In our hands, the normal upper limit was 1.2.
P067 Scintigraphic evaluation acetylcysteine
of
renal
protective
effects
of
J. V. Vesnina, E. V. Rybalchenko, Y. B. Lishmanov; Institute of cardiology, Tomsk, RUSSIAN FEDERATION. Aim. Using radionuclide renoscintigraphy to research nephroprotective effects of acetylcysteine in patients undergoing contrast angiography. Material and methods. Thirty six patients (median age 55,58 ± 1,35 years) were examined before and 1‐2 days after coronary angiography (CAG) using radionuclide renoscintigraphy. As radiocontrast Iobitridole was used. Patients were randomized in two groups: 18 pts (group I) were undergoing CAG without prophylactic taking the acetylcysteine; and 18 pts (group II) receiving 2400 mg of acetylcysteine, given orally in divided doses on the day before and on the day of the radiocontrast procedure. The parameters of filtration and excretory renal functions were estimated. Results. In pts of group I after CAG negative dynamics of the parameters of renal filtration activity was revealed. Thus, significant decrease of the mean value of glomerular filtration rate (GFR) and significant delay of blood clearance took place. What is more, in pts of group I significant increase of mean values of parenchyma and collecting system clearance half‐time was noted. In group II the parameters of renal filtration function were not statistically significant change as compared with initial (before CAG) values. Thus, the mild degree disorder of filtration function under influence of contrast agent only in 5 pts was noted. At the same time in group II negative changes of excretory processes in parenchyma and collecting system were more frequently as compared with filtration activity. But these changes were not statistically significant. Conclusion. Oral acetylcysteine may prevent contrast‐induced nephropathy in patients undergoing radiocontrast procedure.
P068 Evaluation of myocardial perfusion and function by gated SPECT in patients with Obstructive sleep apnea syndrome S. S. Cerci, S. Saglam, O. Ozturk, U. Sahin, M. Yildiz, N. Songur; Suleyman Demirel University, Isparta, TURKEY. Background: Obstructive sleep apnea syndrome (OSAS) is a syndrome characterized by repeated episodes of the upper respiratory tract obstruction during sleep and plays an important role in the pathophysiology of cardiac and vascular disease. Objective: The aim of this study was to determine the prevalence of myocardial perfusion defects and to evaluate left ventricular functions by using gated myocardial perfusion SPECT in obstructive sleep apnea patients. Methods: 57 consecutive cases admitted to the sleep laboratory with symptoms of nocturnal snoring and/or excessive daytime sleepiness. Subjects were classified according to severity of OSAS by using apnea‐hypopnea index (AHI). Thirteen subjects with AHI<5 were considered as OSAS (‐) control group (Group1). Patients with AHI≥5 were accepted as OSAS and classified according to their AHI as mild‐to‐moderate (AHI≥5 and AHI <30) (Group2) and severe (AHI ≥30) OSAS groups (Group3). Stress and rest Tc‐99m MIBI gated SPECT studies were performed in a 2‐ day protocol. Semiquantitative visual interpretation of myocardial perfusion images was done by consensus of two experienced interobservers who were unaware of the patient’s group. Stress and rest left ventricular ejection fraction (SLVEF, RLVEF), left ventricular end‐systolic volume (ESV), and left ventricular end‐diastolic volume (EDV) were calculated. Using non‐gated SPECT images myocardial perfusion scores [summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS)] and perfusion defect extent as percentage [stress (%SS), rest (%RS), ischemic (%DS)] were determined. %SS, %RS classified as normal (0‐4), mild (5‐9), moderate (10‐14), severe (>14) Results: The mean ages of groups 1, 2, 3 were 46.84±6.37, 49.88±8.02, and 49.00±8.56 years respectively. Perfusion defect extent (%SS, %RS, %DS) of group 1 was also found different when compared with group 2 (P=0.000, P=0.006, P=0.001) and group 3(P=0.000, P=0.000, P=0.019). But there was no significant difference between myocardial perfusion parameters of group 2 and 3. Any statistically difference was not observed in stress and rest left ventricular ejection fractions and ESV, EDV among the three groups (P>0.05). Conclusion: Although in OSAS positive patients, abnormalities were detected in left ventricular myocardial perfusion, it was observed that left ventricular functions were not affected from OSAS.
P069 The relationship between Tc-99m MIBI myocardial perfusion SPECT findings and levels of C - reactive protein in Patients with obstructive sleep apnea S. S. Cerci, O. Ozturk, S. Saglam, U. Sahin, M. Yildiz, N. Songur; Suleyman demirel university, Isparta, TURKEY. Background and aim: Inflammation has been shown to be an important component in the progression of cardiovascular disease. The combination of hypoxemia and sleep deprivation characterizes patients with obstructive sleep apnea (OSA) and may lead to increased levels of inflammatory markers in these patients. C ‐ reactive protein (CRP) is a nonspecific marker of inflammation and may contribute to vascular disease. In this study, we aimed to determine the effects of OSA on myocardial perfusion and level of CRP and to investigate a relationship between Tc‐99m MIBI myocardial perfusion SPECT findings and CRP levels. Methods: The studied 57 subjects who were referred to sleep laboratory for suspected OSA. Subjects were classified according to severity of OSA by using apnea‐hypopnea index (AHI). Thirteen subjects with AHI<5 were considered as OSA (‐) control group (Group1). Patients with AHI≥5 were accepted as OSA and classified according to their AHI as mild‐to‐moderate (AHI≥5 and AHI <30) (Group2, n: 25) and severe (AHI ≥30) OSA groups (Group3, n: 19). Tc‐99m MIBI myocardial perfusion SPECT was performed at stress and rest in a 2‐day protocol. Using SPECT images myocardial perfusion scores [summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS)] and perfusion defect extent as percentage (stress, rest, ischemic % LV) were determined. Serum levels of high‐sensitivity CRP were measured in all subjects. Results: The mean CRP levels of the groups were 3.76±4.47, 4.26±4.08, 4.23±4.35 respectively and there were no significant difference between groups. Myocardial perfusion scores (SSS, SRS, SDS) of group 1 was significantly different from both of group 2 (P=0.000, P=0.006, P=0.001) and group 3 (P=0.000,
P=0.000, P=0.019). Perfusion defect extent as percentage (stress, rest, ischemic % LV) of group 1 was also found different when compared with group 2 (P=0.000, P=0.006, P=0.001) and group 3(P=0.000, P=0.000, P=0.019). But any significant difference in myocardial perfusion parameters of group 2 and 3 were not observed. There were no correlation between high‐sensitivity CRP and quantitative parameters of myocardial perfusion scintigraphy of all groups, whereas a positive correlation was observed between AHI and CRP levels (r=0.47, p=0.038) in severe OSA group. Conclusion: While statistical difference in myocardial perfusion parameters of OSA negative and positive patients were determining, any significance in high‐sensitivity CRP levels did not observe.
P070 Left and Right Ventricular Normal Limits for Gated Blood Pool SPECT Studies Processed with QBS Software D. Daou1, M. Tawileh1, C. Coaguila2; 1Cochin Hospital, Paris, FRANCE, 2 Centre Hospitalier Sud Francilien, Corbeil Essonnes, FRANCE. Aims: Gated blood pool SPECT (GBPS) radionuclide angiography (RNA) is useful for the evaluation of left and right ventricular (LV, RV) function. It can be processed with the QBS software. Its recent version, QBS allows the measurement of LV and RV function based on 2 different methods: its previous gradient method (Gd) and the newly added maximal activity threshold method (MAT). We aimed to define the normal limits of LV and RV ejection fraction (EF) and end 2 diastolic and end systolic volumes indexed to body surface area (EDVi, ESVi, ml/m ). Materials and Methods: Were included 79 patients free of cardiac disease addressed for a baseline RNA study before chemotherapy. Age was 55±14 years, heart rate 74±14 beats/min, systolic arterial pressure 125±22 mmHg, 99m‐Tc injected dose 880±210 MBcq and 43% were male. GBPS RNA was processed with the QBS software: LV and RV EDVi, ESVi with both Gd (EDVi‐Gd, ESVi‐Gd) and MAT (EDVi‐MAT, ESVi‐MAT) methods were calculated as well as LV and RV EF based on MAT as the ratio of volumes (LVEF MAT‐V) and as the ratio of activities (LVEF MAT‐A) and LVEF based on Gd as the ratio of Gd volumes (LVEF‐Gd). Stepwise linear regression was realized to study the correlation between LV and RV global function parameters versus gender, age, heart rate (HR), systolic blood pressure, and 99m‐Tc injected dose. Values are reported as mean±SD. Results: LVEF for MAT‐A, MAT‐V, and Gd methods were: 77±8%, 67±8%, and 69±8% respectively. For RVEF these were: 52±12%, 45±11%, and 46±10% respectively. For MAT‐V and Gd methods, LV EDVi were 78±15 and 55±12 ml/m2, LV ESVi were 26±9 and 17±7 ml/m2, RV EDVi were 104±25 and 75±18 ml/m2, and RV ESV were 56±13 and 40±10 ml/m2 respectively. LVEF‐MAT‐A, LVEF‐ MAT‐V, LVEF‐Gd were only correlated to age: r=0.32, r=0.32, and 0.40 respectively (P<0.004). RVEF‐MAT‐A, RVEF‐MAT‐V, and RVEF‐Gd were only correlated to HR: r=0.39, r=0.36 and r=0.39 respectively (P<0.001). LV EDVi‐Gd (but not LV EDVi‐MAT), LV ESVi‐MAT and LV ESVi‐Gd were correlated only to age: r= ‐0.25, r= ‐0.34 and r= ‐0.35 (P<0.03). RV EDVi‐MAT and RV EDVi‐Gd were gender specific (P<0.03). RV ESVi‐MAT and RV ESVi‐Gd were only correlated to HR: r= ‐0.37 and r= ‐42 (P<0.001). Conclusions: We defined normal values for LV and RV EF, EDVi and ESVi for the different methods of calculation provided by the recent version of QBS software. Our results need to be confirmation in larger studies.
P071 Investigating the correlation between the difference in the oxygen saturation, measured erect and supine, and the radioisotope right-left shunt measurements in patients with pulmonary arteriovenous malformations N. Tunariu, B. Ariff, S. Khan, C. Shovlin, A. Al-Nahhas; Imperial College NHS Trust, London, UNITED KINGDOM. Aim: To assess the correlation between the differences in pulse oximetry (PO) measured on air in the erect and supine positions with the radioisotope measurement of right to left (R‐L) shunts in the routine evaluation of the pulmonary arteriovenous malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT). Methods: We randomly selected 30 patients with HHT who had routine serial measurements of the following: (1) arterial oxygen saturation (SaO2) by PO in erect and supine positions and (2) quantitative radioisotope measurements of R‐L shunt using IV 99mTc‐labeled macroaggregates of albumin (MAA). Each patient had their O2 saturation measured for 10‐11 minutes and the mean value for the entire duration was calculated in the supine and erect positions. 16 patients had measurements performed pre‐ and post‐ embolisation. Differences between the erect and supine O2 saturation were assessed using Wilcoxon matched pair’s test and presented as mean difference (95% CI) p value. Correlation between the differences in PO and the shunt measured using IV 99mTc‐MAA (calculated as a percentage of cardiac‐output/dose (CD) and as a percentage of cardiac‐output/lungs (CL)) was assessed using Spearmans correlation (r ; p value). Results: There was a significant difference between the O2 saturation measured erect and supine (mean difference = ‐ 0.5% (‐0.86, ‐0.02); p = 0.002); n = 68. A significant correlation was found between the absolute difference in PO (measured erect and supine) and the shunt size measured using 99mTc‐MAA calculated using CL, albeit weak (r = 0.3; p = 0.03), but not with CD (p = 0.08).
P072 The value of perfusion lung scintigraphy and first pass radionuclide angiography in evaluation of right ventricle function and pulmonary microcirculation in children with pulmonary hypertension associated with congenital heart disease Y. B. Lishmanov, K. W. Zavadovskiy, N. G. Krivonogov; Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. Aim. To investigate the right ventricle function and regional lung perfusion in children with congenital heart disease (CHD) and pulmonary hypertension. Material and methods. We examined 45 septal defects patients (aged 5‐17) with mean pulmonary artery pressure (PAP) 68,7±33,5 mmHg. The first‐pass radionuclide angiography (FPRA) was performed with 99mTc‐ DTPA 0.5‐1.0 MBq/kg. We performed FPRA thrice: at rest; 3 min after sublingual administration of 10 mg nifedipine; one hour after i.v. administration of enalaprilate (Enap 1.25 mg in drops). The time of radionuclide bolus transit throughout arterial (TAM) and venous (TVM) sections of
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P073 Extracardiac finding on G-SPECT MUGA studies for left ventricular function J. D. Birchall, N. Storry, I. Jones; Royal Derby Hospitals NHS Foundation Trust, Derby City General Hospital, Derby, UNITED KINGDOM. Aim and background: G‐SPECT MUGA is an evolution of the planar LAO MUGA scan performed post in vivo labelling of red blood cells with Tc99m pertechnetate following prior administration of tin chloride. Its may advantage is that one assess both ventricles function rather than the right ventricle alone. Knowledge of an accurate assessment of the left ventricular ejection fraction is essential in the patient with cardiac failure and also in the patient receiving cardiotoxic chemotherapy. In manner similar to sestambi /tetrofosmin myocardial perfusion scintigraphy upon review of the acquisition data and or body SPECT reformat one can perceive extra cardiac finding. Method: Retrospective review of 3 years studies and review of both SPECT acquisition data on cine and body reformats post iterative (OSEM) reconstruction ( 2 iterations 10 subsets) to assess the presence of extracardic findings. Results: 197 G‐SPECT MUGAs were performed, 41 on patients receiving chemotherapy for known tumours and 156 in patients referred by cardiologists for assessment of left or right ventricular function. Breast cancer was the most common cancer diagnosis (20 patients 48.7%) followed by lymphoma (5 patients 12.1%). Three of the oncology patients had increased uptake corresponding to hepatic deposits, 4 had areas of reduced uptake corresponding either to a large tumour with central necrosis (liposarcoma), a pleural effusion (mesothelioma), and 2 with ascites with peritoneal deposits (ovarian cancer). In the cardiac referrals one patient’s known extensive varices were evident and in an other patient increased uptake corresponding to the site of a suspected phaeochromocytoma on CT. Eight patients (had finding not previously revealed, 3 abdominal aortic aneurysms, 2 reduced uptake to a kidney and 3 increased uptake within hepatic haemangiomata confirmed on US. Conclusion: Labelled RBC SPECT in the oncology patients can reveal both lesions that have a high blood pool eg hepatic deposits and also those that do not such as mucinous deposits from ovarian carcinoma. Such an imaging approach could offer a cheap and readily available method of assessing the effect of anti‐anti‐genesis drugs on tumour blood volume. In cardiac patients whole body review was most valuable in assessing other aspects of cardiovascular health presence of aortic aneurysms and change in relative renal function.
P074 Multivariate analysis of a clinical-practice Gated Myocardial Spect database by means of quantification and biplot display. R. Ruano1, M. Diego2, A. Martin1, F. Gomez-Caminero1, P. Tamayo1, P. Garcia-Talavera1, D. Garcia1, G. Correa2; 1Universitary Hospital. Nuclear Medicine Department, Salamanca, SPAIN, 2Universitary Hospital. Cardiology Department, Salamanca, SPAIN. Background: routine clinical practice creates a huge amount of useful data that may not match up with those originated by clinical trials, which are the ones usually reported in scientific papers and used to define clinical guidelines. A comprehensive analysis of these data would improve the knowledge that clinicians would have about the "real‐world" population.It is our aim to present a suit of multivariate statistical techniques appropriate for analysing clinical‐practice databases, using all the available information, that is, without sacrificing any patient or any variable. Methods: we analysed our clinical‐practice Gated Myocardial Spect database of 6965 patients with perfusion test done for ischemic cardiopathy certain or suspected. We used two sequential methods to deal with the data. Firstly, we quantified the multivariate system in order to transform it into a linear one so that any linear multivariate technique could be applied. Secondly, we used a biplot display adapted to deal with the missing data, so that a display of patients and variables could be attained without sacrificing any row or any column. Results: Necrosis and Ischemia were the main agglomerative factors in the first factorial plane of the biplot display. Summed rest scores (SRS), Ejection Fraction and left ventricle volumes appeared closely related with Necrosis; whereas summed difference scores (SDS) and transient ischemic dilatation exhibited high correlations with Ischemia. Related to both, necrosis and ischemia, were Summed Stress Scores (SSS), number of segments and number of coronary vessels affected. We found a high negative correlation between stress and rest left ventricular ejection fractions and the stress and rest ventricular volumes (diastolic and systolic). Conclusion: The use of the mixed multivariate system and low‐dimensional representation of the quantified system by means of a biplot display adapted to deal with missing data, showed to be an effective way to simultaneously analyse all the available information in a clinical‐practice database for ischemic cardiopathy. This analysis revealed the main patterns of ischemia and necrosis of the studied population.
P075 Selection of scaling variable for cardiac size normalization depends on the dimension of the cardiac variable being scaled : evidence from radionuclide ventriculography (RNV) data in children
G. Arsos1, E. Moralidis2, C. Sachpekidis1, V. Sachpekidis3, D. Ekklisiarchos4, C. Karakatsanis1; 1Dept of Nuclear Medicine, Hippokration Hospital, Thessaloniki, GREECE, 2Dept of Nuclear Medicine, AHEPA Univ. Hospital, Thessaloniki, GREECE, 3Dept of Cardiology, King's College Hospital, London, UNITED KINGDOM, 42nd Cardiology Clinic, Hippokration Hospital, Thessaloniki, GREECE. Background ‐ Aim : As heart growth and development parallel changes in body size during childhood, normalization of cardiac size to body size is necessary for both between‐studies comparability and determination of abnormality threshold. Body weight (BW) is a simple, metabolically meaningful measure of body size. However, using the echocardiographically determined left atrial dimension (LAD, in mm) in children, substantial residual correlation of the LAD/BW ratio to BW was found and BW was reported as inappropriate scaling variable for per ratio cardiac to body size normalization (Neilan TG et al. 2009). Diminishing or removal of residual association after indexing is a hallmark of successful indexing. Left ventricular (LV) volumes (in ml) can be conveniently assessed by RNV. The aim of the present study is to explore the appropriateness of BW as a scaling variable of cardiac size in children when dealing with volumes rather than linear cardiac variables. Patients and Methods : Two hundred twenty four cardiac disease‐free children and adolescents, aged 1.5 months‐18 years, weighing 4.5‐120 kg, submitted to RNV either before initiating potentially cardiotoxic chemotherapy or as childhood malignancy survivors. LV end diastolic volume (LVEDV) was calculated using a previously validated count ratio‐based method (Massardo T et al. 1995). Equivalent LV diameter (LVEQD, in mm) was calculated as the diameter of a sphere isovolumic to LVEDV. Per‐ratio indexing included the LVEDV/BW and LVEQD/BW ratios. The association between BW and LVEDV or LVEDV/BW was assessed by ordinary linear regression analysis and that between BW and LVEQD or LVEQD/BW by fitting allometric (power) functions of the form : Y = aBWb , where Y the cardiac size variable. Results : The Pearson’s correlation coefficient (r) for BW‐LVEDV and BW‐LVEDV/BW correlations was 0.817 and 0.008 respectively, showing removal of the correlation with BW after indexing to it. In agreement to Neilan’s findings, r values for BW‐LVEQD and BW‐LVEQD/BW correlations were 0.883 and ‐0.967 respectively, indicating a paradoxe strengthening of the association after indexing. Conclusions : Our findings indicate that the appropriateness of BW for cardiac size indexing purposes depends on the dimension of the cardiac parameter being indexed. Three‐ dimensional cardiac parameters (volumes), dissimilarly to the linear ones, can be indexed by BW. These results call for attention in the selection of indexing parameters.
P08 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: central nervous system tumours
P076 FDG-PET predicts survival following anti-angiogenic therapy in recurrent high-grade gliomas C. Colavolpe1, E. Guedj1, J. Mancini2, C. Bequet-Boucard3, P. Metellus4, M. Barrie3, D. Figarella-Branger5, O. Chinot3, O. Mundler1; 1Department of Nuclear Medicine, CHU Timone, Marseille, FRANCE, 2Department of Public Health, CHU Timone, Marseille, FRANCE, 3Department of Neuro-oncology, CHU Timone, Marseille, FRANCE, 4Department of Neurosurgery, CHU Timone, Marseille, FRANCE, 5Department of Neuropathology, CHU Timone, Marseille, FRANCE. Aim To assess the independent prognostic value of 18F‐Fluoro‐Deoxy‐Glucose Positron Emission Tomography (FDG‐PET) on Overall (OS) and Progression Free Survival (PFS) of recurrent high‐ grade gliomas (HGG) treated with bevacizumab and irinotecan (B/I), in comparison with the other prognostic factors at recurrence. Materials & methods We retrospectively included 32 patients with histologically‐proven recurrent HGG ‐ 24 glioblastomas multiforme (GBM) et 8 anasplastic gliomas (GA) ‐ who underwent FDG‐PET within three months before starting chemotherapy with B/I. FDG uptake before anti‐angiogenic therapy was assessed by the T/CL ratio between tumour and symmetric controlateral maximal Standardized Uptake Value (SUV). OS and PFS following B/I therapy were determined by Kaplan‐Meier analysis and compared to FDG uptake by univariate and multivariate analysis, including the following prognostic factors : Karnofsky Performance Status (KPS), histological grade, corticotherapy and number of previous treatments. Results Median PFS and OS of the whole group were 4.1 months (range 3.8‐4.5) and 6.9 months (range 6‐ 7.8) respectively. T/CL uptake ratio was the only significant prognostic factor on PFS (p=0.009;HR=2.3) and OS (p=0.002;HR=3.1). T/CL ratio remained significant in multivariate analysis independently from KPS, histological grade, corticotherapy and number of previous treatments (p=0.004 and p=0.002 for PFS and OS respectively). Tumour maximal SUV had lower prognostic value on OS (p=0.037; HR=1.1) and tended to predict PFS (p=0.087). Conclusion The ratio between tumour and controlateral FDG uptake before anti‐angiogenic therapy independently predicts overall and progression free survival in recurrent high‐grade gliomas treated with bevacizumab/irinotecan.
P077 Clinical impact of C-11 methionine PET management of patients with brain neoplasm
on
expected
T. Yamane1, S. Sakamoto2, M. Senda1; 1Institute of Biomedical Research and Innovation, Kobe, JAPAN, 2Department of Radiology, Kobe University Graduate School of Medicine, Kobe, JAPAN. Background: C‐11 methionine positron emission tomography (MET‐PET) is helpful for initial diagnosis of brain tumor as well as for differentiating tumor recurrence from radiation necrosis. However, it is not obvious how the MET‐PET affect the clinical management. In this study, we retrospectively surveyed the diagnostic capability and clinical impact of MET‐PET. Materials and Methods: This study reviewed 89 MET‐PET scans for 80 patients (42 men and 38 women, aged from 7 to 91‐year old). These scans were classified into two groups by the purpose of MET‐PET; 20 scans (group A) for initial diagnosis of brain tumor, and 69 scans (group B) for differentiating
Poster Presentation
pulmonary hemodynamics, and the right ventricle half‐evacuation time (T1/2RV) were assessed. All patients underwent also perfusion lung scintigraphy. Results. We have shown that TAM and T1/2RV raised proportionally to pulmonary artery pressure increase, with correlation coefficient 0.48 and 0.50 respectively. In response to administration of pharmacological agents we discover both increasing and decreasing of TAM and T1/2RV. In postoperative period pulmonary homodynamic normalization occurred in patients with TAM and T1/2RV pharmacological test (FT) increasing. In patients with TVM and T1/2RV FT decrease residual pulmonary hypertension was diagnosed. In inoperable patients (because of high risk of postoperative acute right ventricle failure) TAM and T1/2RV FT decrease predominated. In inoperable patients and in children with residual pulmonary hypertension we discovered mottled lung perfusion pattern. Conclusion. The performing of perfusion lung scintigraphy and first pass radionuclide angiography with vasodilatators allows to estimate right ventricle function and pulmonary microcirculation. It predicts postoperative right ventricle function and pulmonary artery pressure normalization.
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tumor recurrence from radiation necrosis. The MET‐PET scans were visually evaluated as positive or negative by nuclear medicine physicians. The final diagnosis and the efficacy of MET‐PET were obtained from the data by the referring physicians and medical records. For all scans and for each group, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for the MET‐PET in diagnosing brain neoplasm were evaluated respectively. Furthermore, the rate of scans with changes in intended management was also evaluated. In evaluating the change, “major change” was defined as therapy to non‐therapy, non‐therapy to therapy or changing therapeutic methods (e.g. operation to radiation therapy), and “minor change” was defined as changes limited within the method of intended therapy (e.g. widening the field of radiation exposure, or shortening the follow up period). Results: The clinical reference data ware obtained in 64 scans for evaluating diagnostic capability and in 58 scans for evaluating clinical impact. In evaluating diagnostic capability, sensitivity, specificity, PPV, NPV and accuracy were 83.3%, 75.0%, 90.9%, 60.0% and 81.3% in group A, 89.2%, 81.8%, 94.3%, 69.2% and 87.5% in group B, and 87.8%, 80.0%, 93.5%, 66.7% and 85.9% in overall scans respectively. The rate of scans with major changes in intended management for group A, group B and overall scans were 8/16 (50.0%), 18/42 (42.9%) and 26/58 (44.8%) respectively. The rate of scans with either major or minor changes in intended management for group A, group B and overall scans including minor change were 10/16 (62.5%), 19/42 (45.2%) and 29/58 (50.0%) respectively (Table). Conclusions: MET‐PET can provide useful information in initial diagnosis of brain tumor as well as in differentiating tumor recurrence from radiation necrosis. This study also indicated that in about half of the cases the intended management was changed by the result of MET‐PET. MET‐PET scans with changes in intended management
Major change Minor change No change
Group A (n=16); Initial diagnosis
8 (50.0%)
2 (12.5%)
6 (37.5%)
Group B (n=42); Post radiation therapy 18 (42.9%)
1 (2.4%)
23 (54.8%)
Overall (n=58)
3 (5.2%)
29 (50.0%)
26 (44.8%)
P078 Non invasive quantification of cerebral metabolism rate of 18 glucose using dynamic F-FDG PET-CT and Patlak analysis in patients with brain tumor M. L. Calcagni1, L. Leccisotti1, L. Indovina2, M. Lavalle1, C. Nucci3, A. Mangiola3, C. Anile3, G. Galli1, A. Giordano1; 1Nuclear Medicine Institute, Università Cattolica del Sacro Cuore, Rome, ITALY, 2Medical Physics Institute, Università Cattolica del Sacro Cuore, Rome, ITALY, 3Neurosurgery Institute, Università Cattolica del Sacro Cuore, Rome, ITALY. Aim To evaluate the feasibility of non‐invasive quantification of cerebral metabolic rate of glucose (CMRglu) using dynamic 18F‐FDG PET‐CT and Patlak analysis in patients with brain tumour. Materials And Methods Nine patients (8 males, mean age 56 yrs, range 35‐76 yrs) with histopatological proved brain tumour: 7 glioblastoma (WHO IV), and 2 oligoastrocytoma (WHO II) underwent to dynamic 18F‐FDG PET‐CT. After iv bolus of 18F‐FDG (300MBq) 3D dynamic acquisition lasting 45min was performed. Time activity curves (TACs) were derived from three regions of interest (ROIs) manually drawn, using a dedicate software (PMOD, Zurich) over tumour, carotid arteries (for input function), and over contra‐lateral tissue. We studied the kinetic of 18F‐FDG using Patlak approach deriving the following parameters: volume distribution (VD) and inflow constant (Ki). We also calculated the cerebral metabolic rate of glucose (CMRglu) using the Lumped Constant (LC=0.42) applying the following formula: CMRglu= Ki*glycaemia /LC. The goodness of the linear fit in Patlak plots was checked by F and R2 . Results The mean values of Ki and VD in brain tumours were: 0.040 min‐1 + 0.023 (ranging from 0.011 to 0.076 min‐1)), and 0.95 + 0.29 (ranging from 0.63 to 1.38), respectively. The mean values of Ki and VD in background were: 0.032 min‐1 + 0.014 (ranging from 0.01 to 0.65 min‐1), and 1 + 0.318 (ranging from 0.52 to 1.5), respectively. We did not find any significant difference between tumour and contra‐lateral tissue of Ki (p=0.23) or VD (p=0.68) values (paired T test). The mean value of R2 linear fit of the Patlak plot was 0.96 + 0.04. The mean value of CMRglu in brain tumours was: 8.12 mg/100g/min + 7.30, ranging from 2.54 to 26 mg/100g/min. Conclusion The Patlak plot is the most commonly‐ used technique of graphical analysis. Its use in clinical practice is infrequent as the determination of the input function requires arterial and venous sampling which complicates the routine use. Hybrid PET‐CT scanner allows to use the intracranial carotid vessels for image‐derived input function; the dynamic acquisition allows to study the kinetic of the tracer. These preliminary 18 results, in accordance with literature, demonstrate the feasibility to study the kinetic of F‐FDG routinely. As well known, quantitative data are more robust than qualitative analysis or SUV values, and they can be obtained easily applying Patlak analysis. They can contribute in clinical practice to better understand the cellular mechanisms and the biological tumour response after radio‐chemotherapy.
P079 11
C-Methionine PET for Detection of Tumor Progression in Treated Low-Grade Cerebral Gliomas
E. Malakhova, T. Skvortsova, Z. Brodskaya, A. Gurchin; The Institute of the Human Brain RAS, Saint-Petersburg, RUSSIAN FEDERATION. The purpose of this study was to assess the diagnostic value of the positron emission tomography with 11C‐methionine (Met‐PET) for detection of early tumor progression in treated low‐grade cerebral gliomas. MATERIAL AND METHODS: Serial data of Met‐PET obtained for 61 patients before and after therapy of primary low‐grade cerebral glioma were included in retrospective analysis. PET‐images were analyzed by visual interpretation and semiquantitative uptake values. 11 C‐Met uptake index (ratio of tracer uptake levels ROI/referent area) was calculated for dividing lesion to reference activity. RESULTS: In 32 patients a single or multiple focal areas of increased 11 C‐Met uptake were found (mean lesion‐to‐brain ratio 2,78±1,22, range 1,44‐6,0) that considered as tumor recurrence. From 12 cases with low‐grade glioma transformed to more 11 malignant grade C‐Met uptake index increased in 10 patients (range 2,0‐5,8) compared with pretreatment condition. Before tumor expansion the increase 11C‐Met uptake index was revealed in 9 patients. The median time to tumor progression was 20 months (range 3‐97). These observations reinforced the notion that serial Met‐PET scanning may detect malignant degeneration of low‐grade glioma and early regrowth. In 29 cases PET showed negative 11C‐Met
uptake or small focus slightly increased accumulation in the primary tumor site (mean lesion‐to‐ brain ratio 1,27±0,35, range 1,0‐2,29). Considering the clinical, PET and MRI follow‐up studies these findings were interpreted as post‐treatment changes (n=12) or residual glioma (n=17). CONCLUSION: 11C‐Met‐PET has been shown to be a promising tool in early detection of low‐grade cerebral tumor progression after primary or second‐line therapy.
P080
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Postoperative PET with C-Methionine for the Assessment of the Extent of Resection in Patients with Cerebral Gliomas T. Skvortsova, Z. Brodskaya, E. Malakhova, A. Gurchin; Institute of the Human Brain of Russian Academy of Sciences, Saint-Petersburg, RUSSIAN FEDERATION. The aim of the study was to assess the diagnostic value of positron emission tomography using 11 C‐methionine (PET‐Met) to control the extension of glioma resection in clinical setting. Material and methods. 105 patients have been examined by PET‐Met after surgical removal of the cerebral glioma. Studies were performed within 4 to 56 days after surgery. 66 patients had preoperative PET investigation. The tumor samples resected were graded histologically as low‐ grade astrocytoma or oligoastrocytoma (n=37), oligodendroglioma grade II‐III (n=8), anaplastic astrocytoma (n=20), glioblastoma (n=40). The assessment of PET images included visual analysis and calculating the 11C‐methinine uptake index (UI). Visual analysis included the determination of focal increased of 11C‐methionine uptake in the original tumor area as well as in other brain regions, its extent and borders. For quantitative analysis UI was calculated by dividing the tracer activity in the region of interest (ROI) to activity in contralateral unaffected cortex (C). A circular region of interest (10‐mm diameter) was placed in the hottest area of the ROI. According different ROI were calculated four UI: for residual tumor (T/C), for perifocal nonspecific reaction of brain tissue, for bone wound and soft tissue of the head in the operative field. Results. PET‐ Met clearly delineated the extent of the residual tumor as locally increased 11C‐methionine uptake in the original tumor area in 89 out 105 patients. In the remaining 16 patients PET‐Met showed no focal increased amino acid uptake nearby the resection cavity wall consistent with complete tumor resection. In the residual tumor UI ranged from 1,6 to 6,4. 11C‐methionine uptake index either kept the preoperative value both in low‐grade gliomas and high‐grade ones or decreased on 26‐60% in comparison with the initial study. The decline of T/C ratio was clearly seen in gliomas with high vascularization. Besides residual tumor the slightly increased 11C‐ methionine accumulation was noted around the resection cavity, in the bone wound and soft tissue in the craniotomy area. Conclusion. PET‐Met seems to be a valuable tool for the control of completeness of glioma resection and the evaluation of the metabolic changes in the residual tumor due to surgery. This information can be used in follow‐up studies for monitoring treatment effect. It can be emphasized that the effectiveness of postoperative PET studies with 11C‐ methionine does not depend on the timing of the follow‐up images and nonspecific brain tissue changes.
P081 Multimodal imaging of tumor heterogeneity in cerebral gliomas with [18F]FET-PET and MR-spectroscopy B. D. Kläsner, A. Förschler, F. Ringel, J. Gempt, C. Zimmer, B. Krause, M. Schwaiger, A. Drzezga; Klinikum Rechts der Isar, Technical University of Munich, Munich, GERMANY. Background and aims: FET‐PET is a highly valuable tool for in vivo identification of viable brain tumor tissue, e.g. for definition of the biopsy focus. MR‐spectroscopy (MRS) also is able to detect concentrations of various metabolites to characterize biologic and metabolic parameters of glioma. FET‐PET and MRI/MRS give complementary information about tumor biology and activity and could possibly allow an improved guidance/selection of diagnostically meaningful biopsy sites. The aim of this study was to use FET‐PET & MRS for the diagnosis of cerebral gliomas and to assess whether the localisation of maximum signal intensity potentially differs between both methods which could be indicative for tumor heterogeneity. Methods: 8 patients with high grade gliomas underwent an imaging protocol including FET‐PET and MRI (3D‐MPRAGE, 3D‐EPI, 3‐D‐ MPR‐TFE and axial Flair‐Sequence). Data were evaluated retrospectively. For FET‐PET, a lesion/healthy brain uptake ratio > 1.6 and for MRS a Choline (Cho)/ Creatine (Cr) ratio > 2.3 were considered positive for high grade glioma tissue (1, 2). The location of the maximum PET uptake was then compared to the location of the maximum Cho/Cr peak to determine whether they were identical. In case they were not identical, the corresponding uptake values were calculated. Results: All tumors could be visualized, both in FET‐PET and MRS. Concordant findings in 6 out 8 patients. In 2 cases the tumor size was larger in MRS than in FET‐PET (edema). In 7 out of 8 patients the location of the maximum FET‐PET‐Uptake was not identical with the location of the maximum Cho/Cr peak in MRS. In the FET‐PET images, the maximum FET‐PET uptake ratios (2.5±0.75) were significantly higher compared to the FET‐uptake ratios measured in the regions with max. Cho/Cr peak (1.25±0.33) (p<0.05). Vice versa, the max. Cho/Cr peak values (16.3±25.4) were higher compared to Cho/Cr values measured in the locations of the max. FET‐PET uptake (8.7±11.4), although it did not reach statistical significance (p<0.1). Conclusions: Our results demonstrate that the foci of maximum signal intensity detected in FET‐PET and MRS in most of the cases are different with respect to their location. The information of MRS in addition to FET‐ PET warrants further histological correlation to investigate the pathophysiology of these differences and to assess the potential role for more exact preoparative imaging or guidance of biopsy sites. 1. (Floeth et al. J Neurosurg 2005). 2. (Di Costanzo et al 2008)
P082 (11)C-methionine positron emission tomography for surgical planning in pituitary tumor; in comparison with FDG-PET, MRI, and pathological findings T. Abe, H. Shinjoh, K. Kawakura, T. Hashizume, Y. Miura, S. Imai, T. Saginoya, S. Takekawa, H. Munechika; Southern Tohoku General Hospital, Koriyama, JAPAN. PURPOSE: To evaluate responsible focus in pituitary tumor using the information of preoperative (11)C‐methionine (MET) positron emission tomography (PET) in compared with Magnetic
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P083 Methionine PET of (pseudo) tumour progression after stereotactic radiotherapy/ radiosurgery of brain tumours ; differential diagnosis of radiation necrosis and tumour recurrence. G. Wester; Univ. Medical Center Groningen, Groningen, NETHERLANDS. Background: Following radiosurgery/stereotactic radiotherapy (SRS/SRT) of primary and secondary brain tumours, differentiation between radionecrosis and recurrent tumour in case of increasing abnormalities on MRI may be difficult. The purpose of this study was to determine the added value of Methionine PET (MET‐PET) to MRI in the differentiation between radionecrosis and recurrent tumour and to assess the prognostic value with regard to clinical outcome. Material and Methods: Scheduled MRI follow up of 12 patients after SRS/SRT(glioblastoma n=2 meningioma n=2 and metastases n=9) showed increase in gadolinium (GADO) high signal areas outside the original tumour area. MET‐PET was performed at the time of progression and was co‐ registered with the MRI at the time of progression and the MR before progression in BRAIN LAB IPlan image 4.1®. The area of progression was determined by subtracting the GADO+ area of the tumour at SRS/SRT at baseline from the GADO+ area at progression. Maximal standard uptake value of MET‐PET of this area, original tumour area and SUV max of the contralateral normal hemisphere were calculated. Ratios of SUVmax of the progression area or original tumour area over SUVmax of the normal brain were calculated (SUVpa/nb and SUVot/nb, respectively). Two groups of patients were defined depending on clinical outcome after (pseudo) tumour progression. Results: Clinical outcome was defined as good (n=5) if patients remained alive, neurologically stable after MET‐PET (n=0) and additional follow up scans showed regression or no further progression (n= 4). In one case, no further MR was performed. Outcome was defined as poor (n=7) if patients showed progressive neurological decline, died (n=5), showed progressive changes extending into distant normal brain on MRI (n=1), or showed vital tumour at craniotomy (n=1). In good outcome patients, the mean SUVpa/nb was 0.95 (min .68 max 1.1) versus 1.34 (min .90 max 1.68) in poor outcome patients. SUVot/nb were 1.18 (.60‐1.78) and 1.24 (.52‐1.77) in good and poor outcome respectively. SUVpa/nb correlated significantly (Pearson ‐.65 p= 0.02) with outcome whereas SUVot/nb did not (Pearson ‐.080 p=.80). Conclusions: Low MET‐PET SUVmax of progression area after SRS/SRT was correlated with good outcome and likely represents radionecrosis whereas high MET‐PET SUV max of the area of progression associated with poor outcome and likely represents true tumour progression.
P084 Image co-registration followed by Combined Voxel Based Analysis of functional MRI and FDG-PET data in glioma patients F. Giesel1, H. Laue2, A. Afshar-Omarei1, C. von Gall1, C. Kratochwil1, C. Zechmann1, M. Weber1, L. Gerigk3, M. Essig3, U. Haberkorn1; 1University of Heidelberg, Heidelberg, GERMANY, 2Frauenhofer Institute / MeVis, Bremen, GERMANY, 3German Cancer Research Center, Heidelberg, GERMANY. Introduction: The enforcement of combined acquisition technologies such as PET/CT and the recently introduced PET/MRI promote the diagnostic accuracy and biological understanding of cancer. However, still only static post contrast enhanced imaging technique in MRI and CT where co‐registered with FDG‐PET images. Our new approach was to combine microvascular tumor information using dynamic MRI (DCE‐MRI and DSC‐MRI) with FDG‐PET image data to enable cross modality voxel based functional tumor analysis. Material and Methods: 7 patient with brain lesions (4 with high grade gliomas; 3 with low grade gliomas) where acquired using MRI and PET. MRI protocol: T1w, T2, FLAIR and T1‐dynamic (FLASH) /T2*(EPI)‐dynamic for further kinetic analysis. The T1‐/T2*‐Dynamic MRI sequences were further analysed, undergoing a one‐ and two compartment kinetic modeling. The FDG‐PET data were co‐registered to the MRI kinetic modeling results using rigid body transformation and resampling technique. Results: In all 7 patients the data where successfully acquired and MRI kinetic modeling of the one‐ and two‐ compartment model enabled a discrimination of normal microcirculation of the gray/white matter and higher perfused tumor tissue. The rigid body co‐registration allowed a direct intra‐ individual voxel based comparison of MRI contrast enhanced kinetic tumor tissue parameters (Amp, Kep, Kel, CBF, CBV, MMT) and metabolic rate of the FDG‐PET data (SUV [k1,k2,k3]). Conclusion: This investigation presents a new approach of functional tumor analysis using information of functional MR and PET imaging modalities on a voxel level comparison. Further investigations are ongoing and have to verify the clinical impact of these initial results.
P09 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: head and neck cancer
P085 Diagnostic capability of C-11 methionine PET/CT for neck lymphnode metastasis from head and neck cancers versus trunk cancers S. Ohashi1, K. Yoshikawa1, S. Toubaru1, M. Hasebe1, H. Ishikawa1, K. Sagou1, K. Tamura1, K. Tanimoto1, S. Kandatsu1, J. Mizoe1, T. Fukumura1, T. Saga1, K. Kawaguchi2, Y. Hamada2, H. Tsujii1; 1National Institute of Radiological Sciences, Chiba, JAPAN, 2First Dept. of oral & Maxillofacial surgery, Tsurumi University, Yokohama-shi, JAPAN. PURPOSE We sometimes encounter nodular activities in neck area on whole body PET/CT using C‐11 methionine (MET) of patients with cancer. We evaluated detectability of MET‐PET/CT for neck lymphnode metastasis from head and neck tumor or from the other primary origin tumor of trunk. METHODS AND MATERIALS We reviewed MET‐PET/CT images of 1749 studies, from June 2006 to February 2007, searching for any nodular accumulation in neck area. We picked up 84 patients with any nodular accumulation in neck area as suspicious candidates for lymphnode metastasis. There were 91 lesions in total, and 47 nodules were from head and neck cancer and 44 nodules were from other primary origin tumor of trunk. All sites of nodular accumulation were confirmed by pathology or by clinical follow‐up. We evaluated diagnostic indexes and made ROC curve analysis. We use TNR, tumor to normal tissue ratio, to estimate MET accumulation. We analyzed the relationship between TNR and the final diagnostic result of the neck region. RESULTS Twenty‐eight nodules in 26 patients found out as metastasis. Twenty‐five positive nodules were from head and neck cancers and only 3 positive nodules were from other primary origin tumor of trunk. Each positive ratio was 53.2% and 6.8%. When we use 2.48 TNR as cutoff value to diagnose metastasis from 91 nodules, sensitivity, specificity and accuracy were 53.6%, 85.7% and 75.8%, respectively. When we use the same cutoff value for cases with head and neck cancer, sensitivity and specificity and accuracy were 56.0%, 81.8% and 68.9%, and for cases with other primary origin tumor of trunk, they were 66.7%,87.8% and 86.4%, respectively. We had very few neck lymphnode metastasis from trunk cancers, but the diagnostic capabilities (especially specificity and accuracy) of neck lymphnode from trunk cancers were very high. From ROC curve analysis, Az value was 74.4 for all 91 nodules. CONCLUSION MET‐PET/CT was useful for diagnosis of neck lymphnode metastasis and especially specificity was relatively high. There were very few true positive metastasis in neck lymphnode accumulation in MET‐PET/CT study from trunk cancers compared to head and neck cancers. But diagnostic capability for neck lymphnode metastasis from trunk cancers was higher than from head and neck cancers.
P086 Prognostic value of combined FDG-PET/CT in Head and Neck Tumors: is there any potential for further improvement of outcome prediction? A. Abramyuk1, K. Zöphel1, S. Tokalov1, G. Shakirin1, U. Haberland2, E. Klotz2, G. Wolf1, N. Abolmaali1; 1TU Dresden, Medical Faculty Carl Gustav Carus, Dresden, GERMANY, 2Siemens AG, Forchheim, GERMANY. Aim: Combined FDG‐PET/CT provides comprehensive information concerning location, spread, biological characteristics and pathophysiological activity of Head & Neck Tumors (HNT). It has been demonstrated in several series that higher FDG uptake is associated with shorter survival. However, recently published data show some controversy concerning impact of FDG‐PET/CT in predicting HNT outcome. At the same time, tumor blood supply parameters (blood volume, transfer constant), which can be measured by dynamic contrast enhanced computed tomography (DCE‐CT), are important characteristics influencing both radio‐ and chemotherapy outcome. The attempt of this work was to clarify whether implementation of DCE‐CT in pre‐therapeutical FDG‐ PET/CT protocol could be of clinical interest in patients with HNT. Materials and Methods: Ten consecutive patients (median age 50 [range 47‐74]) with histologically proven HNT in stages T2 N0 M0 ‐ T4 N2c had been included into the study. Further inclusion criteria comprised: no previous therapy (Chemo, OP), only curative RT and follow up time of at least 24 months. Patients underwent FDG‐PET/CT with additional DCE‐CT before treatment using a PET/CT scanner (Biograph 16, Siemens) and a double head power injector (Injectron CT 2, MedTron). FDG uptake was measured SUVmax. Tumor blood volumes (TBV) were determined from DCE‐CT using Patlak analysis (FuncCT prototype software, Siemens) and compared with time‐to‐progression and overall survival. 2D PET images and TBV maps from DCE‐CT were compared on a pixel‐by‐pixel basis using Pearson coefficient of correlation. Results: Three out of 10 patients with low FDG uptake (SUVmax: 8±1) and 5 from 7 patients with higher FDG uptake (SUVmax:15±4, P=0.004) were free of local recurrency. All 7 patients with homogeneous tumor blood supply and high TBV (9.3±3.9 ml/100ml tissue) in DCE‐CT were free of local recurrency, while 2 of 3 patients with heterogeneous tumor blood supply and regionally low TBV (3.2±1.3 ml/100 ml tissue, P=0.06) within the tumor died during follow‐up because of tumor relapse. However, a weak correlation between PET and DCE‐CT analysing images on the pixel‐by‐pixel basis was observed (R2 = 0.1). Conclusions: Our preliminary data show that FDG‐PET/CT and DCT‐CT are complementary methods for surveillance assessment in patients with HNT. Implementation of DCE‐CT in pre‐ treatment FDG‐PET/CT protocol seems to improve tumor outcome prediction. However, a more extensive prospective study is needed.
P087 The role of PET-CT in staging patients with head and neck cancer in comparison with CT and MRI F. Vlachou, D. Kechagias, L. Gogou, V. Filipi, D. Tsevas, E. Kotsalou, A. Nikaki, K. Dalianis, K. Gogos, J. Andreou, V. Prassopoulos; Department of PET/CT D.T.C.A. Hygeia Hospital, Athens, GREECE.
Poster Presentation
Resonance (MR) imaging, (18)F‐2‐fluoro‐2 deoxy‐D‐glucose (FDG) PET, and pathological finding. Material and Methods: MET PET‐CT and FDG PET‐CT was performed in twenty of consecutive patients with pituitary tumor diagnosed by MRI for preoperative estimation. The institutional review board approval and written informed consent was obtained in all patients. On the day of surgery T2 or Gadolinium (Gd) enhanced T1 weighted imaging MR sequence for planning was carried out. All PET and MR image data sets were fused based on skull shape. Surgical planning was taken from the MET or FDG uptake area from MRI fusion imaging. RESULTS: The median MET standardized uptake value (SUV) was 5.8(range, 1.6‐17.6)in 19 of 20 (95%) patients. The median FDG SUV was 8.4(range, 2.5‐16.1)in 14 of 20 (70%) . All 5 patients without FDG uptake had MET SUV < 3.0. In those, MET uptake range was larger than FDG tumor uptake and some different from T2 or Gd T1 suspected MR area individually. MET uptake range leaded to accurate information more than FDG‐PET and MRI sequences. CONCLUSION: MET uptake was as well as the operative pathological findings and leaded to accurate prediction for the tumor resection.
S328 Aim:Head and neck cancer count for 5% of all malignancies. Considering that 80% of the patients in early stages are curable, accuracy in initial staging is very important. The gold standard technique in initial staging of head and neck cancers is refered to be CT. The aim of this study was to compare classic imaging techniques to PET‐CT in their efficacy in staging patients with head and neck cancer. Materials‐Methods:This study is retrospective and it concerns 28 patients with head and neck cancer who came to our department for initial staging. Men: 24, Women: 4, Mean age: 57.9±14.6. All patients underwent PET‐CT scan 60 minutes after the intravenous injection of 370±30MBq 18F‐FDG (Biograph II, Siemens). The results were compared with MRI (12 cases) group A and CT (18 cases) group B. The staging was according to TNM classification. All patients after the initial staging underwent radiotherapy. Results:Group A: Out of 12 patients there was agreement of PET‐CT staging as compared to MRI in 5 patients (41.7%).In 3 patients PET revealed more findings and therefore PET/CT upstaged 25%.of the patients. In 4 patients (33.3%) there was downstaging. In particularly for “T” staging there was agreement in 7 patients (58.3%), upstaging in 2 patients (16.5%) and downstaging in 3 patients (25%). Accordingly for “N” staging agreement occurred in 9 patients (75%), upstaging in 2 patients (16.6%) and downstaging in 1 patient (8.4%) Group B:There was agreement of PET‐CT staging as compared to CT in 8 patients (44.4%)In 5 patients PET revealed more findings, 27.7%. upstaging. In 4 patients (22.2%) there was downstaging.In particularly for “T” staging there was agreement in 14 patients (77.8%), upstaging in 3 patients (16.6%) and downstaging in 1 patient (5.6%).Accordingly for “N” staging agreement occurred in 12 patients (66.7%), upstaging in 2 patients (11.1%) and downstaging in 4 patient (22.2%) All patients were treated in our hospital and follow up confirmed PET‐CT findings. In 1 patient (3.6%) a 2nd primary malignancy was diagnosed. Conclusion: PET‐CT imaging combines anatomic and functional imaging, providing more accurate diagnosis and improved patient management. PET‐CT is an especially useful method in the initial staging of the patients with head and neck cancer. In our study PET‐CT changed the stage of the disease and the radiotherapy planning in 54% ‐ 58% of the patients.
P088 Pre-treatment FDG Standardized Uptake Value as a Prognostic Factor in Head and Neck Cancer K. Kavak1, M. Aydin2, A. Yapar2, M. Reyhan2, G. Nursal2, A. Aktas1; 1 Baskent University, Ankara, TURKEY, 2Baskent University, Adana, TURKEY. Objectives: Standardized uptake value (SUV) is a semiquantitative method for FDG‐PET scanning in oncology. The potential value of FDG uptake in predicting outcome in head and neck cancers has been suggested in small series. In this study, the patients with head and neck cancer (HNC) were enrolled onto a retrospective evaluation of PET/CT pre‐treatment FDG uptake as a predictor of complete metabolic response and progressive metabolic disease. Materials and metods: We studied 23 patients (6 women, 17 men, ranging from 15 to 79 years old, median age 59±15 years) with HNC from December 2006 to December 2008. The primary HNC most frequently occurred in the larynx (n=11), followed by nasopharynx (n=8) and oral cavity (n=4). All patients underwent FDG PET/CT study for initial staging and restaging. According to the restaging exam, the patients were divided into two groups; complete metabolic response (group A; n=15) and progressive metabolic disease (group B; n=8). SUVmax in primary tumor and lymph nodes were compared. The Mann‐Whitney U test (SPSS 9.5) was used to compare the SUV median values in groups. Results: In group A; the values for tumor SUVmax and lymph nodes SUVmax were 13±5, 7±7, respectively. In group B; the corresponding values were: 21±9 and 5±6, respectively. Statistically difference existed in tumor SUVmax values between the groups (p=0.04), whereas no significant difference was detected for lymph node SUVmax values. Conclusion: The results have shown that pre‐treatment SUV in patients with progressive disease is significantly higher than patients having a complete metabolic response. FDG uptake, as measured by the SUV, has potential pre‐ treatment value as a predictor of the progression disease activity.
P089 Detection of Distant Metastases and Second Primary Tumors with FDG PET/CT in Head and Neck Cancer K. Kavak1, M. Aydin2, A. Yapar2, M. Reyhan2, G. Nursal2, A. Aktas1; Baskent University, Ankara, TURKEY, 2Baskent University, Adana, TURKEY.
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Purpose: Distant metastases and second primary tumor development are bad prognostic factors in patients with head and neck cancer (HNC). FDG PET/CT is used successively for staging, radiotherapy planning, treatment response and recurrence research in this patient group. In this study, we examined distant metastases and second primary tumor frequency in patient with HNC whom PET/CT was performed for initial evaluation and re‐staging. Methods: We performed whole‐body FDG PET/CT for primary staging work‐up and follow‐up in 169 consecutive HNC patients (32 F, 137 M, age range from 15 to 84 years , mean age 58±14 years) examined between December 2006 and December 2008. Patients with pathological FDG uptake outside of the head and neck area were evaluated with further diagnostic methods, biopsy and clinical follow‐up. Thereby, second primary tumor sites and metastases were detected and frequency of distant lesions were expressed as a proportion. Results: Distant malignant lesions were detected in 27 patients (15.9%). PET scan was performed for initial staging in 18 of them and for re‐staging in 9 of them. Among these patients, there were 13 laryngeal cancer, 4 nasopharyngeal cancer, 7 oral cavity tumor and 3 salivary gland tumor. Second primary tumor was detected in 8 patients (4.7%, 6 laryngeal tumor, 2 oral cavity tumor). Conformation was made with histopathological examination in 6 and with imaging and clinical follow‐up in 2 patients. These lesions were small cell lung cancer in 6 patients, thyroid papillary cancer in 1 patient and prostate cancer in 1 patient. Other distant lesions were decided as a metastases after evaluation with PET scans, conventional imaging methods, clinical follow‐up or histopathological examination. Nineteen patients were detected with distant metastases: 13 lung, 5 mediastinal, 5 bone and 1 brain metastases. Conclusion: The results of this retrospective study revealed that the frequency of distant malignant lesions were not low in HNC and PET/CT is a useful screening method for both initial and re‐staging of distant lesions in this patient group.
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P090 Nasopharyngeal cancer pathology - correlation with 18FFluorodeoxyglucose PETCT derived standardized uptake values. A. Ab Aziz1, Y. S. Song2, J. C. Paeng2; 1University Kebangsaan Malaysia Medical Centre (UKMMC), Cheras, Kuala Lumpur, MALAYSIA, 2Seoul National University College of Medicine, Seoul, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA. Objective: To investigate the relationship between nasopharyngeal cancer (NPC) histopathological type, tumour stage, EBV positivity and uptake of 18F‐Fluorodeoxyglucose (FDG) as measured on PETCT Methods: This retrospective investigation included 15 patients consisting of 10 males and 5 females (age range: 18‐84 years old) who were referred to our department for whole‐body positron emission tomography‐computed tomography (PETCT) with newly diagnosed, biopsy‐proven nasopharyngeal carcinoma (NPC). Medical records and PETCT images were reviewed to obtain the histological subtypes, the tumour staging (T), EBV positivity and the FDG uptake, measured as maximum standardized uptake value (SUV) of the primary tumour. Results: The histopthologic subtypes were: squamous keratinizing WHO Type I (n=3), n=1 in each of T2, T3 and T4; non‐keratinizing squamous WHO Type II (n=4), all 4 are of T1; and undifferentiated WHO Type III (n=8), T1(n=3), T3(n=3) and T4(n=2). The SUV of the primary tumour ranges from 4.5‐32.8. The mean SUV is 12.3, 15.2 and 11.1 for histological type I, II and III respectively (p=0.76). There is also no significant association between SUV and tumour grade (p=0.84). 6 (Type II: n=3; Type III: n=3) out of 15 patients are positive for EBV. The mean SUV for positive and negative EBV group is 14.6+/‐10.1 and 11.0+/‐7.2 respectively (p=0.43). Conclusions: Our study observed that Type II NPC exhibited a higher FDG uptake than either Type I or Type III; also higher SUV is found in EBV positive tumour. However, the difference do not reach statistical significant. As plasma EBV is an important prognostic factor for NPC, further study with bigger sample size is necessary to study SUV as a possible useful prognosticator.
P10 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: breast cancer
P091 Interest of Fluoro-Deoxy-Glucose (FDG) Positron Emission Tomography (PET) in the preoperative evaluation of breast cancer C. Soler1, C. Bouteille2, B. Geissler1, A. Steiner-Emptaz1, E. Gremillet1; CHPL, Saint-Etienne, FRANCE, 2Centre Anti Cancéreux Léon Bérard, Lyon, FRANCE.
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Purpose: FDG‐PET was applied to breast cancer patients for the purpose of preoperative evaluation and surgical management. Methods: FDG‐PET was performed pre operatively in 108 patients with breast cancer. The maximum Standard Uptake Value (SUV‐max) and the size of breast tumors were calculated. Axillary SUV‐max and focal accumulation of FDG in the axillary region (with the help of tomodensitometry to locate the axillary region) were also evaluated. Results: of the 108 patients, 108 had breast cancer on histopathology. PET showed focal accumulation in 101 patients. In these 101 patients, SUV‐max and breast tumor size were ranged from 1.88 to 24.55 and 1.5 to 5 centimetres respectively. In all 101 cases, focal accumulation of FDG was superior at the histopathology measurement (tumor). Of the 108 patients, 77 had lymph node metastasis on histopathology. PET‐ FDG showed axillary focal accumulation in 40 cases (37 %), SUV‐max ranged from1.3 to 12 (3 range from 1.3 to 2.3 and 21 range from 2.31 to 12). Of the 108 patients, 31 had not lymph node metastasis on histopathology; SUV‐max was noted at zero in all 31 patients. So, what about modifications for the clinical management of breast cancer due to FDG‐PET conclusions. On 45 patients (42%), FDG‐PET results changed the management of the disease. In 13 cases (28,5%), clinical tumor size were noted T2 stage (> 2centimeters) without focal accumulation of FDG in the axillary region, then, Sentinel Lymph Node Biopsy procedure was nevertheless initiated and total axillary dissection was avoided. In 11 cases (24%), patients had focal accumulation of FDG in axillary region but no suspect lymph node at physical examination. During surgery, node was histological studied and total axillary dissection was performed when node had metastases. In 13 cases (28,5%), FDG‐PET showed unknown distant metastasis avoiding large surgery replaced by chemotherapy. In 8 cases (17%), the treatment changes for others raisons ( lymphoma diagnosis, thymus cancer diagnosis, benign controlateral nodes). Only in 1 (2%) case, we mistake because of the negative axillary FDG‐PET about a T2 tumor. Conclusions: FDG PET seems to be important in the management of breast cancer to make the right choice for the treatment avoiding over treatment or under treatment
P092 Impact of FDG-PET in patients with initially breast cancer based on unknown metastatic lesions detection and modified previous radiotherapy treatment planning: Preliminary study. P. Pifarre, M. Simo, A. Escudero, P. Plaza, V. Marco, E. Miralles; CRCQuiron, Barcelona, SPAIN. Purpose: Distant metastases at diagnosis are an important prognostic factor in patients with breast cancer and play a central role in treatment decisions planning. Also, on accurate detection of all nodal stations involved by tumour are essential for radiotherapy treatment planning. In this preliminary study, we investigated the utility of FDG‐PET in this setting. Materials: Twenty one women (mean age: 45 years old) with initially breast cancer were studied. Histological type included invasive lobular carcinoma (n=1), invasive ductal carcinoma (n=19) and medullary (n=1). All were unifocal breast carcinoma except one with multicentric neoplasm. Hormone receptor and HER2 were positive in 78% and 28% patients respectively. Seven patients had axillary nodal infiltration and four patients distant metastases previous PET scan acquisition. FDG PET studies were performed with a Biograph 6 slice from Siemens Manufactures. All lesions that changed
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P093 The Value of FDG PET in the Initial Staging of Breast Cancer Patients O. V. Mukhortova1, I. P. Aslanidis1, I. V. Shurupova1, E. P. Derevyanko1, Z. N. Shavladze2, D. L. Strojakovskii3; 1Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, RUSSIAN FEDERATION, 2Research Center of Medical Radiology, Obninsk, RUSSIAN FEDERATION, 3Moscow City Oncologic Hospital №62, Moscow, RUSSIAN FEDERATION. Aim. To evaluate the clinical impact of FDG‐PET in patients with newly diagnosed breast cancer. Methods. 51 patients with biopsy proven breast cancer were studied with FDG‐PET for initial staging. PET was done before (8 pts) or not less than 7 days after (43 pts) biopsy. According to results of conventional diagnostic methods 16 patients were referred to I‐IIa stages of disease (1 group) and 35 patients (2 of them with bilateral cancers) were referred to IIb‐IIIb st. (2 group). Whole‐body PET images were obtained in 60‐90 minutes after administration of 350‐420 MBq FDG. PET images were assessed visually or with SUV calculation. In equivocal cases the region of interest was additionally scanned in 3,5 hours after FDG injection. PET results were compared with conventional diagnostic methods and clinical follow‐up in all cases and with postsurgical histopathological data in 46 patients (48 breast with lymphatic collectors). Results. PET sensitivity in detection of primary tumor was 91% (48/53): in the 1 gr. ‐ 81% (13/16) and in the 2 gr. ‐ 95% (35/37). Multifocal type of tumor was proved by PET in 14% pts of the 2 gr. (5/37). Histopathological data revealed axillary metastasis in 81% (39/48): 63% in the 1 gr. (10/16, 4 of them had micrometastasis) and 91% in the 2 gr. (29/32, 2 of them had micrometastasis). In the 2 gr. metastatic involvement of other lymphatic collectors was found in 22% of cases (7/32). PET results were true positive for axillary node involvement in 67% (26/39): 40% (4/10) in the 1 gr. and in 76% (22/29) in the 2 gr. In 5/7 pts (71%) extra‐axillary nodal metastatic involvements were correctly identified on PET. Distant lesions were detected on PET in 14% (5/35) pts of the 2 gr. In all 5 pts distant metastasis were confirmed by other diagnostic methods. Stage of disease was changed according to PET results in 24% of pts (12/51): in 2/16 pts of the 1 gr. and in 10/35 pts of the 2 gr. Treatment was changed in 9/35 pts of 2gr. (26%). Conclusions. 1) FDG‐PET was found to be high sensitive in detection of primary tumor, regional and distant metastasis in patients with locally advanced breast cancer. PET results altered treatment management in ¼ of these patients. 2) FDG‐PET preliminary results in patients with early stages of disease didn’t reveal real advantages for primary staging in comparison with complex of conventional diagnostic methods.
P094 Can FDG PET/CT replace conventional imaging in patients with locoregional breast cancer recurrence? T. S. Aukema, E. J. T. Rutgers, W. V. Vogel, H. J. Teertstra, H. S. Oldenburg, M. T. F. D. Vrancken Peeters, J. Wesseling, N. S. Russell, R. A. Valdés Olmos; Netherlands Cancer Institute / Antoni van Leeuwenhoek Hospital, Amsterdam, NETHERLANDS. Abstract Aim: The prognosis and clinical management of patients with locoregional recurrence of breast cancer depends on the extent of the disease. Conventional work‐up, consisting of bone scintigraphy, liver ultrasound, and X‐ray or CT of the thorax, may underestimate the local extent or miss the presence of overt distant metastases. The aim of this study was to evaluate the impact of 18F‐fluorodeoxyglucose positron emission tomography/ computed tomography (FDG PET/CT) on clinical management in patients with locoregional breast cancer recurrence amenable for locoregional treatment and compare the results with conventional imaging. Materials & Methods: We performed a retrospective analysis of all patients referred for FDG PET/CT with locoregional breast cancer recurrence between January 2006 and August 2008. PET/CT findings were compared with results of additional imaging, pathology and follow‐up. The impact of FDG PET/CT images on clinical management of patients was evaluated on the basis of clinical decisions obtained from patient files. Results: 56 patients were included in this study. In 93% of the patients FDG PET/CT showed the confirmed recurrence. In 32 patients (57%) FDG PET/CT revealed additional tumour localisations. FDG PET/CT had an impact on clinical management in 27 patients (48%) by detecting more extensive locoregional disease or distant metastases. In 25 patients (45%), at least one FDG‐avid lesion was not visible on conventional imaging. In 20 patients (36%) unnecessary surgery was prevented and treatment was changed to palliative systemic treatment. Conclusion: FDG PET/CT, in addition to conventional imaging, plays an important role in staging patients with locoregional breast cancer recurrence since its result changed the clinical management in almost half of the patients . FDG PET/CT could potentially replace conventional staging imaging in patients with a locoregional breast cancer recurrence.
P095 The diagnostic accuracy of PET or PET-CT with patients with breast cancer: a meta-analysis
18
FDG in
G. Marina-Corro, R. Alcázar-Alcázar, M. Rodríguez-Garrido, C. AsensioDel-Barrio; Agency for Health Technology Assessment, Madrid, SPAIN.
Aim: To study the diagnostic effectiveness of Positron Emission Tomography (PET) as an imaging test in patients with breast cancer. Methodology: Systematic review of the literature from November 2003 to May 2008. An electronic search of Medline (PubMed), Embase, Centre for Reviews and Dissemination (CRD), SciSearch, SCOPUS, Global Health, and the Cochrane Library was conducted, without any language restriction. Lists of references from the identified articles were manually searched. Studies assessing the diagnostic accuracy of PET or PET‐CT, with the radiotracer 18FDG, in patients with breast cancer and using the biopsy or a follow‐up for at least 6 months as standards of reference were considered. Methodological quality of studies was assessed independently by two investigators, according to the levels of evidence of the Centre of Evidence‐Based Medicine of Oxford. Meta‐analysis using MetaDisc software was performed including only articles with enough primary data to construct a 2x2 cross‐table. Threshold effect and heterogeneity among studies were explored. Forest plots of each diagnostic estimate and the summary receiver operating characteristic (SROC) curves were made. Pooled diagnostic indexes using a random effects model and the area under the SROC curves (AUC‐SROC) were calculated. Subgroup analyses were conducted according to the different clinical indications of PET. Results: Forty eligible studies, which enrolled a total of 2468 patients, met the inclusion criteria. Twelve articles were classified as 1bA quality level; 12 as 2bB; 9 as 3bB; and 7 as 4C. There were no heterogeneity among studies for tumor recurrence, for detection of bone metastases, nor for the localization of tumor in cases of increased tumor markers with conventional imaging indeterminate or negative, while heterogeneity was visual and statistically significant (P‐value <0,001) for axillary lymph node infiltration. Threshold effect could be discarded for all indications except for bone metastases. The pooled diagnostic odds ratio (DOR) with the 95% confidence interval (95% CI) was 25.60 (10.63‐61.65) for axillary lymph node involvement; 27.35 (15.64‐47.82) for recurrence; 80.26 (15.45‐416.74) for bone metastases; and 30.63 (11.35‐82.66) for patients with increased tumor markers. The AUC‐SROC of PET for these indications was 0.93, 0.85, 0.97, and 0.89, respectively. Conclusions: PET is a highly effective imaging technology in breast cancer, with an important role for assessing axillary lymph node and for the detection of tumor recurrences, even if only tumor markers are increased, and bone metastases. These results make PET to be a potentially decisive tool in the clinical management of these patients.
P096 Impact of 18F-FDG/PET-CT in suspected breast cancer recurrence A. Palomar Muñoz1, A. M. García Vicente1, M. P. Talavera Rubio1, B. González García1, I. Cepedello Boiso1, J. Espinosa Arranz2, J. P. Pilkington Woll1, M. E. Bellón Guardia1, V. M. Poblete García1, J. M. Cordero García1, J. Quejigo García3, A. Soriano Castrejón1; 1Nuclear Medicine Department. Hospital General. Ciudad Real, Ciudad Real, SPAIN, 2Oncology Department. Hospital General. Ciudad Real, Ciudad Real, SPAIN, 3 Investigation Unit. Hospital General. Ciudad Real, Ciudad Real, SPAIN. Aim: To evaluate retrospectively the impact of 18F‐FDG‐PET/CT in the assessment and management of suspected recurrent breast cancer. Material and methods: 70 women (age between 34‐84 years, mean 61.3 y) with treated breast cancer (10 patients stage I, 26 stage II, 22 stage III and 12 stage IV) and suspected recurrence of breast cancer underwent whole‐body FDG‐ PET/CT, that was performed approximately 60 minutes following iv injection of 370 MBq of 18F‐ FDG on the contralateral arm of the primary lesion. They had equivocal findings on CT (n=51), bone scintigraphy (n=1), 18F‐FDG‐PET/CT (n=2) and/or elevated tumours markers (n=28). 18F‐ FDG‐PET/CT study was considered pathological if there was at least one pathological lesion. The final diagnosis was established by histological assessment (n=17), diagnostic imaging procedures (n=26) and clinical follow‐up (n=27) with a mean interval of 12.7 months (6‐24 m). Results: 36 patients (51.4%) had a normal distribution of FDG without evidence of disease, confirming the absent of disease in 32 of them (88.9%) and showing in 4 patients (11.1%) false negative results (2 cerebral metastasis, 1 malignant microcalcification in the contralateral breast and 1 liver lesion). The other 34 patients (48.6%) had abnormal FDG‐PET/CT, in which the presence of malignant disease was identified in 29 of them (85.2%), having the other 5 patient (14.7%) false positive results (2 inflammatory tissues, 1 atelectasis, 1 degenerative bone and 1 inflammatory lung nodule). The sensitivity and specificity of FDG‐PET/CT in patients with suspected recurrence breast cancer were 87.8% and 86.4% respectively. Results of FDG‐PET/CT had impact on the management in 29 patients (41.4%). Conclusion: FDG‐PET/CT is a useful technique in the evaluation of the suspected recurrence in breast cancer, and in the decision‐making of the therapeutic approach.
P097 FDG PET and other imaging modalities for the evaluation of breast cancer recurrence and metastases: A meta-analysis L. Pan; Shanghai Renji Hospital, Shanghai, CHINA. Background and purpose: Breast carcinoma is the most common cancer in female patients with a propensity for recurrence and metastases even after surgery in early stage. The accuracy of US, CT ,MRI ,SMM and PET in diagnosing the recurrent and/or breast cancer has never been systematically assessed, and present systematic review was aimed at this issue. Methods: We searched for articles published from January 1995 to August 2008, inclusion criteria including: Articles were reported in English or Chinese; US, CT , MRI ,SMM or PET whether interpreted with or without the use of CT, was used to detect recurrent and/or breast cancer; Histopathologic analysis and/or close clinical and imaging follow‐up for at least 6 months. We extracted data to calculate sensitivity, specificity, SROC curves and AUC and to test for heterogeneity. Result: In 42 included studies, US and MRI had highest pooled specificity (0.962 and 0.929 respectively); MRI and PET(with or without CT) had highest pooled sensitivity (0.9500 and 0.9530 respectively). The AUC of US, CT, MRI, SMM and PET were 0.9251, 0.8596, 0.9718, 0.9386 and 0.9604 respectively. Results of pairwise comparison between each modality demonstrated AUC of MRI and PET(with or without CT), were higher than that of US or CT, p<0.05.No statistical significance was found when compared with that of MRI and PET. There was heterogeneity among studies and evidence of publication bias. Conclusion: In conclusion, MRI seemed to be a more useful supplement to current surveillance techniques to assess patients with suspected recurrent and/or metastatic breast cancer. If MRI shows an indeterminate or benign lesion or MRI was not applicable (e.g. pacemaker), FDG‐PET could be performed in addition.
Poster Presentation
treatment planning and with no morphologic correlation by CT were confirmed by histological analysis or RMI/Bone scan. Results: ‐ All primary breast neoplasm was detected by PET/CT. Maximum SUV ranges were 2.57‐12.85, with a mean value of 6. Lowest uptake corresponds to ductal carcinoma type. ‐ Ten patients showed nodal infiltration: axillary (n=4), internal mammary chain (n=1), axillary plus internal mammary chain (n=4) and axillary plus infraclavicular region (n=1). In 6 of these patients, radiotherapy treatment planning was modified. ‐ Suspected distant metastases were detected by PET/CT in 10 women: Bone (n=4), lung (n=1), liver (n=1), mediastinal (n=1), soft tissue (n=1) and multiple sites (n=1). ‐ 5 patients with morpho‐metabolic discordance were confirmed by histological verification (n=4) or by RMI/Bone scan (n=1): Bone metastases were finally diagnosed in two patients and was rule out in other women with blastic bone lesions by CT. Two false positives for breast cancer metastases were founded: Invasive thymoma in patient with an hypermetabolic mass in the anterior mediastinum and a neurilemoma in upper abdomen. Conclusion: PET/CT can provide information on extra‐axillary lymph node involvement and can detect occult distant metastases in a significant percentage of patients. Solitary distant lesions detected by PET had to be verified.
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P098 Assessing Axillary Lymph Node Status in Breast Cancer using FDG-PET: A Review of the Literature and Meta-Analysis R. Peare1, R. T. Staff1, S. D. Heys2; 1NHS Grampian, Aberdeen, UNITED KINGDOM, 2University of Aberdeen, Aberdeen, UNITED KINGDOM. Introduction The most powerful prognostic indicator in patients with breast cancer is axillary lymph node status. Current practice is that all patients with invasive breast cancer have a histological assessment of their axillary node(s). These are surgical techniques which have associated post‐operative morbidities, such as post‐operative pain, sensory disturbances, impaired movement, lymphoedema, psychological distress and effects on the activities of daily life. Clearly, a non‐surgical method would be ideal. FDG‐PET offers a possible non‐invasive alternative and a number of studies have investigated the use of FDG‐PET to stage the axilla with varying results. The aim of this study was to review the literature and aggregate the results of these studies in a meta‐analysis. Methods A meta‐analysis of studies that compared FDG‐PET to histological assessments of axillary nodes, in patients with breast cancer, was carried out to assess the performance of this technique. Results Sensitivities ranging from 20% to 100%, and specificities ranging from 65% to 100% have been reported. An aggregated ROC analysis found an area under the curve of 0.95 (95% CIs 0.92‐0.97) and a Q* value of 0.90 (95% CIs 0.86‐0.93) in a total of 26 studies involving 1954 patients. Conclusion The sensitivity of the technique currently remains below that which is required to replace assessment of axillary node status by surgical biopsy and histological assessment. However, this result should be seen in the context of current and future developments in PET/CT. PET/CT also has the ability to detect distant metastases and in the future this modality may provide a ‘one stop’ staging tool which may, at least in part, include the assessment of the axilla.
P099 Combined use of tumor markers and F-18 FDG PET/CT in the follow-up of patients with breast cancer: a single cancer center experience. L. Travascio1, F. Ponzo2, I. Nofroni3, E. L. Kramer4, M. Colandrea1, G. Ronga1; 1(1) Nuclear Medicine Unit, Department of Clinical Sciences, University of Rome La Sapienza, Rome, ITALY, 2(2) Department of Radiology, NYU School of Medicine, New York, NY, UNITED STATES, 3(3) Department of Experimental Sciences, University of Rome La Sapienza, Rome, ITALY, 4Department of Radiology, NYU School of Medicine, New York, NY, UNITED STATES. Aim. Follow‐up of breast cancer patients after primary therapy is performed by clinical examination, serological tumor markers and diagnostic imaging. Present data do not support the use of CA 27.29 or CEA in the strict surveillance of these patients, mainly because of a low sensitivity in predicting relapse and in monitoring response of metastatic disease to treatment. Aim of the present study was to evaluate the diagnostic impact of F18‐FDG PET/CT compared to tumor markers in a selected high‐risk population, followed in a Cancer Center. Materials and methods. Thirty patients underwent at least 2 serial PET/CT scans with tumor markers (CA 27.29 and/or CEA) performed within 45 days of each PET/CT examination. Reports of each scan were retrospectively reviewed and tabulated. The first PET/CT and serum tumor markers (TM) were considered positive or negative for disease, while progression/regression/stability of disease was evaluated on serial scans and TM levels. Site of metastatic spread and any ongoing therapy were also collected. Confirmation of results was based on other imaging studies, clinical records and biopsy findings. Sensitivity, specificity and accuracy of PET/CT and tumor markers were calculated at baseline, at time point 1, 2 and overall. 95% confidence interval was calculated for each index. Results. PET/CT proved to be more sensitive and accurate than TM at every time point. Specificity was similar for the two tools employed. 95%CI were wide, as the investigation was carried on a small population of patients. As a preliminary result, it is noteworthy considering that tumor markers were false negative in case of monitoring after therapy for metastatic disease and in case of bony lesions; on the other hand, PET/CT was false positive in case of BOOP and sarcoid. Conclusion. PET/CT was a valuable tool in diagnosing and monitoring metastatic disease from breast cancer in patients followed in a Cancer Center. Tumor markers improves their accuracy after diagnosis of disease spread was made. Though, our results have to be confirmed on a larger population.
P100 The usefulness of brain 18F-FDG PET/CT in addition to totalbody scan in breast tumors A. Niccoli-Asabella, P. Santoro, C. Altini, G. Rubini; Nuclear Medicine, Bari, ITALY. Aim. To assess the usefulness of 18F‐FDG‐PET/CT brain scan in addition to total‐body scan in patients (pts) with breast cancer. Materials and methods. 980 18F‐FDG‐PET/CT were performed from September 2006 to January 2009 at Nuclear Medicine Unit of Policlinical Hospidal of Bari, in pts with breast cancer. 876/980 (89.4%) PET/CT scans including brain scan in addition to total‐ body scan. Examinations were performed in 3 pts to diagnose breast cancer, in 21 pts to stage, in 684 to restage, in 168 pts to make a follow‐up. 867 exams were performed in female and 8 in male subjects. Average age of pts was 59.6 years (range 27‐86 years). Results. In 30/876 (34%) 18F‐FDG‐PET/CT, brain scans were positive for the detection of lesions in the head; in 9/30 (30%) there wasn't any other previous head checks (RMN and/or CT and/or brain PET/CT); in 21/30 (70%) cases there was a previous brain imaging procedure; of these 21 PET/CT only in 6 cases (28.6%) the previous brain scan was positive, in the other 15 (71.4%) the previous exam was negative (11 PET/CT with brain relapses, 2 with surgery scars, 2 with vasculopathy). In 846/876 (96.6%) brain PET/CT were negative; in 438/846 (51.7%) cases were avaible previous brain exams; in 20/438 (46%) the previous scan was positive (3 PET/TC with bone relapses, 6 with meningoma, 2 with vasculopathy and 9 with brain relapses); in the other 418/438 (95.4%) the previous scan was negative. Conclusions. In our group of positive brain PET/CT with negative previous head imaging, in 11/15 cases the lesion was a relapse. Otherwise there are exams in which PET/CT didn’t show recidivous disease or benign neoplastic lesions. Therefore cerebral
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 PET/CT has an heterogenous behavior regarding brain repetitive lesions. It could be connected with multiple reasons such as histologic type of primary tumor, its staging or the time range elapsed from the previous exam to PET/CT relating to time of diagnosis. Therefore, it is necessary to choose selection’s criteria that allow to distinguish pts in which brain relapses are more easily observed in brain PET/CT.
P101 Global Patlak parametric images for improved analysis of dynamic breast F-18-FDG PET studies A. Krol1, A. Magri2, W. Lee1, D. Feiglin1; 1SUNY Upstate Medical University, Syracuse, NY, UNITED STATES, 2Syracuse University, Syracuse, NY, UNITED STATES. Objectives: To improve specificity of dynamic breast F‐18‐FDG PET studies. Method: The F‐18‐ FDG‐PET images were acquired using PET/CT scanner with patient positioned prone on the scanner bed with breast freely suspended. A low‐dose CT for anatomical correlation and attenuation correction was covering a single axial FOV centered over the breasts. It was followed by administration of 10 mCi of F‐18‐FDG and immediate series of 50 dynamic PET scans over 1‐ minute intervals in the selected FOV containing the breasts. Nonrigid breast F‐18‐FDG PET/CT image registration was performed using fiducial skin markers and finite element method. The target image was the first dynamic PET scan and the matched images were the remaining dynamic scans. As a result, each consecutive PET scan was nonrigidly registered to the first scan. Nonlinear curve fitting of activity vs. time, based on a realistic two‐compartment Patlak model, was performed for each voxel of the PET/CT volume. Three parameters for this model were fitted; two of them describe the activity levels in the blood and in the cellular compartment, while the third characterizes the washout rate of F‐18‐FDG from the cellular compartment. The half‐life of F‐18‐FDG in the blood compartment (set at 12 minutes) and the input function were estimated based on published data. Initial values of fitted parameters were estimated for each voxel, assuming realistic average physical tissue properties. Patlak analysis was performed on all fitted TACs. Parametric graphs of correlation between Patlak intercept and Patlak slope for whole breast volume, with every voxel contributing one data point, were created (~500,000 voxels). Voxels contributing to the parametric graph are color‐coded to display their physical location (e.g. region of tissue or lesion of origin). In addition, 3D images of spatial distribution of Patlak intercept and slope are obtained registered with the CT anatomical image, thus allowing determination of areas with high values of these parameters. Results: After registration and curve‐fitting voxels contributing from areas with different metabolic properties occupy well‐ differentiated and more compact regions with smaller overlap in the obtained parametric graphs. There is a strong correlation between location of area on the parametric graph and high probability of malignancy. Conclusions: The proposed parametric graph method might improve specificity of dynamic breast F‐18‐FDG PET studies for breast cancer detection.
P11 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: lung cancer
P103 An useful orthotopic transplantation animal model for human lung cancer research Y. Kang, M. Omura, A. Suzuki, T. Inoue; Graduate School of Medicine, Yokohama City University, Yokohama, JAPAN. Purpose/Introduction Lung cancer is the most frequent type of malignant cancer in the world. Recently, developing anticancer agents or imaging agents began to focus on targeting cancer specific molecules. However, the use of subcutaneous (s.c.) tumors growth in animal models does not adequately reflect the interaction between the specific organ environment and tumor cells. This may alter the tumor response to imaging agents or anticancer therapy. The purpose of this study is to establish an orthotopic tumor transplantation model in nude mice that closely resembles the clinical features of human lung cancer. Subjects and Methods Human lung squamous carcinoma SQ5 cell line was used in this orthotopic transplantation model. Tumor cell suspensions were directly injected into the main bronchi of anesthetized athymic nude mice with simultaneous administration of 0.01 M EDTA. Bromodeoxyuridine (BrdUrd) were injected to mouse 20 min before kill. Lung tissue with tumor nodules or s.c. tumor were fixed with formalin. Tissue sections were stained by HE or anti‐BrdUrd antibody. Proliferation index was calculated. Results Orthotopic SQ5 tumor colonies showed various sizes. Tumor colonies formed mainly in the upper lob of right lung and left lung. SQ5 solid tumors formed primarily from bronchioles. Orthotopic SQ5 tumors with minor diameter 40 to 700 µm, major diameter 80 to 830 µm had no definite necrosis. Orthotopic SQ5 tumors with minor diameter 540 to 5200 µm, major diameter 600 to 6100 µm displayed necrosis in the central of tumor. Proliferation index of orthotopic SQ5 tumors was significant higher than in s.c. SQ5 tumors. Discussion/Conclusion. In this orthotopic lung cancer transplantation model, tumor nodules distributed in a similar manner with the lung cancer in human. Various growth stages of lung cancer were formed. Proliferation index of SQ5 tumors in orthotopic model was more than that of tumors in s.c. model. Our data suggest that this orthotopic transplantation model may adequately reflect the interaction between the specific organ environment and tumor cells. This orthotopic transplantation model may provide suitable tool for human lung cancer research in nuclear medicine field.
P104 N-staging in Lung Cancer - combined 18-FDG PET and Diagnostic CT U. Talleruphuus1, M. Siemsen2, H. Hansen1, L. Friberg1; 1Bispebjerg University Hospital, Copenhagen, DENMARK, 2Rigshospitalet, Copenhagen, DENMARK. Introduction This study investigates to what extend high‐quality, preoperative PET/CT scanning correctly can stage mediastinal lymph node involvement in lung cancer patients. According to
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P105 Preoperative Staging of Peripheral Sarcoidosis with F18-FDG-PET-CT
Lung
Tumor
and
W. Plastowez1, C. Happel1, M. Harth2, J. Gurung2, I. Selkinski1, W. T. Kranert1, M. Middendorp1, J. Diener1, T. Vogl2, F. Grünwald1; 1Klinikum der Wolfgang Goethe Universität, Klinik für Nuklearmedizin, Frankfurt am Main, GERMANY, 2Klinikum der Wolfgang Goethe Universität, Institut für Diagnostische und Interventionelle Rad., Frankfurt am Main, GERMANY. Aim: In case of a peripheral lung cancer associated with sarcoidosis, histological examination of mediastinal lymph nodes of great importance to decide the possibility of operative therapy of the tumor. Material and Methods: An 80‐years‐old patient was referred F18‐FDG‐PET/CT work‐up after diagnosis of a subpleural soft tissue formation in chest x‐ray and CT measuring about 1.4 x 2 cm reaching with pleural contact and multiple pathologically enlarged mediastinal and hilus lymph nodes measuring up to 1.6 x 2.4 cm. The patient had a history of smoking with 40 packs year until 1982. The PET‐CT was done with a Biograph 6 (Siemens Medical Systems) with i.v. application of 202 MBq F18‐FDG (standard procedure with 8 bed positions every 3 minutes; rest phase p. i. 73 minutes). The PET‐CT was followed by mediastinoscopy and CT‐guided biopsy. Results: The PET‐CT showed a hypermetabolic lung nodule attached to the pleura in lateral segment of right upper lobe (segment 2) with maximum SUV of 7. It also showed pathologically enlarged mediastinal and hilus lymph nodes bilaterally with increased FDG utilisation (at the level of carina ‐ maximum SUV 6.4; inferolateral to arch of aorta ‐ maximum SUV 4; left main bronchus ‐ maximum SUV 4 and infracarinal ‐ maximum SUV 6.4). The PET‐CT TNM classification was T2 N3 M0. The histological findings of mediastinoscopy and CT‐guided biopsy showed no signs of malignancy. Depending on the histological findings (absence of lymph node metastases) an operative treatment was decided upon. An atypical resection of right upper lobe with radical lymphadenectomy was done. The histolopathological examination of the resected lung showed moderately differentiated squamous cell carcinoma (TNM: pT2 G2 R0). The resected mediastinal and hilus lymph nodes showed a granulomatous lymphadenitis corresponding to sarcoidosis. Conclusion: After exclusion of metastatic lymph nodes, the TNM classification of the moderately differentiated squamous cell carcinoma was pT2 pN0 G2 R0. Due to negative histological findings after mediastinoscopy and CT‐guided biopsy, the lung cancer was removed.
P106 18
FDG PET for grading malignancy in thymic epithelial tumors: 18 Significant differences in FDG uptake and expression of glucose transporter-1 and hexokinase II between low and high risk tumors
M. Nakajo1, Y. Kajiya1, A. Tani1, M. Ueno1, S. Yoneda2, H. Shirahama3, M. Nakajo4; 1Department of Radiology, Nanpuh Hospital, Kagoshima, JAPAN, 2 Department of Thoracic Surgery, Imakiire General Hospital, Kagoshima, JAPAN, 3Department of Pathology, Imakiire General Hospital, Kagoshima, JAPAN, 4Department of Radiology, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, JAPAN. Aim: To evaluate the potential of 18FDG PET for grading of malignancy in thymic epithelial tumors and analyze relationships between 18FDG uptake and expression of glucose transporter 1 (Glut‐1) and hexokinase II (HK‐II) in thymic epithelial tumors. Materials and Methods: Eleven patients with a thymic epithelial tumor who underwent 18FDG PET examination before treatment were enrolled in the present study. Comparison of the 18FDG lesion maximum standardized uptake value (SUVmax) was made between low‐risk (Types A, AB and B1) and high‐risk (Types B2, B3 and thymic cancers) tumors grouped by use of a simplified WHO histological classification. The expression of Glut‐1 and HK‐II in the thymic tumors was analyzed by immunohistochemistry. The percentages of positive stained cells were rated using a semiquantitaive scale as 0‐10%, 11‐50%, or 51‐100%. The intensity of the staining was graded as negative, weak, or strong. The staining result was scored from 0 to 4 according to the intensity and percentage of positively stained cells (0= negative or weak with 0‐10 %, 1= weak with 11‐50%, 2= weak with 50‐100% or strong with 0‐ 10%, 3= strong with 10‐50%, 4=strong with 50‐100%). Results: Tumors included 6 low‐risk tumors and 5 high‐risk tumors. On visual inspection, all tumors showed 18FDG uptake. The SUVmax was significantly higher in the high‐risk tumors (5.24 ± 2.44) than in the low‐risk tumors (3.05 ± 0.55) (P= 0.008). The both staining scores in the high‐risk tumors were higher than those in the low‐risk tumors (Glut1: low‐risk vs. high‐risk: 0 ± 0 vs. 2.00 ± 1.87, P =0.036 and HK‐II: low‐risk vs. high‐
risk: 0.50 ± 0.84 vs. 2.20 ± 1.30, P=0.030). A significant correlation was observed between SUVmax and the staining scores of Glut‐1(P=0.027, ρ=0.70) and HK‐II (P=0.015, ρ=0.77). Conclusion: These preliminary data suggest that 18FDG PET has the potential of grading malignancy in thymic epitherial tumors and Glut‐1 and HK‐II may play an important role for determining the degree of 18FDG uptake in thymic epitherial tumors.
P107 Computed tomography with contrast and FDG-PET in lung hamartoma G. Marotta1, G. Basilico2, L. Santambrogio2, P. Gerundini1; 1Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Nuclear Medicine Department, Milano, ITALY, 2Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Department of Surgery, Thoracic Unit, Milano, ITALY. Objectives: Despite the expanded lung cancer screening, accurate differentiation of benign from malignant lesions remains unsolved. Pulmonary hamartomas are the most common benign lesions of the lung and represents 8% of all solitary pulmonary nodules. The aim of the study was to assess the ability of computed tomography with contrast and 18F‐FDG‐PET to distinguish these lesions from malignant lesions. Methods: A retrospective analysis was performed on 13 patients with pathologic diagnoses of lung hamartoma who underwent multidetector computed tomography (with and without contrast) and PET scan with 18F‐FDG during workup for surgical removal of the single nodular lesion at our institution from 2001 to 2008. Visual analysis for evaluation of specific morphologic features (lesion size, margins, shape and presence of calcification or fat) was carried out on all computed tomography studies. Qualitative visual analysis was performed on all (corrected and non corrected for attenuation) PET scans. Semiquantitative metabolic activity, through SUVmax normalised to body weight, was reported on 11 studies only, for technical problems. Computed tomography scans and PET were evaluated separately, and interpretation of one was blinded to the results of the other. Results: All lesions were solid, 8 nodules were in right lung (5 in upper lobe, 2 lower lobe. 1 median lobe) and 5 nodules in left lung (1 upper lobe, 4 lower lobe). Computed tomography suggested malignancy in 5 cases (38%), whereas 8 studies were interpreted as benign (for intranodular fat and popcornlike chondroid calcifications). PET scan was considered benign in all cases and SUVmax ranged from 0.7 to 2.2 (median value 1.6). Conclusions: In the present study, PET/CT provided better results than CT, diagnosing all pathological confirmed lung hamartoma as benign. The appropriate use of the PET with CT scan may reduce invasive procedures.
P108 Post-recurrence survival in patients with Non Small Cell Lung Cancer in whom recurrent disease was diagnosed by FDGPET/CT J. F. Jiménez-Bonilla, R. Quirce, I. Banzo, I. Martínez-Rodríguez, A. SainzEsteban, J. E. Barragan, H. Portilla-Quattrociocchi, P. C. Medina-Quiroz, J. M. Carril; HU Marqués de Valdecilla. Universidad de Cantabria., Santander, SPAIN. Aim: To evaluate post‐recurrence survival in patients in whom the extension and location of the recurrent disease were established by FDG‐PET/CT. Material and methods: During the last two years a follow up study was perform in 34 patients (25 men and 9 women) with recurrence of their Non Small Lung Cancer (NSCLC), 14 with initial stage I or II, and 20 with advanced stage. In all of them, the extension and location of the recurrence were assessed by FDG‐PET/CT and confirmed by histology or follow up. In 14 there was a local recurrence and in 20 there were distant lesions. Data of survival have been collected during 20 moths after recurrence was diagnosed, although in 7 patients the follow up period has been shorter. We considered two time points for evaluation, 10 and 20 months. Results: Post‐recurrence survival at 10 moths was 64% and at 20 moths 44%. In the local recurrence group the survival rates were 86% and 77%, while in the non local recurrence group the rates were 50% and 14% respectively. When the initial diagnostic staging was considered the survival rates were 71% and 63% for non advanced stages and 60% and 31% for advanced stages. Conclusion: This data, although have been obtained during a short follow up period, suggest that the post‐recurrence survival time in the patients with NSCLC in whom the FDG‐PET/CT was applied for evaluation of the recurrent event can be superior than the previous reported in the literature when it was not employed. Up to now there are not studies of post‐recurrence survival in patients in whom the diagnosis of recurrence was established applying FDG‐PET/CT.
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Clinical impact of F-FDG PET on the management of patients with early non-small-cell lung cancer by conventional workup R. Yen, C. Yu, Y. Lee, Y. Chang; National Taiwan University Hospital, Taipei, TAIWAN. Purpose: 18F‐FDG PET is an imaging modality that is effective in diagnosing, staging and restaging non‐small‐cell lung cancer (NSCLC).The objective of the this study was to determine the impact of additional 18F‐FDG PET on the management of patients who were scheduled for surgery after conventional workup (CWU). Methods: This study includes consecutive 121 histologically‐verified NSCLC patients (66 male and 55 female; age: 63.6± 11.0 years) who had received additional 18F‐ FDG PET studies before their surgery. All 121 patients have been followed up for more than 12 months clinically after their PET studies. Results: PET scan resulted in change of clinical management for 28 (23.1%) patients. Of these 28 patients, 22 were upstaged while 6 were downstaged. After clinical follow‐up for at least 12 months clinically, 2 patients died from surgical complication immediately after their surgery and 36 patients developed recurrent/metastatic diseases. Among them, 8 patients died of lung cancer progression or chemotherapeutic side‐ effects. Conclusion: The result of this study shows that addition of 18F‐FDG PET to CWU affected the management of early NSCLC patients in near 1 out of 4 patients. However, the impact of PET results on the clinical outcome for these NSCLC patients needs further long term investigation.
Poster Presentation
The American College of Chest Physicians, 2007, the sensitivity and specificity of mediastinal staging by PET has been reported around 75 % and 85% respectively. Subjects and methods The patients were examined between January 2007 and December 2008. PET/CT scans were performed on a Gemini TOF 64 slice scanner (Philips inc.). They received 375 MBq 18F‐FDG i.v. CT‐scans were performed with diagnostic quality and contrast enhanced CT when kidney function was normal. All patients were examined in a standard routine examination protocol. Reporting of the PET/CT scans and staging of the expected lung cancer was done in collaboration with a specialised nuclear medicine physician and a specialised radiologist. At a multi‐disciplinary conference attended by thoracic surgeons, it was decided if the patients were eligible for further surgical work up. Lymph node involvement in mediastinum was explored and staged by mediastinoscopy and thoracotomy when performed. The standard TNM‐classification (1997) was used for staging. Results Among 859 consecutively performed PET/CT‐scans in patients with suspected lungcancer, 69 (8%) patients were referred for further surgical investigation. Median age was 67 years and 51% were female. Of these 10 patients had inflammatory diseases and two had recurrent malignancy and were excluded. Fourteen patients did not undergo a thoracotomy either because mediastinoscopy proved advanced disease (4 patients) or because of technical inoperability in 10 patients, which were excluded. The distribution of N0, N1 and N2‐3 was 22, 17 and 8 respectively. Median time from PET/CT to first surgical procedure was 21 days. PET/CT correctly staged mediastinal disease in 7 of 8 patients and excluded mediastinal disease in 32 of 39 patients, thus resulting in a sensitivity and specificity of 88% (95% CI, 64% ‐ 100%) and 82% (95% CI, 69% ‐ 94%) respectively. Conclusion With PET/CT we found mediastinal lymph node involvement in staging of lung cancer, with an overall sensitivity and specificity of 88% and 82% respectively. This is slightly better than the numbers reported in the literature. We find that 18F‐ FDG PET with diagnostic CT should be part of the routine preoperative investigation of lung cancer.
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Inmunohistochemical expression of P16 in patients with non small cell lung carcinomas. Correlation with other biological parameters and the values SUV-18F-FDG-PET.
Clinical impact of the FDG-PET/CT over the mediastinal staging (N) in patients diagnosed of NSCL assessed by histological samples
A. Sanchez-Salmon, J. Cortes, A. B. Ciobotaru, P. Arce-Calisaya, I. Abdulkader, F. Gude, L. Leon, A. Ruibal; Hospital Clinico Santiago, Santiago de Compostela, SPAIN.
R. Quirce, J. F. Jimenez-Bonilla, I. Banzo, I. Martinez-Rodriguez, A. SainzEsteban, J. Barragan, H. Portilla-Quattrociocchi, P. Medina-Quiroz, J. M. Carril; H.U.M.Valdecilla. Universidad de Cantabria, Santander, SPAIN.
In order to study its behavior , we have analyzed by means of tissue‐arrays (Acm 0A315 Kit PharmDX MTM. Germany. Prediluted)) the expression of p16 in 115 patients with small cell lung carcinoma (67 squamous cell type and 48 adenocarcinomas) and we have related it to the expression of Cox‐2, HIF‐1alfa, p 63, EGFR and MIB1. The expression of p16 (> 10 % positive cells) was higher (p:0,043) in adenocarcinoma (20/48) that in the squamous cell carcinomas (p 0,087) and was inversely related to the clinical stage (I: 14/33; the IInd: 4/16; the IIIrd: 18/47 and the IVth: 0/19); I‐II vs III‐IV: 18/49 vs 18/66: 0,001). The expression of p16 was correlated inversely with that of EGFR (p:0,027) and p63 (p:0,021). In 49 patients we compared the expression of p16 with the values SUV in the 18F‐FDG‐PET, observing that those were higher (p: 0,024) in the cases p16 ‐ (17,4 +/‐8,3) that in p16 + (12,6 +/‐5,2) . After a follow up of 110 patients with multivariate analysis, we stated that the clinical stage (I‐II vs III‐IV; HR: 2,3; IC: 1,33‐4,02) was a independent outcome factor whereas the expression of p16 (HR: 0,64; CI: 0,36‐1,15) was associated to a better outcome, but not reaching the statistical significance. The previous results induce us to the following considerations: 1) the expression of p16 is higher in adenocarcinoma that in the squamous cell carcinomas and relates inversely to the clinical stage and EGFR's expression; 2) SUV's values are higher in the p16 negative tumors that in the positive ones; 3) the expression of p16 might help to explain SUV's major values described in the squamous cell carcinomas opposite to the adenocarcinomas; 4) the clinical stage was a factor of bad outcome, whereas the expression of p16 was of good outcome, nevertheless did not reach the statistical significance after multivariate analysis.
AIM To assess the contribution of FDG‐PET/CT scintigraphy to mediastinal staging (N) in patients with non small cell lung cancer (NSCLC) by comparison with histological results. MATERIAL AND METHODS 46 patients diagnosed of NSCLC in 2008 were included for N staging. All had conventional techniques and FDG‐PET/CT. In all, histological diagnosis was available. In 22 patients by biopsy and/or mediastinoscopy, 29 histological samples were obtained and in 18 malignancy was confirmed; in 24 patients by thoracotomy, 83 samples were obtained and in 22 malignancy was confirmed. RESULTS: With regard to the samples evaluation FDG‐PET/CT showed a PPV of 84% and a NPV of 70% in the obtained by biopsy or mediastinoscopy. However in the 83 samples obtained by thoracotomy the PPV was 61% and the NPV 87%. In 7 nodal stations the histological analysis was perform both by punction and by thoracotomy. The results agree in 5 cases (3 TN, 1 TP and 1 FN) and disagree in 2 (1 FN obtained by EBUS but TP by FDG‐PET/CT and 1 FP by FDG). In the group of 22 patients without thoracotomy N staging by FDG‐PET/CT agree in 18 with the histological staging (1 N0, 1 N1, 11 N2 and 5 N3) and disagree in 4, upstage in 1 N0 and downstage in 3 N2 in whom the biopsy was performed to investigate malignant CT findings that not showed FDG uptake. In the group of 24 patients with thoracotomy, NSCLC was rule out in 1. In the other 23 patients with NSCLC, N staging by FDG‐PET/CT agreed with the histology in 20 (6 N0 and 14 N2) and disagreed in 3, upstaging in 2 N0 and 1 N1. CONCLUSION In this group of patients with NSCLC FDG‐PET/CT has been an useful tool for mediastinal staging. It allows the selective nodal biopsy and the optimization of the diagnostic resources. In our population, when it was applied there was not any patient with a presurgical mediastinal downstage.
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FLT-PET/CT for Lung Cancer Patients Receiving Carbon-Ion Radiation Therapy: Prognostic Significance
Can N2 disease be predicted by FDG uptake in the primary lung tumour or hilar lymphadenopathy: preliminary results.
T. Saga, M. Koizumi, M. Inubushi, K. Yoshikawa, T. Fukumura, M. Baba; National Institute of Radiological Sciences, Chiba, JAPAN.
T. A. Szyszko1, Z. Viney2, M. J. O'Doherty1, T. O. Nunan1, S. Rankin2, G. Santis2, R. Breen2, J. King2, L. Lang-Lazdunski2, K. Harrison-Phipps2, T. Routledge2, P. Cane2, E. McLean2, S. F. Barrington1; 1PET Imaging Centre at St Thomas, Kings College Division of Imaging, London, UNITED KINGDOM, 2Guys and St Thomas NHS Foundation Trust, London, UNITED KINGDOM.
Aim: To investigate the prognostic significance of positron emission tomography (PET) using F‐18‐ fluorothymidine (FLT), a tracer for cellular proliferation, for lung cancer patients receiving carbon‐ion radiation therapy (CIRT). Materials & Methods: Twenty‐one consecutive patients (mean age 73 years, 12 male and 9 female) with lung cancer who are going to be treated with CIRT received FLT‐PET/CT before and 3 months after CIRT. Fifty minutes after intravenous injection of approximately 300 MBq of FLT, PET/CT data were acquired. Maximal standardized uptake value (SUVmax) of the tumor was measured by using CT image as a reference of ROI placement. Reduction rate of tumor uptake was also calculated (RR = (pre‐SUVmax ‐ post‐ SUVmax)/pre‐SUVmax). Patients were followed for the development of recurrence and/or metastasis (follow‐up period: 8 ‐ 29 months). The study plan was approved by the Institutional Ethical Committee and informed consent was obtained from all patients before FLT‐PET examination. Results: Squamous cell carcinomas tended to show higher FLT uptake than adenocarcinomas, but the difference was not statistically significant (3.70 +/‐ 1.88 versus 2.85 +/‐ 1.55, p=0.27). Two patients were excluded from the follow up study because of the presence of liver metastasis before CIRT in one case and the detection of second malignancy (gastric cancer) in the follow‐up period in the other case. Seven of 19 patients developed recurrence and/or metastasis in the follow‐up period determined by histological analysis in 3 cases and by clinical follow‐up including various imaging modalities in 4 cases, and 4 of these 7 patients died. Patients who developed recurrence and/or metastasis showed higher pre‐SUVmax than those who did not develop recurrence and/or metastasis (3.90 +/‐ 1.33 versus 2.54 +/‐ 1.38, p=0.051). Post‐ SUVmax and RR did not show any significant difference between the two groups (p=0.633 and 0.111, respectively). Kaplan‐Meier analysis showed that pre‐SUVmax threshold of 3.7 best discriminated patients having favorable post‐CIRT course from those having unfavorable post‐ CIRT course (p=0.004 for progression‐free survival and p=0.011 for overall survival). Conclusion: Although the number of patients is small and the follow up period is not long enough, the present data suggests the prognostic significance of FLT‐PET performed prior to treatment in lung cancer patients being treated with CIRT.
P112 NSCLC staging by FDG-PET/CT: Significance of unspected extrathoracic findings P. Medina-Quiroz, R. Quirce, J. F. Jimenez-Bonilla, I. Banzo, I. MartinezRodriguez, A. Sainz-Esteban, J. Barragan, H. Portilla-Quattrociocchi, J. M. Carril; Hospital Universitario Marqués de Valdecilla. Universidad de Cantabria., Santander, SPAIN. AIM To assess the contribution of the FDG‐PET/CT extrathoracic findings observed during the initial staging of NSCLC patients. MATERIAL AND METHODS A group of 46 patients were submitted for initial staging of a NSCLC with FDG‐PET/CT. In 11 patients 14 extrathoracic FDG uptake foci were found. To identify the nature of these foci histological studies were indicated. RESULTS A final diagnose was obtained by histology in 8 patients. Malignant lesions were found in the 13% (6/46) of the patients at the initial staging of the NSCLC. In 2 patients metastatic unsuspected foci were found: breast and a supraclavicular adenopathy. In 3 patients a synchronic colorectal adenocarcinoma was discovered, and in 2 of these patients there were found also 2 colonic adenomas. In another patient a premalignant tubulovellose adenoma was the aetiology of the FDG uptake. Benign pathology was establish in 2 patients: 1 mandibular radionecrosis overinfected related to a previous cervical malignancy and in 1 patient there were concomitant oesophagitis with a peptic gastric ulcus. CONCLUSION FDG‐PET/CT can show unsuspected and relevant extrathoracic findings that can be crucial for the correct staging (M) and also for detection of synchronic malignancies. The histological investigation of these uptakes must be considered when they are found.
Aim To assess nodal uptake on 18F‐FDG PET/CT to see if N2 disease can be predicted by uptake in the primary tumour or hilar lymphadenopathy Methods 18F‐FDG PET/CT scans were performed on two GE PET/CT scanners (DST and VCT) during the latter half of 2008. Uptake time was 90 minutes. Scans were assessed by two observers and compared with the original PET/CT reports. Visual and semiquantitative assessments were made of the primary tumour, hilar and mediastinal nodes which were considered as negative, equivocal or positive. The ratio of SUV uptake in nodal groups (ipsilateral N1 to contralateral N1; ipsilateral N1 to N2 nodes and ipsilateral N1 nodes to primary tumour uptake) were assessed and compared to histologically proven N1 and N2 disease. Results 50/119 consecutive cases of NSCLC had suitable histology from nodal sampling by EBUS or surgery. 30 patients were male. In 13 patients with histologically proven N1 disease, the ratio of SUV in involved N1 nodes to contralateral nodes ranged from 0.95‐14.8 (mean 4.6). In 21 patients with histologically negative N1 disease; the ratio ranged from 0.64‐1.4 (mean 1.0). Using a ratio above 1.4, N1 disease would have been identified in 83%. No N2 disease was missed on visual assessment in cases with concurrent N1 disease, but 2 cases staged as N0 were found to have small volume N2 disease at surgery. In 7/20 scans reported as equivocal for N2 disease, histology was negative in 5. For N2 positive disease, the N2 SUV ranged from 1.4 ‐20.8 (mean 7.2). A ratio of 0.56 (N2/tumour SUV) has been suggested in the literature to predict the likelihood of N2 disease. Applying this ratio to histologically proven N2 disease, only 50% of nodes would have been identified. For those with both N2 disease and N1 disease, the lowest N1 SUV was 5.2 and the lowest SUV in the primary tumour was 7.5. The ratio of N1/tumour uptake varied from 0.1 to 1.0; the ratio of N1/liver uptake varied from 1.6 to 17, hence these were not useful predictors of N2 disease. Conclusion Visual assessment missed 2 cases of small volume N2 disease in the 50 scans assessed. N1 SUV is not a good predictor of N2 disease. If the ratio of ipsilateral to contralateral hilar SUV is above 1.4, then 83% of N1 nodal disease would be identified. This needs to be confirmed with review of a larger patient population.
P115 The Clinical Impact of 18F-FDG PET/CT on Management of Patients with Lung Cancer M. Zsiray1, Z. Markóczy1, M. Magyar1, Z. Lengyel2, S. Szakáll2, A. Fekésházy3, M. Kásler4, K. Borbély4; 1National Korányi Institute of Pulmonology, Budapest, HUNGARY, 2Positron Diagnostic LTD, Budapest, HUNGARY, 3PET-CT LTD, Budapest, HUNGARY, 4National Institute of Oncology, Budapest, HUNGARY. Objectives: Results of multiple studies have confirmed the benefit of positron emission tomography (PET) with 18F‐fluorodeoxyglucose (18F‐FDG) in the management of primary lung carcinoma. 18F‐FDG PET is the most sensitive noninvasive imaging modality for the evaluation of solitary pulmonary nodules (SPN). The technique is superior to CT in terms of sensitivity and specificity for the diagnosis and staging of lung cancer. Our purpose was to test the clinical impact of PET/CT in our patients with lung cancer. Methods: The study population consisted of 408 patients / 415 studies. PET/CT studies were performed with indication of metabolic characterization of SPN (n=154), preoperative staging (n=175), or restaging (n=86) of patients with primary lung carcinoma. The results of PET/CT studies were analyzed retrospectively and compared to clinical and radiologic data. Results: The sensitivity, specificity, positive predictive value, and negative predictive value of 18F‐FDG PET/CT was 92%, 75%, 72%, and 94%,
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P116 Usefulness of C-11 methionine PET/CT for predicting recurrence, metastasis and prognosis of patients with lung cancer treated by carbon ion radiotherapy. S. Toubaru1, K. Yoshikawa1, S. Ohashi1, M. Hasebe1, H. Ishikawa2, K. Sagou2, K. Tamura1, K. Tanimoto1, S. Kandatsu1, M. Baba1, T. Fukumura1, T. Saga1, K. Kawaguchi2, Y. Hamada2, H. Tsujii1; 1National Institute of Radiological Sciences, Chiba, JAPAN, 2First Dept. oral & maxillofacial surgery, Tsurumi University, Yokohama, JAPAN. The carbon ion radiotherapy (CIRT) has been introduced in our institute, and we have treated lung cancer using carbon ion beam. We performed C‐11 methionine (MET) PET/CT and compared the difference of MET uptake level before and after CIRT among lung cancers. We evaluated whether MET uptake and its change after CIRT were early predictor for recurrence, systemic metastasis or survival factors in patients with lung cancer. Methods: MET‐PET/CT was performed in 56 patients with lung cancer before and after CIRT. There were 26 squamous cell carcinoma, 31 adenocarcinoma and 1 large cell neuroendocrine carcinoma (2 patients had double cancers with squamous cell carcinoma and adenocarcinoma). The average patient age was 74.6 years (range 40 to 89). Patients were followed for 5.4 to 58.5 months (mean: 23.1 months) after CIRT. PET with 2‐raw MDCT, Biograph Duo, was used for PET/CT imaging. PET/CT was performed before and after CIRT for each patient. Post therapeutic PET/CT were done at 1 month (23 cases) or 3 months (33 cases) after CIRT completion. Tumor MET uptake was measured with a semi‐ quantitative index, tumor to normal tissue ratio (TNR). The tumor TNR, its change after CIRT, result of recurrence, result of systemic metastasis and result of prognosis were entered into Kaplan‐Meire analysis. Results: We examined the relationship between TNRs (TNR before CIRT, TNR after CIRT, change of TNR by CIRT) and clinical factors (recurrence, metastasis, prognosis). Nine relations between them were analyzed by Kaplan‐Meire analysis. There were statistically significant relations between baseline TNR and recurrence, baseline TNR and prognosis, TNR at 3 months after CIRT and prognosis. Patients with high TNR before CIRT had a significant higher recurrence rate and poorer prognosis than patients with low TNR (Cutoff 4.0 and 4.4, p=0.001 and 0.023, respectively). Patient with high TNR at 3 months after CIRT had a significant poorer prognosis than patients with low TNR (Cutoff 3.0, p=0.038). TNR at 1 month after CIRT didn’t show any statistically significant relation to recurrence, metastasis or prognosis. There was no significant relation between any TNRs and incidence of metastasis. Conclusions: MET uptake in lung cancer was a successful predictor of recurrence and survival. TNR at 3 months after CIRT is better predictor for prognosis than TNR at 1 month after CIRT.
P117 The value of FDG PET/CT to stage non-small cell lung cancer: Ankara University experience O. Küçük, S. Laçin, M. Soylu, G. Aras; Ankara University Medical Faculty Nuclear Medicine Department, Ankara, TURKEY. FDG PET/CT is routinely performed to evaluate non‐small cell lung cancer (NSCLC) lymph node staging. In this retrospective analysis, the results of PET/CT and CT were compared with histopathological findings and the SUV values were investigated. Material and Methods: 22 primary lesions and 152 lymph nodes in 22 patients (22 male, 42‐81 years old) were evaluated. Contrast enhanced CT was performed within 1 week to PET/CT. All patients were operated; 13/22 had lobectomy, 8/22 pneumonectomy and 1 had wedge resection. The histopathological results were compared with CT findings, PET/CT findings and SUV values. Results: The increased FDG uptake was seen in all primary lesions (SUVmax 4.7‐20.9). All primary lesions were malign except 1 patient whose primary lesion was evaluated as hyalineased fibrous tissue with SUVmax 10.9 and lymph node was granulomatous tissue with SUVmax 7.3. On the evaluation of 152 lymph node with FDG PET/CT 9 was FP, 7 FN, 4 TP, 132 TN. The value of SUVmax of TP lymph nodes were 1,6‐5.5 and FP lymph nodes were 2.9‐7.7. the SUVmax was less than 2.5 in all TN and FN lymph nodes. On the evaluation CT no TP results was found while 36 FP, 9FN and 107 TN lymph nodes were observed according to histopathology. Conclusion: In this retrospective analysis it should be in mind; PET/CT was beter than CT to stage lymph node involvement and the SUVmax of primary malign lesions was more than 2,5 but on the other hand the lymph nodes with SUVmax less than 2.5 might be metastatic.
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Contribution of FDG-PET/CT in the management of patients with bronchoalveolar carcinoma (BAC): work in progress
possible recurrence, 1 was upstaged, in 2 patients extra lesions were detected by 18FDG‐PET/CT (time interval 21‐48days) and in the other 2 there was agreement of 18FDG‐PET/CT findings with conventional modalities. 18FDG‐PET/CT, performed in 2 patients for follow‐up, upstaged 1 and downstaged 1 patient and finally upstaged the only patient examined for initial staging. Maximum standardized uptake value (SUVmax) ranged between 3.7‐7 in the recurrence cases and between 2.8 and 3.7 in the re‐staging cases. Conclusion: 18FDG‐PET/CT has been reported to have a low sensitivity in the initial diagnosis of BAC due to low FDG uptake. Our initial results indicate that 18FDG‐PET/CT may provide further information especially in patients evaluated for recurrence or restaging post‐therapy due to the fact that the SUVmax values increase. It seems that lesions become FDG avid in the cases of recurrence or in cases of unsuccessful treatment allowing for appropriate therapy or changing it.
P119 The role of PET/CT in malignant mesothelioma: preliminary data L. Gogou, D. Kechagias, F. Vlachou, V. Filipi, D. Tsevas, E. Kotsalou, K. Gogos, K. Dalianis, J. Andreou, V. Prassopoulos; Department of PET/CT, D.T.C.A.Hygeia Hospital, Athens, GREECE. AIM:The aim of this study is to evaluate the role of 18F‐FDG PET/CT in malignant mesothelioma. MATERIAL‐METHODS:10 patients, 3 woman and 7 men, underwent 11 PET/CT examinations, from 01/07/2004 to 01/04/2009 for pleural tumor involvement. Out of 10 patients 6 were evaluated for initial staging and 5 patients for restaging. One patient came twice (for staging and restaging the disease after treatment). The age of the study group varied from 51 to 84 years old. All patients underwent PET‐CT scan 60 minutes after the intravenous injection of 370±30MBq 18F‐FDG (Biograph II, Siemens). RESULTS: We compared the results from whole body imaging with those of conventional imaging procedures (CT of the thorax and abdomen). All patients had pleural thickening disease on CT studies with pleural effusions and atelectasis. Two CT studies revealed lymph nodes in the same hemithorax of the pleural disease and one study had paraortic lymph node. Increased uptake of 18F‐FDG was observed in all the sites detected by CT. Moreover PET/CT revealed increased metabolic activity of the hilar and mediastinal lymph nodes in 1/6 patients , the presence of nodular disease in the contralateral hemithorax in 2/6 patients , and two unsuspected distant metastases (2 lymph node and 1 bone metastasis). 18F‐FDG PET/CT for restaging demonstrated increased metabolic activity in local recurrence (5/5 patients with SUV>10), in a subdiaphragmatic lymph node (1/5 patient), in nodular disease in the contralateral pulmonary field (1/5 patient) and in liver lesion (1/5 patient). CONCLUSION: Preliminary data showed that PET/CT is a useful method to examine the extent of the local tumor, the mediastinal nodal metastases and to identify extrathoracic metastases. PET/CT is a useful modality for restaging patients with malignant mesothelioma, as it can evaluate local recurrence, lymph node involvement, extra thoracic metastases and also identify the best site for biopsy when necessary.
P120 The incremental value of including the brain in F-18 FDG PET/CT staging of NSCLC lung cancer. J. D. Birchall1, R. H. Ganatra2, S. C. S C Chua3; 1Royal Derby Hospitals NHS Foundation Trust, Derby City General Hospital, Derby, UNITED KINGDOM, 2Nuclear Medicine Clinic Nottingham University Hospitals, Queens Medical Centre Clifton Boulevard Nottingham NG7, Nottingham, UNITED KINGDOM, 3Department of Nuclear Medicine and PET, The Royal Marsden Hospital NHS Foundation Trust, Sutton, UNITED KINGDOM. Aim and Background: Recently due to more accurate noninvasive staging F‐18 FDG PET/CT has become almost routine in the staging of nonsmall cell lung cancer as such changes anticipated management in upto 30‐40% of patients compared to conventional staging with CT. Routine PET/CT imaging is from skull base to midthigh and does not include the brain based on earlier cerebral PET studies. We consider that routine inclusion of the brain on modern scanners is both timely and appropriate due to has not been part of routine staging of NSCLC and early studies with F‐18 FDG PET suggested no increment improvement. Method: Retrospective review 6 months of PET/CT referrals for primary staging NSCLC. Presence of known cerebral disease, outcome of subsequent cerebral imaging (CT/MRI) and whether alive at 12months post referral was assessed. Results: 51 patients of whom 2 were known to have cerebral disease (with intent to treat this curatively), 3 patients (6%) in whom on body PET/CT disease was suitable for curative therapy had unsuspected cerebral disease and 2 patients developed cerebral relapse on CT at 6 months post PET. One‐year survival post PET was 14% (a cerebral relapse patient) compared to 89% of those without any cerebral disease. Conclusion: We conclude that including brain in routine PET/CT revealed unsuspected distant disease changing management to palliative intent and that presence or absence of cerebral disease on initial staging PET/CT gives important prognostic information.
P121 Is SUVmax Reliable Quantitative Parameter in NSCLC ?
E. V. Skoura, D. Exarhos, M. Skilakaki, P. Rondogianni, E. Vlontzou, I. E. Datseris; Evangelismos Hospital, Department of Nuclear Medicine, Division of PET/CT, Athens, GREECE.
N. Can1, Ö. Akdemir2, M. Unlu2; 1MEDICANA International Hospital, Ankara, TURKEY, 2Gazi University Medical Faculty Nuclear Medicine Department, Ankara, TURKEY.
Aim: The imaging modality of 18FDG‐PET/CT has been reported to have a low sensitivity in the initial diagnosis of bronchoalveolar carcinoma (BAC) due to its low metabolic activity. The aim of our study is to assess the value of 18FDG‐PET/CT in the management of patients with already known BAC. Materials and Methods: During the period 2/2007‐ 2/2009, thirteen patients (13), (9 male, 4 female; mean age 67.2 yrs) with diagnosed BAC were examined by 18FDG‐PET/CT. Five (5) patients were assessed for restaging post‐therapy, 5 for possible recurrence, 1 for initial staging, and 2 for follow‐up as they had equivocal findings in conventional imaging (CT, MRI). All patients underwent integrated PET/CT 60 minutes after the intravenous injection of 370MBq 18F‐ FDG. The examinations were reviewed by a nuclear medicine physician and a radiologist and agreement was reached by consensus. Results: Two of the patients examined for restaging had 18 an agreement of FDG‐PET/CT findings with conventional modalities performed (time interval 15‐29 days), 2 patients were upstaged and 1 was downstaged. Of the patients evaluated for
AIM: To show if there is any relation of maximum standard uptake value ( SUVmax ) with fasting blood glucose level, dose injected, body mass index ( BMI ) and tumor size‐ location in newly diagnosed NSCLC patient group. MATERIAL‐ METHOD: We included 26 patients with adenoca ( 5 female, 21 male; aging 60 ± 10 ) and 37 patients with epidermoid ca ( 2 female, 35 male; aging 60 ± 8 ), all had recent diagnosis and administered for initial staging with 18F‐FDG PET/ CT. All patients are injected 0.14 mCi/kg 18F‐FDG after 6 hour fasting and all were scanned 60± 5 minute later than injection. In statistic analysis T test, X2, Fischer exact t test and regresion analysis were used. RESULTS: Mean SUVmax in adeno ca and epidermoid ca groups was as follows: 14.29± 5.2, 14.7± 4.5. There was no significant difference in respect to gender, age, fasting blood glucose level, BMI, tumor location between two groups ( p> 0.01 ). SUVmax was independent of BMI, dose injected, fasting blood glucose, histological type of tumor and location of tumor in both groups. In respect to tumor size there was a weak linear relation in epidermoid ca group.
Poster Presentation
respectively. Conclusion: The selection of most appropriate therapy for patients with lung carcinoma is of high importance. The results of 18F‐FDG PET/CT had a high impact on the management of patients by improving dramatically the sensitivity and diagnostic accuracy. However, due to the low specificity of 18F‐FDG PET/CT, tissue sampling of suspicious mediastinal lymph nodes is highly recommended for the optimal selection of patients for surgery or radiotherapy.
S334 CONCLUSION: In NSCLC patients SUVmax is reliable parameter independent of dose injected, BMI, fasting blood glucose level. In adeno ca and epidermoid ca groups there is no significant difference in SUVmax.
P122 Diagnostic accuracy of 18F FDG PET/CT for N0 staging of non-small cell lung cancer : Differences in the pathological and PET/CT findings S. Lee, J. Park, S. Bae; Inje University College of Medicine, Pusan Paik Hospital, Busan, REPUBLIC OF KOREA. Purpose: 18 F FDG PET/CT is useful tool in staging non‐small cell lung cancer(NSCLC). The aim of this study is to evaluate the difference in the pathological and PET/CT finding between true negative(TN) and false negative(FN) patient group of N0 on 18 F FDG PET/CT. Method: 31 patients(M:F=17:14, 11 squamous cell carcinoma, 19 adenocarcinoma, 1 adenosquamous cell carcinoma) of NSCLC, who were regarded as N0 based on preoperative 18 F FDG PET/CT, were reviewed retrospectively. Their surgical result and parameters of 18 F FDG PET/CT(max SUV, and volume of max SUV50% ) were compared. Results: 21 patients were TN(5 squamous cell carcinoma, 15 adenocarcinoma, 1 adenosquamous cell carcinoma), and 10 were FN(6 squamous cell carcinoma, 4 adenocarcinoma). Among 15 adenocarcinoma patients of TN, 8 had bronchioloalveolar cell carcinoma(BAC) component, but in the FN group there were no adenocarcinoma cases having BAC component. While all cases of TN group showed peripherally located malignant lesion, 5/10 of FN group showed centrally located malignant lesion. There was no significant difference of mean in the max SUV(8.34±5.96 vs 10.32±6.57, p=0.36) and volume of max SUV50% (15.12±16.08cc vs 11.0±7.17cc, p=0.97). Conclusion: N0 on the preoperative 18 F FDG PET/CT staging was less accurate, but in the case of adenocarcinoma with BAC component and peripheral location was highly accurate.
P123 role of 18F-FDG PET/CT in the prognosis of malignant pleural mesothelioma using a semiautomated 3-D volume based analysis S. Lucchini1, C. Rodella2, S. V. Gabanelli1, E. Puta1, G. Merli1, C. Pizzocaro3, A. Terzi3, F. Bertagna3, G. Bosio3, P. Rossini3, G. Savelli3, R. Giubbini1; 1Chair of Nuclear Medicine University of Brescia, Brescia, ITALY, 2 Health Physics Unit, Spedali Civili Brescia, Brescia, ITALY, 3Nuclear Medicine Unit, Spedali Civili Brescia, Brescia, ITALY. AIM: Malignant pleural mesothelioma (MPM) is an aggressive tumor that arises from the pleura and frequently extends to adjacent structures. 18F‐FDG‐PET is useful for the differentiation of benign from malignant lesions, for staging and monitoring metabolic response to therapy, and prognostic assesment. The purpose of this study was to develope a 3‐D method for evaluating the total mesothelioma metabolism volume (MMV) and to evaluate the prognostic impact of this method in comparison to the maximum standardized uptake value (SUV max). Materials and metods: We evaluated 38 pts (aging 63 ± 10 yrs), 28 M, 10 F. The average follow‐period was 331 ± 246 days (range 22‐1106). SUV max was calculated in each pts according to standard software. We calculated the histogram distribution of SUV using General Electric ADW 4.2 workstation and semiautomated threshold method on cross‐sectional images; we defined the MMV as the area of the SUVcurve distribution using as limits of integration the SUV threshold and the SUV max. In our study group the MMV ranged from 34.7 to 153391 (g/ml x ml). We performed a Kaplan‐ Meyer analysis choosing a cut‐off MMV value corresponding to the median of the pts MMV frequency distribution. Death was considered the outcome endpoint. During our observational period we had 8 events. RESULTS: the cut‐off MMV value was fixed at 6219 (g/ml x ml); for the patiends with the MMV value below this value we found a survival probability of 95% at 600 days versus a 20% survival probability for the subjects over the cut‐off value, Hazard‐Ratio=0.10 (CI 95% 0.03‐0.59), p<0.01. For the patiends with the SUV max value below the cut‐off value of 6.4 (g/ml) we calculated a 90% survival probability at 600 days versus 45% survival probability for the subjects over the SUV max cut‐off, Hazard‐Ratio=0.22 (CI 95% 0.06‐1.36), p=0.12. CONCLUSION: our study shows that the MMV value has high prognostic impact in pts with MPM and seems to provide an incremental prognostic value over the simple calculation of SUV max.
P12 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: lymphoma
P124 Standardized uptake value of pre-therapeutic F-18-FDG-PET is a predictor of outcome in patients with malignant lymphoma H. Ahmadzadehfar1, M. Rodrigues1, N. Zojer2, P. Knoll1, H. Ludwig2, S. Mirzaei1; 1Institute of Nuclear Medicine, Wilhelminenspital, Vienna, AUSTRIA, 2Department of Oncology, Wilhelminenspital, Vienna, AUSTRIA. Metabolic imaging with F‐18‐fluorodeoxyglucose (FDG) positron‐emission tomography (PET) is widely used for staging and treatment evaluation of malignant lymphoma. Up to now only few studies indicated that reduced glucose metabolism measured by FDG‐PET before or early in the course of treatment of malignant lymphoma is associated with a favorable outcome. The aim of this study was to assess the prognostic impact of FDG‐PET maximum standardized uptake value (SUVmax) in patients with malignant lymphoma at the time of diagnosis. Material and Methods: We retrospectively analyzed data from 71 patients (male 35, female 36; age range 19‐80 years) with malignant lymphoma [22 patients with Hodgkin’s disease (HD) and 49 patients with Non‐ Hodgkin’s lymphoma (NHL)] who had not received treatment before FDG PET imaging (4,7 MBq/Kg body weight, Siemens EXACT). Complete or partial remission was observed in 50 patients (70,5%) while progressive disease or relapse was found in 21 patients (29,5%). Results: A significantly lower (p<0,01) baseline SUVmax level was found in patients with subsequent response (median: 5,7; range 1,5‐14,5) compared to those with progressive or relapsing disease (median
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 SUVmax 11,5; range 7,4‐20). All 40 patients with baseline SUVmax <7,4 achieved long‐lasting remission with completion of chemotherapy (median follow‐up: 18,5 months; range 9‐69 months). Within this group with favorable outcome, no significant differences between SUVmax values in HD and NHL were found. A heterogeneous outcome was noted in 27 patients with a SUV max 7,4‐14,5 at diagnosis, with 17 patients experiencing disease progression or relapse while in the other 10 patients long lasting remission was noted. All 4 patients with a SUVmax >14,5 showed disease progression during follow‐up. Conclusion: Semiquantitative measurement of glucose metabolism (SUVmax) by FDG PET at diagnosis is a predictor of outcome of patients with HD and NHL.
P125 Diagnostic Accuracy of Postitron Emission Tomography Computed Tomography (PETCT) and Contrast Enhanced Multi Slice Computed Tomography (CEMSCT) in the staging of Hodgkin’s Disease (HD) and Non Hodgkin Lymphoma (NHL) A. Fè1, T. Cavallo2, E. Scarano2, S. Schiavariello1, L. Martino1, B. Lamorgese2, M. Pizzuti3, M. Ciminiello3, A. Olivieri3; 1Nuclear Medicine San Carlo Hospital, Potenza, ITALY, 2Radiology San Carlo Hospital, Potenza, ITALY, 3Ematology San Carlo Hospital, Potenza, ITALY. Purpose of this work was to compare retrospectively diagnostic accuracy of PETCT and CEMSCT, in the staging of HD and NHL patients. From November 2005 to March 2008 we studied 26 patients with biopsy proved lymphoma ( 21 NHL 5 HD, mean age 46, range age 18 ‐81) at staging. All the patients were submitted to at least a PETCT (Discovery ST GE) and a CEMSCT (Somaton Sensation 64 slices Siemens) scan with standard acquisition protocols at staging time at a distance of no more than 10 days from one to the other. All the patients were submitted at least to a PETCT and CEMSCT control during follow‐up. Findings were interpreted separately by a nuclear medicine physician (PETCT) and by a radiologist (CEMSCT) both with at least 3 years of experience in their respective imaging methods. Pathological sites were divided: in Lymph Nodes Station (LNS) and Extra Lymph Nodes Station (ELNS). Findings were considered concordant when PETCT and a CEMSCT scan were both negative or positive in the same sites, discordant if a finding regarded as positive for disease (and accompanied by other PETCT or CEMSCT positive sites in the same patient) was not present in both imaging methods; the accuracy of the single imaging method was evaluated afterwards, as disappearance of the lesions described by the basic exam after therapy. The total highlighted pathological sites by two imaging methods were: 227 LNS and 45 ELNS; 119/227 with PETCT (52%), 108/227 with CEMSCT (47%) for LNS; 33/45 with PETCT (73%) and 12/45 (27%) with CEMSCT for ELNS; in 22/26 patients the two methodical obtained discordant results especially in 15/22 PETCT revealed more pathological areas, and in 6/22 of these there was significant upstaging (at least from 2° to 3° stadium) while the CEMSCT in 7/22 and only in 2/22 there was significant upstaging. This work shows that PETCT and CEMSCT have similar accuracy for the pathological LNS while PETCT is more accurate for ELNS and produces significant upstaging in 6/22 patients affected by HD and NHL respect to CEMSCT in which that only happens in 2/22 patients.
P126 Predictive value of early PET-TC in diffuse lymphoma
large-cell
M. Cortes Romera1, C. Gamez Cenzano1, A. Fernández Leon1, P. Caresia Aróztegui1, J. Robles Barba1, Y. Ricart Brulles2, E. González Barca3, A. Palacios Abufón4; 1PET IDI-H.U.BELLVITGE-IDIBELL, L´hospitalet 2 MN-H.U.BELLVITGE-IDIBELL, L´hospitalet (Barcelona), SPAIN, (Barcelona), SPAIN, 3Hematología-ICO, L´hospitalet (Barcelona), SPAIN, 4 Hematología-HU. Vall d´Hebron, Barcelona, SPAIN. AIM: To assess the value of PET‐CT with FDG after two or three cycles of chemotherapy for prediction of response to treatment in diffuse large B cell Lymphoma (DLBCL). MATERIAL AND METHODS: Forty patients diagnosed with DLBCL were included (mean age: 48 years): 32 patients were evaluated at initial staging and 8 at relapse before therapy. All patients underwent FDG‐PET at 3 times: 1) staging (prior chemotherapy), 2) after two or three cycles of chemotherapy (early treatment evaluation), and 3) after completion of chemotherapy (end of treatment evaluation). Early treatment evaluation findings were correlated to end‐treatment scans and follow‐up. We established different categories about the response treatment evaluation depending on the metabolic activity reduction (SUVmax). In the early treatment evaluation, the SUVmax decrease > 50% or a complete disappearance of disease was considered a good response indicator (GRI). At the end of treatment evaluation, PET findings determined 4 types of response: no changes, partial metabolic response (PMR‐ SUVmax >50%), complete metabolic response (CMR) and progression disease (PD). Mean follow up was more than 6 months. RESULTS: The early evaluation showed GRI in 36 of 40 patients (90%) and 33 of them showed CMR at the end of treatment (92%). In the follow up, 30 of 33 patients remained without evidence of disease and only 3 of them relapsed. The patients without GRI in the early treatment response (4) showed: PD (2), PMR (1 after change of treatment) and CMR (1 after autologous transplantation). In most of cases we found a correlation between an early good response, the end of treatment complete response and the progression‐free follow‐up. CONCLUSION: PET/CT after the first cycles of chemotherapy is predictive of outcome at the end of treatment response in patients with DLBCL. It could be used to modify earlier the treatment in non responder’s patients to standard treatments.
P127 Evaluating for bone marrow involvement in pre-treatment staging of high-grade lymphoma. The clinical utility of F-18 Fluorodeoxyglucose (FDG) PET/CT. A. E. H. Tan1, D. E. N. Ng1, H. Lai1, T. Kok1, M. H. W. Toh2; 1Department of Nuclear Medicine and PET, Singapore General Hospital, Singapore, SINGAPORE, 2Department of Diagnostic Radiology, Singapore General Hospital, Singapore, SINGAPORE.
S335
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P128 FDG PET/CT but not PET alone predicts future recurrence after completion of therapy in patients with malignant lymphoma (ML). K. Isohashi, M. Tatsumi, A. Inoue, H. Kato, K. Nakajo, E. Shimosegawa, J. Hatazawa; Osaka University, Suita, JAPAN. Objective: To examine the relation of a post‐treatment imaging evaluation based on International Working Group Criteria (IWC) and Revised Response Criteria (RRC) in ML patients and a recurrence during later follow‐up period. Methods: Forty patients(Hodgkin’s Lymphoma:7, non‐ Hodgkin's Lymphoma:33)underwent CT/MRI in suspected lesions and whole‐body PET or PET/CT before and after therapy from October 1998 to March 2009. All PET or PET/CT scans after therapy were performed at least 3 weeks after completion of chemotherapy and/or immunotherapy and 8 weeks after completion of radiation or chemo‐radiotherapy. Each size of ML lesions on CT/MRI was evaluated according to IWC. The presence of abnormal FDG uptake was evaluated visually and interpreted according to RRC. The CT/MRI based and FDG‐PET based imaging evaluation at the end of therapy was investigated in relation to progression‐free survival (PFS) during later follow‐up period. Results: A total of 41 post‐treatment imaging evaluations including one same patient were analyzed. Median follow‐up period was 427 days (25‐1988 days). The concordance of complete remission (CR) according to IWC and RRC was found in 17 of 41 evaluations at the end of therapy. All these did not show relapse during the later follow‐up period. The concordance of partial remission(PR)was found in 10 evaluations, and 3 of 10 relapsed. The discrepant evaluation between CT/MRI (PR according to IWC) and PET (CR according to RRC) was found in 11 evaluations, and 4 of 11 relapsed. The 2‐year actuarial PFS rate was 100% for the patients evaluated with CR according to IWC and 79% evaluated with CR according to RRC. Conclusion: The concordance of CR with CT/MRI‐based IWC and PET‐based RRC at the end of therapy predicted a longer PFS in ML patients.
P129 Early FDG PET in assessing treatment response and clinical outcome in pediatric patients affected by nodular sclerosing hodgkin’s disease (NSHD) E. Lopci, A. Golemi, A. Maffione, A. Musto, A. Ambrosetti, C. Fuccio, I. Santi, V. Ambrosini, P. Caroli, L. Fantini, S. Fanti; Hospital S. OrsolaMalpighi, Bologna, ITALY. AIM: Early PET is not routinely performed in pediatric patients, although in adult HD it is reported as an accurate and independent predictor of progression‐free survival (PFS). The aim of this study is the evaluation of interim‐PET usefulness in pediatric patients affected by Nodular Sclerosing HD (NSHD). MATERIALS AND METHODS: We studied 15 pediatric subjects (mean age 14,5years) affected by NSHD (stage II‐IV). They all had a baseline PET before treatment, an interim‐PET scan after 2‐4 cycles of chemotherapy (ABVD) and an end‐treatment examination. Pretreatment evaluation included IPS value (International Prognostic Scoring System), B symptoms and presence of bulky masses at CT scan. Clinical outcome was established on the basis of combined criteria (clinical, radiological or histological), up to 36 months of follow‐up . RESULTS: All patients were PET positive at presentation. At interim‐PET 9 scans out of 15 resulted negative, while 6 showed a residual disease. Out of the 9 CR patients, 7 had still a negative scan at the end‐ treatment evaluation (77.7%), while in 2 cases PET scan became positive. Out of the 6 PR patients at interim‐PET, 2 showed a CR after chemotherapy completion and 4 (66.6%) had still a positive scan (3 PR and 1 PD). Clinical outcome during follow up documented 9 CR, 4 PD and 2 cases of relapse. Out of the 9 CR, 6 patients were CR at interim‐PET, while 3 were PR. Out of the 4 PD patients, 2 were CR at interim‐PET and 2 had a PR. The 2 relapsed patients during follow‐up were respectively CR and PR patients at interim‐PET. Early PET and the end‐treatment scan were condordant in 11 cases (73.3%), which were consistent with final outcome in 8 patients (overall 53.3%). No statistical significance was found in between CR versus PR at interim‐PET with respect to PFS, as well as with the other prognostic criteria, although both CR patients at interim‐PET, resulting positive at post‐treatment evaluation and presenting a progression disease at final outcome, had high IPS values (>3).CONCLUSION: Despite the objectively small study population, our results point out a questionable utility of interim‐PET, which does not seem to give additional
information on treatment response and final outcome. No significant correlation was seen between interim‐PET and PFS, but other prognostic factors may play an important role. Therefore further studies are needed in order to assess a proper value of early PET evaluation in pediatric lymphoma.
P130
18
Reliability of F-FDG PET/CT after 2 Cycles of Chemotherapy for Prognosis Prediction in Patients with Diffuse Large B-cell and Follicular Lymphoma. M. Myslivecek1, P. Koranda1, T. Papajik2, E. Buriankova1, Z. Sedova2, J. Ptacek1, M. Kaminek1, K. Indrak2; 1Dept. of Nuclear Medicine, University 2 Dept. of Hospital Olomouc, Olomouc, CZECH REPUBLIC, Hematooncology, University Hospital Olomouc, Olomouc, CZECH REPUBLIC. Aim: To assess the prognostic value of early 18F‐FDG PET/CT after 2 cycles during first‐line chemotherapy using SUV semiquantification and visual analysis in patients with diffuse large B‐ cell (DLBCL) and follicular (FL) lymphoma. Methods: Twenty‐six patients (pts) with newly diagnosed DLBCL (19 pts) and FL (7 pts) underwent contrast enhanced 18F‐FDG PET/CT prospectively before and after 2 cycles of chemotherapy (interim examination). Maximum SUV (SUVmax) normalized to body surface area were computed on the most intense uptake areas. The SUVs changes and visual analysis over time were used for prediction of patients prognosis. Average follow‐up of patients was 16.4 months. Results: No statistically significant differences in SUVmax reduction (%) from baseline to interim 18F‐FDG PET/CT examinations were found between groups of patients with complete remission and relapsed or progressive disease. Sensitivity, specificity, positive and negative predictive values and accuracy of visual assessment were 50%, 78%, 57%, 83% and 73%, respectively. Conclusion: In our study, SUVmax changes and visual based assessment of therapeutic response after 2 cycles during first line chemotherapy does not seem to predict reliably the risk of relapsed or progressive disease during the subsequent follow up of patients with DLBCL and FL. This work was supported by IGA grant, Ministry of Health, Czech Republic, NR/9502‐3.
P131
18
Prognostic value of F-FDG-PET/CT in Hodgkin disease patients during chemotherapy M. Colandrea, L. L. Travaini, G. Trifirò, E. Cocorocchio, C. De Cicco, S. Fracassi, A. Vanazzi, M. Calabrese, G. Martinelli, G. Paganelli; European Institute of Oncology, Milano, ITALY. Imaging with Positron Emission Tomography/Computed Tomography and Fluorodeoxyglucose ([18F]FDG‐PET/CT) can provide early prediction of response to chemotherapy in Hodgkin disease (HD). Aims: to evaluate the prognostic value of [18F]FDG‐PET/CT after three cycles of chemotherapy (PET2) and to compare it with [18F]FDG‐PET/CT at the end of treatment (PET3). Materials and methods: twenty six HD patients (mean age 35 years) performed staging with [18F]FDG‐PET/CT (PET1) and, during chemotherapy, (6 cycles with chlorambucil, vinblastine, procarbazine, prednisone, doxorubicin, vincristine, bleomycin, VP16) were submitted to PET2 and PET3. PET imaging were analyzed visually as positive or negative depending on the FDG uptake in the lesion that exceed the uptake on the background. Visual response assessment was subsequently confirmed by clinical and radiological data, when available. Mean follow‐up was 15.8 months (range 3.7‐46.1 months). Progression free survival (PFS) were calculated using Breslow test for patients PET2 (positive vs negative) and for PET3 (positive vs negative), while overall survival (OS) was calculated by Kaplan‐Meier analyses. Finally McNemar test was used to assess the concordance between PET2 and PET3. Results: PET2 was positive in 4 patients (15.4%) and became negative in 2 at PET3: 2 in CR and 2 (PET3 positive) were subjected to high dose chemotherapy for PD. Nineteen out of 22 negative PET2 were confirmed negative at PET3 (still in CR), 1/22 patient became PET3 positive (actually in CR) and 2/22 patients relapsed after 9 and 27 months, respectively (now still in SD). Statistical data were reported in table1. Finally McNemar test was not significant (p=1), meaning a high concordance (88.5%) between PET2 and PET3 and that the small removal among the two tests was casual. Conclusion: our findings clearly showed that PET2 has a high NPV of 90.9% for evaluation of therapy response after ChlVPP/ABVVP chemotherapy while showed a less important PPV. Also PET3 showed high NPV but a much higher PPV. Considering the incidence of false positive and false negative results, the prognostic value of PET2 in HD should be reviewed. It may provides a basis for alternative treatment strategies in non responders patients offering the potential basis for therapy changes in patients with better prognosis. Table 1
PET2
95% IC
PET2
95% CI
Specificity
90.9%
70.8‐98.9
95.5%
77.1‐99.8
Sensitivity
50.0%
6.8‐93.2
50.0%
6.7‐93.2
Accuracy
84.6%
65.1‐95.6
88.5%
69.9‐97.5
NPV
90.9%
70.8‐98.9
91.3%
72.0‐99.0
PPV
50.0%
6.8‐93.2
66.7%
9.0‐99.0
PFS p (Breslow)
0.0045
0.0001
Legenda: negative predictive value (NPV); positive predictive value (PPV)
P132 The role of positron emission tomography scan with 18Ffluorodeoxyglucose (FDG-PET) as the chief predictor of autologous stem cell transplantation in aggressive B-cell nonHodgkin lymphoma. P. Caroli, L. Fantini, V. Ambrosini, E. Lopci, A. Musto, A. Maffione, A. Golemi, I. Santi, C. Fuccio, C. Tsamita, E. Derenzini, P. Zinzani, S. Fanti;
Poster Presentation
Aim: To investigate the clinical utility of FDG PET/CT in determining diffuse bone marrow involvement in patients with newly diagnosed high‐grade lymphoma. Materials and Methods: Retrospective analysis of department data from the Radiological Information System (RIS) database from January 2007 to January 2009 was performed to identify patients with histologically proven high grade type lymphomas that were referred for FDG PET/CT pre‐ treatment staging. FDG PET/CT was performed as a single examination using a Siemens Biograph scanner with imaging performed after 60‐80 mins following FDG administration. All images were interpreted on a Syngo workstation by 2 experienced nuclear medicine physicians in consensus. PET/CT findings in regards to bone marrow findings was stratified into “no involvement”, “diffuse increased FDG uptake” and “focal abnormal FDG uptake”, and correlated with bone marrow trephine histological findings, which is taken as the gold standard. Results: 86 patients were included into the study, 44 Male and 42 Female, ranging in age from 19 to 85. There was a range of high‐grade lymphoma histological types (Diffuse Large B‐Cell Lymphoma, Hodgkin’s Lymphoma, Follicular Lymphoma, Anaplastic T‐cell Lymphoma, Mantle Cell Lymphoma, NK/T cell Lymphoma). 64 patients were determined as “no involvement”, of which all had negative marrow trephine results, giving a negative predictive value of 100%. 9 patients had “diffuse increased FDG uptake”, with a positive marrow trephine result for 1 patient while the rest were negative for lymphomatous marrow involvement, with marrow hyperplasia a common finding. 13 patients had “focal abnormal FDG uptake”, of which 6 were positive for marrow involvement by marrow trephine assessment, while the rest were negative. Most of the positive cases had multifocal involvement, and 3 of the negative cases had gross evidence of bony destruction with further core biopsy of one of the focal lesions demonstrating lymphomatous involvement. Conclusion: Our findings overall support the clinical utility of FDG PET/CT in pre‐treatment staging of high‐grade lymphomas, demonstrating a strong negative predictive value in excluding diffuse lymphomatous involvement of the marrow. It suggests the possibility of risk‐stratifying patients; based on FDG PET/CT findings, into groups requiring bone trephine biopsies and those with justifiably low risk for marrow involvement, for whom bone marrow biopsy may conceivably be omitted.
S336 Azienda Ospedaliero-Universitaria di Bologna, S.Orsola-Malpighi University Hospital, Bologna, ITALY. BACKGROUND: The role of pretransplantation 18‐fluorodeoxyglucose (FDG)‐positron‐emission tomography (PET) in patients affected by aggressive non‐Hodgkin Lymphoma (NHL) was essential for the evaluation of response and outcome. There are a few records concerning the role of second‐line chemotherapy response evaluated by positron emission tomography (PET) as a prognostic factor in patients with aggressive non‐Hodgkin Lymphoma (NHL) who undergo autologous stem cell transplantation (ASCT). The aim of this study was to analyse the main determinants of prognosis in patients with aggressive B‐cell NHL highlighting the impact of pretransplantation PET, secondary age‐adjusted International Prognostic Index (sAA‐IPI) score, histology, and previous response to first‐line chemotherapy. METHODS: Seventy‐five patients affected by a diffuse, large B‐cell lymphoma or grade 3 follicular lymphoma were examineted: they have been treated with second‐line chemotherapy (combined ifosfamide, etoposide, and epirubicin [IEV]) followed by ASCT between September 2002 and September 2006. All patients have been evaluated by PET after 1 to 3 courses of IEV chemotherapy before ASCT, and all patients have received a conditioning regimen of combined carmustine, etoposide, cytosine arabinoside, and melphalan. The prognostic impact of pretransplantation PET, sAA‐IPI score, histology, and previous response to first‐line chemotherapy have been studied by univariate and multivariate analyses. RESULTS: Seventy‐two of 75 patients have been subject to an ASCT. In a univariate analysis for progression‐free survival (PFS) and overall survival (OS), a significant association has been observed with pretransplantation PET (PFS, P< .00001; OS, P< .01) and previous first‐line response (PFS, P= .02; OS, P= .04). In the multivariate framework, pretransplantation PET have been identified as the only independent prognostic factor (PFS, P< .001; OS, P= .01). CONCLUSIONS: The results confirms that pretransplantation PET is the main prognostic predictor in patients affected by aggressive B‐cell non‐Hodgkin Lymphoma who have been programmed for autologous stem cell transplantation.
P133 False Positive (FP) F-18 FDG Uptake in PET/CT Studies in Pediatric Patients with Abdominal Burkitt's Lymphoma R. Riad1, W. Omar1, M. Kotb1, I. Sidhom1, M. Zamzam1, I. Zaky1, H. M. Abdel-Dayem2; 1Children's Cancer Hospital, National Cancer Institute, Cairo, EGYPT, 2St. Vincent's Medical Centers of New York, New York, NY, UNITED STATES. Introduction: We previously presented the results of F‐18 FDG PET/CT scans in 74 pts (106 studies) who were diagnosed with Pediatric Malignant Lymphoma. Causes of FP FDG uptake were due to colitis and enteritis. Pediatric population is prone to higher incidence of complications secondary to chemo than adults, especially in the abdomen. The incidence of these complications is not properly estimated. More data in this regard is needed to guide during treatment and follow‐up. Aim of Study: Pt. population: 6 pts with pathologically confirmed Burkitt’s Lymphoma had PET/CT studies following chemo and or surgical excision for evaluation of pts symptoms and response of underlying malignancy. Results: Pt 1: Intestinal and mesenteric lymph nodes (LN). CT after 3 cycles chemo showed thickened loops. Pt is symptomatic, PET/CT showed residual mass in bowel, high FDG uptake, SUV 3.8, excision and biopsy showed inflammation and malignant cells. Pt 2 and 3: Both had small bowel and mesenteric mass. After 6cycles of chemo pts were symptomatic. PET/CT showed increased uptake in Rt iliac mass (SUV 3.7) in one and mid‐ abdomen (SUV 3.1) in second. Excision of both masses showed acute inflammation and no evidence of malignancy. Pt 4: Interstinal mass, excised, received 6 cycles of chemo, CT no masses, PET/CT showed multiple foci in abdomen (SUV 19.2, 17.9, and 21.2) all were due to acute inflammation. Pt 5: Interstinal mass, excised, 6 cycles of chemo. PET/CT negative for active disease. Pt 6: Gastro‐hepatic, mesenteric and iliac mass, 6 cycles of chemo, CT showed residual mass, PET/CT negative for active disease.Conclusion: F‐18 FDG PET/CT has proven its accuracy for evaluating pts following treatments in malignant lymphoma. In abdominal Burkitts lymphoma in Pediatric pts there is a high incidence of FP FDG uptake due to acute inflammation of the bowel and abdominal LNs in 4 out of 6 pts with or without active disease. This high incidence should raise great concern among nuclear medicine physicians, medical and surgical oncologists to be aware of in pt management. We hope to report a larger series in the future.
P134 Role of Early Interim PET-FDG in Predicting Final Response to Therapy in Hodgkin’s Disease and High-Grade NonHodgkins’s Lymphoma F. Azevedo Silva, P. Lapa, G. Costa, A. Albuquerque, J. Pedroso de Lima; Hospitais da Universidade de Coimbra, Coimbra, PORTUGAL. Introduction Positron Emission Tomography with 2‐[18F]Fluoro‐2‐Deoxy‐D‐Glucose (PET‐FDG) has high sensitivity in Hodgkin’s Disease (HD) and high‐grade non‐Hodgkin’s Lymphoma (NHL) staging. With the possibility of inducing complete remission after chemo and/or radiotherapy, the evaluation of response to therapy is of the up most importance. PET‐FDG is increasingly used for this purpose, with notorious advantages over the conventional staging methods, namely CT. Aim Assess the role of early interim PET‐FDG (up to the 4th chemo course) in predicting final response to therapy and failure‐free survival, in HD and high‐grade NHL. Material and Methods Retrospective study of HD and high‐grade NHL patients who underwent PET‐FDG in our Department between October 2003 and April 2007. Inclusion criteria were early interim PET‐FDG (up to the 4th course of chemo), end‐treatment response evaluation PET‐FDG and follow up for at least 12 months, either clinical or by imagiological methods. Twenty patients with HD (9 men and 11 women) and 16 with NHL (8 men and 8 women) were enrolled. Results In the HD group we observed that all 17 patients with negative (no pathological FDG uptake) interim PET‐FDG achieved and remained in complete remission throughout the follow‐up. Two of the 3 patients with positive interim PET‐FDG (67%) subsequently achieved remission. These results translate into a 90% concordance (18 of 20 cases) between interim and final therapy response evaluation PET. In the NHL group, of the 8 patients with negative interim PET‐FDG, 6 (75%) achieved and remained in complete remission throughout the follow‐up, while only 3 (37.5%) of the 8 patients with positive interim PET subsequently achieved complete remission, translating into a 69% concordance between interim and final therapy response evaluation PET. Conclusions Our results demonstrate that early interim PET‐FDG (up to the 4th chemo course) predicts, with a high degree of confidence, the final response to therapy and failure‐free survival, mainly in the HD group. A
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 negative interim PET‐FDG is associated with a favourable final response to therapy and absence of early recurrence. On the other hand, the vast majority of patients with positive early interim PET‐FDG were shown to have persistent or early disease recurrence, mainly in NHL patients.
P135 The predictive value of 18F-FDG PET-CT performed after autologous stem cell transplantation (ASCT) in patients with lymphoma M. Lavalle1, V. Rufini1, F. Sorà2, M. L. Calcagni1, L. Leccisotti1, N. Piccirillo2, L. Pinnarelli3, S. Sica2, A. Giordano1; 1Nuclear Medicine Institute, Catholic University, Roma, ITALY, 2Haematology Institute, Catholic University, Roma, ITALY, 3San Filippo Neri Hospital Trust, Roma, ITALY. Aim: Limited data exist about 18F‐FDG PET performed post‐ASCT as prognostic factor in patients with lymphoma. The aim of the study was to evaluate: 1) the role of 18F‐FDG PET‐CT performed after ASCT to detect residual/recurrent disease in order to design treatment intensification or complementary radiotherapy; 2) its impact on progression‐free survival (PFS) and overall survival (OS). Material and Methods: From 12/2004 to 6/2008, 53 patients (34 males, 19 females; median age 50 years; range 15‐66) were enrolled: 46 non‐Hodgkin’s lymphomas (NHL), 7 Hodgkin’s lymphoma (HL). Patients were homogeneously treated with salvage chemotherapy. Before ASCT 28/53 (53%) were in complete remission (CR), 19/53 (36%) in partial remission (PR), 18 6/53 (11%) had stable disease (SD). F‐FDG PET‐CT was performed 100 days after ASCT. A correlation between the presence of abnormal FDG uptake (PET positive) or its absence (PET negative) and patient outcomes was performed. Univariate analysis using Kaplan‐Meyer method and the log‐rank test was performed for survival and time to progression. Multivariate analysis using Cox regression was performed to test the following parameters: sex, age at ASCT, histological subtype, the presence of symptoms and post‐ASCT PET‐CT results. Results: After ASCT, PET‐CT was negative in 39/53 patients (74%; 38 NHL and 1 HL): 37 are alive without disease progression after a median follow‐up of 23.5 months (range 5‐38) and 2 classified in CR died 5 and 8 months after ASCT for unrelated causes; PET‐CT was positive in 14/53 (26%; 8 NHL and 6 HD): 7 died for progression at a median of 13 months (range 10‐39); the other 7 showed PR and 4/7 with limited disease received radiotherapy on involved fields and are alive after a median of 21 months (range 6‐37). The PFS rates were 97% and 94% at 1 and 2 years respectively for PET negative patients compared to 50% and 40 % at 1 and 2 years respectively for PET positive patients (p< 0.0001). The OS rates were 95% at 1 and 2 years for PET negative patients compared to 76% and 47% respectively for the PET positive group (p= 0.01). Multivariate analysis indicated that post‐transplantation PET‐CT was an independent prognostic predictor in patients undergoing ASCT for relapsed/refractory lymphoma. Conclusion: 18F‐FDG PET‐CT performed after ASCT is able to predict PFS and OS in LNH and HD, a positive PET indicating a poorer outcome. Interestingly, radiotherapy was able to induce durable remissions in some cases with limited disease after ASCT.
P136 The role of 18F-FDG PET/CT in patients with lymphoma J. Muñoz Iglesias1, R. Iglesias2, J. Groiss3, J. Infante3, I. Rayo3, M. Domínguez3, L. García3, C. Durán3, J. Serrano3; 1Hospital Oncologico de Galicia, A Coruña, SPAIN, 2Complejo Hospitalario de Ourense, Ourense, SPAIN, 3Hospital Infanta Cristina, Badajoz, SPAIN. OBJECTIVE To assess the diagnostic accuracy of PET‐CT studies in patients with diagnosis of lymphoma. MATERIAL AND METHODS Three hundred fifty six studies were retrospectively examined in 231 patients, 132 males, with a mean age of 49 yrs (range: 5‐83 yrs), who underwent PET‐CT study to staging, primary mass study or assessment of treatment response. Studies were obtained by PET‐CT camera GE Discovery, after administration of mean dose of 288.6 MBq of 18F‐FDG. Mean time since disease onset was 21.5 months. Of the total cases, 80 patients presented a Hodgkin’s Lymphoma (HL), 149 Non Hodgkin’s Lymphoma (NHL) and 2 Lymphoproliferative syndromes, with a mean age significantly lower in HL. Results were compared with clinical‐radiological follow‐up and/or biopsy. RESULTS PET‐CT detected 507 pathological lymph nodes (79 of them down on centimetre) against 323 lymph nodes detected by means of CT. This meant a increasing of 57% in the number of malignant focus. A greater number of extranodal involvements in NHL were observed (60 vs 12 in HL) of which a 28% were localized in bone structures, 27% in gastrointestinal tract, 10% in supraadrenals and 7% in breasts PET‐CT result changed staging of disease in 65% of the cases and modified therapeutic management in 154 patients (81% of studies). Significant statistical relation wasn’t demonstrated between semicuantitative values of uptake and histologic grade of lymphoma. PET‐CT study showed a high sensitivity, specificity and accuracy, with lower positive predictive value. CONCLUSIONS PET‐CT result led to change in initial staging and therapeutic management of patients. It was especially useful in assessment of residual mass which had unclear aetiology in radiologic study. Hybrid technique permitted to resolve false‐positives due to uptake in brown fat, muscles or gastrointestinal tract.
P137 18F-FDG-PET utility in multiple myeloma. New durie-salmon plus staging system. Our experience C. Ramos Font1, L. García Entrena2, I. Garía Cabrera2, A. Rodriguez Fernandez1, A. Santiago Chinchilla1, M. Gallego Peinado1, M. M. NavarroPelayo1, Á. C. Rebollo-Aguirre1, J. M. Llamas Elvira1; 1University Hospital Virgen de las Nieves, Granada, SPAIN, 2University Hospital Virgen de las Nieves. Hematology department, Granada, SPAIN. Background: Increasing use MR, CT, and FDG‐PET have conducted to a new MM classification, Durie‐Salmon Plus staging system.X‐ray survey was the gold standard, but can be negative in the presence of myelomatous lesions, and its sensitivity is markedly decreased in extramedullary lesions. FDG‐PET compare to CT or MR discriminates between necrotic or scar tissues and new or old active lesions. It is especially valuable in the evaluation of recurrences and non‐secreting myeloma. Aim: to evaluate the utility of FDG‐PET in MM compare to conventional imaging techniques (CIT). Methods: Descriptive analysis of 41 patients with MM, MGUS, and
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P13 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: oesophageal and gastric cancer
P138 FDG-PET/CT in oesophageal carcinoma (OC) M. Marzola1, G. Grassetto1, E. Banti1, L. Rampin1, V. Ambrosini2, C. Nanni2, S. Cittadin1, A. Massaro1, S. Fanti2, D. Rubello1; 1Nuclear Medicine Service PET Centre, Hospital Rovigo, Rovigo, ITALY, 2Nuclear Medicine Service PET Centre, Hospital S.Orsola Malpighi Bologna, Bologna, ITALY. Objectives: To prospectively evaluate the prognostic value of FDG‐PET/CT in OC. Methods: This prospective study started in Jan 08, and 12 pts affected by OC were enrolled until now. All were investigated by FDG‐PET/CT before combined chemio/radiotherapy (C‐CH/RT) for staging. At the moment, 8/12 pts finished C‐CH/RT and underwent a new PET/CT to evaluate the response to therapy before surgery. Among these 8 pts, 4 had the oesophageal lesion only, while the others had also supra‐ and/or sub‐diaphragmatic lymph nodes metastases (mts). PET/CT WB scan was performed 1 hr P.I. of low FDG dose (2.2 MBq/kg bw) after at least 6 hr fasting. No pt was diabetic. SUVmax (mean +/‐ SD) of the cancer lesions before and after C‐CH/RT was compared by Student t test. Results: In all the 8 pts the SUVmax of the primary oesophageal lesion significantly decreased after C‐CH/RT in comparison to the baseline value (15.6+/‐4.2 vs. 4.6+/‐1.2, p<0.01). Similarly, in 3/4 pts with lymph nodes mts at first staging a significant SUVmax decrease until complete negativization in the post C‐CH/RT PET/CT was observed, while in 1 pt post C‐CH/RT PET/CT showed a disease progression in the lymph nodes and lungs. Consequently, 7/8 pts were operated on, while in 1 pt a second‐line chemotherapy was given. Conclusions: In our experiencethe majority of pts showed a good response to C‐CH/RT at the level of the primary oesophageal lesion, and in the absence of disease progression in other sites this observation was useful to us to plan subsequent surgery. The behaviour of metastatic spread to lymph nodes and distant sites seems to be more variable after C‐CH/RT. To clarify the prognostic relevance of this observation a prolonged follow‐up is necessary.
P139 Use of PET/CT in the assessment of neoadjuvant therapy response and prediction of disease-free survival in locally advanced esophageal cancer J. Robles1, C. Gámez1, M. C. Galán2, A. Font3, A. P. Caresia1, M. Cortés1, A. Fernández1, E. Andía4, E. Carmona1, R. Mast5, L. Farran6, M. Miró6; 1IDI. PET Unit. Hospital de Bellvitge, L'Hospitalet de Llobregat, SPAIN, 2ICO. Oncology Department. Hospital de Bellvitge, L'Hospitalet de Llobregat, SPAIN, 3ICO. Oncology Department. Hospital Germans Trias i Pujol, Badalona, SPAIN, 4IDI. Radiology Department. Hospital de Bellvitge, L'Hospitalet de Llobregat, SPAIN, 5ICS. Radiology Department. Hospital de Bellvitge, L'Hospitalet de Llobregat, SPAIN, 6ICS. Surgery Department. Hospital de Bellvitge, L'Hospitalet de Llobregat, SPAIN. AIM: To evaluate the utility of FDG‐PET/CT in the assessment of neoadjuvant therapy response (decrease of uptake and length of the primary tumor) and prediction of disease‐free survival in patients with locally advanced esophageal cancer. METHODS: Twenty‐four male patients (average age: 59 y.o., range 47‐79 y.o) diagnosed with locally advanced esophageal cancer (18 squamous cell, 6 adenocarcinoma) treated with neoadjuvant chemoradiotherapy and surgery were included in this study. All patients underwent FDG‐PET/CT scans before and after 4 weeks of neoadjuvant chemoradiotherapy. Patients were classified in 3 groups based on the decrease of metabolic tumor length (TL) and maximum standardized uptake value (SUVmax) between the initial scan and the PET/CT after the neoadjuvant therapy: Group 1) No changes or non‐significant response (TL & SUV decrease < 50%), Group 2) Partial response (TL & SUV decrease > 50%) and Group 3) Complete response. Reference standards for treatment response and recurrence were histopathology results. It was evaluated whether decrease of TL and SUVmax could predict histopathologic response to treatment and Free Recurrence Interval (FRI). RESULTS SUVmax in post‐treatment scan was not estimated due to severe esophagitis in 3 patients. Attending to metabolic response, groups 1, 2 and 3 included 6, 11 and 4 patients respectively. All patients included in group 3 had squamous cell cancer. Recurrence was detected in 66% of patients of group 1 (avFRI= 9 months; range: 1‐20), 45% of patients of group 2 (avFRI: 8 months; range:1‐20)
and 25% of patients of group 3 (avFRI: 11 months; range 5‐22). Independent analysis of adenocarcinoma (N=6) showed that no patient achieved a complete response on PET/CT: 4 had a partial response and 2 no changed (50% of recurrence; avFRI: 10 months, range: 1‐19). CONCLUSION The reduction of TL and SUVmax in PET/CT after neoadjuvant chemoradiotherapy in locally advanced esophageal cancer seems to be a predicting factor of treatment response and disease‐free survival. In our study, no patient with adenocarcinoma showed a complete response, but those who achieved a partial response showed a similar pattern of recurrence than squamous cell carcinoma.
P140 Comparison between endoscopic findings and FDG-PET/CT that shows diffuse gastric uptakes in cancer screening K. Tamura1, I. Sakata1, J. Ishida1, K. Machida1, Y. Yoshizumi1, K. Yoshikawa2, M. Hasebe2, S. Toubaru2, S. Ohashi2, S. Kosuda3, N. Shigematsu4, Y. Abe1; 1Tokorozawa PET Diagnostic Imaging Clinic, Tokorozawa-shi, JAPAN, 2National Institute of Radiological Sciences, Chibashi, JAPAN, 3National Defense Medical College, Tokorozawa-shi, JAPAN, 4 Keio University Hospital, Tokyo, JAPAN. Purpose: FDG uptakes in the stomach, especially diffuse uptakes often pester nuclear medicine physicians with the interpretation as to whether “ normal or not.” The purpose of this study is to investigate the necessity of endoscopy after FDG‐PET/CT that shows diffuse gastric uptakes in cancer screening. Materials and methods: We studied 50 people who had a check‐up for cancer using FDG‐PET/CT. All people showed diffuse uptakes in the stomach. Fifteen people were female and thirty‐five people were male, and mean age was 57.3±10.1 (36 to 80). The uptakes of the stomach were higher than of the liver in 32 people, similar to the liver in 12 people, and lower than of the liver in 6 people. Thirty‐two people underwent biopsy from the stomach. Pathological findings were categorized into five groups according to the following scale: Group 1: normal tissue or benign lesion without atypical cell; Group 2: benign lesion with atypical cell ; Group 3: borderline lesion; Group 4: suspicion of cancer; Group5: cancer. Results: All people had no gastric cancer. Gastritis was detected in 35 people, ulcer in 2 people, hyperplastic polyp in 2 people, metaplasia in one. Ten people had normal findings. On the value of SUV, there was no significant difference between gastritis (3.65±0.60SD) and normal findings (3.55±0.33SD, p=0.619). The specimens from biopsy were Group 1 in 27 people and Group 2 in 8 people. No specimens showed Group 3, Group4, and Group 5. No significant difference was found between Group 1 (3.55±0.59SD) and Group 2 (3.68±0.60SD). Helicobacter.pylori was detected in 17 people. No significant difference was found between H.pylori positive group (3.70±0.46SD) and negative group (3.43±0.71SD, p=0.198). Conclusion: Our results indicate that an additional endoscopy for detecting gastric cancer does not seem to be necessary after FDG‐PET/CT that shows diffuse uptakes in the stomach.
P141 Can 18FMISO PET be useful in response prediction for patients with advanced esophageal cancer treated by combined radiochemotherapy? C. Cheze Le Rest1, O. Pradier2, D. Visvikis3, J. Codet4, A. Volant5, J. Metges6; 1Academic department of Nuclear Medicine, CHU Morvan, Brest, FRANCE, 2Radiotherapy Department, CHU Morvan, Brest, FRANCE, 3 INSERM U650, LaTIM, CHU Morvan, Brest, FRANCE, 4Biology 5 Department of Department, CHU Morvan, Brest, FRANCE, Anatomopathology, CHU Morvan, Brest, FRANCE, 6Oncology department, CHU Morvan, Brest, FRANCE. Objectives: The use of FDG PET for prediction of therapy response in esophageal cancer (EC) is not yet widely accepted. FMISO targeting hypoxia may help in this context. Because hypoxia and angiogenesis are related, we designed a feasibility study combining functional imaging with FMISO and FDG with biological markers of angiogenesis in esophageal cancer. Materials and Methods: At present, 12 patients with newly diagnosed EC have been included (12 males, 62 +/‐ 11y). 11 patients had squamous cell EC and one had an adenocarcinoma. All had advanced disease (stage 3 or 4) and were considered for exclusive radiochemotherapy. Before treatment all patients underwent an FDG and FMISO PET study (mean interval between the two studies of 7days). A dynamic FMISO PET protocol over the area of interest was used between 0‐60 min with additional whole body acquisitions 2 and 3 hours after the IV injection of a mean activity of 300 MBq. A standard whole body FDG acquisition was performed 60 min post‐injection. Maximum SUVs and tumor to background rations were calculated for all primary lesions. P53, epidermal growth factor receptor (EGFR) and endothelial growth factor (VEGF) expressions were assessed on blood samples before treatment. Response to therapy was evaluated using RECIST criteria by conventional imaging performed one month after treatment. Results: FMISO uptake was lower than FDG uptake in all primary lesions. Eight patients have been classified as responders (R) and 4 as non responders (NR). SUVmax was 8.6 +/‐ 3 using FDG (7 +/‐ 2 vs. 11.2 +/‐ 2.9 in patients R and NR respectively). FMISO uptake was low in the primary lesion for all patients with a SUVmax of 0.7 +/‐ 0.2. (0.8 +/‐ 0.3 for NR and 0.6 +/‐ for R). VEGF, p53 and EGFR measured on blood samples before treatment could not predict response to therapy Conclusions: These preliminary results show that both tracers provide similar information concerning discrimination of responders and non responders to radiochemotherapy in esophageal cancer.
P142
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Peak F-FDG tumor uptake correlates with pathological subtype in patients with untreated esophageal cancer. W. A. Bhatti, L. S. Zuckier, L. E. Harrison, N. V. Ghesani; New Jersey Medical School - University of Medicine and Dentistry of New Jersey, Newark, NJ, UNITED STATES. Title: Peak 18FDG tumor uptake correlates with pathological subtype in patients with untreated esophageal cancer. Aim: To retrospectively investigate the relationship between pre‐treatment peak FDG activity and pathologic subtype in esophageal cancer (primarily adenocarcinoma and
Poster Presentation
plasmocytomas, and imaging results in the diagnosis and treatment. Results: 71 FDG‐PET, 25 MR and 36 CT in 41 patients. When compare to CIT, FDG‐PET revealed understaging in 15 patients. In four patients initial staging was change from I to III, and five were up‐staged from II to III. The other six showed higher number of lesions but without changing the stage. Interestingly one patient was FDG‐PET positive, but in complete remission (CR) considering the rest of diagnostic tools. Myelomatous infiltration was histologically proven. Post treatment FDG‐PET was negative. FDG‐PET was negative in all eleven patients in CR and the four cases in CR after ASCT. In patients with partial response FDG‐PET showed a decrease in the number and intensity uptake of the lesions. There were seven patients with positive consistent RM, CT, bone scintigraphy and FDG‐ PET, but in this the number and extension of the lesions were lower, been able to discriminate active from necrotic, scar tissue. All patients with active disease were FDG‐PET positive, including a postransplant relapse. When MGUS patients were evaluated, they all were FDG‐PET negative. Interestingly there was a patient with a left maxilar plasmocytoma in which CT was the one which defined local disease compare to non specific focal activity described in the FDG‐PET Sumary: New Durie‐Salmon Plus staging system integrates FDG‐PET and MR information in the evaluation of MM. FDG‐PET studies are positive in active MM and plasmocytomas. It significantly increases the number of lesions and extension of the disease that conducted to changes in the staging and therapy approach patients. It also discriminate the nature of non defined lesions, excluding myelomatous infiltration in some cases. When partial response to treatment occur a decrease of FDG‐PET uptake was observed in the lesions. Additionally, all cases with complete response and the case of MGUS were FDG‐PET negative.
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squamous cell carcinoma), which heretofore has not been described. Materials & Methods: We identified by review of PACS PET‐CT cases 23 patients who underwent 18F‐FDG PET‐CT for initial staging of esophageal carcinoma prior to neoadjuvant chemoradiation between 4/1/2004 and 4/1/2009. Scanning was performed 45‐60 minutes following administration of ~15 mCi of FDG on a GE Discovery LS PET‐CT. Peak weight‐corrected SUVs were measured within the identified primary tumor volume (MIMvista workstation). Patients subsequently underwent endoscopic or open biopsy of the primary tumor. Tissue samples were classified according to tumor histology and level of invasiveness. Results: Twenty‐three patients were identified, age 41‐78 yrs (mean 64) at the time of the PET‐CT scan. 13 tumors were adenocarcinoma (56%), 9 were squamous cell carcinoma (39%), 1 was poorly differentiated carcinoma. Highest peak SUV was 24.0, seen in moderately differentiated invasive squamous cell carcinoma. Minimal peak SUV obtained was 2.86 for moderately differentiated adenocarcinoma. Peak FDG uptake (mean ± SD) segregated according to pathology as follows: Adenocarcinoma 10.65 ± 6.25; squamous cell carcinoma 16.72 ± 6.06. The difference in peak tumor SUVs between adeno and squamous cell carcinoma was statistically significant (p<.035). 83% of tumors with peak SUV > 18 were squamous cell carcinoma while 83% of tumors with peak SUV < 14 were adenocarcinoma. Conclusion: Patients with squamous cell carcinoma demonstrate peak SUVs which are significantly higher than those seen with adenocarcinoma. FDG may therefore have a role in non‐invasively predicting whether esophageal cancer is of the adeno or squamous cell subtype prior to therapy.
P14 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: colorectal cancer
P143 FDG-PET/CT in patients with locally advanced rectal cancer undergoing neoadjuvant therapy L. L. Travaini, C. Leonardi, F. Elisei, G. Zampino, S. Iodice, G. Trifirò, M. Ferrari, R. Mei, R. Orecchia, G. Paganelli; European Institute of Oncology, Milano, ITALY. AIM: To assess the value of Positron Emission Tomography with Fluorodeoxyglucose (FDG‐ PET/CT) in locally advanced rectal cancer patients (LARC) for staging purpose and planning radiotherapy and to assess the impact of sequential PET in predicting the response to neoadjuvant therapy. MATERIALS AND METHODS: Twenty consecutive patients with histologically proven rectal adenocarcinoma were submitted to total body Computed Tomography with contrast enhancement (ceCT), Magnetic Resonance of the pelvis (MR), endoscopy and colonoscopy. FDG‐PET/CT was performed at baseline (PET1), at 40 Gy (PET2) and at the end of radiotherapy (PET3). Patients received capecitabine concomitant to radiotherapy to the pelvis (50.4 Gy/28 fractions), followed by two cycles of capecitabine up to 2 weeks prior to surgery. PET images were evaluated visually and by maximum standardized uptake value (SUVmax) measurement. We also calculated the percentage reduction of SUVmax along the three PET (PET1‐2, PET2‐3, PET1‐3). The contouring of the target was performed by three independent physicians. Pathological response was defined as ypT0. RESULTS: All primary tumor was visualized (mean SUVmax 25.6, range 9.9‐65). Lymph nodal status was characterized by 14 concordant results (10 positive and 4 negative) and 9 discordant results (6 ceCT+/PET‐ and 3 ceCT‐/PET+). In 1 patient liver metastasis was detected by PET alone. Three patients were defined as responders. No statistical difference was observed between the SUV values in the two sub‐ groups of patients except for the SUV2 that was statistically higher in the non‐responders (P=0.05). The PET1‐3 was higher in the responders, but not statistically significance (P=0.19), probably due to lack of power. A borderline significant difference was observed in PET1‐2 (P=0.08). No statistical difference was also observed between the three operators in volume delineation. CONCLUSION: PET was able to detect one metastatic liver lesion not detected by MR. The volume area delineated by the three operators was not statistically significant. Our preliminary results showed a tendency of median reduction (PET1‐2 and PET1‐3) that was higher in responders. Further enrolment is necessary to better understand the role of PET for predicting response to neoadjuvant therapy in LARC. Table 1. Comparison of median SUV values and median percentage reduction in responders and non‐responders.
Responders Non‐responders P‐value* (n=3) (n=17)
Median SUVmax (IQR):
SUV1
19 (18,36) 27 (15,33)
0.92
SUV2
8 (7,8)
13 (10,15)
0.05
SUV3
5 (5,6)
7 (6,8)
0.12
Median percentage reduction (IQR):
PET1‐3
73 (72,83) 61 (51,79)
0.19
PET1‐2
63 (56,78) 47 (27,59)
0.08
PET2‐3
24 (24,38) 37 (23,49)
0.48
*P‐value from the Wilcoxon Two‐Sample test; IQR: Interquartile range
P144 The value of delayed phase FDG PET imaging of rectum in the patients with rectum carcinoma F. Aydin, F. Gungor, A. Boz, A. Yildiz; University of Akdeniz, Antalya, TURKEY. Aim The aim of this study was to determine the value of delayed phase F18‐FDG PET/CT imaging of rectum in the patients with rectum carcinoma. Material and Methods The study population comprised 16 consecutive operated patients (11 men, 5 women; mean age 58.8±10.3), with rectum carcinoma (n=15), and one patient had carcinoma of primary unknown with liver metastasis. Seven subjects (with lung carcinoma; 5 men, 2 women; mean age 63.6±7.1) were also included as control group. Initial “early” whole body imaging commenced 45 minutes after the injection of F18‐FDG to all patients. An additional “delayed” scan focusing only pelvic area was
obtained 120 minutes after the injection. The maximum standardized uptake values (SUV max) were measured in early and delayed phases. The percentage of the differences between delayed and early SUV max values were also calculated for the patients and control group. Final diagnosis was done by biopsy (n=6) and follow up with clinical‐laboratory‐other imaging methods (CLI). Results In the patient group, 12 subjects were found to be malignant (biopsy in 4 subjects, CLI in 8 subjects), 4 subjects benign (biopsy in 2 subjects, CLI in 2 subjects) concerning with rectum. Early and delayed phase SUV max values were found to be 13±8.6 / 17.8±11 and 7.7±1.9 / 9.2±2.9 in the patient and control group, respectively. On the delayed imaging 3 of the 4 benign patients and all malignant patients demonstrated an increase in SUV max values. However, no statistically significant was found between SUV max values in early and delayed imaging in the patient and control groups (p>0.05). Furthermore, the values of the percentage of the difference between early and delayed SUV max in the benign and malignant patients were overlapped (range: 2‐181%, 44‐81% in the malignant and benign patients, respectively). Conclusion Delayed phase FDG PET/CT imaging of the rectum could not be helpful in the evaluation of recurrence or residue in the patients with rectum carcinoma.
P145 PET/CT using 18F-FDG in patients with familial adenomatous polyposis - preliminary report R. Czepczyński1, T. Banasiewicz2, J. Paszkowski2, I. GuzikowskaRuszkowska1, M. Drews2, J. Sowiński2; 1PET/CT Centre Euromedic Poznan; Poznan University of Medical Sciences, Poznań, POLAND, 2Poznan University of Medical Sciences, Poznań, POLAND. Familial adenomatous polyposis (FAP) is an inherited condition in which malignant transformation into colorectal cancer occurs frequently. Extracolonic manifestations like desmoids, osteomas as well as other malignancies may occur in some patients. The treatment of choice is a prophylactic proctocolectomy with a formation of intestinal pouch followed by monitoring of the digestive tract and subsequent excision of polyps suspected of malignancy. The role of PET/CT in FAP patients after proctocolectomy is not quite clear. In this prospective pilot study, our aim is to determine the significance of 18F‐FDG PET/CT in the management of FAP. Material and methods. Nine patients (6 women and 3 men aged 21‐71, median 36) with FAP were qualified to the study. All patients were treated with proctocolectomy 4‐21 years ago and since then have been monitored with the use of standard methods as endoscopy, ultrasonography, CT and laboratory tests. The patients’ selection was based on a clinical evaluation indicating a high risk of malignancy and difficulties in decision‐making regarding further management. PET/CT was performed 60 min after injection of 18F‐FDG (5MBq/kg) with Discovery STE scanner (General Electric). Results. In 3/9 patients PET/CT pathologic 18F‐FDG activity in the digestive tract was observed implying invasive procedures. In one patient 3 foci were found together with previously not known pulmonary and lymph node metastases. In the remaining 2 patients, suspected foci of increased 18F‐FDG activity were observed in the pouch wall; one of them had also some 18F‐FDG accumulation in the gastric wall. In 2/9 patients no pathologic 18F‐FDG activity was found in the locations that had been suspected of malignancy in other diagnostic modalities (pouch wall stiffening, ovarian cyst), resulting in the disqualification from invasive procedures after PET/CT. Watch‐and‐wait strategy was chosen in these cases. FAP‐ associated symptoms were diagnosed: cranial osteoma in 1 patient and 9 desmoids in 2 patients ‐ only 2 out of 9 desmoids showed slight 18F‐FDG activity. Other findings: focus of high 18F‐FDG accumulation in the uterus requiring gynecological intervention; diffuse thyroid and slight adrenal 18F‐FDG activity (endocrinological diagnostics recommended). In 7/9 patients focal 18F‐ FDG activity in the remnant stump was observed. Conclusion. These preliminary data show that PET/CT may have an impact on the management of patients after proctocolectomy due to FAP. Follow‐up of these patients will verify the significance of the findings.
P146 A Pictorial Review of the Role of PET CT in Colorectal Cancer B. E. Drake1, A. Leonard1, A. McKay Ferguson2, G. Vivian1, T. Sulkin2, S. Higgins3; 1Peninsula Radiology Academy, Plymouth, UNITED KINGDOM, 2 Royal Cornwall Hospital, Truro, UNITED KINGDOM, 3Torbay NHS Foundation Hospital, Torbay, UNITED KINGDOM. Introduction The national PETCT service commissioned in England and Wales in April 2008 has provided wider access of the modality across the UK. This review illustrates the impact on the management of patients with colorectal cancer. Specifically, the role of PETCT in staging colorectal cancer prior to hepatic resection, monitoring of disease response and its role in disease recurrence are considered. Subject / Methods Data is presented from the South West of England Peninsula group of hospitals covering a population in excess of 1.5 million. Each of the hospitals has access to mobile dedicated oncological PETCT. Imaging Findings A pictorial review is presented highlighting the role of PETCT in avoiding the geographical misses which occur in CT and in detecting occult sites of disease. This is significant prior to hepatic resection and helpful in the common clinical scenario of raised CEA but apparently normal CT. Mapping of hepatic disease within the liver prior to hepatic resection by PETCT is also demonstrated. Practical issues including the timing of PETCT for patients receiving neo‐adjuvant chemoradiotherapy are described. The limitations of using PETCT in the initial staging of disease are also reviewed. Examples of common imaging pitfalls encountered in patients with colorectal cancer including post radiotherapy change, fistulas, abscesses and sutural granuloma are provided. Where appropriate correlative CT, MRI and histology are presented. The current literature is summarised. ConclusionPETCT has a great deal to offer in the management of colorectal cancer particularly prior to metastatectcomy and in disease relapse. Access to PETCT is leading to a gradual step change in patient management, enabling clinicians to tailor treatment more appropriately. Its wider use is encouraged
P147 Utility of the delayed images 18F-FDG/PET-CT in the correct evaluation of abdominal uptakes in patients with gastrointestinal tumour P. Talavera Rubio, A. García Vicente, M. Bellón Guardia, I. Cepedello Boiso, V. Poblete García, B. González Rodríguez, J. Cordero García, P.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 Pilkington White, A. Palomar Muñoz, A. Soriano Castrejón; HGCR, Ciudad Real, SPAIN.
that further evaluation for spleen uptake on 18 F FDG PET/CT image is worthy of increasing the specificity for differential diagnosis of hepatobiliary malignant disease from inflammatory lesion.
Aim: To assess the value of dual time point 18F‐FDG/PET‐CT imaging in the correct evaluation of doubtful abdominal uptakes in patients with gastrointestinal primary tumour. Material and methods: We studied 31 abdominal gastrointestinal focal uptakes (25 studies; 22 patients: age 34‐79y; 7 females). The primary tumours were: gastric cancer (4), duodenum adenocarcinoma (1), colon cancer (13) and rectum cancer (4). The doubtful lesions were in or close to gastrointestinal tract. 2 studies were for staging, 16 post‐treatment control and 7 recurrence suspect. All patients underwent 18F‐FDG/PET‐CT: first study at 60 min and the second study at abdominal location, 2‐3 hours after intravenous injection of 370 MBq 18F‐FDG/PET‐CT. The images were evaluated qualitatively and quantitatively. The maximum standardized uptake values (SUV max) of the lesions were measured for both studies and was calculated the percent changes of the SUV max between them. Any uptake higher than hepatic activity and with increase in delayed images was considered pathologic (malignant). The final diagnostic was by histological study in seven lesions, follow up 18F‐FDG/PET‐CT in eight cases and clinic follow up (range 5‐26 months; mean 17 months) or other diagnostic techniques in sixteen lesions. Results: 7 lesions were considered in relation with physiologic uptake by the 18‐F‐FDG/PET‐CT. All were finally clinic benign uptakes. 24 lesions were considered pathologic by 18F‐FDG/PET‐CT. The percent change was higher than 10% in all of them. 7/24 lesions were finally considered false positive, 5 out of 7 lesions were in surgery area and other was a physiologic uptake in anal muscle. 17/24 lesions were diagnosed as malignant: 9 were mesenteric implants and 8 local recurrences.
P150
Physiologic 7 4,8‐13,2 (7) uptake
0‐12,3 (3,5)
‐100/‐7
Pathologic 24 3,2‐13,3 (6,6) uptake
4,6‐21,3 (9,2)
+12/+96 0 7 17 0
0 0 0 7
Conclusion: This study showed evidence that dual time point 18F‐FDG/PET‐CT abdominal imaging is a useful method for the discrimination of malignant lesions in patients with primary gastrointestinal tumour except in cases with previous surgery.
P148 Efficacy of inflating a colon by air pumping to reduce physiological uptake on FDG-PET K. Murakami, K. Kitajima, E. Yamazaki; Dokkyo Medical University, Tochigi, JAPAN. OBJECTIVES: Physiological accumulation in colon is sometimes confused with a lesion to spoil the usefulness of FDG‐PET in abdomen and pelvis. There are reports such as administration of anticholinergic agent as methods to reduce physiological accumulation in colon, but it is not adequate. Our object is to clarify the effectiveness of inflating a colon to reduce physiological uptake of FDG. MATERIAL AND METHODS: Patients who has gastrointestinal disease or history of gastrointestinal disease were excluded in this study. Of the patients who showed strong physiological deposit in colon by usual PET scan (1 hour after FDG injection), eight patients (men; five, women; three) agreed to entry the study. After confirmation that all eight patients revealed unchanged physiological colon uptake by delayed PET scan (2 hours after FDG injection), we inflated colon by air pumping, then, another PET scan was performed. Degree of FDG accumulation before inflation and after inflation of colon was compared. We also examine the accumulation by using hand‐made a cast and a hollow phantom that had same cross section area. RESULTS: All eight patients showed prominent decreased physiological accumulation in colon after inflation. We can reproduce similar accumulation in contracted and dilated colon by using cast‐shaped and hollow‐shaped phantom. Partial volume effect (count recovery) may be one of the reason why contracted colon shows increasing FDG uptake. CONCLUSIONS: We can conclude that to inflate a colon by air pumping is effective method to decrease physiological uptake.
P15 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: pancreatic cancer
P149 The relation between splenic FDG uptake and accompanying hepatobiliary inflammation in hepatobiliary cancer patients S. Lee, J. Park, S. Bae; Inje University College of Medicine, Pusan Paik Hospital, Busan, REPUBLIC OF KOREA. Purpose: 18 F FDG PET/CT shows increased glucose metabolism not only in the malignancy but also inflammation. The aim of this study is to evaluate the spleen uptake of FDG in the condition of inflammation and predict the contribution to differential diagnosis in inflammatory and malignant hepatobiliary disease. Methods: 18 F FDG PET/CT of 68 healthy control and 78 hepatobiliary cancer patients without past history of diffuse hepatic parenchymal disease such as liver cirrhosis, were enrolled. Mean SUV of spleen was compared in the two groups. Among hepatobiliary cancer patients, those with recent PTBD(<2 weeks) and remote PTBD(>2 weeks) were compared each other, and those with clinical sign of infection and those without sign of infection following PTBD also compared. Results: Mean SUV of spleen of those with recent PTBD was significantly higher than healthy control(2.66±1.3 vs 1.79±0.32, p<0.01). But in the cases of remote PTBD, mean SUV of spleen was not different from healthy control(1.85±0.32 vs 1.79±0.32, p=0.40). Those with clinical sign of infection or inflammation also showed significantly higher mean SUV of spleen than patient group without sign of infection or inflammation(2.36±1.07 vs 1.83±0.33, p<0.01). And those without sign of infection or inflammation did not show significant difference of mean SUV of spleen from healthy control(1.83±0.33 vs 1.79±0.32, p=0.50). Conclusion: Although benign inflammatory hepatobiliary disease did not be enrolled due to retrospective study, active Infection or inflammatory reaction in hepatobiliary disease is suspected to cause increased glucose metabolism of spleen. We think
T. Okamura1, Y. Hamazawa1, H. Seura1, Y. Masuoka1, K. Koyama2, N. Ozawa1; 1Saiseikai Nakatsu Hospital Osaka, Osaka, JAPAN, 2Osaka City University graduate school of Medicine, Osaka, JAPAN. Aim: We compared the FDG PET/CT in the pancreas cancer, autoimmune pancreatitis and tumor forming pancreatitis. Patients and methods: Thirty‐six patients with pancreas disease were studied. Twenty‐three patients had pancreas cancers(Cancer), 8 patients had autoimmune pancreatitis(AIP) and 5 patients had tumor forming pancreatitis (TFP). The SET‐3000BCT/L PET/CT system (Shimadzu Corp.,Kyoto,Japan) was used. Early scan was started at 50 min after FDG administration and delayed scan at 110 min after administration. Location of FDG uptake and SUV max in each scan was evaluated. Results: Eight pancreas cancers demonstrated FDG uptake at pancreas head, 6 cancers at pancreas body, 7cancers at body‐tail, and 2 cancers showed no FDG uptake. Six AIP cases showed FDG uptake at pancreas head and body‐tail, and 2 AIP cases showed regional FDG uptake at head only. SUV max of early scan of pancreas cancer was 5.4±2.9(2.9~15.5), and that of delayed scan was 6.9±3.8 (3.7~19.5). SUV max of early and delayed scan of AIP was 3.9±1.3 (2.7~7.0)and 4.8±1.3 (3.5~7.7), respectively. SUV max of early and delayed scan of TFP was 3.3±2.2 (2~7.2)and 4.2±3.5 (1.8~10.3), respectively. There were significant differences between SUV max of delayed scan of Cancer and that of TFP(p=0.03), between SUV max of early scan and delayed scan in Cancers(p<0.0001) and between SUV max of early scan and delayed scan in AIP (p=0.01) . Conclusion: The highest SUV max is shown in the delayed scan of Cancer. SUV max of delayed scan of AIP was higher than that of TFP, though there was only significant difference between delayed SUV max of Cancer and that of TFP, statistically. It is difficult to differ between AIP with regional FDG uptake and Cancer. It should be refer to clinical data and the other lesions with AIP for differential diagnosis.
P16 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic
Oncology
-
PET,
PET/CT:
liver
and
hepatoma
P151 Evaluation of therapy response in patients with hepatocellular carcinoma treated with bevacizumab and transarterial chemoembolisation (TACE) by using C-11-acetate PET and F18-FDG PET E. Dimou, M. Peck-Radosavljevic, W. Wadsak, M. Mitterhauser, H. Duan, E. Trifina, F. Hajos, H. Eidherr, R. Dudczak, K. Kletter, S. Li; Medical University of Vienna, Vienna, AUSTRIA. Aim: hepatocellular carcinoma (HCC) is the fourth most common cancer worldwide. Bevacizumab (AvastinTM) is a humanised monoclonal antibody targeting vascular endothelial growth factor (VEGF). The aim of this study was to evaluate the response of HCC lesions to bevacizumab and transarterial chemoembolisation (TACE) by using both 11C‐acetate‐PET and 18F‐FDG‐PET. Materials and Methods: 15 Patients (15 males, age range 44‐72 years) with histologically confirmed HCC were included in the study. TACE was carried out with doxorubicin:lipiodol (1:1) in a total volume of 20 mL; after administration of doxorubicin:lipiodol, additional embolisation was carried out with beadblock‐endospheres. TACE was repeated every 4 weeks for 3 cycles. All patients received bevacizumab (5 mg/kg bw) i.v. prior to the first TACE and every 14 days thereafter for 52 weeks. 11C‐acetate‐PET and 18F‐FDG‐PET were performed within 4 weeks before treatment and 3 months after initiation of therapy. Whole‐body 11C‐acetate‐PET and 18F‐ FDG‐PET were performed following injection of 930 +/‐ 100 MBq of 11C‐acetate and 420 +/‐ 30 MBq of 18F‐FDG, respectively. Results: Before treatment with bevacizumab and TACE, the patient‐related sensitivity was 60% in FDG‐PET and 80% in acetate‐PET, respectively. Visual estimates of the acetate‐PET scans showed 9 of 12 patients (75 %) having response to the treatments and three patients (25 %) having non‐response to the treatments. Another 3 patients had negative acetate‐PET scan results before and after the treatments. Visual estimates of the FDG‐PET scans demonstrated 7 of 9 patients (78 %) showing response and 2 of 9 patients (22 %) having non‐response to the treatments. 6 patients were negative in FDG‐PET during the study. Among them, two patients showed positive acetate‐PET results. There was a significant decrease in max. tumour SUV in both acetate‐PET and FDG‐PET positive lesions after treatments. Conclusion: Our results indicate that both 11C‐acetate‐PET and 18F‐FDG‐PET are useful for monitoring the response of patients with HCC to bevacizumab and TACE.
P152 F-18 Choline PET-CT in the assessment of recurrences and metastases of patients with hepatocellular carcinoma: a case report L. Imamovic1, M. Beheshti2, F. Fitz2, S. Pöcher1, W. Langsteger1; St.Vincent's Hospital, Linz, AUSTRIA, 2St. Vincent's Hospital, Linz, AUSTRIA.
1
Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and the third most common cause of cancer mortality worldwide. Early detection of recurrences and metastases has an important role for therapeutic management and prediction of disease prognosis. Recently, F‐ 18 Choline PET‐CT was introduced as a promising method for the assessment of HCC. We report on a 71 year‐old male patient with HCC and intra‐ and extrahepatic recurrences after liver transplantation. Segmental intrahepatic resection and multiple trans‐catheter arterial‐ embolizations, mechanical embolization of the rib metastasis as well as radiotherapy of the hemi‐
Poster Presentation
SUVmax 1study PET‐CT N SUVmax 2study Range(mean) % change FN FP TP TN Range(mean) Diagnosis
Comparison of FDG PET/CT in the pancreas cancer, autoimmune pancreatitis and tumor forming pancreatitis
S340 thorax were performed for intrahepatic recurrences and right ribs metastases. FDG PET ‐ CT was performed for the therapy evaluation which showed only mild increased tracer accumulation in the right ribs. However, FCH PET clearly detected multiple extrahepatic metastases in the pericardial and hillar lymph nodes, peritoneal carcinosis and multiple bone metastases. FCH PET‐ CT showed clearly superior results comparing FDG PET‐CT in the detection of distant metastases of HCC. Conventional imaging modalities were either negative or non‐diagnostic due to post‐ surgical morphological changes, thus demonstrating once more the major advantage of metabolic imaging when compared with morphological imaging modalities. Our data confirmed the recent published reports concerning the advantages of FCH PET‐CT for the early detection of extrahepatic recurrences and metastases of HCC which in turn has a crucial role in the therapeutic management of HCC patients.
P153 FDG PET as a Prognostic Predictor in the Early PostTherapeutic Evaluation for Unresectable Hepatocellular Carcinoma. T. Higashi1, R. Nishii1, E. Hatano2, I. Ikai2, Y. Nakamoto2, K. Ishizu2, K. Togashi2; 1Shiga Medical Center Research Institute, Moriyama, JAPAN, 2 Kyoto University Hospital, Kyoto, JAPAN. Purpose: To elucidate the post‐therapeutic diagnostic and prognostic role of 18F‐ fluorodeoxyglucose (18F‐FDG) positron emission tomography (PET), we conducted a comparative retrospective cohort study analyzing the clinical factors which affect long‐term survival after non‐ operative therapy for unresectable hepatocellular carcinoma (HCC). Experimental Design: Forty‐ eight patients (age: 59.1+/‐14.7) with unresectable HCC who received non‐operative therapy (transcatheter arterial chemoembolization: n=22, transcatheter arterial infusion chemotherapy: n=26) and have received FDG‐PET for the evaluation of the treatment effect within one month after the end of the therapy were evaluated retrospectively. FDG‐PET was evaluated by visual diagnosis and quantitative analysis using SUVmax. Post‐therapeutic viability of hepatic lesions and extrahepatic metastatic lesions were confirmed by clinical follow‐up more than 6 months, and these results were compared with PET results. Clinical outcome was studied in case records using the univariate and multivariate analyses of relevant clinical and laboratory parameters. Results: Visual FDG‐avidity analyzed by PET immediately after therapy was a good predictor of overall survival of HCC patients. Low FDG‐avid group (stage II‐III: n=11, stage IV: n=11) showed significantly longer survival (average: 541days) than that (average: 261days) of the high avid group (stage II‐III: n=13, stage IV: n=13)(p<0.0001). Multivariate analysis showed three significant prognostic factors for the survival of HCC patients treated by non‐operative therapy; visual FDG‐ avidity (risk ratio=0.378, p=0.03), post‐therapeutic “SUV (lower than 5.0 or not)” (risk ratio=0.332, p=0.006), and post‐therapeutic Milan Criteria (fulfill or not) (risk ratio=0.001, p=0.003). On the contrary, post‐therapeutic diagnostic value of FDG‐PET for viability of lesions was relatively lower in main hepatic lesions (sensitivity: 60%, specificity: 92%, accuracy: 69%), while relatively higher in extrahepatic metastatic lesions (sensitivity: 65%, specificity: 90%, accuracy: 81%). Conclusions: The present study suggests that 1) post‐therapeutic PET performed within one month after non‐operative therapy can be a good predictor of survival in unresectable HCC patients, 2) FDG‐PET is useful for early evaluation of post‐therapeutic tumor viability in extrahepatic metastasis, but not so accurate in hepatic lesions.
P17 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: melanoma
P154 Comparison of I-123 IMP SPECT, F-18 FDG PET/CT and F-18 Dopa PET/CT in detection of uveal malignant melanoma K. Kato1, S. Abe2, M. Ikeda1, H. Terasaki3, S. Naganawa3; 1Nagoya Univ. School of Health Sciences, Nagoya, JAPAN, 2Nagoya University Hospital, Nagoya, JAPAN, 3Nagoya Univ. Graduate School of Med., Nagoya, JAPAN. Aim: I‐123 IMP SPECT is a sensitive and accurate method for the detection of uveal malignant melanoma, whereas the efficacy of F‐18 FDG PET for this purpose is low due to a high incidence of false negative results (Kato K, et al. J Nucl Med. 2006;47:404‐409). The efficacy of F‐18 Dopa PET/CT for detection of uveal malignant melanoma is unknown. The purpose of this study is to compare the efficacy of I‐123 IMP SPECT, F‐18 FDG PET/CT, and F‐18 Dopa PET/CT for detection of primary and metastatic lesions of uveal malignant melanoma. Materials and Methods: Seven patients with suspected uveal malignant melanoma were examined by I‐123 IMP SPECT, F‐18 FDG‐PET/CT, and F‐18 Dopa PET/CT. I‐123 IMP SPECT was performed 24 hours after intravenous administration of I‐123 IMP using a gamma camera (Symbia; Siemens, E.COM Toshiba) with LEHR Fan‐beam collimator. F‐18 FDG‐PET/CT and F‐18 Dopa PET/CT was performed 60 minutes after intravenous administration of F‐18 FDG or F‐18 Dopa using a PET/CT camera (Biograph, Siemens). Results: One case was positive in F‐18 FDG PET/CT, whereas 4 cases were positive in I‐123 IMP SPECT and F‐18 Dopa PET/CT. In two cases which showed negative results with all these three examinations, there was no uveal melanoma lesion. One case is positive in I‐123 IMP SPECT and in F‐18 Dopa PET/CT, respectively, and these two cases were negative in the other two examinations; and in these two cases there were uveal malignant melanoma. In the cases which showed positive results with all these three examinations, the tumor diameter was longer than 1cm. On the other hand, the tumors with a diameter less than 1cm exhibited positive results in both I‐123 IMP SPECT and F‐18 Dopa PET/CT but negative results in F‐18 FDG PET/CT. I‐123 IMP SPECT seems to show higher tracer accumulation than F‐18 Dopa PET/CT. Conclusion: Uveal malignant melanoma with a diameter longer than 1cm exhibited positive results in all of I‐123 IMP SPECT, F‐18 FDG PET/CT, and F‐18 Dopa PET/CT. The tumors with a diameter less than 1cm exhibited positive results in both I‐123 IMP SPECT and F‐18 Dopa PET/CT but negative results in F‐ 18 FDG PET/CT. I‐123 IMP SPECT seems to show higher accumulation than F‐18 Dopa PET/CT in detecting uveal malignant melanoma with a diameter shorter than 1cm.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P155 Effectiveness of FDG PET-CT for the detection of distant metastases at initial staging of localized high risk melanomas T. L. J. Wagner1, S. Zerdoud2, F. Courbon2; 1Purpan Univ. Hosp., Toulouse Cedex, FRANCE, 2Claudius Regaud Inst., Toulouse Cedex, FRANCE. Aims Positron emission tomography (PET) using fluorodeoxyglucose (FDG) has proven to be superior to other imaging modalities for the detection of distant metastases (M+) in patients with melanoma. However its role for the initial staging of patients with high risk localized melanoma (large Breslow index (BI) and/or ulceration) is not clearly defined. The aim of this study was to asses the rate of M+ in a population of melanoma patients with a BI superior to 4 mm or a BI between 1 and 4 mm with ulceration, at initial staging using PET FDG. Materials and methods Patients We included 48 consecutive patients with 1 4 mm (regardless of ulceration status). The patients did not present any clinical sign of nodal involvement or of distant metastasis. Methods All PET‐CT procedures were performed on GE Discovery ST® scanner (General Electric Healthcare, Waukesha, WI, USA). All PET‐CT scans were interpreted by at least one experienced nuclear medicine physician, aware of all the clinical findings. PET‐CT findings were classified as positive (FDG uptake indicative of M+), negative (absence of FDG uptake indicative of M+) or inconclusive (FDG uptake not typically indicative of M+ but it could not be ruled out). The gold standard for M+ was conventional imaging and clinical follow‐up, confirmed by biopsy whenever feasible. Results Sex ratio was 2.33 (M/F). The mean BI was 5.3 mm (+/‐ 3.6). Eighteen patients had a BI between 1 and 4 mm with ulceration and 30 patients had a BI > 4 mm. Thirty‐eight tumors showed ulceration. No patient had a positive PET‐ CT for M+. Eight patients (17 %) had a non conclusive PET‐CT; none of them presented with M+ within 12 months. FDG uptake corresponded to schwannoma, pituitary adenoma. Forty patients (83 %) had a negative PET‐ CT, amongst them one patient (2.5 %) presented with M+ within a year, 2 months after the PET‐CT. Conclusion PET FDG does not seem to be effective at detecting M+ at initial staging in patients with high risk localized melanoma. This comes probably from the low prevalence of macroscopic metastatic disease at this stage. PET FDG might be more useful in the follow‐up of these patients with a high risk of metastatic dissemination.
P156 Is there any role of 18F-FDG PET/CT in initial staging of patients with malignant melanoma? A retrospective study F. Vlachou, R. Efthimiadou, L. Gogou, D. Savidou, A. Nikaki, D. Tsevas, O. Karamini, K. Dalianis, K. Gogos, J. Andreou, V. Prassopoulos; Department of PET/CT D.T.C.A. Hygeia Hospital, Athnes, GREECE. AIM: The incidence of malignant melanoma is constantly rising and is responsible for 1.4% of cancer deaths. Major prognostic factors are: histologic features of the tumor, micro/macrometastasis in lymph nodes, number of lymph nodes involved, satellite and in‐transit metastasis, the total burden of disease. The purpose of this study is to evaluate the contribution of 18F‐FDG‐PET/CT in pre‐treatment staging patients suffering from malignant melanoma. MATERIAL AND METHOD: 18 patients, 26‐70 years old, 8 female and 10 male with newly diagnosed malignant melanoma and histological evidence or clinical/ imaging suspicion of advanced disease were included in the study. Location of the primary tumor involved: trunk (6 patients), lower limps (1), head and neck including eyes and oral cavity (6), genitalia (2), while the primary site was unknown in 3 cases. All patients were staged according to AJCC staging system by physical examination and conventional imaging (CT, MRI, US, Bone scan) before undergoing PET/CT examination. We evaluated the impact of PET/CT in staging patients with malignant melanoma, in comparison with conventional imaging techniques. RESULTS: PET/CT did not alter the stage in 9 cases, 8 of which were negative, upstaged 4 patients, downstaged 3 patients, one with lung nodules <5mm (false negative). Particularly PET/CT revealed more metastatic lesions in 4 patients‐ involving lymph node invasion, soft tissue, satellite and in‐transit metastasis and bone metastasis. Moreover PET/CT revealed a second primary tumor of stomach with regional lymph node invasion in one patient. As far as the patients with unknown primary site of the tumor are concerned, PET/CT revealed the primary site in 1/3 patients (brain melanoma), gave 3 possible solutions in the second (all were metastatic lesions) and showed extensive metastatic disease in the third. CONCLUSION: PET/CT is a whole body imaging modality, useful in staging patients with malignant melanoma, able to reveal metastatic lesions in unsuspected sites. Brain and extremities should be included in the study when necessary. However, because of its lower spatial resolution, findings in lungs even in low‐dose CT should not be ignored, as well as sentinel lymph node biopsy for best lymph node staging. PET/CT can be helpful in finding the primary site of the tumor when it is unknown.
P157 Should FDG PET/CT scanning of patients with malignant melanoma include the lower extremities? V. Furuly, T. Cappelen, A. Tulipan, T. V. Bogsrud; The Norwegian Radium Hospital, Oslo, NORWAY. Background: Our standard FDG PET/CT imaging protocol for patients with malignant melanoma includes scanning from vertex through feet with arms down. This extended scan adds about 15 minutes to our standard imaging protocol including scanning from base of skull to thighs used in other cancers. For every second patient with malignant melanoma a whole body study from base of skull to thighs is displaced. Aim: The aim of this retrospective study was to evaluate to clinical value of including the lower extremities in the FDG PET/CT imaging protocol in patients with malignant melanoma. Material and methods: All patients with malignant melanoma studied with FDG PET/CT in our institution from August 2005 until March 2009 were included. The 301 included patients were 166 men and 136 females, average age 56±16 y (range 29‐84) and 53±14 y (18‐86), respectively. Results: A hypermetabolic lesion located on the lower extremities below inguinal regions was confirmed or highly suspicious of metastasis from malignant melanoma in 38 patients.Among these 38 patients, 23 (60.5 %) had a prior confirmed lesion located on the lower extremities. Nine of the 38 patients (23.7%) had metastases to inguinal lymph nodes as well. In 8/38 patients (21.1%) the lesions on the lower extremities below the inguinal regions were the only lesions detected. Conclusion: In patients with malignant melanoma, FDG PET/CT scanning of the lower extremities seems to be justified.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Diagnostic Oncology - PET, PET/CT: cervical, uterine and ovarian cancer
P158 Role of 18F-FDG PET/CT in recurrent ovarian cancer after surgery and chemiotherapy: Preliminary results of a prospective study L. Rampin1, C. Barile2, E. Banti1, M. Marzola1, G. Grassetto1, E. Milan1, S. Cittadin1, A. Massaro1, D. Rubello1; 1Nuclear Medicine Service - PET Centre - Hospital Rovigo, Rovigo, ITALY, 2Department of Oncology - Hospital Rovigo, Rovigo, ITALY. Aim : To evaluate the role of 18F‐FDG PET/CT to detect recurrent ovarian carcinoma after surgery and chemotherapy. The results PET/CT were compared with contrast enhanced (c.e.) CT results and serum Ca 125 levels. Methods : In the period from Jan. 2008 to Dec. 2008, 13 consecutive pts with treated ovarian carcinoma (mean age of 58.6 years, range 42 ‐ 84 years) underwent a PET/CT study 60 min. after the administration of 2.2 MBq/Kg b.w. of 18F‐FDG. Pts were evaluated in fasting condition, and glucose levels measured before radio‐tracer injection were < 180 mg/dL A hybrid PET/CT scanner (STE GE Discovery) with a 3D modality acquisition was used. Images were reconstructed by OSEM method. Interpretation were based on visual inspection and SUVmax analysis: it was performed by two nuclear medicine physicians blinded with clinical data and final diagnosis was reached by consensus. The results of PET/CT examination were compared with c.e CT results and serum Ca 125 levels. Results : 8/13 pts (61.5 %) had positive findings on PET/CT and 7 of them (53.8%) on c.e. CT also. However, in 4 pts (30.7 %) PET/CT visualised more metastatic lesions than c.e. CT. 7/13 pts (53.8 %) had increased serum Ca 125 levels. Among these, 6/7 pts (46.1 %) had positive PET/CT and 5 pts (38.4%) had positive c.e CT also. On the other hand, 6/13 patients (46.1%) had normal Ca 125 levels. Of them, 2/6 patients (15.3 %) had positive metastatic lesions both at PET/CT and c.e CT, whereas 4/6 patients (7.6 %) were negative both at PET/CT and c.e. CT. Surgical and histopathological findings were taken as the gold standard procedure. Conclusions : In our preliminary prospective study, 18F‐FDG PET/CT showed positive findings in a higher number of pts with ovarian carcinoma and more metastatic lesions in half of these pts. Furthermore, in several cases FDG PET/CT revealed tumoral deposits despite of normal serum Ca 125 levels.
P159 Role of FDG-PET/CT carsinomas
to
evaluate
recurrence
ovarian
T. Kacar Guveli, T. Ozpacaci, T. Ozulker, M. Mulazımoglu, M. Tamam, O. Eker, F. Ozulker, A. Kucukoz Uzun, H. S. Yavuz; Okmeydani Training and Research Hospital, Istanbul, TURKEY. PURPOSE: In our study, we try to determinate positive and negative aspects of FDG‐PET which is new for oncologic trials in recurrent metastatic ovarian carcinomas. METHODS: The 45 patients who were send to Ministery of Health Okmeydani Training and Research Hospital Nuclear Medicine Department for FDG‐PET/CT application in September 2007 to March 2008 and have recurrent ovarian carcinomas doubt attended to study. Patients had primary surgery and basal chemotherapy and then had recurrence doubt because of clinical findings, tumor markers and/or other image studies in follow up period. Age of patients ranged from 24 to 76 years and the period from diagnosis ranged from 3 to 126 months and the period from last therapy ranged from 3 to 78 months. The PET examinations were made with high resolution PET scan which was integrated with 6 sectional multidetector CT. RESULTS: In evaluation of recurrent ovarian carcinomas, the sensitivity, specificity and accuracy of the FDG‐PET/CT were found %93,1, %93,8 and %93,3, respectively and the sensitivity, specificity and accuracy of CA 125 tumor marker were found %72,4, %62,5 and %68,9, respectively and the sensitivity, specificity and accuracy of conventional image studies were found %48,3, %62,5 and %53,3, respectively. Local recurrence in 15 patients, pelvic lymph node metastases in 18 patients, paraaortic, mediastinal and cervical lymph node metastases in 20 patients, distance metastases in 7 patients and peritoneal carcinomatosis in 4 patients were determinated with PET/CT. When we looked at FDG involved areas in positron emission tomography, 1‐5 lesion areas in 10 patients, 5‐10 lesion areas in 9 patients and 10 or more lesion areas in 8 patients were reported. CONCLUSION: As a result, to determinate the recurrent ovarian carcinomas, the FDG‐PET/CT is quite effective and superior than CA 125 tumor marker levels and other conventional image studies which are used in determination of recurrent illness. But it’s sensitivity and accuracy are reduced for determination of recurrent ovarian carcinomas with low volumes.
P160 The impact of PET/CT in preoperative restaging in suspected recurrent ovarian cancer. A. P. Caresia Aroztegui1, C. Gámez Cenzano1, M. Cortés Romera1, A. Fernández León1, A. Sánchez Márquez1, J. Robles Barba1, J. Ponce Sebastià2, B. Pardo Burdalo3; 1IDI. Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, SPAIN, 2Gynecology Department. Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, SPAIN, 3ICO. Oncology Department. Duran i Reynals., Hospitalet de Llobregat, Barcelona, SPAIN. Aim: To determine the incremental information provided by PET/CT in the preoperative restaging of patients with suspected recurrent ovarian cancer and to assess the impact of PET/CT on the clinical management. Methods: Eighteen women (mean age 56 years; age range 38‐76 years) with a previous history of ovarian carcinoma and suspected recurrence based on elevated CA‐125 (mean value 58 U/L) and potentially resectable lesions in the anatomical imaging were studied with FDG PET/CT. As the planned management was surgery (+/‐ chemotherapy or radiotherapy), any change after PET/CT was recorded. Results of PET/CT were correlated with pathological
findings and follow up (mean time 17 months). Results: In 11/18 patients PET/CT was more sensitive than anatomical imaging and showed unsuspected lesions: 1 patient died before any treatment, 6 patients presented unresectable disease (instead of surgery they received chemotherapy and progression disease was confirmed in the follow up) and 4 patients were operated of all lesions observed (3 of them confirmed by a relapse‐free follow up). In 5/18 patients PET/CT showed the same lesions than anatomical imaging and 4 of them were successfully treated with surgery. In 2/18 patients PET/CT was negative and no evidence of disease was detected during the follow up. PET/CT changed treatment in 8/18 patients (44%): 6 received chemotherapy and 2 changed to watching. Conclusion: FDG PET/CT could be very useful in preoperative restaging in suspected recurrent ovarian cancer. Although diagnostic accuracy in the prediction of full resectability is limited, surgical planning may be improved by identifying additional sites. The detection of more sites of disease than anatomical imaging techniques can avoid unnecessary surgeries.
P161 Role of 18F-FDG PET in the detection of recurrence in patients with cervical cancer P. Paredes, D. Fuster, F. Lomeña, X. Setoain, S. Lafuente, S. Rubí, B. Domenech, F. Pons; Hospital Clínic, Barcelona, SPAIN. Aim. To value the usefulness of positron emission tomography (PET) with 18F‐FDG in the detection of recurrence in patients with cervical cancer. Materials and methods: The study included 32 patients (mean age 66 years, range 23‐82) previously treated by chemorradiotherapy and eventually lymphadenectomy. All patients underwent a whole‐body PET/CT scan. Sensibility (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) were estimated. In 20 cases these results were compared with CT findings. FDG‐PET and CT findings (tumour recurrence, paraaortic and pelvic node involvement and distant metastases) were evaluated taking into account histopathological results as the gold standard. Follow‐up or other image techniques were used in some cases. Extra‐abdominal node involvement was considered as a metastasis of primary tumour. Results. In the detection of local recurrence PET and CT showed Se, Sp, PPV and NPV as follows: 82%, 95%, 90%, 91% and 86%, 92%, 86%, 92%, for PET and CT respectively. In the detection of paraaortic lymph node involvement, PET showed low Se 63% compared to CT results (100%), but higher Sp: 100% vs 92%. In the detection of pelvic node involvement, Sp and NPV are 100% for both techniques, but Se is lower than in other locations (67% and 71%, PET and CT respectively). In the detection of distant metastases, PET showed higher sensibility than CT (89% vs 67%). PET accuracy was 91% for loco‐regional recurrence and 97% for distant metastasis. When global assessment was analyzed, PET studies had a Se of 91% for the detection of recurrence in any location, and a NPV of 82%. Distant metastases were found in bone (2 cases), peritoneal ovarian implant (1 case), mediastinal lymph nodes (1 case) and supraclavicular nodes (2 cases). Conclusions. 18F‐ FDG PET/CT has a sensibility for local recurrence detection similar to CT scan; but shows poor results in the evaluation of paraaortic and pelvic node involvement. Nevertheless, has good accuracy in the detection of global recurrence. Moreover, PET study can diagnose distant metastasis with higher accuracy than CT scan.
P162 FDG-PET for metastatic para-aortic lymph nodes diagnosis in patients with cervical carcinoma. H. Gauthier, E. Leblanc, F. Narducci, A. Pereira, M. Boukerrou, P. Carpentier; Centre Oscar Lambret, Lille, FRANCE. Aim. The aim of this study was to assess the accuracy of 18FDG‐PET for the diagnostic of metastatic para‐aortic lymph nodes in patients with cervical cancer compared to surgicopathologic results. Materials and methods. 53 locally advanced (FIGO stage IIB‐IVA) cervical cancer patients were eligible to be included in this prospective study. All patients underwent 18FDG‐PET scans before extraperitoneal surgical exploration for para‐aortic 18 lymphadenectomy. Patients were explored 1 hour after the injection of 370 MBq of FDG on a dedicated PET scanner (GE Advance). Based on histologic confirmation, the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the PET for para‐aortic lymph node metastasis were calculated. Results. The average age was 48 (range 10‐ 88). 45 squamous cell carcinoma and 8 adenocarcinoma were diagnosed. FIGO stages were as follow: 22 IB, 2 IIA, 14 IIB, 1 IIIA, 12 IIIB, 2 IVA. An average of 19 lymph nodes were removed per patient (range: 4‐45). Histological examination revealed metastases in 13 patients (24.5%). Rates of false negative (10/40) and false positive (1/4) PET results were 25% each. The accuracy, sensitivity, PPV and NPV of 18FDG‐PET were 79%, 23%, 97.5%, 75% and 79.6% respectively. The sensitivity decreased from 37.5% (9/24) for lymph nodes‐invasion diameters higher than 5 mm to 0% (0/5) for lymph nodes‐invasion diameters lower than 5 mm. Free survival and global survival were significantly lower in case of positive PET (mean follow up: 18 months). We observed 12.5% (5/40) of recurrence, 1 death in case of negative PET scan, and 31% (4/13) of recurrence, 4 deaths in case of positive PET scan. Conclusion. In this study, 18FDG‐PET has a low sensitivity and PPV (especially for microscopic metastases) and cannot replace surgical staging. However, it still might be useful in order to detect metastases in patients for whom surgical staging inappropriate and helpful to plan the management especially for the selecting radiation fields.
P163 Comparison of Cu-62-ATSM and C-11-Methionine in cancer of the Cervix treated by radiation therapy M. Hasebe1, K. Yoshikawa1, S. Ohashi1, S. Toubaru1, H. Ishikawa2, K. Sagou2, K. Tamura1, H. Kiyohara1, S. Kato1, K. Susumu1, T. Fukumura3, T. Saga3, K. Kawaguchi2, Y. Hamada2, H. Tsujii1; 1Research Center Hospital for Charged Particle Therapy , National Institute of Radiological Sciences, Chiba-shi, JAPAN, 2First Dept. of oral & Maxillofacial surgery, Tsurumi University, Yokohama-shi, JAPAN, 3Molecular Imaging Center, National Institute of Radiological Sciences, Chiba-shi, JAPAN. Purpose To determine if Cu‐62 labeled diacetyl‐bis (N (4)‐methylthiosemicarbazone); (Cu‐62‐ ATSM) imaging of tumor hypoxia is associated with C‐11‐methionine imaging of amino acid
Poster Presentation
P18 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
S342 metabolism in cervical cancer. The carbon ion radiotherapy (CIRT) has been introduced in our institute, and we have treated cervical cancer using carbon ion beam or intracavitary treatment and whole pelvis irradiation.Cu‐62‐ATSM has been used clinically as a positron emission tomography (PET) tracer for the delineation of hypoxia. Tumor hypoxia is a critical factor in irradiation of malignant tumor. Method PET/CT was performed in eighteen patients with cervical cancer for evaluation of both tumor hypoxia using Cu‐62‐ATSM and amino acid metabolism using C‐11‐Methionine. Histologically confirmed ten squamous cell carcinoma, five adenocarcima, two Adenosquamous carcinoma and one Malignant melanoma were enrolled in this study. PET/CT studies were underwent before and after treatment. Tumor uptake of each tracer was analyzed semi‐quantitatively by Tumor‐to‐Normal‐Tissue‐Ratio (TNR). Result Pretherapeutic mean TNR was 8.7 in C‐11‐Methionine and 2.9 in Cu‐62‐ATSM, and thus image contrast between tumor and surrounding normal tissue was higher in C‐11‐Methionine PET/CT image than in Cu‐62‐ATSM PET/CT image. Pretherapeutic TNR of both Cu‐62‐ATSM and C‐11‐Methionine showed significant difference between squamous cell carcinoma and other tumor group (p=0.0165, p=0.0060, respectively). Posttherapeutic mean TNR was 2.9 in C‐11‐Methionine and 2.1 in Cu‐62‐ATSM. Posttherapeutic TNR of either Cu‐62‐ATSM and C‐11‐Methionine showed no significant difference between squamous cell carcinoma and other tumor group, respectively. TNR of squamous cell carcinoma in Cu‐62‐ATSM PET/CT after treatment was significantly lower than pre‐ therapeutic TNR (p<0.0001). It might imply that squamous cell carcinoma of uterine cervix tended to hypoxic in pre‐terapeutic condition and CIRT might improve its hypoxic condition. The improvement of hypoxic condition might be associated with therapeutic effect of CIRT. But there was no significant difference in TNR of other tumor group between pre‐ and post‐therapeutic TNR (p=0.061). Conclusion Cervical cancer had a greater tendency to incorporate C‐11‐ Methionine than Cu‐62‐ATSM before any treatment. The improvement of hypoxic condition in squamous cell carcinoma of uterine cervix might be associated with therapeutic effect of CIRT.
P164 Same day abdominal CT and PET-CT in the asssessment of regional lymph nodes in women with locally advanced cervical cancer before radiotherapy planning. P. Skrobowski1, M. Dziuk1, A. Gizewska1, J. Jonska2, K. Bujko2; 1Military Institute of Health Services and Masovian PET-CT Centre, Warsaw, POLAND, 2Institute of Oncology, Warsaw, POLAND. In locally advanced cervical cancer the standard radiotherapy planning is based on abdominal contrast enhanced CT. Although PET‐CT provides potentially higher sensitivity in metastatic lymph nodes detection it is frequently omitted in order to shorten diagnostic work‐up before delivering the therapy.. The aim of the study was to assess the feasilibility of the simultaneous diagnostic CT and PET‐CT and comparison of both modalities in the assessment of nodal involvement in women with locally advanced cervical cancer planned for radiotherapy. Methods: Both studies were performed seqentially (low dose PET‐CT followed by the diagnostic abdominal CT) on the same day on the 16‐row PET‐CT scanner with the weight adjusted dose of FDG and the iv contrast media at the rate of 3.5ml/min. They were assessed independently by a nuclear medicine physician and radiologist. In ceCT we reported lymph nodes >/= 10 mm. In PET‐CT we reported all nodal changes with increased metabolism of FDG. Results: There was an excellent correlation between ceCT and PET‐CT (r=0.997, p<0,0001). No lymph nodes involvement was seen in 11 patients in both modalities. There was almost 4.9 percent difference in the number of the affected lymph nodes in ceCT and PET‐CT. The difference was caused by the metastatic lymph nodes smaller then 10 mm not reported in ceCT (in total 5 lymph nodes). There was also a trend towards higher number of internal and external iliac lymph nodes detected in PET‐CT. There were 3 patients in whom the results were discordant. In 2 patients PET‐CT identified nodal involvement above the diaphragm. In 2 patients we found metastases to other organs ‐ seen in both methods ‐ PET‐CT and ceCT in liver and ovary. In 1 patient there were metastases in skeleton missed in ceCT. The radiotherapy planning was based on information from both modalities. Diagnostic CT PET‐CT P Aortic 13 12 NS Iliac comm. 12 14 NS Iliac ext 30 33 NS Iliac int 27 27 NS Total 82 86 <0.05 Conclusion: The same‐day diagnostic ceCT and PET‐CT protocol in the assessment of nodal status in cervical cancer before radiotherapy planning is feasible and both modalities provide comparable results about the number of involved lymph nodes. PET‐CT may be more sensitive in detection of the metastatic disease and may indicate the need of alternative therapy.
P165 Supradiaphragmatic Spread in Ovarian Cancer Staging: Added Value of 18F-FDG-PET/CT Versus Conventional Diagnostic Work Up A. Musto, V. Ambrosini, C. Nanni, P. Castellucci, V. Allegri, F. Lodi, V. Pettinato, A. M. Maffione, E. Lopci, R. Franchi, S. Fanti; Azienda Ospedaliero Universitaria di Bologna, Policlinico S.Orsola-Malpighi, Bologna, ITALY. Aim: The aim of our study is to assess the usefulness of PET/CT in ovarian cancer staging, detecting unusual supradiaphragmatic spread which could be missed by conventional diagnostic work‐up. Materials and Methods: we reviewed our experience of PET/CT scan performed in 100 patients in staging for ovarian cancer, from 2003 to 2008. The patients were considered positive for supradiaphragmatic PET/CT malignant lesions when one or more supradiaphragmatic findings, with FDG uptake higher than liver or background, were observed. PET/CT findings were compared to thoracic CT carried out within 2 months before or after the PET/CT scan, or to a biopsy of PET lesions. Results: 30/100 women (30%) showed supradiaphragmatic spread at PET/CT. The histological types were: 10/30 poorly‐differentiated adenocarcinoma, 14/30 papillary‐serous, 1/30 borderline papillary‐serous, 2/30 endomethryoid, 2/30 endomethryoid and papillary‐serous, 1/30 signet‐ring cells. In 17/30 patients, a thoracic CT had been obtained before PET/CT. CT had revealed supradiaphragmatic findings only in 13/17. In 13/30 patients, thoracic CT and/or biopsy was performed after PET/CT, targeted on PET results. CT and/or biopsy confirmed the supradiaphragmatic PET positive findings in 6/13 women. In 2/13 patients, CT did not confirmed the PET/CT findings, but the suggestion of a thoracic check lead to find millimetric lung localizations. CT or biopsy were negative in 5/13 patients. Discussion and conclusions: PET/CT demonstrated to have more sensitivity than CT alone on mediastinal lymph nodes and in particular on mammary internal chain, that were negative on CT. On the other hand, some
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 millimetric CT‐positive lung nodularities were missed by PET, because of the resolving power of the technique (5‐6 mm). Moreover, biopsy revealed one PET/CT false positive, showing a chronic inflammatory disease in lymph nodes with high FDG uptake. However, PET/CT contributed to correctly stage 25/100 (25%) patients (17 with previous CT and 8 without previous CT), in which conventional approach would have shown only 13/100 (13%) cases with supradiaphragmatic spread. Despite some limitations, our results suggest that PET/CT could provide an important contribution to ovarian cancer staging.
P166 The Role of PET CT in the Management of Cervical Cancer B. E. Drake1, A. Leonard1, A. McKay Ferguson2, G. Vivian1, T. Sulkin2, S. Higgins3; 1Peninsula Radiology Academy, Plymouth, UNITED KINGDOM, 2 Royal Cornwall Hospital, Truro, UNITED KINGDOM, 3Torbay NHS Foundation Hospital, Torbay, UNITED KINGDOM. Introduction PETCT is well established in oncological practice in the United Kingdom (UK). Cervical cancer was not included in the initial evidence based approved indications for the national PETCT service commissioned by the Department of Health in England and Wales in April 2008. In light of recent evidence practice is changing. The authors present a review of the important emerging role of PETCT in the management of patients with cervical cancer. Subject / Methods Data is presented from the South West of England Peninsula group of hospitals covering a population in excess of 1.5 million. Each of the hospitals has access to mobile dedicated oncological PETCT. FIGO stage 1B cervical cancers and above are described. Imaging Findings: A pictorial review is presented with correlative MRI, CT and histology illustrating the use of PETCT in the initial staging, follow up and re‐staging of recurrent disease in cervical cancer. The added value of PETCT in mapping nodal spread is demonstrated. PETCT can influence management decisions resulting in appropriate selection of patients for surgery and accurate radiotherapy planning. The prognostic significance of PETCT and its use in treatment response and disease relapse are discussed. Finally potential pitfalls in image interpretation are presented along with a summary of the current literature. Conclusion: This review demonstrates the evolving role of PETCT in cervical cancer. By sharing our experience of PETCT and the evidence base behind our practice it is hoped that other centres will embrace this important application of PETCT.
P167 Is FDG-PET/CT useful for malignant ovarian cystic tumor difficult to diagnose with morphological imaging? H. Akagi1, T. Komori2, M. Kino2, K. Matsumura3; 1Osaka Medical College, Takatsuki, JAPAN, 2Hokusetsu general hospital, Takatsuki, JAPAN, 3 Higashitemma clinic, Osaka, JAPAN. Objective: It has been reported that no FDG accumulation is seen in benign ovarian cystic tumor. However, there have been few studies on usefulness of FDG‐PET for diagnosis of malignant ovarian cystic tumor when the tumor does not show lymph node metastases, intraabdominal dissemination, or a tendency toward invasion to surrounding tissue on CT or MRI. We studied whether FDG‐PET/CT would be useful or not for diagnosis of malignant ovarian cystic tumor difficult to diagnose with morphological imaging. Subjects: The study involved 16 patients with malignant ovarian cystic tumors, the diagnoses of which had been pathologically confirmed (11 patients with ovarian cancer, 3 patients with borderline ovarian cancer, and 2 patients with germinomas). Methods: FDG was administered after the patients fasted for 5 hours, and images were taken 1 hour later (from crown to femor) by a PET/CT (GE Discovery ST). The mean dosage was 205.0 +/‐ 33.5 MBq. SUVs max of the malignant ovarian cystic tumors were used for semiquantitative assessment, and presence or absence of intracystic FDG accumulation was examined for visual assessment. Results: Intracystic FDG accumulation was seen in 10 of the 16 patients (62.5%), and the mean SUV max of the malignant ovarian cystic tumors was 5.10 +/‐4.45. In 13 of the 16 patients (81.3%), the SUVs max were 2 or higher. In all the 3 patients with SUVs max of less than 2, FDG accumulation was seen. This shows that combination of semiquantitative procedures and visual procedures was able to achieve diagnoses of malignancy in all the 16 patients. Conclusion: Our study suggests that combination of assessment of presence or absence of intracystic FDG accumulation and evaluation of SUV max is useful for diagnosis of malignant ovarian cystic tumor without lymph node metastases, intraabdominal dissemination, or a tendency toward invasion to surrounding tissue on morphological imaging.
P168 Uterine Cervical Cancer Locally Advanced, It’s possible the evaluation of lymph nodes through the 18F-FDG PET? M. Ortega1, A. Ruíz2, P. Fuste3, C. Trampal1, J. Pahisa3, X. Perich1; 1CRCMAR, Barcelona, SPAIN, 2IAT, Barcelona, SPAIN, 3Hospital Clinic, Barcelona, SPAIN. Objectives: The staging of uterine cervical cancer (UCC) is primarily clinical, based on the findings of the exploration, complemented by other diagnostic tests. The clinical staging provides information on the extent of locoregional tumour. Although the clinical staging is well correlated with the prognosis of the disease, it is known that the regional lymph node involvement is a prognostic variable of the first magnitude. Overall we found positives lymph nodes involvement from 20 to 40% of cases. Precise knowledge about lymph node involvement and its extent determines not only the prognosis of the disease furthermore the therapeutic planning. The experience of the use of 18F‐FDG‐PET scan in UCC is still limited. The aim: 1.‐ To evaluate the efficacy of PET with [18F]‐FDG in the staging of uterine cervical cancer, especially in cases with locally advanced disease. 2.‐ Compare the results obtained with PET‐FDG scan with those provided by magnetic resonance (MR) and laparoscopic retroperitoneal lymphadenectomy lumboaortic (Gold Standard). Material and method: We have studied 40 women (mean age: 52 years old) with UCC with clinical stages (FIGO) of Ib2 to IVa. All the patients were made, subject to acceptance of informed consent, an abdominopelvic MR and a PET study with [18F]‐FDG, followed by a lymphadenectomy lumboaortic retroperitoneal laparoscopic to obtain the anatomopathology stage at this level. We intend to study the effectiveness of PET with [18F]‐FDG in the identification of lymph nodes disease comparing it with MR and lymphadenectomy studies.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 We have studied the false positive and the false negative, referred in the pathological findings ("gold standard") of the lymphadenectomy. Results: FDG‐PET has been able to identify lymph node metastases in 14/40 (35%) patients, lymphadenectomy (gold standard) showed positivity in 10/36 patients. The PET scan identified 4/40 patients (10%) with metastatic disease localized in liver, bone and lung. The sensitivity, specificity and NPV of PET were 72%, 96% and 88.8% respectively and the RM were 72%, 91% and 80%. Both PET and MR showed a false positive. Conclusion: PET using FDG has proven its utility and diagnostic value in assessing the lymph node in locally advanced UCC. Its high NPV could have been avoided lymphadenectomy in a high percentage of patients, taking into account lymphadenectomy retroperitoneal that is not without morbidity. The used of PET‐FDG complemented a RM for localized metastatic disease in a different localization. This project has been financied by “Instituto Carlos III” (beca FIS PI05/1952)
P19 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: prostate and testicular cancer
P169
Aim: To assess the ability of 18F‐FDG‐PET to detect residual or recurrent disease in patients with extragonadal germ cell tumor, in comparison with CT and serum tumor markers (TM). Materials & Methods: We retrospectively reviewed 13 FDG‐PET scans in 9 patients (M:F=8:1, age 14 ‐ 49 yrs) with pathologically proven extragonadal germ cell tumors (1 seminoma, 7 nonseminomas, and 1 not classified). Original tumor sites included mediastinum (n=5), retroperitonium (n=3), and unknown (n=1). The indication of PET scan was response assessment after chemotherapy in 4 cases, or relapse surveillance in 9 cases. Corresponding CT scans (n=12) and change of tumor markers (n=11), including AFP and HCG, were also evaluated. All results were validated by histology (n=4) or at least 6‐month clinical follow‐up (n=9). Results: Residual or recurrent diseases were finally confirmed in 7 of 13 cases. Overall sensitivity, specificity and accuracy are shown in table below. The specificity and accuracy were highest in PET, while the sensitivity was highest in CT. Among the 4 cases for response assessment after chemotherapy, all cases were accurately diagnosed in PET, while two were missed in CT (1 FP and 1 FN). For relapse surveillance, PET and CT accurately diagnosed in 6 of 9 cases and in 6 of 8 cases, respectively. PET findings affected therapeutic management in 2 cases. Conclusion: Our preliminary data indicates that FDG‐PET had reasonably higher diagnostic accuracy, compared to CT and tumor markers, and that it can have clinical impact in patients who are suspected of having residual or recurrent extragonadal germ cell tumor. Overall sensitivity, specificity, and accuracy.
Rating of 18F-Fluorocholine PET/CT in prostate cancer patients in apparent complete remission after curative radiotherapy
Sensitivity Specificity Accuracy
PET (n=13)
71%
83%
77%
CT (n=12)
83%
50%
67%
F. Buchegger1, H. Vees2, M. P. Wissmeyer1, C. Steiner1, O. Ratib1, R. Miralbell2; 1Service of Nuclear Medicine, Geneva, SWITZERLAND, 2Service of Radio-Oncology, Geneva, SWITZERLAND.
Tumor marker (n=11) 43%
75%
55%
Objective: The interpretation of 18F‐Fluorocholine (18F‐FCH) PET/CT in recurrent prostate cancer patients after curative radiotherapy (RT) is challenging. The differentiation between radiation induced fibrosis, prostate tissue remodelling and small local recurrences may be difficult as has been shown for MRI. We investigated 18F‐FCH three‐phase PET in the situation of patients after curative RT without evidence of relapse at low PSA. Methods: Ten patients in complete remission (PSA<0.35 ng/ml) >5 years after curative RT of prostate cancer who have a minor probability of recurrence in the future underwent dynamic prostate bed PET followed by whole body PET (3‐4 min/bed) and delayed prostate bed PET (5 min) after injection of 300 MBq 18F‐FCH. Frames of 3 minutes each were generated from dynamic PET and qualitatively analyzed together with whole body and delayed PET by consensus of two experienced readers. Maximal standardized uptake values (SUV) were calculated for equivocal or suspicious lesions. The imaging sequence was rated as previously shown in recurrent prostate cancer. Results: Suspicious and equivocal (low probability) lesions of prostate and seminal vesicles were found in 6 to 7 of 10 patients when analyzed as individual frames of dynamic and whole body PET scanning (0 to 14 minutes after injection). Delayed scanning at 45 minutes showed only 2 equivocal lesions. When analyzed over the 3 phases in a grouped analylsis, only 1 patient remained with an equivocal observation. Conclusion: Single frames of prostate 18F‐FCH PET in patients in complete remission after RT provided a high number of equivocal and/or suspicious lesions of the prostate and seminal vesicles. Delayed imaging was more reliable. Three‐phase analysis significantly decreased the number of equivocal PET (1 equivocal/10). These data indicate the potential limitations of early imaging alone in 18F‐FCH PET after curative RT.
Parametric Fusion Imaging Using 11C-Choline PET/CT And Diffusion-Weighted MRI for the Identification of High-Risk Primary Prostate Cancer
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The role of FDG PET/CT in the evaluation of post chemotherapy residual masses in patients with seminoma P. Rondogianni1, E. Panagiotidis1, E. Skoura1, D. Exarchos2, C. Giannopoulou1, P. Chroni1, I. Datseris1; 1Nuclear medicine Department “Evangelismos”General Hospital, Athens, GREECE, 2Radiology Department “Evangelismos”General Hospital, Athens, GREECE. AIM: To estimate the role of 18FDG PET/CT in the detection of viable tumor in patients with seminoma and post chemotherapy residual masses. PATIENTS‐METHOD: This is a retrospective study involving 36 patients with seminoma aged 17‐54 (mean age: 30.4 years) who have been referred to our hospital from February 2007 to December 2008.All of them had undergone orchectomy completed by first line chemotherapy with cisplatin, etoposide and bleomycin. They had residual masses of at least 1cm diameter on CT or MRI but normal serum tumor markers. 18 FDG PET/CT was done at least 30 days after the end of chemotherapy. All scans were reviewed by two expert physicians (one nuclear medicine physician and one radiologist) and confirmed by follow up, histology or second PET/CT findings. RESULTS: 22/36 (61%) patients had negative post treatment PET/CT excluding viable tumor. 12 among them are disease free after an observation period of 6‐20 months (median: 18 m).2 patients relapsed within a period of 20 months. For the remaining 6 patients the results of PET/CT are not yet confirmed as they are still under observation. 6/36 (16.6%) had abnormal 18FDG uptake in the residual mass.4 had a mass of a diameter>3 and 2< 3cm.In 3 of these patients the mass was dissected surgically and histology confirmed the presence of viable tumor. The fourth patient relapsed within an 8 months’ period. The fifth patient had a second scan indicating relapse while for the sixth patient data are not yet available. In 8/36 (32.4%) patients PET/CT did not show any residual 18FDG uptake in the mass but revealed metastases in distant lymph nodes or organs not evident from other imaging modalities. CONCLUSIONS: 18FDG PET/CT seems to be a useful method for the discrimination between patients with seminoma having viable tumor in a residual mass after chemotherapy from those with masses containing only fibrosis as further treatment is needed for the first group but simple surveillance is enough for the second one. Further investigation with prospective studies is, however, needed to confirm these results and to evaluate their impact on clinical decision making.
P171 Clinical value of germ cell tumor
18
F-FDG-PET in patients with extragonadal
K. Kawai, Y. Nakamoto, T. Suga, K. Nakatani, K. Ishizu, K. Togashi; Kyoto University Graduate School of Medicine, Kyoto, JAPAN.
M. R. Piert, H. Park, A. Khan, H. Hussain, C. Meyer, R. Shah, D. Wood; University of Michigan, Ann Arbor, MI, UNITED STATES. Objectives: Based on multi‐center trials, survival benefits after surgery for primary prostate cancer (pPC) seem to be restricted to patients with Gleason >=7. We assessed whether parametric fusion imaging based on 11C‐choline (CHOL) PET/CT and diffusion‐weighted (DW) MRI identifies such disease. Methods: CHOL PET/CT and DW‐MR imaging were performed in 16 patients with untreated pPC (pT2b‐pT3b) followed by prostatectomy. Accurate registration of in‐ vivo imaging with histology was achieved performing ex‐vivo MRI of the prostatectomy specimen and whole mount sectioning with block face photography as intermediate steps. Image registration was done using a non‐linear (mutual information) kernel with established low registration errors in the range of 2‐4 mm for registering human prostate glands. Data analysis was therefore possible from registered 3‐dimensional volumes derived from a) whole‐mount HE histology, b) immunohistochemistry for the cell proliferation marker Ki67, c) high‐resolution ex‐ vivo MRI of the prostatectomy specimen (to facilitate the co‐registration of in‐vivo and ex‐vivo data), d) 11C‐choline PET/CT, e) diffusion‐weighted MR, and f) T2 weighted 3T transpelvic coil MR imaging as reference space. Volumes of interest were defined in histologically proven tumor and normal tissues and transferred to registered CHOL and DW‐MR volumes calculating tumor‐to‐ normal prostate (T/N) ratios as well as creating parametric image volumes using a quotient of CHOL over DW‐MR maps. Imaging results were compared with local Gleason score pattern and the Ki67 labeling index. Pathological risk classification of pPC was as follows: Low risk: Gleason<=3+3 + Ki67=5; high risk: Gleason>=4+3 or Gleason=3+4 + Ki67>=5%. Receiver operating characteristics (ROC) curves were generated using the tumor volume as weighting factor. Results: 46 tumors were identified by histology (range 0.01‐12.6 ml). The CHOL and DW T/N ratios were significantly elevated in high risk disease (CHOL ROC 0.86; DW ROC 0.81; p<0.001), while separating low and intermediate risk groups was not possible. Both, CHOL and DW T/N ratios correlated with the Ki67 (p<0.05). Parametric fusion imaging (CHOL/DW) further improved discrimination between low/intermediate and high risk disease (ROC 0.93). Conclusions: The data obtained from this small group of patients suggest that CHOL PET/CT and DW‐MRI may identify aggressive pPC. CHOL PET/CT and DW‐MRI therefore offer the potential to non‐invasively identify patients who would benefit from curative treatments. Parametric fusion imaging further improved risk prediction (based on pathological markers) indicating that future hybrid PET/MR imaging of prostate cancer might be useful.
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The role of Positron Emission Tomography with F-FDG in the evaluation of residual masses for seminoma F. Netter, S. Grandpierre, B. Menerous, P. Olivier, G. Karcher; CHU Brabois, Nancy, FRANCE. PURPOSE: To analyse the accuracy of 18F‐FDG Positron Emission Tomography (FDG‐PET) in the treatment of residual mass of seminoma. MATERIAL AND METHODS: In a retrospective study, we studied sixteen patients with seminoma, in which 21 FDG‐PET were performed, from 2003 to 2007, for suspected residual disease. PET results were compared either with histopathological findings, when available, or with clinical evolution. RESULTS: Seven FDG‐PET examinations were followed by a biopsy. Among patients without surgical exploration, 5 relapse and 9 did not. Overall, seven patients had viable tumor after chemotherapy, accounting for 33 % of all the patients. Out of 21 PET examinations, 2 were false positive, both on lesions > 3cm. PET was false negative in two lesions >3 cm and in 1 lesion < 3 cm. Sixteen examinations correctly predicted the status of the residual mass (negative 12 and positive 4). In detecting residual disease the sensitivity, specificity, predictive positive value and predictive negative value were 57%, 86%,67 % and 80 % respectively, for PET and 50%, 50% , 36 % and 70% respectively, for TDM (< or > or =3 cm).CONCLUSION: The results of the FDG‐PET in this indication are less encouraging than those of literature, however better than TDM results, particularly in term of specificity. Studies with more important enrollments would be necessary to confirm the performances of this imaging modality
Poster Presentation
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P174 18-F-Fluoromethylcholine (18-F-FCH) positron emission tomography/computed tomography (PET/CT) in recurrent prostate cancer S. P. Gambarrota1, E. Perrone1, V. Frusciante1, A. Iannelli2, C. Latiano3, P. Tabacco1, G. Valle1; 1Nuclear Medicine, Research Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo, ITALY, 2Health Physics, Research Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo, ITALY, 3 Urology, Research Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo, ITALY. Background & Aim: Prostatic Specific Antigen (PSA) is the main laboratory marker to monitor prostate cancer activity. In case of an abnormal PSA values, conventional imaging is not always sensitive enough in order to localize recurrences. 18‐F‐Fluorodeoxyglucose (18‐F‐FDG) has only limited usefulness in prostate cancer. We evaluate the role of PET/CT with 18‐F‐FCH in the detection of recurrences in prostate cancer. Patients & Methods: 75 consecutive patients treated for prostate cancer with PSA level > 0.1 ng/ml or a Gleason’s score (GS) ≥ 6 were investigated by 18‐F‐FCH PET/CT. First line therapy was radical prostatectomy in 33 cases, hormonal therapy alone in 17, partial prostatectomy and/or external radiotherapy in 25. In 19 pts hormonal therapy followed prostatectomy or external radiotherapy. After i.v. injection of 3.7 MBq/kg of 18‐F‐FCH, early (3‐5 mins after injection) and late (50‐60 mins after injection) PET/CT scans were acquired in 3D mode. Early PET/CT scan was carried on the pelvis and consisted of 2 bed positions each lasting 5 mins; late scan consisted of 7 bed positions, 2.5 min. each. Standard Uptake Value (SUV) max was determined on areas with visually increased uptake. PET scan was interpreted positive in consensus by two independent. operators. Results & Conclusions: We found a pathological increased uptake of 18‐F‐FCH in 53/75 patients; 40 patients showed increased uptake in prostatic bed, 23 pts showed increased uptake in one or more skeletal sites and 10 ppatients had positive foci in 1 or more lymph‐nodes. 18‐F‐FCH PET/CT scan resulted positive in 100% in patients with PSA > 4 ng/ml, 55% in the PSA range between 0.1 and 4 ng/ml. The percentage of positive scans was 39% in patients with a Gleason Score (GS) ≤ 7 whereas it was 83% in patients with a GS > 7. Delayed uptake was significantly higher than early uptake both in prostatic area and in skeletal sites. Patients on androgen deprivation therapy showed, as a trend, a lower positivity rate (68% vs 73%) and mean lower SUV max in prostatic bed and in lymph‐nodal and bone metastases compared with the corresponding values recorded in patients without antiandrogen medication. However, due to the limited number of patients no definitive conclusions could be atteined. Detection rate of recurrences with 18F‐FCH PET/CT resulted quite satisfactory also in patients with PSA levels below 4 ng/ml. We conclude that 18‐F‐FCH PET/CT allows early local and distant recurrences detection with obvious clinical advantages.
P175 Detection of local prostate carcinoma with 11C- acetate and PET-CT J. Kemppainen1, R. Borra1, J. Heikkinen2, V. Lepomäki1, R. Parkkola2, H. Minn1; 1Turku University Hospital and Turku PET Centre, Turku, FINLAND, 2 Medical Imaging Centre of Southwest Finland, Turku, FINLAND. Background and aims FDG is not reliable tracer for prostate cancer imaging. Therefore other possible tracer candidates are being investigated. Fatty‐acid synthesis is increased in prostate cancer itself and therefore high concentration of ¹¹C ‐acetate is observed in local and metastatic lesions. The aim of the present study was to assess the applicability of ¹¹C ‐acetate and PET‐CT in localizing prostate carcinoma. PET findings were validated against MRI and 3D proton magnetic resonance spectroscopy (1H MRS) findings. Methods 12 patients (age 62 years) with prostate cancer were investigated with PET‐CT and ¹¹C‐acetate. The average Gleason score was 6.3. After PET imaging the prostate carcinoma was localized with MRI (Siemens Avanto 1.5T) and 1H MRS using a surface coil. 1H MRS metabolic maps covering the entire prostate volume were calculated using the choline‐to‐citrate ratio. Results Local lesions in prostate lobes were detectable with ¹¹C ‐ acetate PET‐CT. These lesions matched well with localization based on 1H MRS and prostatectomy results. The average maximal standardized uptake value (SUV) in tumor affected regions was 5.8 ± 1.0 and 3.7 ± 0.6 in unaffected regions, p<0.0001. Conclusions ¹¹C‐acetate is promising tracer for detection of local prostate cancer. Validation with 1H MRS spectroscopy confirms that highest tracer activity is seen in tumor lesions. Further investigation is needed to assess the role of ¹¹C‐acetate and PET in detection of primary prostate cancer, staging and re‐ staging of the disease.
P20 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: renal cell and bladder cancer
P176
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Role of F-FDG PET/CT in the management of urologic cancer R. Jover-Diaz, C. G. Gordaliza, L. Gorospe, D. Lourido, J. Alfonso; Instituto Tecnologico PET, Madrid, SPAIN. AIM: To assess the value of PET/CT in post‐treatment evaluation in urologic tumours. MATERIALS AND METHODS: This retrospective study included 41 patients (31 men, mean age: 65 ± 8.2 years old). The neoplasms were 18 kydney, 17 bladder, 5 urinary tract and 1 adrenal. The reasons to perform PET/CT were: presence of metastases (22 patients), malignancy relapse (12 patients), follow‐up (6 patients) and high serum tumoral marker (1 patient). Features consistent with malignancy in conventional imaging (CT/MRI) were detected in 23 patients (56%). PET/CT was performed in an hybrid camera using using low doses CT (80 mA, 140 Kv) and a PET 2D‐mode (4 minutes/bed, iterative reconstruction). Images were acquired 60 minutes post‐iv of 18FDG (0.15 mCi/Kg). All studies were assesed by a nuclear medicine with experience in PET/CT and a radiologist physician. RESULTS: PET/CT was abnormal in 38 patients (92%).
Abnormal PET (34 patients)
• Neoplasic suggestive features (32): ‐ Metastatic disease: 19 ‐ Relapse: 6 ‐ Second tumor: 3 (Lung and rectal cancer) ‐ Non‐specific disease: 4 (1 metastases vs bone infarction, 3 uncertain relapsed) • Non‐neoplasic disease (2): 1 Paget, 1 post‐radiotherapy changes
‐ In 4 patients CT suggested malignancy but PET was normal. ‐ All PET findings showed anatomic correlation in CT. Abnormal TC ‐ CT re‐staged neoplasic disease in 9 patients for features not detected by PET (38 patients) (lung micronodules) . CONCLUSIONS: In our study PET/CT was abnormal in 92% of patients. Malignancy was suggested in 84% of cases. In 13 patients, PET/CT allowed re‐stage of tumor. PET/CT can improve diagnosis in patients with urologic cancer.
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Diagnostic Oncology - PET, PET/CT: muscle, bone and connective tissue tumours
P177 Does additional Whole-body F-18 sodium fluoride PET change the clinical radiotherapy treatment of bone metastasis? S. Fujita1, S. Nagamachi2, H. Wakamatsu2, S. Ueno1, Y. Umemura1, R. Nishii2, S. Tamura2, T. Fujimoto1; 1Fujimoto Hayasuzu Hospital, Miyazaki, JAPAN, 2University of Miyazaki Hospital, Miyazaki, JAPAN. Purpose: As bone metastases might be present in various cancer despite a normal bone scan, positron emission tomography (PET) using F‐18 sodium fluoride (NaF) was more sensitive than bone scintigraphy using Tc‐99m MDP. It is useful for a change of radiotherapy treatment of bone metastasis to find metastases early depending on new therapy using Strontium‐89. The purpose of this study was to measure the accuracy, clinical value of radiotherapy treatment using Whole‐ body NaF PET against bone scintigraphy using Tc‐99m MDP. Methods and Materials: Thirty‐five patients (19 prostate cancer, 12 breast cancer, 4 lung cancer) were underwent the NaF PET and Bone scintigraphy using Tc‐99m MDP. PET images were obtained 1hour after injection of 555 MBq of NaF, and Bone scintigraphy images were obtained 3hours after injection of 740 MBq of Tc‐99m MDP. After all patients scanned whole body images, we measured the rate of clinical radiotherapy changes (change or no change). Results: Both images found 24 patients of bone metastases, and 21 patients were performed radiotherapy treatment of Linear Accelerator. But 3 patients change the clinical radiotherapy treatment using Strontium‐89 after many bone metastases finding by NaF PET (clinical changing rate 12.5%). Conclusions: Whole‐body NaF PET is an excellent skeletal imaging and higher accuracy than bone scintigraphy using Tc‐99m MDP. It changes a therapy of the patient by NaF PET, and it is useful to add Whole‐body NaF PET examination in the clinical radiotherapy treatment.
P178 Incidence and findings of intramuscular metastasis on FDG PET/CT
18
F-
I. Yoo, W. Choi, Y. Park, S. Kim, S. Chung; The Catholic University of Korea, Seoul, REPUBLIC OF KOREA. OBJECTIVE: To evaluate intramuscular metastases found on 18F‐FDG PET/CT images of cancer patients. MATERIALS AND METHOD: We retrospectively reviewed cases suspicious for intramuscular metastases on PET/CT images from November 2003 to November 2008. Cases with direct invasion of tumor, seeding metastases to muscle surface, lymphoma, and melanoma cases were excluded. Cases were further studied in correlation to enhanced CT or MRI. From the PET/CT images, maximum standardized uptake value (SUVmax) and location of intramuscular metastasis were recorded. RESULTS: 54 out of 9176 cancer patients (0.59%) were suspicious for intramuscular metastasis on PET/CT. CT or MRI was available in 37 cases, and all 37 showed positive findings. Muscle metastasis was diagnosed at the time of initial staging in 19 of 37 patients, found during follow‐up for known cancer in 18 patients. The primary tumor sites were diverse: 5 cases originating from the lungs, 5 colon, 5 cervix, 3 kidneys, 3 ureter/bladder, and 16 other sites. The SUVmax of the muscle metastases ranged from 1.0 to 25.2 (mean: 6.1±4.6). Metastases most commonly involved the buttock, paraspinal, iliopsoas, chest/abdominal wall, thigh and shoulder muscles. In 3 patients, PET/CT found metastatic foci in left ventricle myocardium. 17 out of 37 patients had solitary muscle lesion. All but one case had additional metastatic lesions outside of the skeletal muscles. CONCLUSION: Intramuscular metastases originated from diverse primary tumor. The SUVmax varied greatly. The most commonly involved sites were the buttock and paraspinal muscles.
P179 Role of F-18 FDG PET/CT in Chondrosarcoma (CHS) M. Mikhaeil1, H. M. Abdel-Dayem1, R. Libes2, H. Lin1, G. Rosen2; 1St. Vincent's Medical Centers of New York, New York, NY, UNITED STATES, 2 St. Vincent's Comprehensive Cancer Center, New York, NY, UNITED STATES. Introduction: CHS is an uncommon osseous tumor that has different pathological types, treated by resection followed by high dose radioth and/or chemoth. Local recurrence is a problem to detect early by CT or MR. CHS usually metastases to lungs, liver, other bones and unusual sites. No functional imaging agent in successful with CHS so far. Aim of the Study: Present our experience with 8 pts of CHS who had 28 PET/CT studies, 5 M and 3 F, age 30‐85 yrs. Methods: All pts had resection of primary tumor when possible for pulmonary mets followed by chemoth. or radioth. Results: Are in the following table. All lesions were concordant between PET and CT. FDG
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Pituitary Gland
6.20
2.33 to 16.1
Pt. Site of # Primary
Parotid Gland/ Submandibular 29 2.36
0.51 to 6.65 2.67
0.67 to 7.38
Thyroid
29 1.95
0.64 to 4.1
2.42
0.75 to 5.29
Lymph Nodes
26 0.51
0.04 to 1.75 0.66
0.06 to 2.31
Breast
18 0.62
0.06 to 1.23 0.76
0.09 to 1.71
Bone marrow
30 1.02
0.4 to 2.14
1.22
0.49 to 2.35
Liver
30 5.96
1.14 to 14.78 6.39
1.51 to 15.13
Spleen
29 20.69
7.82 to 47.43 22.51
9.1 to 48.77
Pancreas
28 3.02
0.71 to 13.73 3.5
0.79 to 16.12
Stomach
29 5.57
2.7 to 11.09 6.28
3.05 to 12.23
Small Bowel
30 2.84
0.76 to 2.13 3.56
0.94 to 10.28
Large Bowel
30 2.11
0.59 to 5.99 2.6
0.67 to 7.11
Adrenals
27 6.48
1.72 to 12.5 8.37
2.12 to 14.35
Kidneys
29 10.15
2.35 to 28.33 11.25
2.59 to 31.27
Prostate
12 2.69
2.04 to 4.1
2.2 to 4.3
1
Lt. Hip
2
Lt. Iliac Bone
3
Rt. Frontal Mets Lt. Femur & Bone Lumber Spine
# PET/CT Studies
Multiple Pulm. Mets 1 Rec. Rt. Acctabulum 1
11 3
SUV max Range
Findings Pulm. Mets
21.6‐3.7
Multiple Pelvic Lesions (all active) 3.5‐6.0 Multiple Pulm. Mets Retroperitoneal, Rt. femora head 1.6‐5.5 & shaft Pelvic Rec. & Rt. Pelvic Bone (all active)
4
Rt. Femur Pulm. Mets
5
Rt. Distal Femur
Follow Up
1
Post‐Op uptake; No Rec; No mets
6
Lt. Foot
Follow‐up
6
Post Op uptake decreasing with time. Thymic hyperplasia
Disease progression in Lung
1.4‐7.3
7
Cervical Spine,
Mets to Lungs, Chest wall & T‐11
8
Pulm Mets & fifth Lt. Femur, rib
4 1
All active
2.7‐4.9
2.6
Conclusion: F‐18 FDG PET/CT studies has adds more information to CT or MR in CHS for: 1. Differentiating post‐op changes from local recurrence; 2. Identify unusual sites of mets; 3. Monitoring chemotherapy response
2.2 to 9.1
2.81
Conclusion: Evaluation of a lesion with low or atypical uptake of 68Ga DOTATATE can be challenging, especially if these occur near organs demonstrating high physiological uptake like the thyroid, adrenals, spleen and kidneys. Therefore, knowledge of normal uptake patterns and a reference range of SUVs for physiological uptake of 68Ga DOTATATE provided in this study would be useful in such cases.
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How can 18F-FDG PET/CT modify clinical management of differentiated thyroid cancer (DTC)
Diagnostic Oncology - PET, PET/CT: endocrine and neuroendocrine tumours
P180 18F-DOPA vs. 18F-FDG PET/CT in aggressive metastatic thyroid carcinoma: Preliminary results of a prospective study M. Marzola1, M. Ferdeghini2, G. Opocher3, G. Grassetto1, M. Ambrosetti2, L. Rampin1, E. Banti1, D. Rubello1; 1Nuclear Medicine Service - PET Centre Hospital Rovigo, Rovigo, ITALY, 2Morphologic-Biomedical Department Verona University, Verona, ITALY, 3IOV-IRCCS – Padova, Padova, ITALY. Aim: To compare the diagnostic accuracy of 18F‐DOPA vs. 18F‐FDG in aggressive metastatic medullary thyroid carcinoma (MTC). Methods: In the period from Dec. 2008 to Feb. 2009, five pts with aggressive metastatic MTC and very high serum calcitonin levels (1200 to 67,000 pg/ml) were evaluated by conventional imaging (neck‐abdomen US, chest‐abdomen c.e. CT) and by 18F‐ DOPA PET/CT and 18F‐FDG PET/CT. All pts were previously operated by total thyroidectomy and loco‐regional lymphoadenectomy (pT4N+ at histological examination, sporadic MTC in all cases). PET/CT was performed by a hybrid system (GE, Discovery STE), in fasting condition, and serum glucose levels were measured before low dose (2.2 MBq/Kg b.w.) 18F‐DOPA and 18F‐FDG administration. WB acquisition started 1 hr after radio‐tracers injection using the 3D method. OSEM algorithm was used for reconstruction. SUVmax values were calculated. All imaging modalities were performed within a 4‐week period. Cytological and/or histological findings were taken as the gold standard. Results: A total of 72 metastatic lesions were detected in five pts: 24 neck lymph nodes, 29 mediastinum lymph nodes, 10 liver metastatic deposits, 5 lung deposits, 4 bone deposits. Lesion size ranged from 7 mm to 4 cm, median 2.3 cm.18F‐DOPA PET/CT revealed 72 lesions, 18F‐FDG PET/CT 59 lesions, c.e. CT 32 lesions, neck US 27 lesions. There was a good agreement between 18F‐DOPA and 18F‐FDG PET/CT results: in particular, all lesions detected at 18F‐FDG were positive at 18F‐DOPA also. However, it is worth noting that SUVmax calculated at 18F‐FDG PET/CT was higher than 18F‐DOPA PET/CT (median 10.7, range 2.7 ‐ 15.8, vs. median 5.2, range 1.8 ‐ 7.9, respectively). Lastly, all lesions detected by c.e. CT and/or US were visualized also at 18F‐DOPA PET/CT. Conclusion: In our preliminary experience, 18F‐DOPA PET/CT seems to be the most sensitive imaging method to detect metastatic deposits from aggressive metastatic MTC. The relatively higher SUVmax calculated at 18F‐FDG than at 18F‐DOPA may be related to the fact that FDG is a good marker of cancer aggressiveness.
P181 Normal Distribution Pattern of 68Gallium DOTATATE in disease free subjects. M. Shastry1, I. Kayani1, D. Wild1, M. Caplin2, S. Gacinovic1, J. Bomanji1; University College Hospital, London, UK, 2Royal Free Hospital, London, UK.
1
Introduction: DOTA‐DPhe, 1Tyr3‐octreotate (DOTATATE) is a somatostatin analogue which has very high affinity for somatostatin receptor type 2 (SSTR‐2). Positron Emission Tomography (PET)/Computed Tomography(CT) scans using 68Gallium labeled DOTATATE has been used for imaging neuroendocrine tumours. In normal subjects, SSTR‐2 are widely distributed throughout the body in varying densities. It is important to have knowledge of the physiological distribution of tracer, in order to interpret the scans. Aim: Using PET/CT to outline the normal distribution pattern of 68Ga ‐DOTATATE in disease free subjects and provide standardized uptake values (SUV) in various organs. Materials and Methods: Analysis of 30(18M; 12F) patients with normal 68Ga‐ DOTATATE PET/CT scans, was performed. Patients were injected with an average of 145MBq of tracer and imaging was performed 1hr post‐injection, using GE Discovery ST PET/CT scanner (GE Healthcare, Milwaukee, Waukesha, USA). SUVs were measured for various organs in the body. Results: The average mean and maximum SUVs and range obtained for the different organs are displayed in the table. The SUV values ranged from 0.04 to 48.77 in the organs quantified. Organ
No
SUV Mean SUV Mean Average Range
SUV Max SUV Max Average Range
J. García Garzón1, M. Soler Peter1, J. González González2, M. Ysamat Marfà2, S. Fuertes Cabero1, M. Ortega Sánchez1, E. Riera Gil1, M. Buxeda Figuerola2, F. Lomeña Caballero1; 1CETIR Grup Mèdic, Esplugues de Llobregat, SPAIN, 2Centre de Tecnologia Diagnòstica, Terrassa, SPAIN. AIM: Patients with DTC are treated with throidectomy and radioiodine ablation. Many of them will present increased thyroglobulin (Tg) levels and negative whole body scintigraphy performed with diagnostic dose of 5‐10 mCi (dWBS) It could be recommended to performe a second whole body scintigraphy with a standar dose of 100 mCi (tWBS) to confirm the lack of feasibility to intake radioiodine. Our aim is to evaluate if 18F‐FDG PET/CT may modify this algoritm. MATERIALS AND METHODS: Twelve patients with clinical suspicious of DTC relapse due to maintained increased Tg levels have been retrospectively analyzed with PET/CT. All of them had previous thyroid dWBS. tWBS was performed after PET/CT with a diagnostic or therapeutic purpose. Two nuclear medicine physicians analyzed the PET/CT images independently. RESULTS: The patients were divided in two groups. In the first group, six patients presented positive dWBS, matching with the ultrasonographic (US) and CT findings (neck disease in four patients and neck and lung disease in two). In the second group, six patients had negative dWBS. US and CT suggested neck recurrence in three patients and pulmonary in one patient. In two patients there was no evidence of recurrence. PET/CT was negative in two patients with neck relapse and positive in the other two with neck recurrence and in the two patients with neck and lung disease of the first group. In the second group, PET/CT was positive in three patients with suspicious of neck relapse. In one patient it also detected lung disease. The patient with known lung affection had also mediastinum and bone infiltration.PET/CT was negative in the two patients with negative US and CT. CONCLUSIONS: In DCT patients with positive thyroid dWBS, the PET/CT did not add new information. These patients should be treated with surgery or radioiodine. DCT patients with negative dWBS, positive PET/CT contraindicates radioiodine ablation. DCT patients with high thyroglobulin levels and no image detection of disease, PET/CT is mainly negative as tWBS is. In these cases follow up is recommended.
P183 Usefulness of fluorine 18 (18F)-labeled fluorodeoxyglucose positron emission Tomography/computed tomography (FDGPET/CT) scan in the evaluation of thyroid nodules with cytopathology of fine-needle aspiration (FNA) classified as “indeterminate”. M. A. Muros, H. Palacios-Gerona, J. M. Villar, A. Santiago-Chinchilla, T. Muros, M. Lopez de la Torre- Casares, J. M. López-Ruiz, A. RamírezNavarro, J. M. Llamas-Elvira; H.U. Virgen de las Nieves, Granada, SPAIN. Purpose: To determine the accuracy of the fluorine 18 (18F)‐ fluorodeoxyglucose positron emission tomography / computed tomography (FDG‐PET/CT) scan in the evaluation of thyroid nodules with cytopathology of fine‐needle aspiration (FNA) classified as “indeterminate”. Patients and Methods: A prospective pilot study of 14 patients with thyroid nodules (isolated thyroid nodules or multinodular goiter) in whom adequate FNA was diagnosed as indeterminate (follicular proliferation). All patients underwent a physical exam, US, whole‐body FDG‐PET/CT scan followed by thyroidectomy. Preoperative FDG‐PET/CT results and the histopathology of the surgical specimen were compared. FDG‐PET/CT scan (Biograph 16 SIEMENS, 370MBq 18F‐FDG iv) was performed using a conventional protocol. PET/CT studies were evaluated by two blind nuclear medicine experts. For the qualitative data interpretation, FDG uptake foci in thyroid were considered positive. For the semiquantitative data interpretation SUV max were registered in 13/14 studies. Results: The FNA demonstrated follicular proliferation in all patients. The histopathology of the surgical specimen revealed 5 papillary carcinoma and 2 follicular carcinoma). ‐ The histopathology of the surgical specimen revealed thyroid cancer in 7/14 (50%) patients: The FDG‐PET/CT scan was positive in 6 patients with thyroid cancer and 1 patient had a false‐negative study (papillary microcarcinoma). ‐ The histopathology of the surgical specimen revealed non‐malignant disease in 7/14 (50%) patients: The FDG‐PET/CT scan was negative in 3 patients and positive in 4 patients. Thus, 4 patients had false positive FDG‐PET/CT scans.
Poster Presentation
Patient Status
30 4.82
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Thyroid cancer (N=7) Non‐malignant disease (N=7)
PET‐TAC (+)
6
4
PET‐TAC (‐)
1
3
4
1.50‐17.70 (5.00)
SUV max (N=13) 2.58 ‐22.92 (12.60)
10
The sensitivity of FDG‐PET/CT to detect a malignant focus was 85.71% with a specificity of 57%. The positive predictive value was 60% and the negative predictive value was 75%. The mean SUV max was 12.60 in thyroid cancer group versus 5.00 in Non‐malignant disease group. Conclusions: FDG‐PET/CT study offers an adecuate sensitivity in patients with thyroid carcinoma and cytopathology of fine‐needle aspiration (FNA) classified as “indeterminate”. FDGPET/CT was not a predictable indicator of benign or malignant disease and must not be used by clinicians to consider foregoing thyroidectomy for cytologically indeterminate nodules.
P184 Impact of Multiphase Ga-68-DOTATOC-PET/CT on Therapy Management in Patients with Neuroendocrine Tumors J. Ruf1, F. Heuck2, J. Schiefer1, T. Denecke3, F. Elgeti3, A. Pascher4, M. Pavel2, L. Stelter5, S. Kropf6, B. Wiedenmann2, H. Amthauer1; 1Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Magdeburg A.ö.R,, Magdeburg, GERMANY, 2Medizinische Klinik m. S. Hepatologie und Gastroenterologie, CharitéCentrum 13 für Innere Medizin mit Kardio-, Gastroentero-, Nephrologie, Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin, GERMANY, 3Klinik für Strahlenheilkunde, CharitéCentrum 6 für diagnostische und interventionelle Radiologie und Nuklearmedizin, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, GERMANY, 4Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, CharitéCentrum 8 für Chirurgische Medizin, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, GERMANY, 5Nuclear Medicine Research Laboratory, Memorial SloanKettering Cancer Center, New York City, NY, UNITED STATES, 6Institut für Biometrie und Medizinische Informatik, Universitätsklinikum Magdeburg A.ö.R, Magdeburg, GERMANY. Aim: Retrospective evaluation of the impact of Ga‐68‐DOTATOC‐PET/CT on the therapeutic management of patients with neuroendocrine tumors (NET). Methods: The Ga‐68‐DOTATOC‐ PET/CT data of 66 patients (31 m, 35 f; 29‐79, mean: 56 yrs.) with known or suspected NET were included. Imaging data (PET and triple‐phase contrast‐enhanced CT) were evaluated in consensus by two readers for the visualization of NET‐manifestations. Combined PET/CT, clinical and imaging follow‐up as well as histopathology, if available, served as the reference standard. In order to assess the impact of the respective submodalities on the therapeutic strategy chosen, the results were compared to the treatment decision made by the interdisciplinary NET tumor board of our institution. Results: In 50/66 patients (76%) a total of n=181 NET‐manifestations were detected by PET/CT. Of these, 59 (32.6%) were detected by one submodality only (CT 17.1%, PET 15.5%, p for comparison of both=0.459). Combined PET/CT‐reading had an impact on the therapeutic management in 24/66 (36%) of all patients (primary resection n=5, curative lymph node resection n=1, initiation/switch of chemotherapy (CTx) due to progressive disease n=10, no surgery due to systemic disease n=2, radiopeptidereceptortherapy instead of CTx n=1, additional bisphosphonate‐therapy n=4, hepatic brachytherapy n=1). In 12/24 (50%) of these patients, relevant findings were detected by a single submodality only (CT n=5, PET n=7; p for comparison of both=0.774). Conclusion: Ga‐68‐DOTATOC‐PET/CT influences therapeutic management in about one third of all patients examined. Both CT and PET are comparably sensitive, deliver complementary information and equally contribute to therapeutic decision‐ making. Thus, despite the merits of the PET‐modality, the CT‐component must not be neglected and an optimized multiphase CT‐protocol is recommendable.
P185 Clinicopathological features of metastasis of liver from rectal carcinoid determined by F-18-FDG uptake and expression of glucose transporter I and hexokinase II Y. Arisaka, N. Oriuchi, T. Higuchi, K. Endo; Department of Diagnostic Radiology and Nuclear Medicine Gunma University Graduate School of Medicine, Maebashi, JAPAN. Purpose The purpose of the present study is to evaluate F‐18‐FDG PET and the expression of glucose transporter I and hexokinase II in patients with metastasis of liver from rectal carcinoid. Method and Material We studied six patients with liver metastasis from rectal carcinoid. F‐18‐ FDG PET was performed in all patients. F‐18‐FDG (5‐6 MBq/kg) was administered after the fasting for more than 6 hours. Data acquisition was done at 60 minutes following the administration by 2D‐mode with a dedicated PET scanner. Attenuation correction was performed using an external source of Ge‐68. Uptake of F‐18‐FDG was visually interpreted and semi quantitatively evaluated with standardized uptake value (SUV) and the tumor to normal parenchyma ratio (T/N) was calculated. Pathological examination was performed. Samples from the surgical resection of six patients and 3 cases of biopsy specimens having enough viable components were chosen for immunohistochemical staining. Results All metastatic liver lesions from carcinoid showed remarkably low F‐18‐FDG uptake. Immunohistochemical study revealed that hexokinase II expression was positive, but glucose transporter I expression was low or negative. Conclusion We analyzed F‐18‐FDG PET and immunohistochemical expression of Glut‐I and hexokinase II in patients with metastatic liver lesions from rectal carcinoid. Unlike other neoplasm, liver metastasis from rectal carciond showed significantly low F‐18‐FDG uptake and negative expression of glucose transporter I.
P186
18
111
The role of FDG-PET/CT and In-Pentetreotide in the follow up of medullary thyroid cancer with elevated serum calcitonin
F. Perez Angel, J. Sanchez Catalicio, L. Mohamed Salem, C. Moreno Capdevila, L. Frutos Esteban, M. I. Castellon Sanchez, F. Nicolas Ruiz, J. L. Navarro Fernandez, M. A. Claver Valderas; Department of Nuclear Medicine, Virgen de la Arrixaca University Hospital, Murcia, SPAIN. BACKGROUND: Medullary thyroid carcinoma (MTC) is a neuroendocrine tumor of the parafollicular or C cells of the thyroid gland. MTC accounts for approximately 3 to 5 percent of thyroid carcinomas. Most medullary thyroid carcinomas are sporadic, however, some are familial as part of the multiple endocrine neoplasias type 2 (MEN 2) syndrome. The elevation of serum calcitonin is an indicator of residual or recurrent disease after initial treatment. AIM: To evaluate the usefulness of 18FDG‐PET/CT and 111In‐Octreotide scintigraphy in the diagnosis of metastases/recurrence in MTC with elevated serum calcitonin. MATERIAL AND METHODS: We revised retrospectively 14 patients with MTC (7 sporadic and 7 with MEN2A), 9 females and 5 males aged 39‐67 years (mean age 51.5). All patients underwent 18FDG‐PET/CT between November 2006 and January 2009 according to usual imaging protocol with a Geminy Philips PET/CT, we repeated 18FDG‐PET/CT in 4 patients during the follow‐up period. 10 of 14 patients underwent 111In‐Pentetreotide scintigraphy with a Sky Light Philips and with an Infinia Hawkeye 4 GE gamma cameras, with both planar imaging methods and SPECT‐CT. The serum calcitonin was determined in all patients with Biosource CT‐U.S.‐ IRMA Kit according to RIA laboratory. RESULTS: The 18FDG‐PET/CT scan was positive in 5 patients, negative in 8, and inconclusive in 1. The 111In‐ Pentetreotide scintigraphy was positive in 4, negative in 4, and inconclusive in 3. The serum calcitonin was elevated in all patients showing values between 9 and 47700 ng/ml. CONCLUSION: In our study there was no correlation between calcitonin levels and 18FDG‐PET/CT findings. There was no correlation between calcitonin levels and 111In‐Pentetreotide scintigraphy findings. Not always correlation exists among the 18FDG‐PET/CT findings and those of 111In‐Pentetreotide, so that the combination of both studies improves the sensibility. We concluded therefore that there is no imaging modality which is able alone to diagnose reliably recurrent and metastatic MTC in case of elevated serum calcitonin. The combination of different imaging modalities must be considered the method of choice in the follow‐up of the disease.
P187 Multimodality in nuclear medicine imaging methods as an important way helping to find an appropriate treatment for neuroendocrine tumours I. Makaiova1, S. Kovacova1, J. Tomekova1, J. Vesely1, S. Kinova2, V. Lehotska1, T. Salek3, D. Sorkovska1, B. Duchaj1, A. Durkovsky1; 1 St.Elisabeth Cancer Institute and Medical Faculty Comenius University, Bratislava, SLOVAKIA, 2Pediatric Oncology and Medical Faculty Comenius University, Bratislava, SLOVAKIA, 3National Cancer Institute, Bratislava, SLOVAKIA. Aim of the study. For routinely imaging of neuroendocrine tumours (NETs) in well differentianed state the 111In ‐ labelled somatostatine analog, or the noradrenalin analoque 123I ‐ metajodobenzylguanidine (MIBG) is used. While 18FDG ‐ fluorodeoxyglucose has been proven to detect mostly high grade malignant tumours, it shows poor sensitivity for the visualisation of some well ‐ differentianed one, because the tumour glucose metabolism may be insufficiently increased for imaging them. Among the tumours that often show a lack of enhanced 18FDG uptake are NETs and this imaging may be useful only when there is dedifferentiation and loss of the specific histological characteristics. Other situation arised, if in the same patients there are both, the well‐ differentianed tissue visible with these functional radiopharmaceuticals and in the same time also the lesions with dedifferentianed tissue visible with 18FDG, because this question is important for therapy perspectivity (flip ‐ flow phenomenon). Material and methods. This group consists of 55 adult patients ( range 22 ‐ 75 yrs). From this group of patients mostly (44) suffered of carcinoids and other NET tumours. All of this patients had been investigated with 111 In‐octreotide and PET/18FDG and all with active octreoscan had been investigated with 123I‐ MIBG . Results. In this study we show a multimodal imaging techniques including 111In‐octreotide, 123 I‐MIBG and 18FDG and software corregistration between them and also with CT or MRI. From the group of 44 carcinoid patients 30 of them were send for the staging or restaging investigation after surgery before next treatment. In 21 patients from this group the uptake of labelled octreotide was increased, and from these patients in 8 (38,0%) was also positive uptake of 123I‐ 18 MIBG. In the group of labelled octreotide patients was the result PET/ FDG positive in cca 25% (flip‐flop in 12 patients and only PET/18FDG in two patients). Conclusion. Despite of the fact, that mostly NETs are well ‐ differentianed with a good uptake of ,,functional“ radiopharmaceutical as 111 In‐octreotide and sometimes 123I‐MIBG, in the same time can have also dedifferentianed tissue with 18FDG uptake. Because this finding shows the poor differentianed tissue with worse clinical prognosis, this reveal can change of the strategy of the therapy. Multimodality in nuclear medicine imaging methods as an important way to help find the appropriate treatment in neuroendocrine tumours.
P188 Diagnostic accuracy of [18F]FDG-PET/CT in patients with iodine-negative differentiated thyroid cancer (DTC) after stimulation with r-TSH and after l-tiroxine withdrawal: preliminary results. E. Borsò, G. Boni, G. Manca, M. Grosso, E. Biggi, E. Filidei, S. Chiacchio, F. Betti, D. Volterrani, G. Mariani; Regional Center of Nuclear Medicine, Pisa, ITALY. AIM: [18F]FDG‐PET detects recurrences and metastases of differentiated thyroid carcinoma (DTC) in patients with elevated serum thyroglobulin (sTg) levels and negative 131I‐whole‐body scan. Thyrotropin (TSH) stimulates thyrocyte metabolism, glucose transport and glycolysis. To determine the influence of serum TSH levels and of the euthyroid or hypothyroid state on FDG uptake by DTC, patients with suspected recurrent disease were studied sequentially during both these conditions. This study is partially supported by an unrestricted grant by Genzyme srl (Modena, Italy). METHODS: 12 thyroidectomized patients (mean age 60±14 yr, 6 men) with positive Tg levels and negative 131I diagnostic scan underwent FDG‐PET/CT respectively after exogenous TSH stimulation (rTSH‐PET) ‐0.9 mg rh‐TSH i.m. on two consecutive days‐ and after 4‐6 weeks l‐tiroxine withdrawal (hypo‐PET). The mean period between the two studies was 10±4
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RESULTS:
rTSH‐PET
hypo‐PET
Student t‐test
TSH
78 ± 38
74 ± 64
n.s.
sTg
168 (0,5 ‐ 958) 298 (2,9 ‐ 1268) n.s.
pts PET +
7/12
7/12
n.s.
lesions (n°)
29
29
n.s.
neck
20
19
n.s.
lungs
9
10
n.s.
activity (mCi) 9,1 ± 1,6
9,8 ± 0,7
n.s.
TBR max
6,05 ± 3,40
8,73 ± 4,72
p<0,01
TBR med
5,98 ± 3,29
8,35 ± 3,80
p<0,01
SUV max
5,00 ± 2,44
6,40 ± 3,83
p<0,05
SUV med
3,55 ± 1,60
4,41 ± 2,30
p<0,05
CONCLUSIONS: These results confirm that FDG‐PET localizes recurrent or metastatic iodine‐ negative DTC, but also suggest that FDG distribution and uptake by tumor lesions correlate with TSH, fT3 and fT4 levels. Despite better visual contrast of images obtained during hypothyroidism (mirrored by higher TBR and SUV), global FDG‐PET/CT performance during rh‐TSH stimulation was equal to that observed during hypothyroidism (sensitivity 58%). Therefore, to detect metastatic or recurrent DTC with FDG‐PET, preparation by rh‐TSH administration can be preferable, as it provides prompt and effective stimulation and avoids the symptoms of hypothyroidism.
P189 Ga-68 DOTATATE PET In Endocrine Tumors: Comparison With In-111 Octreoscan, Dosimetry And Clinical Impact S. Lastoria, L. D'Ambrosio, M. Aurilio, C. Caraco', L. Aloj; Nuclear Medicine, Istituto Nazionale Tumori, Fondazione "G. Pascale", Napoli, ITALY. Objectives: The diagnostic value of a new somatostatin anolog: 68Ga‐DOTATATE has been investigated with endocrine tumors (ET) previously evaluated by 111In Octreoscan (SRS), along with the dosimetry, the effect of previous therapies and clinical impact. Methods: Ninteen patients (9F/10M, age range: 34‐78 yrs), 5 at diagnosis and 14 during follow up for ET were studied by PET with 68Ga‐DOTATATE (7‐20 mcg, 50‐206 MBq) 30‐40 min after the injection. SUVs were measured in normal organs and ETs; T/B ratios of PET and SRS were compared. Dosimetry of 68Ga‐DOTATATE was estimated. Results: 68Ga‐DOTATATE meanSUV in normal organs ranged from 0.12±0.03 (brain) to 16.7 ±7.7 (bladder). PET was positive in 16/19 patients identifying 55 lesions (33 of the them in the liver) with a meanSUV: 10.1±5.1 (range 1.7‐32) and mean T/B: 5.6±4.8 (range 1.08‐23.8). SRS depicted 39 lesions in 16/19 patients with a mean T/B 3.8±3.12 (range 1.03‐18.3). The T/B ratios of PET and SRS did not show significant differences 3±1.1 vs 2.6±0.7 respectively. The meanSUV in 5 untreated patients (28 ETs) was 9.1±3.3; in 11 patients previously treated (27 ETs) was 10.8±6.4. The mean absorbed dose ranged from (1.6±0.4 E‐03) in the brain to (112 ± 44 E‐03) mGy/MBq in the spleen with an effective dose of (12.7 ± 3.3 E‐03) mSv/MBq. Conclusion: PET with 68Ga‐DOTATATE detected more ETs than SRS, enabling more accurate staging. No differences were found in the T/B ratios obtained by PET or SRS. Futhermore, the SUV values are not influenced by previous therapies. The dosimetry of 68Ga‐ DOTATATE is similar to 68Ga‐DOTANOC and DOTATOC, being significantly lower than that measured for 111In‐Octreoscan.
P190 A comparison of 68Ga-DOTA-TATE PET-CT and 99mTcHYNIC-TOC SPECT/CT in the assessment of bony metastases in patients with malignant endocrine tumours - preliminary results. N. Szalus1, D. Pawlak2, M. Dziuk1, M. Koza3, G. Kaminski4, Z. Podgajny1, E. Dziuk4; 1Military Insitute of Health Services, Mazovian PET-CT Center, Warsaw, POLAND, 2Institute of Atomic Energy Radioisotope Centre POLATOM, Swierk, POLAND, 3Mazovian PET-CT Center, Warsaw, POLAND, 4Military Insitute of Health Services, Warsaw, POLAND. Introduction: In endocrine tumours (ET) the workup it is often difficult not only to visualize but also to co‐localize anatomically the lesions. Bones are one of the most frequent sites of metastases in patients with endocrine tumours. The Tyr3‐octreotate (TATE) somatostatin analogue differs from TOC in that the terminal threonine replaces threoninol. The terminal threonine results in a higher receptor binding (mainly subtype 2) and better internalisation, with the consequence that tumour uptake of the tracer is intense. The aim of the study: To evaluate the diagnostic value of 68Ga‐DOTA‐TATE PET‐CT imaging in detecting bone metastases comparing with 99mTc‐HYNIC‐TOC preparation SPECT‐CT. Material and methods: 99mTc‐HYNIC‐ TOC SPECT/CT and 68Ga‐DOTA‐TATE PET‐CT studies were performed in 9 patients. The interval time between of this two studies was 2 ‐ 28 weeks. The conventional scintigraphy was acquired on the hybrid gamma camera SPECT/CT in 2‐4 h after intravenous injection of 99mTc‐HYNIC‐TOC. The injected activity was 550‐740 MBq (15‐20mCi). The following views were gathered: planar AP, PA and SPECT/CT of the chest and abdomen. PET‐CT scans were acquired 45 ‐ 60 min postinjection of 120 ‐ 200 MBq (3,5 ‐ 5,5 mCi) of 68Ga‐DOTA‐TATE. Data acquisition was performed with a 15‐cm axial field of view (FOV) and 55‐cm transaxial FOV PET‐CT scanner. Patients were imaged in 3‐dimensional mode with the duration of acquisition 3 ‐ 5 min per bed position in emission mode. Results: 99mTc‐HYNIC‐TOC SPECT/CT revealed the presence of bony
metastases in 3 patients, 68Ga‐DOTA‐TATE PET‐CT in 4 patients. In 3 patients positive in SPECT/CT the PET‐CT was able to detect 50% more lesions with 68Ga‐DOTA‐TATE. Lesions with the diameter of less than 10 mm were not visualized in SPECT‐CT. Five patients did not have bony metastases in neither of the modalities. Conclusions: In comparison to 99mTc‐HYNIC‐TOC SPECT/CT, 68Ga‐DOTA‐TATE PET‐CT appeared to be a more sensitive modality in the detection of metastases to the bones in patients with malignant endocrine tumours. Additionally PET‐CT may allow for better localization of the bone lesions.
P191 18
FDG PET/CT in the follow up of patients with differentiated thyroid carcinoma
P. Rondogianni, E. Panagiotidis, M. Skylakaki, E. Skoura, E. Vlontzou, P. Chroni, I. Datseris; "Evangelismos" General Hospital, Athens, GREECE. AIM: To evaluate the role of 18FDG PET/CT (PET/CT) in the follow up of patients with differentiated thyroid carcinoma (DTC), negative post treatment whole body scan (TxWBS) but elevated thyroglobulin (Tg) serum levels. PATIENTS‐METHODS: This retrospective study involved forty (40) patients (15 men, 25 women) aged 15‐80 (mean age: 52, 7 years) all with DTC. The mean disease duration was 6.03 years. 33 patients had papillary (5 mixed and 2 tall cell variant subtypes), 4 follicular and 3 Hurtle cell carcinoma. Multifocal disease was present in 9 cases. 16 patients had known metastatic disease (11 in cervical lymph nodes, 2 bone, 1 lungs and 2 multiple) at presentation. All of them had undergone total thyroidectomy and received 131I (RAI) for thyroid remnants ablation. 20 patients had undergone additional cervical lymph node dissection. All had received >1 RAI for recurrence of the disease and had negative TxWBS but elevated Tg (2‐5000ng/ml‐median 22.5ng/ml). PET/CT was curried out after 1 week of LT4 withdrawal in11 and after human recombinant TSH (rhTSH) administration in 29 cases. RESULTS: PET/CT was positive in 26/40 patients (65%) with no significant difference between the two groups ( rhTSH or LT4 withdrawal).The findings concerned multiple sites (lymph nodes, lungs, bones) involved in 20 cases, only cervical lymphadenopathy in 4 and loco regional recurrence in 2 cases. PET/CT findings were more than that of other imaging modalities used (ultrasound‐U/S, computerized tomography‐CT and/or magnetic resonance imaging‐MRI) in 12/26 (46%) patients, the same in 8/26 (30.7%) patients and less in 4 /26 (15.4%) patients. In one case there were discrepancies between PET/CT and conventional imaging findings (different sites involved). PET/CT was negative in 14/40 patients. 2 among them had a positive CT (small lung nodules< 1 cm).PET/CT findings changed the treatment management in 12/26 (46%) patients showing only loco regional recurrence and/ or cervical lymph node metastases in 9 patients who underwent surgical dissection and wide spread disease not evident in other imaging in 3 patients. CONCLUSION: PET/CT seems to be a useful tool in the identification and localization of recurrence or metastases of DTC in patients with negative TxWBS but abnormal Tg. In this population it helps to confirm or not equivocal findings of the conventional imaging methods before the decision for surgical dissection or external beam radiotherapy is taken.
P192 68
Ga-DOTATOC positron emission tomography in Merkel cell carcinoma
M. C. Kreissl1, P. Mueller2, F. A. Verburg1, L. Frey2, I. Israel1, S. Ugurel2, C. Reiners1, S. Samnick1, J. C. Becker2; 1Klinik und Poliklinik fuer Nuklearmedizin, Wuerzburg, GERMANY, 2Klinik und Poliklinik fuer Dermatologie, Wuerzburg, GERMANY. Objectives: Merkel cell carcinoma (MCC) is a rare aggressive skin tumour with neuroendocrine features which has a rapidly increasing incidence. It is known that MCC is often expressing somatostatin receptors (SSR). Aims of this study were to assess the impact of the 68Ga‐DOTATOC‐ PET on the staging and therapy planning in patients with MCC. Methods: 13 PET studies were performed in 10 MCC patients (1 stage I, 2 stage II and 7 stage III) for staging, restaging and therapy monitoring purposes. 68Ga‐DOTATOC was prepared using a standard protocol and a 60‐ minute whole body PET was acquired 20‐30 minutes after the injection of 81±25 MBq. Results were compared with the most recent CT‐imaging; SSR‐density was graded as 0 (no tracer uptake); 1 (low uptake), 2 (uptake equivalent to liver) and 3 (high uptake) by means of measuring the maximum tracer uptake in the “hottest” lesion and the mean uptake of the tracer into the liver. Results: At initial staging all 9 patients with known MCC tumor manifestations showed a detectable 68Ga‐DOTATOC uptake indicating an expression of SSRs in all MCC tumor lesions. 5/9 patients displayed a grade 1 uptake, 2/9 a grade 2 uptake and further 2/9 patients had a high density of SSR (grade 3). One patient after resection of the primary showed no pathological 68Ga‐ DOTATOC uptake (0); CT‐imaging did not detect any metastases. In 3/10 patients 68Ga‐DOTATOC detected new lesions not known from previous imaging. Therapeutic decisions were influenced in two cases. In three patients who were studied a second time after several courses of chemotherapy, response assessment by PET revealed results concordant to CT imaging (one mixed response, one progressive disease). Conclusions: 68Ga‐DOTATOC‐PET proved to be a valuable imaging tool for the staging, restaging, and therapy monitoring of MCC patients. 18% of all imaged tumors showed a strong expression of SSR, 18% an intermediate expression, and may thus be susceptible to targeted treatments such as radionuclide therapy.
P193 Use Of The Lesions.
18
FDG-PET/TAC In The Diagnosis Of Adrenal
C. Ramos-Font1, R. Sánchez-Sánchez1, H. Palacios-Gerona1, A. Rodríguez-Fernández1, J. Villar2, N. Muñoz-Pérez2, M. Gómez-Río1, J. Llamas-Elvira1; 1Nuclear Medicine Department. Virgen de las Nieves University Hospital, Granada, SPAIN, 2Surgery Department. Virgen de las Nieves University Hospital, Granada, SPAIN. The increasing in the detection of incidental adrenal nodules coupled to the use of high‐ resolution imaging in the study of abdomen, have stressed the need of a correct diagnosis for the appropriate surgical approach. Morphological imaging (CT or MR) are the primary modalities for detection of structural changes but in occasions could be unspecific for the possible tumoral nature of them. This work exposes in terms or diagnostic accuracy our experience using 18FDG‐
Poster Presentation
weeks. Serum TSH, Tg and free thyroid hormones levels (fT3, fT4) were measured. PET/CT images were acquired 60 min after i.v. injection of 290‐420 MBq 18F‐FDG using a hybrid PET/CT scanner (GE Discovery ST8). The PET/CT findings were evaluated by two independent observers and FDG uptake was estimated using tumour to background ratio (TBR, selecting the left lung apex as background) and standardized uptake value (SUV). Any increased 18F‐FDG uptake was compared with the co‐registered CT image to differentiate physiologic from pathologic tracer uptake.
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PET in the study of unexpected adrenal lesions. METHODS Sixteen patients have been studied 60 min after i.v. injection of 370Mbq of 18FDG using a hybrid PET/CT system (Siemens Biographs 16, Knoxville, Milwokee). Imaging was evaluated using visual analysis and by semi‐quantitative estimation of the maximal Standard Uptake Value (SUVmax). In all cases imaging studies were contrasted with the final histological diagnosis of surgical specimen. RESULTS Eleven male and five female (mean age: 53,31±7,2y) have been included. 18FDG‐PET/TAC was positive in 11 patients and negative in 5 cases. In positive scans (mean SUVmax: 8,07±3,65) histology shown 5 metastases, 2 pheochromocytomas and 3 adrenal carcinomas (10 true positive). One case of adrenal adenoma (SUVmax: 5,04) was considered as false positive for tumour. In the 5 negative scans (mean SUVmax: 2,52±0,74) final pathological diagnosis corresponds with adrenal adenoma (n=2), adrenal hyperplasia (n=1) and adrenal cyst (n=1). One study of pheochromocytoma (SUVmax: 1,3) with cystic component was classified as false negative. 18FDG‐PET/TAC offer a Global Diagnostic Accuracy: 87,5%, Sensitivity: 90,9%, Specificity: 80%, and in our population a Predictive Value of 90,9% for positive scan and 80,0% for negative. COMMENTS Instead of so few patients, 18FDG‐PET/TAC seems to be a useful tool in the preoperative characterization of adrenal lesions.
P194
68
123
Comparison of Ga-DOTA- Tyr3 octreotide PET versus I meta-iodobenzylguanidine scintigraphy in patients suffering from neuroblastoma or phaeochromocytoma before radionuclide therapy A. Kroiss, G. Dobrozemsky, D. Putzer, D. Waitz, M. Gabriel, R. Madleitner, F. Karakolcu, S. Buxbaum, C. Uprimny, D. Kendler, I. J. Virgolini (Department of Nuclear Medicine; University of Innsbruck, Austria) 68
123
Introduction: In this study we compared scintigraphy of Ga‐DOTA‐ Tyr3 octreotide PET and I meta‐iodobenzylguanidine [mIBG] to evaluate Somatostatin receptor profile before potential radionuclide therapy in patients suffering from neuroblastoma or phaeochromocytoma. Patient Material: Six patients (4 male and 2 female, ranging from 4 ‐70 years of age; average age: 37 years) were included in this study. Four patients suffered from phaeochromocytoma and two patients from neuroblastoma. Before potential radionuclide therapy we compared scintigraphy of 68Ga‐DOTA‐ TOC PET and 123I mIBG, respectively. The pathologic lesions (metastases) were visually counted and added up. Three possible variations were selected (68Ga‐DOTA‐ TOC PET > [123I]mIBG; 68Ga‐DOTA‐ TOC PET < [123I]mIBG; 68Ga‐DOTA‐ TOC PET equal [123I]mIBG scintigraphy). Results: In all patients pathologic lesions were better detectable in the 68Ga‐DOTA‐TOC PET than in 123I MIBG scintigraphy, both in neuroblastoma and pheochromocytoma diseases due to favorable resolution of PET imaging. Lesion based analyses in 68Ga DOTA TOC PET versus 123I MIBG in ratio (42/18; 18/3; 8/2; 16/8; 9/7; 8/2) all in favor of 68Ga DOTA TOC PET. Conculsion: Pathologic lesions can be better detected by using 68Ga DOTA TOC PET and more accurately estimated before radionuclide therapy treatment in neuroblastoma and pheochromocytoma diseases. In addition, more lesions were detected in the 68Ga DOTA TOC PET than in 123I mIBG scintigraphy.
P23 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: malignancy of unknown origin
P195 Clinical usefulness of FDG-PET for the assessment of primary peritoneal cancer A. Takano1, N. Oriuchi2, Y. Arisaka2, T. Higuchi2, E. Keigo2; 1Tone-ChuouHospital, Numata, JAPAN, 2Gunma University Graduate School of Medicine, Maebashi, JAPAN. [Backgraound]Primary peritoneal cancer (PPC) is a rare disease resembling serous papillary carcinoma of the ovary. Non‐invasive diagnosis of PPC is difficult, although diagnosis of CT and MRI has been reported. Although it is assumed that FDG‐PET is useful for the diagnosis of PPC, only a few report has been made and clinical usefulness of FDG‐PET has not been established. [Materials and Methods]The study included 7 patients with histologically confirmed PPC. PET was performed in four patients as an initial work up and the results were compared with another imaging modalities. In two patients of them, PET was also done after therapy. The other 3 patients underwent PET after the treatment to determine the role of FDG‐PET to assess recurrence of PPC. Clinical follow up and changes in the value of serum tumor marker were correlated. [Results]PET showed increased FDG uptake in the lesion of PPC in all cases. Of note was that PET could clarify that no abnormal uptake of FDG was seen in the ovary and PPC was clinically diagnosed. FDG‐PET could detect more lesions as compared with conventional modalities. In patients after therapy, PET was useful by pointing out metastases to the abdominal lymph node and the distant metastasis such as supraclavicular lymph node. [Conclusion]Present preliminary study with a small number of patients suggests that FDG‐PET was useful for the initial diagnosis as compared with CT and MRI especially for the extension of the lesion of PPC and the absence of primary tumor in the ovary was confirmed. Clinical utility of FDG‐PET for t he assessment of recurrence was also suggested.
P196 The effectiveness of 18F-FDG PET/CT in the detection of carcinoma of unknown primary. A. Bournazos, P. Rontogianni, E. Panagiotidis, D. Exarchos, C. Giannopoulou, A. Samartzis, I. Datseris; Nuclear Medicine1, Computerized Tomography2 and Health Physics3 Departments,"Evangelismos" General Hospital, Athens, GREECE.
AIM: To assess the diagnostic value and accuracy of 18F‐FDG PET/CT in the identification of the primary tumor (CUP) not revealed by other conventional imaging methods in patients with known metastases. PATIENTS‐METHOD: In this retrospective study 65 patients (26 female, 39 male) aged 18‐81 (mean: 55.97 years) were involved. All patients had metastatic disease of unknown primary revealed by conventional imaging methods ( Ultrasound‐U/S, computerized tomography‐ CT, magnetic resonance imaging ‐MRI, bone scintigraphy) .Whole body PET/CT images acquired 60 min after I.V. injection of 370 MBq 18F‐FDG. Additional images of the brain, head and neck or the lower limits were also acquired when necessary. Based on the daily routine, the PET/CT scans were evaluated by crossed trained nuclear physician and radiologist. PET/CT findings were compared to the results of conventional imaging modalities. A lesion by lesion analysis was performed. Final confirmation of abnormal findings was made by clinical follow up and biopsy. RESULTS: PET/CT scans were normal (no findings) in 13/65 (20%) patients. Fewer lesions than other imaging modalities were found in 12/65 (18.5%) of cases while similar findings were found in 22/65 (33.8%) of them. In 18/65(27.7%) patients PET/CT revealed more lesions than all other imaging methods and in 11 among them the site of the primary tumor was identified. These cases concerned: primary lung cancer (9 patients), adrenal gland cancer (1 patient) and colorectal carcinoma (1 patient). CONCLUSION: In the search for unknown primary, the information provided by PET/CT added clinically important information. However, there are certain patients where locating primary cancers remains challenging despite the meticulous examination by different imaging modalities including PET/CT.
P197 FDG PET/CT imaging in the detection of primary tumours in patients with a metastatic carcinoma of unknown primary tumour T. Kacar Guveli, T. Ozpacaci, T. Ozulker, M. Tamam, M. Mulazimoglu, O. Eker, F. Ozulker, A. Kucukoz Uzun, H. S. Yavuz; Okmeydani Training and Research Hospital, Istanbul, TURKEY. PURPOSE: To evaluate the value of Fluorodeoxy‐glucose positron emission tomography (FDG‐ PET/CT) in detecting the primary tumor in patient with suspect metastatic cancers of unknown primary origin. METHODS: The present study has been conducted on 42 patients (17 female, 25 male) with a mean age of 43 years, who applied to Okmeydani Training and Research Hospital Nuclear Medicine Clinic with a suspect of metastatic malignancy of unknown primary origin (11bone, 6 lymph node, 23 visceral metastases suspicion and 2 high tumor marker level ) after extensive conventional imaging methods and laboratory diagnostic work‐up. In these patients, it was searched whether they had malignancy and if they had malignancy primary focus points and metastases with FDG‐PET/CT. FDG PET/CT scans were performed after 45 to 90 minutes (approximately 60 minutes) after the intravenous injection of 7.4 MBq (18)F‐FDG/kg, If it was needed, delayed imaging scans was done to the patients after about 180 minutes. The images were assessed visually. In addition the standardized uptake value (SUV) ≥2.5 on standard PET/CT imaging was considered as positive. The results of the FDG PET/CT were compared to histopathological evaluation or clinical follow up (for about 18 months) RESULTS: The results of FDG‐PET/CT compared with histopathologic results (66,6%) in 28 patients and clinical follow up in 14(33,3%) patients. Malignancy was detected in 27 (64%) out of 42 patients. With PET/CT potential primary tumor focus was reported in 16(59,2 %) out of 27 patients(lung cancer in 16, nasopharenx in 1, endodermal sinus tumor in1, multiple myeloma in 1 and lymphoma in 1 was found out of 27 patients). Metastases focus was determinated and reported 26 patients out of 27. FDG uptake wasn’t observed in 16 patients out of 42 patients. Malignity in 15 patients was excluded in the clinical follow up and conventional imaging methods or biopsy. After the application of mammography with biopsy, breast cancer was diagnosed and it was evaluated as false negativeness of PET/CT. CONCLUSION: FDG‐PET/CT is rather sensitive method in the patients who have suspicious metastases with unknown primary origin and distinction of malign‐ benign lesions and showing primary focus in malign lesion and metastases.
P198 Positron Emission Tomography With 18F-FDG in Unknown Primary Tumors (UPTs) C. P. F. S. Loewenthal, M. R. Vieira; Hospital da Luz, Lisbon, PORTUGAL. Aim: To review the population of patients (pts) referred to our department for an 18F‐FDG PET‐ CT scan in search of an unknown primary tumor. Method: We studied a population of 25 pts who performed 18F‐FDG PET‐CT scans between July 2007 and March 2009. Imaging was obtained 1 hr after iv administration of 3.7MBq/Kg of 18F‐FDG on a Siemens Biograph 16‐slice PET‐CT scanner. We reviewed all patient information available on our hospital electronic records. For pts forwarded from other institutions, we obtained follow‐up information through those institutions. Verification of our results was either by histopathological means or clinical follow‐up. Population: A total of 25 pts, 14 males and 11 females, average age 63.2 yrs (41‐80 yrs), were included. The average follow‐up was 8 months (range 1‐21 months). The disease presentation was varied, but there was a prevalence of bone metastases (7 pts) and lymph node metastases (5 pts). Other presentations were liver metastases (4 pts), lung metastases (3 pts), brain metastases (1 pt), increased CA 19‐9 and weight loss (1 pt), paraneoplastic cerebellar degeneration (1 pt). We excluded 3 pts who did not have definitive evidence of metastatic disease. Results: Hypermetabolic lesions suggestive of malignant disease were shown in 21/22 pts (95%). The only patient who did not present with active disease had had the tumour surgically removed and showed no other tumor sites. The primary lesions suggested by PET‐CT were 1) lung (3 pts); 2) pancreas (3 pts); 3)ovary (2 pts); 4) colon (2 pts); 5) esophagus (2 pts); 6) stomach (2 pts); 7) bone primary (2 pts); 8) base of tongue (1 pt); 9) parotid (1 pt); 10) pharynx (1 pt); 11) breast (1 pt). We were able to confirm these results in 11/22 pts (50%). Conclusion: In our small population, PET‐CT oriented the clinical diagnosis and subsequent diagnostic and therapeutic strategy in a significant percentage of patients.
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Diagnostic Oncology - PET, PET/CT: PET, PET/CT in tumour response assessment
P199 Value of Several Total Glycolytic Indices (TGIs) in Predicting Therapy Outcome in Non-small Cell Lung Cancer (NSCLC) A. H. Khandani, H. Gohil, D. T. Moore, M. A. Socinski, M. Ivanovic; Nuclear Medicine, Hematology-Oncology & Biostatistics, University of North Carolina & UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, UNITED STATES. Aim: To study the value of several TGIs and their possible association with time to event outcomes of chemo‐radiation in NSCLC Material and Methods: 19 patients with stage IIIA/B NSCLC who were studied at our institution as part of a phase I/II trial were included. Patients underwent induction chemotherapy with Carboplatin/Paclitaxel and Bevacizumab followed by concurrent chemo‐radiation with Carboplatin/Paclitaxel, Bevacizumab and Erlotinib. FDG PET‐CT scans (activity 444 MBq; uptake time: 60 min; skull base to upper thighs) were performed before and after induction therapy. SUVmax in each visible lesion in every patient were measured. Also SUVave1‐6 in each visible lesion in every patient were measured with the following 6 thresholds (T): 50%, 40% and 30% of SUVmax (T1‐3); 1.2 x and 1.5 x SUVmax of the descending aorta (T4‐5) and SUV of 3 (T6). Subsequently, in each lesion, the volumes encompassed by each of these 6 thresholds were measured, and their products with the respective SUVave calculated as lesion’s glycolytic indices (LGI 1‐6). Finally, in each patient TGI 1‐6 were calculated as the sum of all respective LGIs for T1‐6. SUV and TGIs were measured on the pre and post induction therapy scans. The median follow‐up time for survivors was approximately 32 months. Univariable Cox regression was used to evaluate the relative strength of association of the various TGIs and the SUVmax of the most intense focus in each patient (SUVMAX) with time to disease progression (TTP) and overall survival (OS). An approximation to Bayes factors, known as the Schwartz Criterion (SC), was used to assess the strength of evidence of association for each of TGIs and SUVMAX with either progression or death. Results: There were 4 deaths and 8 disease progressions (then death). The three strongest associations were for the ‘fold’ differences between the pre‐ and post‐ TGI1, TGI2 and TGI3 (calculated by the difference of the natural log of the pre‐ and post‐ treatment measurements). These three difference scores showed ‘positive’ evidence for an association with OS. In addition, these three scores also showed ‘weak’ evidence for an association for TTP, while most of the other parameters, including SUVMAX were ‘weak’ or ‘positive’ for the null hypothesis of ‘no association’. Conclusion: Some TGIs might be a good predictor of outcome in NSCLC patients undergoing chemo‐radiation. Although due to the small effective sample size care must be taken to not over interpret these results, more investigation may be warranted.
P200 The Role of FDG-PET/CT scan in Gastarointestinal Stromal Tumors S. S. Mut, L. Kabasakal, M. Halac, C. Onsel, I. Uslu; Cerrahpasa Medical Faculty, Istanbul University, Istanbul, TURKEY. Aim:Gastrointestinal Stromal Tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. Although being rare, it accounts for approximately 3% of all gastrointestinal cancers. GISTs are resistant to chemotheraphy and radiotheraphy. Surgical resection is the mainstay theraphy for patients with primary GIST. Imatinib mesylate, a tyrosine kinase inhibitor, has been shown to be highly effective in the treatment of advanced GIST. FDG‐PET/CT scan can be used as a valuable diagnostic tool in evaluating therapeutic response. It provides metabolic information demonstrating responses earlier than other available anatomic imaging modalities. In this retrospective study we aimed to evaluate the role of FDG‐PET/CT scanning in clinical desicion making process of GIST patients. Methods: A total of 34 patients (21 males / 13 females; age range: 22 ‐ 73; mean 52.78±12.52 years) with 73 scans were enrolled to this study. All patients had histopathologically confirmed GIST and were referred to our department for FDG‐ PET/CT scanning. Clinical follow‐up data, histopathological results and FDG‐PET/CT findings of these patientes were retrospectively reviewed. Results: Anatomic site of the primary tumor was stomach in 25.0%, small bowel in 46.97%, colon‐rectum in 12.5%, esophagus in 3.12 and in out of GIS in 12.5% of cases. Mean tumor size was 11.8±10.67cm (range: 4 ‐ 58). According to the pathologic classification; high, intermedite and low risk disease was evident in; 81.82%; 15.15% and 3.03% of the cases respectively. Among 70 FDG‐PET scans which were referred to our department, 45.20% was performed to detect recurrence/metastasis, 42,47% was performed to evaluate therapeutic response and staging/re‐staging was the purpose in 12.33%. FDG‐PET/CT scanning yielded negative results in 52.05% of the cases. The median follow‐up time was 31.16 months (range: 5‐70). Considering scan negative patients, existing treatment protocol was continued in 89.47% and stopped in 10.52%. Based on positive results of FDG‐PET/CT scanning, treatment protocol was changed in 65.71%, treatment protocol was continued in 11.43% and 22.86% were referred for surgical resection. Disease remained stable in 92.3% of those patients who remained FDG negative after definitive treatment. Progressive disease or death observed in 90.9% of those patients who were FDG positive after treatment. Secondary malignancy were detected in 5.88% with FDG‐PET/CT findings. Conclusion: FDG‐PET/CT scan is a valuable tool in patients with gastrointestinal stromal tumor especially for evaluating therapeutic response. It accurately seperates responders from non‐responders in the early phase and also it gives very important prognostic information.
P201 Response assessment of refractory GIST by FDG-PET. A GEIS study D. Fuster1, A. Sierra1, J. R. Ayuso1, A. Poveda2, R. Cubedo3, A. Casado4, J. Martínez-Trufero5, A. López-Pousa6, X. García del Muro7, J. Maurel1; 1 Hospital Clínic. University of Barcelona, Barcelona, SPAIN, 2Instituto
Valenciano de Oncología, Valencia, SPAIN, 3Clínica Puerta de Hierro, Madrid, SPAIN, 4Hospital Clínico San Carlos, Madrid, SPAIN, 5Hospital Clínico Miguel Servet, Zaragoza, SPAIN, 6Hospital Sant Pau, Barcelona, SPAIN, 7Institut Català d'Oncologia, Barcelona, SPAIN. Aim: Small changes in tumor size or density on computed tomography (CT) are sensitive and specific methods of assessing the response of GISTs and correlates well with FDG‐PET in untreated GIST patients. Despite of it, there is inconsistent prospective data in IM refractory disease. Material and Methods: The study evaluated 26 patients with metastatic high‐dose imatinib refractory GISTs treated prospectively in a multicenter phase I‐II study with doxorubicin 15‐20 mg/m2/weekly per 4 cycles (monthly cycles), followed by IM maintanance (400 mg p.o.qd). CT and FDG‐PET were done at baseline and after 2 months of therapy for response evaluation. Response rate was assessed by RECIST criteria by the Principal Investigator. All CT and FDG‐PET (using EORTC‐FDG‐PET criteria) were reviewed by two experts in abdominal CT and one expert on Nuclear medicine respectively in one Institution. Results: Tumor density measurements were not assessed on CT because some studies were not available in DICOM format and different tube currents were used in the series. There were a significant lower number of lesions identified by PI (n=73; median 2, range 1‐6) than AR (n=122;median 5, range 1‐10). Twenty‐eight out of 122 lesions identified by CT, did not demonstrate significant glucose uptake at baseline (upon 800 mg/day of IM treatment) on FDG‐PET. Mean baseline tumor size on CT was 5.9 cm (ranging from 0.9 to 28 cm), and mean baseline SUV max on FDG‐PET was 7.2 (ranging from 1.9 to 26.4). Nine patients had response on FDG‐PET based on EORTC criteria compared with 2 pts and 5 pts with RECIST or modified RECIST criteria (decrease in tumor size of more than 10%), respectively. The sensitivity for RECIST or modified RECIST criteria in identifying PET responders was 22% and 55%, respectively, showing a 100% of specificity by both methods. Good responders on FDG‐PET at 2 months had significantly longer progression free survival (264 days) than those who did not respond (64 days) (P = .01). Conclusions: FDG‐PET is a sensitive and specific method of assessing the response of GISTs pts refractory to high‐dose imatinib. If the prognostic value of FDG‐PET response criteria can be confirmed, these criteria should be employed in future studies of patients with refractory GIST.
P202 Association of classical Hodgkin lymphoma and mediastinal (thymic) large B cell lymphoma: a case report G. Chuto, B. Chetaille, V. Ivanov, D. Coso, J. Rey, I. Brenot-Rossi, R. Bouabdallah; Institut Paoli-Calmettes, Marseille, FRANCE. A 38 year old woman underwent a left supra‐clavicular lymphnode biopsy. The histopathology revealed a sclero‐nodular classical Hodgkin lymphoma (cHL): tumoral Reed Sternberg cells were strongly CD30+, CD15+ and negative for CD20. The initial 18 FDG PET‐CT showed an increased uptake in a mass localized to the upper anterior mediastinum and in left and right supraclavicular and left axillary adenopathies (Fig. 1). There was also a supicious centimetric active lung node (not shown) and the disease was classified as stade IV Bb in the Ann Arbor classification. She was scheduled for 8 courses of ABVD. The interim FDG PET‐CT after 3 courses of ABVD showed a dramatic decrease in the activity of all lesions, but a minimal residual uptake (MRU) in the inferior right part of the mediastinal mass (Fig. 2). A FDG PET‐CT after 5 courses of ABVD showed a progression of the MRU with a focal uptake (Fig. 3): the Hodgkin lymphoma was considered refractory and the patient was proposed a second line of treatment with BEACOPP. A FDG PET‐CT after 2 courses of BEACOPP showed a slight increase in size and uptake of the lesion, two new infracentimetric adenopathies (Fig. 4) and the patient was proposed à third line with ICE. A FDG PET‐CT after 2 courses of ICE showed a slight decrease but a persistent focal uptake (Fig. 5) and the patient was refered for surgical biopsy. The histopathology of the mediastinal mass revealed a proliferation of large tumoral lymphoid cells strongly positive in immunochemistry for CD20, weakly for CD30 and negative for CD15. Such morphological and immunohistochemical constatations led to a diagnosis of médiastinal (thymic) diffuse large B cell lymphoma (DLBCL). The patient was proposed a treatment with R‐Carbo‐DHAP. Association of cHL and mediastinal DLBCL is now well known, especially in young women, and gene expression profiling has suggested a partial overlap of both entities, sharing some clinical features. The 2008 WHO classification of haematological malignancies recognizes a group of lymphomas harbouring features of both entities and known as “médiastinal grey zone lymphomas with features between cHL and médiastinal (thymic) lymphomas”. Nevertheless, the treatment of these two lymphomas differs, as it has been monitored in this case report. This association is rare but should be suspected in case of mediastinal refractory Hodgkin disease, especially in woman aged 30 to 40, and prompt surgical biopsy.
P204 Peripheral Lymph Nodes Involvement in Patients with Malignant Tumors: FDG-PET/CT and US/US-guided FNAB Comparison G. Horvatic Herceg1, I. Bracic1, D. Herceg1, A. Balenovic2, S. Kusacic Kuna1, A. Knezevic Obad1, D. Grosev1, H. Tomic Brzac1, D. Dodig1; 1Clinical Hospital Centre Zagreb, Zagreb, CROATIA, 2PET/CT Centre Medikol, Zagreb, CROATIA. The status of peripheral lymph nodes might influence on final outcome of the malignant disease as it can change the therapeutic approach and is also essential for the prognosis in many types of primary cancer. The evaluation and staging of peripheral lymph nodes is therefore of utmost importance in all patients with possible nodal involvement. Purpose: The aim of this study was to compare the value of FDG‐PET/CT and US/US‐guided FNAB for evaluation of neck, axillary and inguinal lymph node involvement in patients with malignant tumors. In retrospective study sensitivity and specificity of FDG‐PET/CT and US/US‐guided FNAB was analyzed in 63 consecutive patients with malignant tumors (30 female, 33 male, mean age 46 years (17‐75). The group consisted of 35 pts with solid malignant tumors (19 melanomas, 6 gastrointestinal tumors, 4 seminomas and 6 others) and 28 pts with malignant lymphomas (13 non‐Hodgkin's lymphomas and 15 Hodgkin's diseases). Patients were examined by FDG‐PET/CT and US/US‐guided FNAB for staging, recurrency detection and therapeutic response assessment. US and FDG‐PET were performed within two month interval and the findings were compared. Histology and clinical/imaging follow‐up served as gold standard. Results: The sensitivity, specificity, positive predictive value and negative predictive value for PET/CT were as follows: 74%, 80%, 61% and 88
Poster Presentation
P24 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
S350 %; for US: 95%, 80%, 67% and 97% and US/US‐guided FNAB: 89%, 98%, 94%, and 96%. PET/CT findings were false positive in 9 cases (mainly because of inflammatory lymph node hyperplasia and seroma) and false negative in 5 cases (due to small lymph node size or necrosis). US/US‐ guided FNAB was false positive in 1 and false negative in 2 cases. Conclusion: Our series demonstrated better sensitivity and specificity of US/US‐guided FNAB in comparison with PET/CT in the evaluation of neck, axillary and inguinal lymph nodes involvement. For better accuracy in estimation of peripheral lymph nodes we recommend to supplement PET/CT study with US/US‐ FNAB. To our knowledge, this is the first study to compare between 18F‐FDG PET/CT and US/US‐ guided FNAB for peripheral lymph nodes staging in neck, axillary and inguinal region.
P205 Assessment of therapeutic response and prognosis in 18 malignant pleural mesothelioma with F-FDG-PET S. Moriya1, N. Oriuchi1, T. Higuchi1, Y. Arisaka1, A. Takano2, K. Endo1; Department of Diagnostic Radiology and Nuclear Medicine Gunma University Graduate School of Medicine, Maebashi, JAPAN, 2Department of Radiology Tone-Chuou-Hospital, Numata, JAPAN. 1
Malignant pleural mesothelioma (MPM) is an aggressive neoplasm, which has a poor prognosis; although a novel treatment with pemetrexed has shown some effectiveness in MPM. Its incidence is increasing throughout the world. Positron emission tomography with 18F‐FDG (FDG‐ PET) is potentially useful for the differential diagnosis of pleural thickening and the assessment of extent of the tumor in MPM. The aim of the present study is to explore the role of FDG‐PET for the evaluation of response to therapy and prediction of prognosis. Eight patients with MPM were included in the study. All patients had histological proof of MPM and underwent FDG‐PET. Quantitative analysis was done by computing the maximal standardized uptake value (SUV) of the FDG accumulation in the entire lesion on the attenuation‐corrected images. Following chemotherapy or surgical treatment, response was evaluated by routine procedure with CT and clinical follow‐up was done to analyze prognosis. SUV was compared with response and prognosis. All patients showed uptake of FDG in the lesion, although the intensity was variable (SUV, 2.1‐12.6). Chemotherapy including chemothermotherapy and chemoradiotherapy was done in 6 patients and the other two patients were surgically treated. Response according to radiologic criteria was partial response (PR) in 2 patients, stable disease (SD) in 3 patients, and progressive disease (PD) in 3 patients. Average SUVs of PR, SD, and PD patients were 3.3, 4.2, and 9.4, respectively. Time to progression (TTP) of patients with PR was 5 years and 4 months; however, TTP was shorter than 6 months in all three patients with PD. The present preliminary study showed that FDG‐PET could detect MPM lesions in all patients. Although number of patients was small and therapeutic regimens were heterogeneous, FDG‐PET may be useful for prediction of response and survival of patients with MPM.
P206 Evaluation of optimum timing and method of response assessment with F-18 FDG PET during salvage chemotherapy prior to autologous stem cell transplant in relapsed/ refractory aggressive Non Hodgkin’s Lymphoma and Hodgkin’s Lymphoma T. D. Barwick1, A. Hodson2, J. Dunn3, P. Fields2, M. J. O'Doherty3; 1Imperial College Healthcare NHS Trust, London, UNITED KINGDOM, 2Guy's and St Thomas' Foundation NHS Trust, London, UNITED KINGDOM, 3PET Imaging Centre at St Thomas', King's College Division of Imaging, London, UNITED KINGDOM. Aim: The aim was to assess if F‐18‐fluorodeoxyglucose (FDG) positron emission tomography (PET) after 1 or 2 cycles of salvage chemotherapy is predictive of outcome post high dose chemotherapy (HDC)/ autologous haemopoietic stem cell transplant (ASCT) in patients with relapsed/refractory aggressive lymphoma. In addition visual and semi‐quantitative methods of response assessment were assessed. Materials and Methods: Serial PET/CT scans were performed in 20 consecutive patients presalvage, post 1st and 2nd cycles of salvage chemotherapy. Scans were assessed using a 5 point visual scoring system: 1 ‐ CMR (Complete metabolic response) 2 ‐ MRU1 (Minimal residual uptake 1) Visually level of mediastinum 3 ‐ MRU2 (Minimal residual uptake 2) Visually between mediastinum and liver 4 ‐ Stable/ persistent metabolically active disease > liver 5 ‐ Progressive disease (PD). For visual analysis scores 1‐2 were considered responders and 3‐5 as non responders. Using SUV analysis 25%, 50% and 65% reduction in SUV were assessed. Six patients received radiotherapy for localised disease in addition to ASCT and were analysed separately (DXT group). The study end points were progression free survival (PFS) and overall survival (OS). The predictive value of PET was determined using the Kruskal‐Wallis test. Survival curves were estimated using Kaplan ‐Meier analysis and compared using the log rank test. Results: Using the 5 point visual analysis scale, post one cycle there were no responders. The median PFS of the progressors post one cycle was 1.5 months. Post 2 cycles the median PFS in responders was 17 months, non responders 7 months and DXT group 21 months (KW p=0.01; log rank p=0.031). Using semi quantitative analysis 25%, 50% and 65% reduction SUV cutoffs as response all significantly separated the groups post one and two cycles. The median PFS post 2 cycles in the CMR group was 12 months, >65% reduction SUV 8.5 months, PD/<65% reduction SUV 1 month and DXT group 21 months (KW p=0.018; log rank p=0.008). Conclusion: Progressive disease after 1 and 2 cycles of HDC is associated with a poor outcome. In patients with localised disease radiotherapy should be considered in addition to HDC/ASCT since PFS is improved. Post 2 cycles both a five point visual scale and semi quantitative SUV % reduction are predictive of PFS post transplant. Post 1 cycle SUV % reduction appears to be a better predictor of PFS. However larger numbers are required to assess optimum method of response assessment.
P207 Treatment of unresectable neuroendocrine liver tumors with Y-90 microsphere: Ankara University experience
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 Ö. Küçük1, S. Laçin1, S. Yağcı1, I. Öz2, S. Bilgiç2; 1Ankara Universty Medical Faculty Nuclear Medicine Department, Ankara, TURKEY, 2Ankara Universty Medical Faculty Radiology Department, Ankara, TURKEY. The primary therapy of liver lesions of NET is surgery but it is most possible for all patients. Selective internal radiation therapy (SIRT) is a new aviable method to treats liver metastases. AIM To determine the efficacy and safety of treatment of unresectable NET tumors with SIRT. MATERIAL‐METHODS 6 pts with NET were included in the study (35‐88 years old, 2female, 4male). All pts had already been taken several therapies. The liver lesions were clearly identified with dynamic CT and In‐111 octreotide scans befor therapy. Their liver fuctions were normal and no shunt >10% to lung from liver was observed with Tc‐99m MAA scan. 4/6 pts had bilobar, 2/6 had unilobar lesions. All pts were taken the first therapy to right lobe and 2 patients to left lobe additionaly in three months. Brehmsstrahlung images were taken immediately after therapy to exclude the shunt. Liver functions, In‐111 octreotide scan and dynamic CT were performed in the follow up in 6 weeks intervals. RESULTS No acute side effects were observed in all pts except mild nausea and abdominal pain. Liver function did not change during the follow up period. Clinical improvements was seen in first weeks after therapy. The size of lesions were decreased ≥ 50% in the first In‐111 octreotide scan performed 6 weeks after therpy, on the other hand, radiological improvement appeared after 3 months. Follow up period was 10 months. The recurrence was not seen. All pts were accepted on “partial or complet response”. CONCLUSION SIRT with Y‐90 microspheres was a suitable and effective therapy regimes for unresectable liver NET. In‐111 octreotide scan should be the method ohoice to evaluate the response earlier than radiological methods of this therapy.
P208 Evaluation of Y-90 microsphere therapy response of metastatic or primary liver tumor with PDG-PET/CT: Ankara University preliminary results Ö. Küçük1, S. Laçin1, S. Yağcı1, I. Öz2, S. Bilgiç2; 1Ankara University Medical Faculty Nuclear Medicine Department, Ankara, TURKEY, 2Ankara University Medical Faculty Radiology Department, Ankara, TURKEY. Selective intraarterial radionuclide therapy (SIRT) is an hopeful therapy method for primary or metastatic unresectable liver tumors. AIM To evaluate the Y‐90 microsphere therapy response in pts with primary or metastatic unresectable liver tumors with PET/CT. MATERIAL ‐ METHODS 24 pts were evaluated for SIRT but 11/24 pts were excluted because of high bilirubine levels, bad performance status, extented disease and shunt in 1 pt 13 pts were treated with SIRT. MAA shunt scan was performed before therapy. Brehmsstrahlung image were obtaiend after therapy. All pts were evaluated in 6 weeks with PET/CT and dynamic CT and/or MRI. The liver functions were checked after 2 weeks. RESULT Mild nausea, abdominal pain and fever were observed after therapy in 6 pts. 3/13 patients died 6 weeks after therapy due to extent disease. 10 pts are still in follow up. The metabolic activity of lessions was decraesed in 8/10 pts and 3 of them were taken the second dose to other lobe. 2/10 pts were accepted as no response, because new foci were detected despite the activity of liver lesions decreased. CONCLUSION The response rate was higher in pts with unilober and/or nodulary lesions than other lesions. Y‐90 microsphere was a suitable therapy method for primary or metastatic liver tumors and the response was seen earlier with PET in 6 weeks. The response rate was higher in pts with nodulary and unilober lesion than multiple and/or diffuse tumors.
P209 Oncological therapy monitoring by whole body FDG-PET/CT using a semi-automated method A. Sundin1, M. Nair2, A. Van Nuffel3, S. Kohlmyer4, P. Razifar5; 1Karolinska Institute, Stockholm, SWEDEN, 2Uppsala University, Stockholm, SWEDEN, 3 GE Healtcare, Waukesha, WI, UNITED STATES, 4GE Healtcare, Lynnwood, WA, UNITED STATES, 5Uppsala Applied Science Lab, GE Healtcare, Uppsala, SWEDEN. Aim Except for lymphomas, oncological therapy monitoring by FDG‐PET/CT generally rely on manual delineation of the tumours in Region of Interests (ROIs) and the FDG uptake is usually quantified as the Standardized Uptake Value (SUV). Most evaluation software utilizes semi automatic outlining of the ROIs. Still the procedure is laborious, subjective and time consuming even though generally not all lesions are measured. The aim of this study was to evaluate a new software, PET‐VCAR for therapy monitoring whereby the patient´s whole tumour volume is quantified. Materials & Methods Pre‐ and post‐treatment FDG‐PET/CT scans of 22 patients were reviewed and evaluated for therapy response using the soft ware PET‐VCAR by which the examinations were co‐registered automatically and the patients’ whole FDG‐avid tumours load was quantified by three‐dimensional Volumes of Interests (VOIs). Results The analysis was performed by individual bookmarking of the tumours. The automatic function that highlights potential lesions was not used because the subsequent manual exclusion of physiological FDG accumulation was too time consuming in the presence of only a few lesions. The comparison between examinations was done by way of automatic VOI propagation from the baseline to the follow‐up examinations. Accurate positioning of the VOIs was ensured by the image volume realignment function by which the CT examinations of the two studies were co‐registered using a multi‐local rigid technique. It was found that the PET‐VCAR mainly realigns the images accurately. However, manual adjustments had to be made for some cases, mainly because of marked differences in the patient´s position between studies and occasionally because of inferior image quality. The VOI propagation was accurate except for VOIs that delineated tumours positioned adjacent to areas of physiologically high FDG accumulation. In these instances the tumour VOIs were incorrectly propagated to these normal tissues. For such lesions manual VOI adjustment was necessary. The analysis of the pre‐ and post‐treatment SUVs was automated in PET‐VCAR and the resulting diagnosis was reported in a format based on the European Organisation for Research and Treatment of Cancer (EORTC) guidelines and yielded partial response in 8 patients, unchanged tumour status in 4 subjects and progressive disease in 10 cases. Conclusion This study shows the potential of using PET‐VCAR for therapy response monitoring by FDG‐PET/CT. Although care must be taken to visually confirm that the automatic functions of the soft ware are accurately performed, the response evaluation was facilitated and may also improve its reproducibility.
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FDG-PET-CT Supported Detection of Liver Metastases in Cancer: Contrast Enhancement of Liver Foci with Additional Delayed Acquisition I. Szopa, K. Gorczewski, A. D'Amico, B. Jarząb; Maria Skłodowska-Curie Memorial Cancer Centre and Institute of Oncology, Gliwice, POLAND. The aim: The malignancy detection depends on the contrast between the tumor and background uptake. The Standard Uptake Value (SUV) in liver is often used as a reference point in 18FDG PET diagnostics. However, the clinical experience shows that SUV values in liver differ to a large extent between patients. Thus, we first described the relation between the healthy liver SUV and the time which elapsed from the moment of the 18FDG injection to the moment of data acquisition. Next, for a cut‐off, the point in the ‘injection‐ acquisition time’ scale was estimated where the obtained SUV went beyond the value of standard deviation, measured for reference time point (60 min). The aim of this study is to find, if the additional acquisition of liver provides a higher image contrast for cancer metastases detection. Materials and Methods: One hundred patients monitored for the possibility of cancer progression with a negative final PET result, confirmed by the clinical evaluation, were retrospectively examined. There were 46 male and 54 female with the mean age of 47 years. The time between the 18FDG injection and acquisition ranged from 57 to 119 min. The SUV values were calculated for each ROI (region of interest) containing liver non‐specific uptake. On the basis of these data the relation between the healthy liver SUV and the injection‐acquisition time was determined and then, a prospective study was performed. In patients who exhibited a hot region in the liver, the acquisition was repeated after 90 ‐ 120 min. The signal‐to‐noise ratios (SNR) between lesions and healthy liver for both acquisitions (differing in injection to acquisition time) were calculated and compared. Results: On the basis of retrospective studies a tendency of SUV decrease with the increasing injection‐ acquisition time was described. When the time from injection to acquisition was longer than 80 min the obtained liver reference SUV value went beyond the standard deviation range. The delayed acquisition increased the contrast of metastatic lesions and helped for the accurate diagnosis of metastases. The SNR of liver metastases obtained by a delayed acquisition increased in average by 0,61 (max 1,7). Conclusions: The physiological 18FDG uptake in healthy liver may obscure the detection of small cancer foci due to high background level of tracer. Higher SNR of liver lesions leads to better and more accurate detection and delayed acquisition after 90 ‐ 120 minutes is recommended.
P211 Characterisation of system A amino acid transport and 14 system L: uptake mechanism of [ C]MeAIB and 3 [ H]Methionine in human carcinomas S. Kagawa1, R. Nishii1, T. Higashi1, H. Araki2, H. Okudaira2, T. Uehara3, M. Kobayashi3, M. Yoshimoto4, Y. Arano3, K. Kawai2; 1shiga medical center research institute, moriyama, JAPAN, 2Graduate School of Medical Science, Kanazawa University, kanazawa, JAPAN, 3Chiba University, Graduate School of Pharmaceutical Sciences, chiba, JAPAN, 4Research Institute, National Cancer Center, tokyo, JAPAN. [Objective] Although α‐[N‐methyl‐11C]‐methylaminoisobutyric acid ([11C]MeAIB) in clinical PET is known as a highly selective substrate for the system A amino acid transport, the mechanisms and differences of amino acid transport systems in human carcinomas have not been examined in detail. The aim of this study was to assess the uptake mechanism of MeAIB as specific substrate of the system A amino acid transport in human‐derived carcinoma cells, compared with that of L‐ methionine (Met). [Methods] Uptake experiments of amino acid radiotracers, α‐[1‐14C]‐ Methylaminoisobutyric acid ([14C]MeAIB) and [S‐methyl‐3H]‐L‐methionine ([3H]Met) were performed in five types of human carcinoma cells (epidermal carcinoma: A431, colorectal carcinoma: LS180, lung carcinoma: PC14/GL, H441/GL, breast carcinoma: MDA‐MB435). Inhibition studies of system A and L were also performed using MeAIB in Na+‐containing solution + as a specific inhibitor of system A, and BCH in Na ‐free solution as a specific inhibitor of system L. [Results and Conclusions] The uptake of [3H]Met is about 3‐8 times higher than that of [14C]MeAIB in all carcinoma cells. Inhibition study of amino acid transport in carcinoma cells 14 3 revealed that [ C]MeAIB was transported into these cells by the system A, while [ H]Met was by the system L. The contribution of system A amino acid transport and system L in carcinoma cells were 18.6% and 79.7% in A431, 16.8% and 81.0% in H441, 10.8% and 88.3% in MDA‐MB435, 21.9% and 73.7% in PC14 and 24.2% and 72.4% in LS180, respectively. Therefore, the selection and preparation of PET radiopharmaceuticals based on the characterization of amino acid transport system would provide a novel perspective in clinical diagnose and management in patients with carcinoma.
P25 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: PET, PET/CT in radiotherapy planning
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Target volume definition for 18F-FDG PET positive lymph nodes in radiotherapy of patients with non-small cell lung cancer.
N. Rodríguez de Dios1, C. Trampal2, X. Sanz1, R. Jimenez3, P. Foro1, A. Reig3, M. Lacruz1, J. Lozano3, I. Membrive3, M. Algara1; 1Hospitales del Mar y de la Esperanza. Universidad Pompeu Fabra, Barcelona, SPAIN, 2Instituto de Alta Tecnología ( IAT/CRC), Barcelona, SPAIN, 3Hospitales del Mar y de la Esperanza., Barcelona, SPAIN. Introduction: PET with 18F‐FDG has been used in radiation treatment planning for NSCLC. Thresholds of 15%‐50% the maximum standardized uptake value (SUVmax) have been used for
gross tumor volume (GTV) delineation by PET, with 40% being the most commonly used value. To date, lymph nodes have been contoured according to the threshold of % SUV max of the tumor. Objective: Determine if the percentage threshold of maximum SUV (MBeq) of the tumor can provide a method that will adequately delineate volumes for all lymph nodes (PET‐GTVn). Material and Methods: The study included 32 cases with non‐small cell lung cancer, who underwent a diagnostic 18F‐FDG PET/CT scanner (GE Discovery ST). For CT planning, the primary tumor (CT‐GTVt) was delineated using lung L/W settings (1600, ‐600) and the pathologic lymph nodes (CT‐GTVn) using mediastinum L/W settings (400, 40 ). The PET‐based GTV (PET‐GTVt) was delineated for each tumor with 40% threshold isodensity contours. For estimation of the SUV, a square volume of interest was determined for each lesion at its maximal diameter in the axial, coronal, and sagittal planes on the fused PET and CT images. The method entailed locating the lesion within the slices and recording the maximum pixel of the PET image within the region of interest. This volume excluded any lymph nodes. The PET based GTV (PET‐GTVn) for each lymph node/whole anatomical region of the mediastinum was contoured using the same method. First, we used 40% threshold isodensity contours based on SUV max of the tumor (PET‐GTVnt40). A second GTV (PET‐GTVnn40), based on 40% SUV max of each node was created. In order to avoid inter‐observer variability, this was carried out by the same radiation oncologist. Results: The mean sizes of CT‐GTVn, PET‐GTVnt40 and PET‐GTVnn40 were 15.80±15.0, 10.50±14.1 and15.20±16.2 cc, respectively. Compared with CT‐GTVn, the intraclass correlation coefficient for two‐way mixed effects model of PET‐GTVnn40 (0.93; CI: 0.86‐0.96) was higher than the coefficient of PET‐GTVnt40 (0.49; CI: 0.18‐0.71) Conclusions: 18F‐FDG PET‐GTV nn40 correlates more faithfully with CT‐GTVn than PET‐GTVnt40 and it is an effective tool to define the target of GTVn in radiotherapy planning. This work was supported by grants from Instituto de Salud Carlos III‐FEDER, (PI080376)
P213 Evaluation of Bone Marrow Activity after Carbon-Ion Radiotherapy by PET/CT Using a Proliferative Tracer, FLT M. Koizumi, T. Saga, M. Inubushi, K. Yoshikawa, T. Fukumura, M. Baba; National Institute of Radiological Sciences, Chiba, JAPAN. Aim: In the radiation therapy, normal bone marrow is often included in radiation field inevitably. The aim of this study was to investigate the change in 3’‐18F‐fluoro‐3’‐deoxy‐L‐thymidine (FLT) uptake to normal bone marrow after inevitable radiation. Methods: Twenty‐one non‐small cell lung cancer (NSCLC) patients who received carbon ion radiotherapy (CIRT) were studied with regard to bone marrow activity by FLT PET/CT. CIRT was performed with three protocols (42‐44 GyE/1 fraction in 9 patients, 52.8‐60 GyE/4 fractions in 10 patients, and 62.8 GyE/12 fractions in 2 patients). These dose and fraction pairs gave the similar clinical tumor response results. Radiation dose to bone marrow was calculated by three dimensional CT planning system. FLT PET/CT studies were carried out before and after CIRT. Post‐CIRT FLT studies were performed at 1 or 2 day after CIRT (6 patients), 3 months after CIRT (20 patients) and more than 1 year after CIRT (3 patients). FLT uptake was evaluated visually and by a maximum standard uptake value (SUVmax). In some evaluations, the ratio of uptake of irradiated marrow to non‐irradiated counterpart was used. As non‐irradiated control sites, changes in lumbar (L2‐5) bone marrow FLT uptake were measured. Irradiated bone marrow was divided into 2 two groups (10‐30 % of maximum dose, and more than 30% of maximum dose), and the changes of FLT uptake were measured. Results: Ribs were included in the radiation field in all patients; spine in 2 patients, scapula in 7 patients, and sternum in 2 patients. FLT uptake in the bone marrow receiving the 10 % dose or more clearly decreased at all time points after CIRT in comparison with pre‐irradiation values. The FLT uptake was the lowest just after CIRT, somewhat recovered at 3 months, and remained unchanged for more than 1 year. There was no significant difference in reduction of FLT uptake between the area receiving 10‐30% dose and those receiving more than 30%. FLT uptake to non‐ irradiated areas (L2‐5) was not changed after CIRT. Conclusion: Bone marrow receiving as low as 10% dose of carbon ion showed clearly decreased FLT uptake. Bone marrow cells are considered sensitive to low dose. FLT‐PET can sensitively detect these changes and may help to confirm the radiation field.
P214 18F-FDG PET-CT in radiation treatment planning for rectal cancer. A. M. García Vicente1, E. Lozano Martín2, M. P. Talavera Rubio1, M. E. Bellón Guardia1, B. González García1, A. M. Palomar Muñoz1, V. M. Poblete García1, J. P. Pilkington Woll1, I. Cepedello Boiso1, J. M. Cordero García1, L. A. Pérez Romasanta2, A. M. Soriano Castrejón1; 1Nuclear Medicine Department. Hospital General, Ciudad Real, SPAIN, 2Radiotherapy Department. Hospital General, Ciudad Real, SPAIN. Aim: To analyze the impact of 18F‐FDG PET‐CT in the staging and in the target volume delineation in radiation therapy, compared with CT alone, in patients with rectal cancer. Material and methods: Between October 2007 and August 2008, 13 patients (10 males and 3 females, mean age of 69.8) with rectal cancer, candidates for radiotherapy, were prospectively included. All patients had T3 disease, 8 had involved perirectal nodes and 3 distant disease (M1) in conventional diagnostic techniques. The patients underwent PET‐CT scan. This one day exploration was used for staging and treatment planning purposes. We used a hybrid PET‐CT system. After the standard total body PET‐CT (60 min after intravenous administration of a mean dose of 370 MBq‐18F‐FDG) a second PET‐CT of abdominal‐pelvic region was performed, 3‐4 hours after FDG injection, with patient in the prone position using the immobilization devices, with retrograde irrigation of the urinary bladder with 300 cc of physiological saline and intravenous administration of contrast. CT‐gross tumor volume (GTV) delineation was first performed on CT images. PET‐biological target volume (BTV) was selected using a fixed threshold value of 40% of the maximum uptake in the lesion. A combined volume, PET‐BTV + CT‐GTV (PET‐ CT clinical target volume) obtained on PET‐CT fused images, was used for radiotherapy planning. We analyzed the differences between CT‐GTV and PET‐BTV and calculated the discrepancy index, obtained from the ratio of combined volumes to that common volumes. Results: In 5 of 13 cases the use of PET‐CT affected the N staging (2 cases from N0 to N1, 2 cases from N2 to N1 and one case from N1 to N0). In 2 out of these 5 cases, the M stage was changed from M1 to M0 and from M0 to M1 respectively. In 3 cases the radiotherapy protocol was stopping. In the 10 patients underwent radiation planning, PET‐BTV was significantly smaller than CT‐GTV (mean: 41.74 ± 11.45 cm3 and 78.15 ± 17.94cm3 respectively). The mean discrepancy index between both
Poster Presentation
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S352 volumes was 2.49 ± 0.53. Conclusions: FDG PET/CT may have a potential impact on staging in patients with rectal cancer submitted to radiotherapy, with a stage variation in 38% of cases and a change of treatment strategy in 23%. Our preliminary results show that PET based target volume delineation can induce changes in the standard procedure although it is necessary further evaluation and prospective studies to assess the real impact on therapeutic results.
P215 Impact of 18F-FDG PET-CT in planning radiation treatment in lung cancer. A. M. García Vicente1, M. Sanz Martín2, M. E. Bellón Guardia1, A. M. Palomar Muñoz1, V. M. Poblete García1, J. M. Cordero García1, I. Cepedello Boiso1, J. P. Pilkington Woll1, B. González García1, M. P. Talavera Rubio1, L. A. Pérez Romasanta2, A. M. Soriano Castrejón1; 1Nuclear Medicine Department. Hospital General, Ciudad Real, SPAIN, 2Radiotherapy Department. Hospital General, Ciudad Real, SPAIN. Aim: To assess the impact of 18F‐FDG PET‐CT in the staging and radiotherapy indication of patients with inoperable lung cancer. Material and methods: Patients with locally advanced lung cancer and candidates for radiotherapy based on CT results were sent to our department during 2008. All patients underwent 18F‐FDG PET‐CT scan in a hybrid device following a standardized one day protocol. 27 PET‐CT consecutive scans, from 25 patients with lung cancer (mean age of 66.7, all males but one), were prospectively evaluated. All patients, All patients, except 3, had a non‐small‐cell lung cancer. All, except one, had locally advanced disease. 7 underwent previous quimiotherapy treatment. The PET‐CT was used for staging and treatment planning purposes. A standard PET/CT was obtained for staging information and in case of absence of metastatic disease a second PET‐CT scan, 3‐4 hours after FDG injection (mean dose of 370 MBq), was acquired. This second study was performed in the thorax using all the radiotherapy immobilization devices and intravenous administration of contrast following a diagnostic protocol. Radiotherapy planning was performed attending PET‐CT scan results. Target volume delineation (Biological target volume) was performed based on delayed metabolic image using a fixed threshold value (SUV ≥ 2.5). When the lymph nodes were considered positive on PET the whole pathologic anatomic region of the mediastinum, attending to the CT information (gross tumor volume) was included in the clinical target volume. Results: In 17 of 27 cases the use of PET/CT affected the previous TNM staging (10 cases from M0 to M1 and 1 case from M1 to M0). In 4/27 occasions, patients were shifted to palliative treatment and in 9/27 the radiotherapy protocol was suspended due to the diagnosis of a more advanced disease. In one case the PET results indicated surgical procedure, due to the absence of nodal disease that was histologicaly confirmed. Conclusions: 18F‐FDG PET/CT has a potential impact on staging, with a stage variation in 63% of cases. Furthermore, PET information influences treatment planning in a high proportion of cases (52%), changing the treatment strategy.
P216 Utility of FDG-PET-CT on the radiotherapy planning of head and neck tumours. Our initial experience M. E. Bellón Guardia1, L. Pérez Romasanta2, A. M. Garcia Vicente1, M. P. Talavera Rubio1, B. Gonzalez García1, I. Cepedello Boiso1, J. M. Cordero García1, V. M. Poblete García1, A. Palomar Muñoz1, P. Pilkington Woll1, A. Soriano Castrejon1; 1Nuclear Medicine Dept. Hospital General, Ciudad Real, SPAIN, 2Radiotherapy Dept.. Hospital General, Ciudad Real, SPAIN. Aim: To evaluate the impact of FDG‐PET‐CT in the staging and tumour volume definition in radiotherapy planning of patients with head and neck tumours. Matherial and Methods: We studied prospectively 20 patients (12 males and 8 females, mean age of 55y) with head and neck tumours submitted before radiotherapy treatment using a PET‐ CT (GE DSTE 16) for planning, staging or re‐staging. Two of them were excluded because we could not assess tumour on CT or PET images for contouring. From the rest, five patients (5/18) were previously treated with radiotherapy and/or surgery. Other three received quimiotherapy before FDG‐PET‐CT (less than or equal to 3weeks). We analized a total of 28 lesions (18 primary lesions and 10 nodes). The most frecuent location was oropharynx (5 patients). The study was performed according standard procedures and an aditional 3 hours delayed PET image with diagnostic CT parameters (radiologic contrast and 1.25mm thickness) was acquired using the same head‐shoulder mask and table top available for radiotherapy treatment. We analized the nodal status, changes in staging and the differences in GTV volumes obtained with PET and CT. A disagreement index (DI) was calculated (DI= composited volume/common volume) being 1 the complete agreement between them and infinity the total disagreement. A threshold value between 20‐40% SUVmax was arbitrarily established for delineating GTV . Results: PET‐CT induced changes in the nodal status (N) in 9 patients (50%), being three of them upstaging and showed a bone metastasis and a second renal tumour. In 4 patients FDG‐PET‐CT resulted in treatment changes (22,2%). The mean SUVmax of the 28 lesions studied was 14.4 (range 5,0 and 26,4). No statistically significant differences between GTV PET and GTV CT were found (mean 21.9 cm3 and 19.3cm3 respectively) although the GTV PET seemed to be a bit greater. Only in 10 lesions the GTV PET was lower than CT. The DI calculated was 3.1(range 1.36‐4.83). Conclusion: PET‐CT may have an impact in the therapeutic management of patients with head and neck tumours submitted for radiotherapy planning, allowing a more correct staging and producing changes in the volume definition. However, more prospective and randomized studies are necessary to evaluate the possible impact in the therapeutic outcome.
P217 Comparison of PET-CT vs CT simulation in Clinical Target Volume (CTV) definition in radiotherapy (RT) of Hodgkin (HL) and Non Hodgkin (NHL) Lymphomas. F. Grillo-Ruggieri, A. Piccardo, A. Siragusa, L. Amara, E. Biscaldi, G. Villavecchia; Galliera Hospital, Genova, ITALY. Aim: To evaluate the possible role of PET‐CT simulation for a better Clinical Target Volume (CTV) delineation, as defined by the International Commission on Radiation Unit Reports 50 and 62 ,
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 including macroscopic disease and a safety margin for microscopic diffusion, in comparison to standard CT simulation in 3D‐Conformal Radiotherapy. Patients and methods: Fourteen consecutive patients with NHL (8 cell diffuse, 4 follicular, 1 T peripheral type) and HL (1 nodular sclerosis) were referred for radiotherapy. All patients underwent 18FDG PET‐CT: the study was performed in the treatment position on an indexed carbon fiber couch (for accurate repositioning of patients on the linear accelerator identical couch), 50 min after iv injection of an average dose of 370 MBq of 18 F‐FDG. An expert radiation oncologist defined the CTV, on CT images alone and then he defined a new CTV using the fused images from 18F‐FDG PET‐CT instead. Afterwards, the two types of CTV were compared. A difference superior to one third between the two CTV volumes was considered significant. The mean administered dose of radiotherapy was 39.75 Gy in 1.8‐2.0 Gy fractions. Results: CTV was modified in volume according to PET‐CT in comparison to CT alone simulation in 9 out of 14 patients. In particular, in 5 patients the CTV was enlarged and in 4 it was reduced. In 5 patients CTV remained unmodified. Conclusion: In this very preliminary experience PET‐CT appears to have important impact on HL and NHL CTV definition. It is necessary to extend the number of patients to demonstrate if there is statistical significance in the modification of CTV based on PET‐CT instead of more conventional simulation method.
P218 Prospective evaluation of the impact of positron emission tomography (PET) on therapeutic decisions in radical radiotherapy candidates with non-small cell lung cancer (NSCLC) M. Niemiec1, M. A. Dziuk2, L. Kepka1, A. Zawadzka1, K. Bujko1; 1Maria Sklodowska-Curie Memorial Centre Institute of Oncology, Warsaw, POLAND, 2Military Institute of Health Services, Mazovian PET-CT Centre, Warsaw, POLAND. BACKGROUND PET using [18F]‐fluorodeoxyglucose (18F‐FDG) is recommended as useful tool in staging accuracy and radiotherapy (RT) planning for NSCLC patients. As in our center, the 18F‐ FDG‐PET represents a new diagnostic modality, the prospective study was launched to assess how the use of PET impacts our management of radical RT candidates with NSCLC. AIM To evaluate how often the use of PET results in change of decisions about a radical RT for NSCLC patients and how the treatment volumes and schedules are modified in patients who actually receive radical RT after PET. METHOD All consecutive NSCLC patients for whom a decision about a definitive radical RT was done according to departmental policy (stage I‐IIIB, Zubrod 0‐1, FEV1>1l, weight loss<10%) underwent planning CT, then target volumes (+/‐elective nodal irradiation [ENI]), total dose and fractionation were defined. Treatment plans were prepared for pre‐PET target volumes. Subsequently all patients underwent PET imaging and final decision about type of treatment was reconsidered. If decision about radical RT was maintained, treatment volumes were adjusted for PET findings, if needed. For patients with a change of target volumes after PET new treatment plans were realized as definitive (by physicist blind to previous volumes) and in the pre‐PET plans dose coverage was recorded for post‐PET volumes. During first four months 43 patients were included in the study. RESULTS After PET 13/43 (30%) patients did not receive radical RT (8 ‐ distant metastases, 4 ‐ too extensive loco‐regional disease, 1 ‐ relapse not confirmed). In 14/43 (33%) the technique of radical RT has been modified (11 ‐ omission of ENI, 1 ‐ enlargement of ENI, 1 ‐ reduction of dose per fraction due to unexpected mediastinal findings for peripheral tumor). In 16/43 (37%) the technique has not been changed. In 5 on 30 (17%) patients who actually received radical RT, the geographical error would have been done, if PET had not been available; positive lymph nodes (4) and part of GTV within the limits of atelectasis (1) would have been missed. CONCLUSIONS A strong impact of PET‐CT information on the management and radiation planning of radical RT candidates with NSCLC was confirmed especially in staging and lymph nodes irradiation planning.
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Diagnostic Oncology - PET, PET/CT: new clinical methods and radiopharmaceuticals
P219 Usability of the Heparin appositional whole body FDG PET New methods to reduce cardiac physiological accumulation S. Fujita1, S. Nagamachi2, H. Wakamatsu2, R. Nishii2, S. Ueno1, Y. Umemura1, T. Fujimoto1, S. Tamura2; 1Fujimoto Hayasuzu Hospital, Miyazaki, JAPAN, 2University of Miyazaki Hospital, Miyazaki, JAPAN. Objectives: FDG‐PET is useful examination for cancer diagnosis, but, it is difficult in mediastinal lesions for cardiac physiological accumulation. As intravenous injection of Heparin before FDG injection, blood lipoprotein lipase activity develops, and cardiac physiological accumulation reduces because cardiac glycometabolism changes in fatty acid metabolism. We present the early experience of new methods to reduce cardiac physiological accumulation in whole body FDG‐ PET; no previous study assessed the Heparin appositional FDG‐PET for cancer diagnosis. Methods: Twenty patients (11 pericardiac lung cancer, 4 mediastinal tumor, 3 cardiac tumor, 2 sarcoidosis) were underwent the Heparin appositional FDG‐PET. All patients were intravenous injected heparin (50 unit/kg) just before 15 minutes of FDG injection, and PET images were obtained 1hour and 2hours after injection of 185 MBq of FDG. Results: 35 images of 20 patients were no cardiac physiological accumulation in FDG‐PET image after injection of Heparin, so it was useful for diagnosis of cardiac and pericardiac lesions (88%, 35/40). But 2 patients of both images and another only delayed image were visualized cardiac accumulation, so it was difficult for diagnosis of pericardiac lung tumor and cardiac tumor. All patients were not side effect of heparin‐induced thrombocytopenia. Conclusions: This is the first report; the clinical Heparin appositional FDG‐PET has the potential to detect cardiac or pericardiac tumor clearly because of reduction of cardiac physiological accumulation. With care of side effect included heparin‐ induced thrombocytopenia, it is useful method of the heparin appositional whole body FDG‐PET for diagnosing lung and mediastinal cancer.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Novel Bifunctional Bisphosphonates for the Detection and Therapy of Bone Metastases R. Torres Martin de Rosales1, C. Finucane2, S. J. Mather2, P. J. Blower1; Division of Imaging Sciences, King's College London, London, UNITED KINGDOM, 2Centre for Molecular Oncology and Imaging, Institute of Cancer, Barts and The London School of Medicine, London, UNITED KINGDOM. 1
INTRODUCTION: The most used radionuclide tracer for the detection of bone metastases is Tc‐ 99m‐methylenebisphosphonate (Tc‐99m‐MDP). This agent accumulates in highly metabolic areas of the bone such as metastases due to the targeting properties of the bisphosphonate (BP) group. A therapeutic analogue, the beta‐emitter Re‐188‐HEDP, has shown great clinical promise. Despite their proven clinical success, however, it is known that both the Tc‐99m‐MDP and Re‐ 188‐HEDP preparations used in the clinic are not chemically pure, consisting of a mixture of anionic polymers. Furthermore, the therapeutic Re‐188‐BPs are highly unstable in vivo, which is a result of lack of chemical design. AIMS: Our aim is to improve the specificity and properties of current Re‐188‐BPs by using novel stable and well‐designed targeted agents. To achieve this, our design separates a chelating group from the targeting group (BP). RESULTS: A series of new BP‐ chelator based on dipicolylamine (DPA), dimercaptosuccinic acid (DMSA) and dithiocarbamate (DC) with pamidronate, alendronate and neridronate have been designed, synthesized, purified and characterised. These compounds have been radiolabelled with Tc‐99m in excellent radiochemical yields and purity. In vitro experiments have revealed that these compounds show higher and more selective binding to the main component of bone mineral (hydroxyapatite) and less protein binding than Tc‐99m‐MDP. NanoSPECT studies with Balb/C female mice have also demonstrated a remarkably similar biodistribution profile compared with Tc‐99m‐MDP. CONCLUSIONS: These results demonstrate the high potential of our BP‐chelators conjugates as well‐defined and characterised agents for the diagnosis and treatment of bone metastases. We are currently performing labelling studies with Re‐188 before undergoing further in vitro and in vivo pre‐clinical studies. These results will be presented.
P221 18F-Fluoride scintigraphy
PET/CT
in
patients
with
equivocal
bone
D. C. Bortot, G. C. R. Oki, B. J. Amorim, S. B. Gapski, P. P. G. Ruiz, P. T. Arouca, A. O. Santos, M. C. L. Lima, E. C. S. C. Etchebehere, E. E. Camargo, M. F. Barbosa, J. Menguatti, C. D. Ramos; University of Campinas, Campinas, BRAZIL. Aim: The aim of this study was to evaluate the utility of 18F‐Fluoride PET/CT in defining equivocal lesions on bone scintigraphy (BS) as benign or malignant. Materials & Methods: 39 consecutive patients with equivocal lesions on conventional planar BS were prospectively selected for 18F‐ Fluoride PET/CT (15 male and 24 female; mean age 59, 4 ± 24, 5 years; range 34‐84 years). The patients had various oncologic diseases, including cancer of the breast (n = 18), prostate (n = 8), lung (n = 3), colorectal (n = 2) and other cancers (n = 8), with a total of 78 inconclusive lesions on BSs. All patients had the PET/CT performed 1 hour after the intravenous injection of 370 MBq of 18F‐Fluoride, up to 4 weeks after BS. PET/CT and BS images were visually compared. The equivocal lesions identified on BS were interpreted as normal, definitely benign, probably benign, definitely malignant, probably malignant or equivocal, based exclusively on the PET/CT finds. Results: 87% of the equivocal lesions on BS could be defined as definitely malignant (24/78) or definitely benign (44/78) by 18F‐Fluoride PET/CT, 10% as probably malignant (2/78) or probably benign (6/78), and only 2/70 lesions remained inconclusive. PET/CT also revealed 27 additional bone metastases and 3 additional lesions that were considered inconclusive for malignancy. Conclusions: 18F‐Fluoride PET/CT imaging is useful in defining the bone involvement of cancer patients with equivocal lesions on conventional BS.
P222 New high yield HPLC purification with ethanol of 18F-RGDEchi and directly injection in mice M. M. Panico1, L. Lang2, A. Greco3, A. Greco3, S. Gargiulo4, M. Larobina1, S. Del Vecchio5, A. Zannetti1, L. Zaccaro1, L. Zaccaro1, A. Del Gatto1, M. Saviano1, B. Alfano1, M. Salvatore5; 1IBB-CNR Università Federico II, Napoli, ITALY, 2NIH, Bethesda,MD, MD, UNITED STATES, 3Dip. Scienze Biomorfologiche e Funzionali,Università Federico II-CEINGE, Napoli, ITALY, 4 Dip. Di Sc. Biomorfologiche e Funzionali, Univ. Federico II, Napoli, ITALY, 5 Dip. Sc. Biomorfologiche e Funzionali, Università Federico II, Napoli, ITALY. Introduction: The process of new blood vessel formation (angiogenesis) is characterized by the overexpression of the so‐called "angiogenic markers" that normally are not present in resting cells. Among these, αvβ3 and αvβ5 integrins belonging to a large family of heterodimeric transmembrane cell surface receptor family. So far, the pentapeptide cyclo (‐Arg‐Gly‐Asp‐d‐Phe‐ NMeVal‐), referred to as c(RGDf[NMe]V), is one of the most active αvβ3 antagonists reported in the literature. We studied the labelling synthesis with fluorine and a new HPLC purification of this radiocompound, and we tested it in mice. Methods: Pentamethyl 4‐(trimethylammonium trifluoromethanesulnate) benzoate was reacted with anhydrous 18F‐fluoride in presence of kryptofix and potassium carbonate in acetonitrile at 105°C for 10 min to give 18F‐pentamethyl 4‐ fluorobenzoate. The pentamethyl ester was hydrolyzed with 0.1 mL trifluoroacetic acid to give 18F‐4‐fluorobenzoic acid and the acid was converted to 18F‐N‐succinimidyl 4‐fluorobenzoate with N,N‐disuccinimidyl carbonate. The final product was purified with the reversed phase semi‐ prep HPLC column using 25% acetonitrile with 0.15% acetic acid as the eluent running at 6 mL/min. The radioactive product collected in HPLC solvent was trapped on a C‐18 cartridge and eluted with 1 mL dichloromethane to a 2 mL microtube.RGDechi (50 micrograms) in 50 microliters of buffer solution at pH values 8.5 and 9 were transferred to microtube containing the radioactivity, the mixture was reacted at 50°C temperature for 40 minutes. Results: In order to test whether RGDechi peptide was able to in vivo discriminate endogeneously expressed αvβ3 and αvβ5 integrins, microPET/CT imaging studies were performed in nude mice. To avoid the labeling in solution of a Lys15, the RGDechi sequence was modified by substituting this aminoacid
with homocitrulline residue (RGDechi‐hCit) to increase the labeling yield. Conclusions: We used the F‐18 N‐succinimidyl 4‐fluorobenzoate to label the amino group of lysine peptide and we could obtain radiolabelling yields of >15%. To avoid the labeling in solution of a Lys15, the RGDechi sequence was modified by substituting this aminoacid with homocitrulline residue (RGDechi‐hCit) The RGDechi was synthetized replacing the lysine at the C‐terminus with homocitrulline to increase the labeling yield, in fact only one lysine will react with 18F‐N‐ succinimidyl 4‐fluorobenzoate. We carried out also the new purification process of radioligand that was easily purified with ethanol in HPLC and did not require the evaporation of solvents for directly injection in mice. The yield of HPLC fraction was sufficient for carrying out experiments in large number of mice.
P223 Non-invasive Parametric Blood Flow Imaging of the Head-andNeck Tumours Using [15O]H2O and PET/CT G. Komar1, V. Oikonen1, N. Kudomi1, M. Seppänen1, H. Minn2; 1Turku PET Centre, Turku, FINLAND, 2Turku PET Centre and Turku University Hospital, Department of Oncology and Radiotherapy, Turku, FINLAND. Aim: To develop a simple non‐invasive method for measuring blood flow (BF) in [15O]H2O‐ perfusion PET/CT imaging of head‐and‐neck area for the use in daily clinical practice. Patients and Methods: Fifteen patients with confirmed head‐and‐neck cancer were scanned with a GE Discovery VCT scanner. A 6‐min, 26‐frame dynamic [15O]H2O emission scan with simultaneous on‐line radioactivity measurement of radial artery was preceded by a low dose CT scan. The mean injected [15O]H2O dose (ID) was 1173 MBq (range, 1001‐1339) and patients’ mean body mass (BM) was 81 kg (range, 50‐130). Alongside the measured radioactivity curve corrected for physical decay, delay and dispersion (MIF), a model‐based (MB) input function (IF) was calculated using cerebellum activity and a reference‐tissue method developed by Kudomi et al. (J Nucl Med. 2006;47(Suppl 1):361P), and a population‐based standardized IF (SIF) was calculated by averaging all MIF curves corrected for the patient’s ID and BM. SIF curve was rescaled using individual patient’s ID and BM. Parametric perfusion images were calculated for each set of IFs using a linearized two‐compartment model. Perfusion values of tumours, neck muscle and the cerebellum were obtained from all three parametric images. Pearson’s coefficient of correlation and paired T‐test were used to determine correlations and differences between BF values of these methods. Results: There was no correlation between the mean tumour BF values obtained with MIF and MB methods (R=0.149; P=0.595, see Table) with values being significantly different (P=0.039). The correlation between BF measured with MIF and SIF showed borderline significance (R=0.504; P=0.055) while T‐test did not reveal any difference between the two methods (P=0.346). Muscle BF values of MIF correlated very well with those of both MB (R=0.821; P<0.001) and SIF (R=0.900; P<0.001) and t‐test did not detect any differences between the groups. Cerebellum BF values revealed a borderline correlation between MIF and SIF methods (R=0.470; P=0.076) and no correlation between MB and MIF methods (R=0.408; P=0.131) while T‐test found no differences between the three groups. Conclusions: Blood flow of low‐perfusion tissues in head‐and‐neck area (resting muscle) can be reliability quantified using both non‐invasive methods. The higher and more variable BF of malignant tumours and cerebellum makes use of non‐invasive techniques more challenging although SIF method seems to perform reasonably well even with the limited number of patients in our study. This method could be further optimized by correcting the IF for body surface area and thereby reducing the negative impact of obese patients. Mean blood flow values (mL/min/dL) for all three methods
Tumour
Muscle
Measured IF
68.2 ± 21.4
7.0 ± 3.2 54.6 ± 10.6
Model Based IF
54.3 ± 14.4
6.7 ± 3.3 53.0 ± 14.2
Standardized IF
63.0 ± 20.1
6.7 ± 2.9 51.9 ± 17.2
P224 Synthesis and evaluation of microPET in mice
Cerebellum
76
BrDG for tumor diagnosis using
Y. Iida1, N. Ishioka2, S. Watanabe2, H. Yoshioka1, H. Hanaoka1, S. Watanabe2, T. Higuchi1, N. Oriuchi1, K. Endo1; 1Gunma University School of Medicine, Maebashi, JAPAN, 2Japan Atomic Energy Agency, Takasaki, JAPAN. Objectives: 76Br is a positron emitter with long half‐life (16.2hr). It has a suitable property for labeling of various PET tracers. So we planned to develop radiopharmaceuticals labeled with 76Br 18 using for tumor diagnosis with PET. F‐FDG is the most useful tracer for tumor diagnosis, so we synthesized 76Br‐2‐deoxy‐2‐bromo‐D‐glucose (76BrDG) and evaluated its potential as PET tracer for tumor diagnosis in tumor bearing mice. Methods: 76Br was produced via the 76Se(p,n)76Br reaction by irradiating Cu276Se pellet with 20MeV proton beam. 76BrDG was synthesized from mannose triflate according to almost same method with 18F‐FDG synthesis. We prepared LL/2 tumor bearing mice for biodistribution studies of 76BrDG and 18F‐FDG. PET studies were performed on mice bearing LL/2 tumor using with microPET. Results: The yield of 76Br was 250MBq for 8hr irradiation. 76BrDG was obtained about 50% as a radiochemical yield. The biodistribution studies of 76BrDG and 18F‐FDG in LL/2 tumor bearing mice indicated high uptake to tumor (4.4 and 6.5 %dose/g), but 76BrDG showed no accumulation into brain differ from 18F‐FDG (1.3 and 6.5 %dose/g). We obtained clear tumor images of 76BrDG using microPET and they were similar with that of 18F‐FDG. Conclusion: Uptake mechanism of 76BrDG in tumor would differ from that of 18F‐FDG because 76BrDG showed no uptake into brain. But 76BrDG accumulated highly to tumor and we obtained clear images of tumor, so 76BrDG has great potential for tumor detection with PET.
Poster Presentation
P220
S354 P27 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology - PET, PET/CT: prognosis & cost effectiveness
P225 Metabolic tumor volume assessed by 18F-FDG-PET/CT as a predictor of outcome in patients with multiple myeloma R. Fonti1, M. Larobina1, S. De Luca2, R. Fabbricini3, L. Catalano3, B. Rotoli3, L. Pace2, S. Del Vecchio2, M. Salvatore2; 1Institute of Biostructures and Bioimages, National Research Council, Naples, ITALY, 2Department of Biomorphological and Functional Sciences, University "Federico II", Naples, ITALY, 3Department of Hematology, University "Federico II", Naples, ITALY. Prognostic stratification of multiple myeloma patients is based essentially on staging systems that include factors such as β2 microglobulin and haemoglobin. 18F‐FDG‐PET/TC allows the direct measurement of metabolic tumor burden thus providing a potential prognostic index. Aim. To test whether metabolic tumor volume (MTV) determined by whole body 18F‐FDG‐PET/CT can predict overall survival in patients with multiple myeloma. Materials and Methods. Twenty‐nine patients (11 females, 18 males; mean age±SD 62±11 y) with stage IIIA multiple myeloma underwent whole‐body 18F‐FDG‐PET/CT. Imaging data were transferred to a xeleris workstation in DICOM format and 3D region of interest analysis was performed on PET images taking into account all focal lesions with an SUVmax >2.5. MTV of each lesion was calculated using an in‐ house developed SUV‐based automated contouring program that uses a threshold of 40% of the SUVmax. The total MTV of each patient was defined as the sum of metabolic volume of all focal lesions. Patients were treated and then subjected to a mean follow‐up period of 24 months. Results. In the 29 patients studied MTV ranged from 1.3 to 175.2 ml with a median value of 19.8 ml. Patients who died at follow‐up (n=6) had a significantly higher MTV (93±66 ml vs 27±23 ml, p<0.01) than patients that were still alive (n=23). Overall survival was significantly better in patients with MTV ≤19.8 ml as compared to those having MTV >19.8 (93% vs 64%, p=0.05). No differences in age, performance status and therapeutic regimen were found between the two groups. A direct and significant correlation was found between MTV values and β2 microglobulin (r= 0.41, p=0.03) whereas haemoglobin levels were inversely and significantly correlated with MTV (r=‐0.46, p=0.01). Conclusion. The direct measure of tumor burden obtained by calculating the MTV value on 18F‐FDG‐PET/CT images may be a useful tool in predicting overall survival in multiple myeloma patients.
P226 The economic impact of PET-CT in the management of malignant melanoma patients with pulmonary metastases B. Krug1, R. Crott2, I. Roch3, C. Beguin2, J. Baurain2, M. Lonneux2, A. Pirson1, T. Vander Borght1; 1Mont-Godinne University Hospital, YVOIR, BELGIUM, 2Saint-Luc University Hospital, Brussels, BELGIUM, 3Public Health Department, Université Catholique de Louvain, Brussels, BELGIUM. Objectives: Most guidelines consider hybrid imaging (PET‐CT) to detect occult extra‐pulmonary disease prior to lung metastectomy. A cost‐effectiveness analysis, using a Markov model over a 10 year period, was performed to compare 2 different surveillance programs, either PET‐CT or whole‐body CT, in high risk malignant melanoma patients. Methods: Data from published studies provided probabilities for the model. Complication and care costs were obtained from standardized administrative databases from 19 hospitals identified by DRG codes (reported in 2009 Euros). For the calculation of PET‐CT we performed a microcosting. All costs and benefits were yearly discounted respectively at 3% and 1.5%. Outcomes included life‐months gained (LMG) and the number of futile surgery avoided. Cost‐effectiveness ratios were in Euros per LMG. Univariate and probabilistic sensitivity analyses addressed uncertainty in all model parameters. Results: The PET‐CT strategy provided 86.29 LMG (95%CI: 81.50‐90.88 LMG) at a discounted cost of €3,974 (95%CI: €1,339‐12,303), while the conventional strategy provided 86.08 LMG (95%CI: 81.37‐90.68 LMG) at a discounted cost of €5,022 (95%CI: €1,378‐16,018). This PET‐CT strategy resulted in a net saving of €1,048 with a gain of 0.2 LMG. Based on PET‐CT information, 20% of futile surgeries could be avoided. Conclusion: Integrating PET‐CT in management of patients with suspected pulmonary metastasized melanoma appears to be less costly and more accurate by avoiding 1/5 futile thoracotomies, as well as by providing a small survival benefit at 10 years.
P28 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 analyzed quantitatively measuring SUVmax and SUVlbm. Results:There was a statistical significant difference between the SUVmax and SUVlbm values obtained in 2D and 3D modes. Either the first scan was performed in 2D or 3D the values obtained from 3D imaging was significantly lower than those obtained from 2D imaging. On a lesion basis, avarage SUVmax and SUVlbm was 10.48±7.57 and 7.36±5.53 for 2D, while these values were 9.66±6.93 and 6.75±4.97 for 3D (p=0). The absolute differences in SUVs obtained from 2D and 3D imaging were calculated for each lesion, and the mean of the absolute differences was found. The mean values was significantly different from zero (SUVmax mean difference: 1.27±1.44, SUVlbm mean difference: 0.95±1.07, p=0, single tailed t‐test). Visual analysis didn’t demonstrate significant difference regarding lesion detectability between 2D and 3D techniques, and inter‐observer agreement was good. Conclusion: As a conclusion, in oncological PET/CT applications, since SUVmax and SUVlbm values are significantly lower in 3D compared with 2D, when serial scanning is needed to evaluate response to therapy in the same patient, the imaging modality should be taken into account and be done with the same method to avoid misinterpretation. Except this situation, we thought that 3D PET/CT imaging, which is advantageous by decreasing scanning time without loss in lesion dedectability, can be used instead of 2D PET/CT. Key words: FDG, PET/CT, 2D, 3D, SUV
P228 The intra and inter-observer reproducibility measurement: VOI versus ROI method.
of
SUV
M. Simo, P. Pifarre, J. Gispert, P. Plaza, E. Miralles; CRC-Clinica Quiron, Barcelona, SPAIN. Introduction: Quantitative assessment of 18F‐FDG uptake can be performed following methodologies differing in its complexity and reliability of the results. They range from simple visual assessment of the maximum SUV value in the lesion to the complete delineation of the Volume of Interest (VOI). In this study we compare the reliability of these two methodologies. Material and Methods: 60 lesions were evaluated twice during 6 month period by two experienced observers. SUV values were recorded and mean differences where compared in inter and intra‐observer setting and statistical assessment were performed by paired‐sample t‐ tests and variance analysis. Results and Discussion: Errors were always lower for the VOI‐based method than for the ROI‐based one. Inter‐observer mean absolute difference was 4.81 % lower for the VOI method (P = 0.001) and intra‐observer 5.22 % (P = 0.001). For the ROI method the variance component of the operator factor was 4‐fold higher than the repetition one. On the other hand, when the VOI method was used, the operator factor was over 20‐fold lower than the repetition one, thus pointing out the higher reproducibility of VOI method over the ROI‐based one. Conclusions: Our results highly encourage the use of the VOI‐based method to quantify SUV values to improve inter and intra‐observer reproducibility. The use of the VOI method allows the use of SUV as an accurate follow up tool even when two different observers are involved.
P229 Comparison of Isochronal F-18 FDG PET/CT and Tc99m MDP Bone Scintigraphy Findings in the Detection of Bone Metastases A. Küçüköz Uzun, T. Özpaçacı, T. Özülker, F. Özülker, Ö. Eker, M. Mülazımoğlu, H. Özçevik; Okmeydanı Training and Research Hospital, Department of Nuclear Medicine, İstanbul, TURKEY. Aim We aimed to compare the results of isochronal F‐18 FDG PET/CT and Tc99m MDP bone scintigraphy in oncological patients with bone metastases detected by PET/CT. Materials and Methods We prospectively studied 53 oncological patients (36 female, 17 male) with a mean age of 55,6 (range between 28‐86). All of the patients had bone metastases detected on PET/CT and they underwent bone scintigraphy within 1‐90 (mean 35.6 days) following PET/CT. The distribution of the patients according to their primary neoplastic disease was as following; 27 breast cancers, 7 with unknown primary malignant tumor, 5 with lung cancer, 3 with prostate cancer, 2 with nonhodgkin lymphoma, and 9 with other cancers. Among these patients, 27 were referred to PET/CT study for restaging, 12 for staging, 7 for detection of unknown primary and 7 for evaluation of response to therapy. The confirmation of the metastases in PET/CT and bone scintigraphy studies were made with clinical follow up and evaluation of the therapy response. Results In 29 (54.7%) patients PET/CT and bone scintigraphy detected bone metastases equally. In 18 (33.9%) patients PET/CT demonstrated more bone lesions than bone scintigraphy. The nature of the lesions that are not detected by bone scintigraphy was mostly lytic and mixed in CT images and they were mostly located at sternum, scapula, humerus and femur. Bone scintigraphy detected more bone lesions than PET/CT in 6 (11.3%) patients. All of these lesions were sclerotic in CT images and located at cranium, spine and ribs. Conclusion In our patient group PET/CT seems to have higher accuracy than bone scintigraphy in detecting bone metastases. The superiority of PET/CT is more prominent in detecting osteolytic lesions.
Diagnostic Oncology - PET, PET/CT: miscellaneouus
P230
P227
UNEXPECTED PET/CT FINDINGS RELATED OR NOT TO THE PRIMARY MALIGNANCY
Comparison of SUV values obtained from PET/CT Imaging done on 2D and 3D modes in oncological cases B. Kocabaş, A. F. Yapar, M. Reyhan, A. Aktaş, M. Aydin, E. A. Gençoğlu; Başkent Üniversitesi Hastanesi, Ankara, TURKEY. Aim: We aimed to investigate the cross usability of standardized uptake values (SUV) obtained from both 2D and 3D PET/CT imaging, and to compare the images from these techniques subjectively in terms of image quality, lesion dedectability and the presence of artefact. Materials and Methods: We included a total of 100 patients (mean age 54.98±14.18, range:6‐80, 55 male, 45 female) referred for known or suspected malignancy. Using a GE Discovery STE PET/CT system, two subsequent PET imaging was performed to obtain 2D and 3D images after a low dose CT. The patient remained in the same position whilst all acqusition. CT data was used for attenuation correction. PET raw data was reconstructed with OSEM in 2D mode and iteratively in 3D. Subjective analysis of 2D and 3D images was performed by two readers in a blinded, randomized fashion evaluating the following criteria: overall image quality, dedectability of each identified lesion and the presence of artifact. The lesions recognized by the readers visually were also
I. M. A. Abuhid1, G. P. Martins1, L. C. Silva1, J. R. S. Villela1, N. A. Rezende2; 1Hermes Pardini, Belo Horizonte, BRAZIL, 2Federal University of Minas Gerais, Belo Horizonte, BRAZIL. Positron emissions tomography/computed tomography (PET/CT) scan has been used in many types of cancer to characterize the extent of disease as well as to identify the presence of metastases. However, often radiologists and nuclear medicine physicians come across lesions which are non‐malignant or identify other synchronous tumours in patients considered often incidental findings. The purpose of the present study was to retrospectively evaluate the nature and significance of unexpected focal 18‐FDG uptake or unexpected pathology localized by PET/CT. These lesions were newly discovered on PET/CT, had not been previously detected by other modalities, and were atypical in location for metastases on the PET/CT study. Materials and methods: we illustrate with 18 interesting cases unexpected findings at PET/CT that in a certain way turned out in a different final diagnosis and influenced on patient menegement. Routine FDG‐PET/CT scans were reviewed for identification of focal FDG‐avid lesions, and the CT component was independently reviewed for an anatomical lesion and malignant potential based
S355
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P231 The Impact of Time-of-Flight Technology in Clinical Practice P. Scapoli; Institute for Cancer Research and Treatment, Candiolo, ITALY. Background. Time of flight (TOF) systems were ideated more than 20 years ago, but this technology remained undeveloped because of the lack of appropriate detectors. The recent development of fast and bright crystals made such systems available in clinical practice. Aim of the study was to assess the benefit achieved in daily routine using the TOF algorithm compared to the LOR one (the most commonly used in non‐TOF devices). Patients and methods. We used a Philips PET/CT GEMINI‐TF scanner with LYSO crystals and the following characteristics: 600 ps timing resolution, 4.8 mm intrinsic spatial resolution, 700 mm bore opening, 576 mm transverse and 180 mm axial reconstruction field‐of‐view (FOV). This scanner allows to acquire data in either line‐of‐response (LOR) sinogram or list mode format, and reconstruct data with either non‐TOF or TOF algorithms. 102 consecutive patients were included in the study (33 breast cancer; 16 colorectal cancer; 12 lymphoma; 25 other solid tumors; 16 suspected tumoral lesions) with a 18 mean weight of 70.2 Kg. They all underwent F‐FDG PET/CT scan and images were reconstructed with both LOR and TOF algorithms. Images were analysed by two nuclear medicine physicians together. Results. 33% of patients (34/102) had a negative scan in both sets of images. In the remaining 68 patients, the results were as following: the same number of lesions were detected in 51 of them (75%); in 17 patients (25%) one or more lesions were detected only at TOF reconstructed images: in 6 of these 17 patients (35%), including 4 patients who had negative LOR images, the additional lesions were clinically relevant (confirmed by histology or radiological investigations) and led to an upstaging and a different therapeutic approach (p<0.01). The supplementary lesions, all with a size of less than 1 cm, included 10 lymph nodes, 3 pulmonary nodules, 2 peritoneal nodes, 2 adrenal and 1 bone lesions. TOF allowed to reclassify the score of 23 lesions, improving diagnostic accuracy and confidence. Conclusions. Our preliminary data suggest that the use of TOF algorithm in daily practice significantly improves lesion detectability and diagnostic confidence, modifying clinical and therapeutic approach in about 1 out of 3 patients with additional lesions discovered by TOF.
P232 The Clinical Value of Incidental PET/CT
18
F-FDG-avid Foci Detected on
V. Özkol, E. Alper, N. Aydın, H. F. Özkol, N. B. Topal, A. T. Akpınar; Uludag University Faculty of Medicine, Bursa, TURKEY. Objective: This study was performed to demonstrate the malignant potential and clinical value of incidental focal 18F‐fluorodeoxyglucose (18F‐FDG) uptake on positron emission tomography/computed tomography (PET/CT) with the confirmation of histopathologic findings or with a series of consequent correlative imaging methods. Methods: A total of 2,370 18F‐FDG‐ PET/CT studies performed over a 16‐month period in patients with various malignant diseases were retrospectively reviewed. Unexpected PET foci that were in an unusual site for metastatic spread of known malignancy and not considered to be physiologic uptake were evaluated by histopathologic findings or follow‐up with correlative imaging methods for a period of 1 year or longer. There were 121 such incidental PET lesions in 116 patients. Results: Seventy‐four incidental PET lesions in 70 PET/CT patients could be further investigated. Forty‐seven lesions in 46 patients were lost to follow‐up. Fifty‐nine lesions had histopathologic confirmation. Fifteen lesions were evaluated with radiologic methods or instrumental examination. Thirty‐six incidental PET foci were unexpected malignant or premalignant lesions (1.5% of 2,370 patients and 49% of 74 PET foci). Nineteen of these 36 malignant or premalignant lesions were synchronous carcinomas, fourteen lesions were unusual or unexpected malignant spread of known malignancy and three lesions were premalignant colonic adenomas. Thirty‐three of 74 incidental PET lesions were of benign origin (1.4% of 2,370 patients and 44% of 74 PET foci). Five PET foci were false‐ 18 positive findings (7% of 74 lesions). Conclusion: The detection of incidental F‐FDG‐PET foci on PET/CT may reflect unexpected malignant lesions related to unusual malignant spread of primary malignancy or synchronous tumor. Follow‐up of these PET foci may result in significant change in therapy management and early diagnosis of various abnormalities that require a medical approach or surgical intervention. Keywords: 18F‐FDG; PET/CT; incidental; oncology; correlative methods
P233
18
Clinical Experience of FDG PET/CT in Children with Malignant Disease in a Large Greek Tertiary Hospital P. Karampina1, P. Rondogianni1, M. Skylakaki2, I. Houssianakou1, A. Samartzis3, I. Datseris1; 1Nuclear Medicine Department, Evangelismos General Hospital, Athens, GREECE, 2Radiology Department, Evangelismos General Hospital, Athens, GREECE, 3Health Physics Department, Evangelismos General Hospital, Athens, GREECE. AIM: To evaluate the role of 18FDG PET/CT in children with different neoplasias. MATERIALS & METHODS: This is a retrospective study involving 20 children (12 boys, 8 girls) aged 7‐13 (mean age: 14.3 years) with known or suspected malignant disease who had PET/CT scan at our hospital from March 2007 to February 2009. 18FDG PET/CT was performed after the injection of 3.7MBq/kg of 18FDG. Whole body CT and PET scans were obtained 60 min later with adequate acquisition parameters. Additional images of brain, head and neck or lower limits were obtained when necessary. No child needed sedation and the collaboration with all of them was excellent. Totally 30 PET/CT scans have been performed. RESULTS: 17/20 children have been referred for lymphomas (12 HL and 5 NHL) and had totally 26 PET/CT scans: for initial staging (3 scans), end treatment restaging (13 scans), early assessment of treatment response (5 scans), recurrence (3 cases) and follow up (2 cases). 1/20 child was referred for liver‐spleen enlargement and small
mediastinal lymphadenopathy, 1/20 for recurrence of multiforme glioblastoma and 1/20 for recurrence and restaging of Ewing’s sarcoma (2 studies). 18FDG PET/CT and conventional imaging findings were concordant in 5/17 children with lymphomas (29.4%): in 3 children excluding the disease and in 2 showing the same clinical stage. 13/26 (50%) scans were positive showing more sites involved in 6 cases and leading to upstaging in 3 of them, and less sites in 3 cases without change of the clinical stage. 13/26 (50%) scans were negative, correctly excluding residual disease after therapy in 11 cases, showing complete early treatment response in 1 case and excluding recurrence in 1 case. Findings have been confirmed by follow up. PET/CT confirmed recurrence in the cases of pleomorphic glioblastoma and Ewing’s sarcoma indicating treatment response in a second scan in the last case. It failed to reveal any cause of splenohepatomegaly and lymphadenopathy (normal scan) but data have not been confirmed in this case (no clinical information). CONCLUSION: Despite the small number of patients studied, 18FDG PET/CT seems to be well tolerable by children and easy to perform even in a non specialized pediatric hospital. It may be a useful method for the evaluation of lymphomas of the childhood improving the staging and restaging and elucidating equivocal findings of other imaging modalities when recurrence is suspected.
P234 A clinical trail toolkit for diagnostic imaging exchange trough the WEB S. Chauvie1, A. Stancu2, P. Cerello3, A. Gallamini2, A. Biggi2; 1S Croce and Carle Hospital & INFN, Cuneo, ITALY, 2S Croce and Carle Hospital, Cuneo, ITALY, 3INFN, Torino, ITALY. Aim: The use of PET as an early response to therapy is increasing everyday. Several clinical trials are using PET as the only element to make decisions on the treatment strategy of patients. In these cases the analysis of diagnostic images ought to be done by different readers chosen between a committee of experts in the field. These people, that could be worldwide spread, should be able to retrieve the images and feedback their results to the clinic where the patient come from. Materials and methods A Web based collaboration approach was selected for the images and results exchange, due to the ease of use, instant transmission of information and flexibility of the Internet related technologies. In this way a central shared data repository was created, thus minimising the risk of misplacing or losing sensitive information and images. The only requirements for the PET centre is to have a Web browser such as Internet Explorer, Mozilla and others. Upon enrollment into the system, the physicians are automatically provided with individual user name and password. Using these credentials, they can upload the case files, compile the electronic CRF and submit and view results for a particular case. Cases and results, are submitted anonymously, the only identification detail being the case ID. When a case is submitted to the system, an email is automatically sent to the trial’s reviewers, informing them that a new case requires their attention. Within a pre‐established time frame they can download the files, analyse them and load their diagnosis. After the required number of diagnoses is received, the system sends an email with the diagnostic to the clinical centre that enrolled the patient. The system has been designed to be an efficient tool for the PI of clinical trials that can add the patients enrolled in the study, track their status and see the results of the review’s process, download and upload images and manage the users of participating centres. Results and conclusions: This tool is currently used in the HD0607 clinical trial. Until now it proved to be stable and easy to use both by the submitting centres and by the reviewers. It is very flexible, scalable and could be adapted to whatever clinical trial and whichever type of diagnostic imaging technique.
P235 Significance of Focal FDG Uptake in Supraclavicular Lymph Nodes on PET/CT Scans of Cancer Patients Y. Park, I. Yoo, I. Yoo, E. Han, S. Kim, S. Chung; Department of Radiology, The Catholic University of Korea, Seoul, REPUBLIC OF KOREA. Objective The purpose of this study was to find out the clinical significance of focal FDG uptake in supraclavicular lymph nodes (SCLNs) on PET/CT images performed for staging or restaging of various malignancies. Method PET/CT scans of solid cancer patients from November 2003 to September 2008 were retrospectively reviewed. Lymphoma and hematologic malignancy cases were excluded. Of 494 PET/CT cases demonstrating focal uptake in the SCLN, cases with histologic confirmation were selected. The maximum standardized uptake value (SUVmax) from PET/CT images and histologic results were compared. Result 69 cases (47 female, 52 male; mean age 58±14 years) with focal FDG uptake in the SCLN of PET/CT images were confirmed by needle aspiration cytology (n=38) or biopsy (n=31). PET/CT was performed for restaging in 35 cases and staging in 34 cases. The sites of primary cancer were breast (n=21), lung (n=15), ovary (n=10), esophagus (n=6), colon (n=4), thyroid (n=3), uterine cervix (n=3), stomach (n=2), and one each of hypopharynx, liver, gallbladder, kidney, rectum and endometrium. In patients with breast or lung cancer, uptake was seen in SCLN ipsilateral to the primary tumor in 16 cases, contralateral to the primary tumor in 8 cases and bilateral SCLNs in 12 cases. Of the 69 cases, lymph node metastasis was confirmed in 65 (94%) patients. There were 4 confirmed benign lymphadenopathy cases: mycobacterial infection (n=2) and inflammation (n=2). The mean SUVmax of the SCLN demonstrating the highest FDG uptake of each patient was 5.3±3.8 (range 1.6~22.9). The mean SUVmax was 5.4±3.9 for the metastatic lymph nodes, and 4.7±2.4 for the benign lymph nodes. In 10 patients, the positive histologic results for SCLNs changed the M staging from M0 to M1. Conclusion Focal FDG uptake in the SCLN on PET/CT scans of cancer patients indicated metastatic lymphadenopathies in most of the cases (94%). Mycobacterial infection and focal inflammation were causes for false positive results.
P236 Clinical experience with combined PET/CT imaging of pediatric oncological patients. L. Gogou, D. Kechagias, F. Vlachou, V. Filippi, S. Fourlis, A. Nikaki, K. Gogos, K. Dalianis, J. Andreou, V. Prassopoulos; Department of PET/CT D.T.C.A. Hygeia, Athens, GREECE.
Poster Presentation
on CT criteria. Clinical, endoscopic, and histopathology follow‐up was obtained. Some of these lesions were massive tromboembolic desease, pleomorfic parotid adenoma, parathyroid metastasis, gastroenteric fistula, Hashimoto thyroiditis, synchronous tumours , Sapho syndrome and others. Conclusion: these cases exemplifie the relevance of incidental findings detected on FDG PET/CT and should assist other radiologists and nuclear medicine physicians in identification of these incidental findings.
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AIM: PET/CT imaging has rapidly emerged as an important imagine tool in pediatric oncology procedure. In this study we present an epidermiology survey of the first 93 PET/CT cases. MATERIAL‐METHODS: We performed a retrospective review of the first 93 examinations for 62 pediatric patients, considering the indications and the impact in patient’s management, performed with a SIEMENS PET/CT scanner, form July 2004 to April 2009. The patient a population consist of 41 boys and 21girls (age between 3 to 18 years) referred for oncological indications.PET/CT exam was performed using 18F‐FDG. Doses were estimated upon the age and the weight of the patient. RESULTS: Almost 62% of our studied population was Lymphoma. The main referrals for PET/CT examinations, in patient percentages, were as follows Hodgkin´s Lymphoma (51,6%), NHL (10,7%), Thymoma (1,1%), Sarcoma (10,7%), Brain Tumor (1,1%) Head and Neck (4,3%), Endocrine Tumors (6,5% and for thyroid cancer 5,3% and Neuroendocrine 1,1%) and Miscellaneous tumors (14%). Miscellaneous tumors included 2 testicular tumors (2,2%), 1 pancreatic tumor (1,1%) 2 Unknown Primary Tumors (2,2%), 1 Chronic Lymphatic Leukemia (1,1%), a Liver Tumor (1,1%). In 16/62 pediatric oncology patients the follow up perform PET/CT. The following table summarizes the main indications of PET imaging studies. No Exam Exam
Initial Staging Restaging
48
HD
6 / 48 12%
42/48 88%
10
NHL
1 / 10 10%
9/10
1
Thymoma 1 / 1
10
Sarcoma 0/10 0%
10 / 10 100%
2
Brain
50%
1 / 2
50%
6
Endocrine 0/6
0%
6 / 6
100%
13
Misc
5 / 13 38%
8 / 13 62%
4
HN
1 / 4
3 / 4
1 / 2
100% 0/1
25%
90% 0%
75%
CONCLUSION: 18F‐FDG PET/CT seems to the useful procedure for pediatric oncology patient management. 18F‐FDG PET/CT has a role in the initial diagnosis, the staging and restaging of the tumor and finally the treatment follows up of pediatric oncological patients. It provides a quick combine functional and morphological imaging with an increased diagnostic accuracy.
P237 Evaluation of 18F-FDG-PET/CT in comparison with conventional imaging in gastrointestinal stromal tumors (GIST). F. Vlachou, R. Efthimiadou, L. Gogou, V. Filipi, A. Nikaki, A. Archontaki, K. Dalianis, K. Gogos, J. Andreou, V. Prassopoulos; Department of PET/CT, D.T.C.A . Hygeia Hospital, Athens, GREECE. AIM: Gastrointestinal stromal tumors (GIST) are defined as immunohistochemically Kit‐ positive primary mesenchymal tumors of the GI tract. Mitotic rate, tumor size and tumor site are the most important prognostic factors. Surgery is the mainstay therapy, while the introduction of imatinib mesylate show promising results. In order to estimate the usefulness of PET/CT in detecting residual disease and treatment response, we retrospectively examined the files of patients suffering from gist. METHOD AND MATERIAL: A total of 18 patients 11 male, 7 female, 17‐77 years old, suffering from gist underwent 18F‐FDG‐PET/CT scans. All patients had undergone staging of their disease by conventional imaging techniques (CT, MRI, US) 1‐4 weeks prior to PET/CT examination. We separated the patients in two groups: Group A: consisting of 10 patients who had undergone surgical excision of their primary tumor without receiving any other treatment. Group B: 8 patients were treated both with surgical excision of the primary tumor and imatinib mesylate. We compared the results of PET/CT and those of conventional imaging techniques. RESULTS: Group A: clinicians’s most common question was whether the primary tumor was fully resected in order to stage the patient and start therapy with imatinib mesylate. PET/CT and CT agreed in findings in 3/10 patients, 2 of which were negative. PET/CT revealed more extensive burden of residual disease in 2/10 patients, concerning peritoneal dissemination, moreover hepatic and bone metastasis. In 3 cases CT was not conclusive whether findings were post‐surgical or residual disease; PET/CT was negative. In one case the areas of low attenuation on liver shown at CT were not hypermetabolic in PET/CT(cysts). The finding at the left paracolic gutter detected by CT was detected in different position, nonmetabolic in PET/CT four weeks later and was attributed to accessory spleen. Group B: the most common question was if there was response in imatinib treatment. PET/CT and CT agreed in findings in 3/8 patients, one negative. In 2 cases CT was negative while PET/CT showed hypermetabolic lesions. PET/CT revealed more metastatic lesions (in liver, peritoneum) in 2/8 patients. In one case after ablation of one metastatic lesion in liver, CT was inconclusive and PET/CT showed respectively photopenic area. CONCLUSION: PET/CT is a useful modality in evaluating both residual disease after surgical excision and treatment response after therapy with imatinib mesylate in patients suffering from gist. The use of low dose CT is essential for better localization of the disease.
P238 Use of 18F-FDG PET/CT in Pediatric Patients: Indications and Patient Characteristics T. Sucak, Ü. Ö. Akdemir, T. Çakır, N. Gökçora, N. I. Karabacak, L. Ö. Kapucu, M. Ünlü; Gazi University School of Medicine, Department of Nuclear Medicine, Ankara, TURKEY. Aim: To evaluate our experience in pediatric patients in respect to FDG PET‐CT imaging. Methods: FDG PET/CT database in our department, during the period 03/2004 ‐ 03/2009, was analyzed retrospectively. The diagnoses and indications for the examinations were recorded for pediatric (age ≤18 years) patients. Results: In a total of 10,712 FDG PET/CT examinations, 384 (3.6%) were performed on 230 pediatric patients which consisted of 137 males and 93 females with a mean age of 12.9 ± 4.5 (range 1‐18 years). While 148 (64.3%) patients had a single FDG PET‐CT examination, multiple scans were performed on 82 (35.7%) patients. In the whole group, 20 (8.7%) patients were examined for neurological diseases, with the most frequent indication being epilepsy in 10 patients. The purpose for imaging in the oncologic patients was for primary staging in 67 (18.4%), restaging and evaluation of response to therapy in 297 (81.6%) patients. The most frequent indications were lymphoma in 97 (47.7%) patients with Hodgkin’s lymphoma in 79 and
non‐Hodgkin’s lymphoma in 18, primary bone tumors in 34 (14.7%) patients with Ewing’s sarcoma in 17 and osteosarcoma in 14 patients, soft tissue sarcomas in 23 (10%), neuroendocrine tumors in 13 (5.6%), and brain tumors in 11 (4.8%). The other indications were head‐and‐neck tumors in 5, papillary thyroid cancer in 5, leukemia in 5, germ cell tumors in 8, malignant melanoma in 2, cancer of unknown primary in 2, malignant peripheral nerve sheath tumor in 2, colorectal cancer in 1, hepatocellular cancer in 1, adrenal cancer in 1, and Wilm’s tumor in 1 patient. Conclusion: FDG PET/CT seems to be an important imaging tool in the noninvasive evaluation and monitoring of pediatric patients especially with malignancy. Our department’s experience shows that, FDG PET/CT examination is most commonly performed for primary staging, restaging and evaluation of response to therapy in lymphoma and bone and soft tissue sarcomas in the pediatric patients.
P239 Decreases Cerebral FDG Uptake in a Population of Patients with Hematologic Malignancy H. J. Zhu1, M. L. Goris2; 1UAMS University of Arkansas for Medical Science, Little Rock, AR, UNITED STATES, 2Stanford University Medical Center, Stanford, CA, UNITED STATES. Background: In most cases the SUV values in the tele‐encephalon range in values around 10 to 12. In patients with Hematologic Malignancy we observed a high frequency of patients with low SUV values in the brain. Casual observation suggested that the phenomenon was associated with symptoms of infection. Goal: To find a biological correlate of low cerebral SUV values. Materials and methods: The data consist of a 50 PETCT studies in 12patients.Their median age was 49 and 9 were male. They were selected because one of their studies the cerebral SUV values seemed low and all the relevant data were available. In this study we looked at the peripheral WBC count and RBC count, and the Cerebral SUV values. Results: The average WBC count was 5.34 k, the RBC was 3.3 million. SUV values were measured in frontal, central motor, visual cortex and the basal nuclei. The average SUV values were 5.14, 5.67, 7.51 and 5.63 respectively. The values in the different regions correlated strongly (>90%). In contradistinction the WBC and RBC values were not related (P=0.96), suggesting that the phenomenon was not a global marrow one. However, there was a significant correlation between the WBC and brain SUV values and the RBC and brain SUV values. For the WBC the relation was negative: SUV= ‐0.13 WBC + 6.00, with the regression coefficient F=4.30 (p<0.05). For the RBC, the relation was positive: SUV= 1.27WBC + 0.98 with the regression coefficient F=8.36, (P<0.006). In individual patients an increase of the WBC value over 10 universally resulted in a significant drop of cerebral SUV. Conclusion: In a population of patients, treated and untreated low cerebral SUV values were associated with high WBC values. The finding did not seem associated with intrinsic bone marrow disease, since the effect was opposite to the effect of increase in RBC values. We surmise that the finding is associated to clinical or subclinical infection or inflammation, but cannot conclude that the effect is direct or a co‐association with an underlying mechanism.
P240 Whole-body cancer screening with multiple modalities including FDG-PET: a summary of 5 years’ practice for general asymptomatic individuals. S. Nishizawa1, H. Kodama2, Y. Maeda2, H. Okada2; 1Hamamatsu Medical Photonics Foundation, Hamamatsu, JAPAN, 2Hamamatsu Photonics KK, Hamamatsu, JAPAN. Aim: To clarify the performance profile of whole‐body cancer screening with multiple modalities including FDG‐PET. Materials and Methods: We reviewed 4995 screening data of 3129 asymptomatic individuals without a previous hystory of cancer, who underwent initial cancer screening between May 2004 and April 2008. Screening modalities included were whole‐body FDG‐PET, chest and abdominal CT, brain and pelvic MRI, several tumor markers and fecal occult blood (FOB) testing. Test results were classified into one of ‘suspicious’ (A), ‘need to follow’ (B) and ‘benign or normal’. We regarded A and B as positive. To assess if the diagnostic accuracy changes along with time, subjects were divided according to the periods of initial screening into first (F), middle (M) and recent (R) groups. Results: A total of 79 cancers (2.5% of 3129) were detected out of 89 by any of the screening tests, including 15 lung, 15 colon, 14 prostate, 10 thyroid, 8 breast cancers, etc. FDG‐PET, CT and MRI were positive in 49 (55.1%), 34 (38.2%) and 19 (21.3%), respectively. Sixty‐four cancers (2.0%) detected by the initial screening were confirmed in a year and 6 after the second screening. Positive predictive value of FDG‐PET, CT and MRI were 15.4% (9.7%) (percentages were for A and A+B in parenthesis), 7.8% (2.5%) and 14.3% (13.3%) for F, 23.8% (12.3%), 25.9% (6.0%) and 35.7% (14.3) for M, and 40.6% (23.8%), 33.3% (7.7%) and 44.4% (19.4%) for R, respectively. False positive rate of FDG‐PET, CT and MRI were 5.3% (8.9%), 4.5% (15.1%) and 1.7% (2.5%) for F, 3.1% (7.0%), 1.9% (15.1%) and 0.9% (2.9%) for M, and 1.8% (5.8%), 1.5% (14.7%), 0.5% (2.7%) for R, respectively. Six of 8 interval cancers were detected in 1009 who received the second screening and 3 of 4 in 499 who did the third. Conclusion: Although diagnostic accuracy improved through practice, whole‐body cancer screening with multiple modalities still caused a considerable number of false positives, which should be reduced to avoid unnecessary medical expenses for further examinations and psychological stress in subjects. It should be also noted that, while a wide variety of early‐stage cancers can be detected, a considerable number of cancers may be indolent and detection of interval cancers may be limited.
P241 Contribution of 18F-FDG-PET/CT in restaging patients with sarcoma. A retrospective study F. Vlachou1, R. Efthimiadou1, L. Gogou1, D. Kechagias1, D. Kechagias1, A. Nikaki1, O. Karamini1, K. Archodaki1, D. Tsevas1, E. Georgiou2, J. Malamitsi2, J. Andreou1, V. Prassopoulos1; 1Department of PET/CT D.T.C.A. Hygeia, Athens, GREECE, 2University of Athens Medical School Department of Medical Physics, Athens, GREECE. AIM: To evaluate the role of PET/CT in restaging patients suffering from osseous or soft tissue sarcoma. MATERIAL AND METHOD: 56 patients suffering from sarcoma underwent 72 18F‐FDG‐
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P242 Utility of the PET/CT with primary tumors
18
F-FDG in diagnosis of second
M. Garcerant, P. Alonso, L. García-Cañamaque; Hospital del Norte Sanchinarro, Madrid, SPAIN. INTRODUCTION: Recently it has increased the number of patients who are in control by a malignant tumor previously dealt in which a second tumor is detected, according to some authors with a 8.5% frequency. MATERIALS AND METHODS: It is a retrospective study of cancer patients who went to the service of Nuclear Medicine of the Hospital of North Madrid Sanchinarro between May of the 2007 and March of 2009 by habitual control or suspicion of relapse. 9 patients included themselves, was realised a tracking of whole body PET /CT 18F‐FDG according to conventional protocol. For the interpretation of second primary tumors the criteria described by Warren and Gates in 1932 were applied: 1) the two neoplastic injuries must be different and to be in favor separated of healthy weave, 2) must histological be different and 3) the metastasis possibility must be excluded. Also for the case of pulmonary injuries the criteria of Moertel et al in 1977 were applied: a) the injuries must be solitary and b) must histological be different or to be in different stage from differentiation of the primary tumors. RESULTS: Of the total of patients there were 9 with the finding of two pathological imaging and with histological study with diagnosis to one second primary tumors. 77.7% (n=7) were of masculine sex, average of age of 68.44 and a rank of 57‐79. 7 (77.7%) patient ones presented one second primary tumors and 2 (22.3%) had two oncologics antecedents. The primary but frequent tumor was pancreas in 4 cases (44.5%), and the second frequent tumor was lung in 6 patients (66.7%). A patient presented the antecedent of cancer of pancreas and lung and at the moment presented a kidney tumor. The data summary in Table 1. CONCLUSIONS: The PET/CT with 18F‐FDG is a useful study in the diagnosis of second incidental primary tumors in any location with a unique study. TABLE 1 Characteristics of the patients including in the study CHARACTERISTIC
NUMBER
%
AGE, years Average, (Rank)
68,44 (57‐79)
SEX Masculine / Feminine
7 / 2
77,7 / 22,3
SITE OF THE PRIMARY TUMOR 2 Breast 4 Páncreas 1 Urinary Bladder 1 Larynx 1 Melanoma
22,2 44,5 11,1 11,1 11,1
SITE OF 2º PRIMARY TUMOR 6 Lung 2 Kidney 1 Gastric
66,7 22,2 11,1
COMBINATION OF TUMORS Breast ‐ Lung Pancreas ‐ Lung Urinary Blader ‐ Lung Breast ‐ Kidney Páncreas‐ Lung ‐ Kidney Larynx ‐ Gastric Melanoma ‐ Pancreas Thyroid ‐ Lung
11,1 22,2 11,1 11,1 11,1 11,1 11,1 11,1
1 2 1 1 1 1 1 1
P243 Comparison of Tc-99m MIBI and F-18 FDG PET/CT in Patients with Multiple Myeloma: Preliminary Results A. Boz, B. Talay, O. Salim, I. Karadoğan, L. Ündar, A. Yıldız, F. Aydın, F. Güngör; Akdeniz University, Antalya, TURKEY. Aim: The aim of the study was to comparison of Tc‐99m MIBI and F‐18 FDG PET/CT in patients with multiple myeloma. Material and Methods: Thirteen (5 M, 8 F; mean age:58.4±9.6 years)
patients were included in the study. Diagnosis was made according to the standard criteria. Patients were classified as active disease (A; untreated or relapsed or refractory for treatment, n=9), stable disaese (B; reduction of monoclonal component >50%, n=1), complet remission (C, absence of monoclonal component at immunofixation and no evidence of marrow plasma cells or MGUS, n=3). F‐18 FDG PET/CT and Tc‐99m MIBI scintigraphy were performed in all patients. Image assessment: Images pattern was classified on the basis of diffuse (D), focal (F), diffuse and focal (D+F), and normal uptake (N) on both MIBI and PET/CT. Results: Considering clinical and hematological parameters; In group A (n=9): six patients had D pattern, 1 had (D+F) and 1 had N in MIBI scintigraphy, and in PET/CT images 1 patient had D, 2 had (D+F), 5 F and 1 had N. In group B (n=1): The patient had N pattern on MIBI scintigraphy and F pattern on PET/CT images. In group C (n=3): three patients had N pattern on MIBI scintgraphy and in PET/CT images 2 patients had N and 1 had F patterns. Conclusions: F‐18 PET/CT and Tc‐99m MIBI scintigraphy have been shown to be as the valuable methods in the evaluation of multiple myeloma. Although few patients were included in our study, the number of diffuse pattern in active disease shown in F‐18 FDG PET/CT were less than those in Tc‐99m MIBI scintigraphy but more focal pattern was observed in F‐18 FDG PET/CT. We think that although F‐18 FDG PET/CT has an important place in nuclear oncology, Tc‐99m based agents may keep their places in multiple myeloma. Our study has been going on.
P244 Impact of delayed images on the patients with malignancy in FDG-PET/CT by delivery system T. Komori, M. Kino; Hokusetsu General Hospital, Takatsuki, JAPAN. Objective: Delayed images were added to FDG‐PET/CT scans by delivery system and the utility for diagnosis of malignancy and effects on treatment were evaluated. Subjects: 56 consecutive patients who underwent PET scans for malignancy evaluation were examined (26 diagnoses of recurrence, 20 staging evaluations, 10 for benign/malignant differentiation). They consisted of 15 lung cancers, 13 large intestine cancers, 6 malignant lymphomas, 5 pancreatic cancers, 5 ovarian cancers and 12 others. Methods: FDG was administered after fasting for 5 hours and images were taken 1 hour later (from crown to femur) and 2 hours later (thoracoabdominal region) by a PET/CT (GE Discovery ST). Mean dosage was 207.9±88.5MBq. Early images and delayed images were compared and evaluated for (1) lesion detectability, (2) contribution to differentiation of benign and malignant lesions and (3) contribution to changes in therapy. Results: Delayed images were useful in 10 cases (17.9%), and they were useful for (1) in 6 cases (10.7%), (2) in 4 cases (7.1%) and (3) in 7 cases (12.5%). Delayed images were useful for differentiation of benign and malignancy in bowel accumulation (4 cases), clarification of malignant mediastinal lymph nodes (2 cases) and revealing large intestinal recurrence that was difficult to detect in early image (1 case). Among 45 cases in which delayed imaging did not increase information contributing to diagnosis, spotty accumulation in the large intestine was seen in the delayed image in 8 cases (14.3%). False positives were shown in 2 cases which were inflammatory lymph nodes. Conclusion: Delayed images in FDG‐PET/CT by delivery system are useful, including contribution to changes of treatment strategy , however careful interpretation should be needed due to the possibility of false positive.
P245 Value of the FDG PET/CT in the initial staging and bone marrow involvement of Patients with Multiple Myeloma M. S. Sağer, Y. Kutucu-Cantürk, T. F. Çermik; Istanbul Training and Research Hospital, Istanbul, TURKEY. Aim: There is limited number of reports in literature describing role FDG PET/CT in the detection of the bone morrow involvement of patients with multiple myeloma in the initial diagnosis. The aim of this study was to assess the contribution of this technique to the management of patients with multiple myeloma. Material and Methods: Eighteen patients who were referred for the evaluation of primary disease by PET/CT imaging are included in this analysis. PET scan was obtained approximately 60 minutes after the administration of 5.2 MBq / kg 18F‐FDG. The maximum standardized uptake value (SUV) of FDG uptake was measured from the region of interest (ROI), which was placed at the site of the lesion that appeared intense based on visual inspection. All PET/CT results were correlated with follow‐up histopathological or radiological results. Results: Of the 18 bone marrow involvement at the initial presentation, 14 were positive on PET/CT scan. However, CT or MRI did not showed any findings 3 of PET positive 14 patients. Sensitivity of PET/CT in detecting bone marrow involvement was 78%. Conclusion: These data demonstrate that FDG‐PET is useful technique for the assessment of multiple myeloma and may also be superior to radiological techniques for detecting bone marrow involvement at the time of initial diagnosis.
P246 18F-FDG uptake in brown fat: Solutions to avoid false positives without medication. M. Ortega Sanchez, J. Garcia, M. Soler, S. Fuertes, E. Riera, M. Fraile, F. Lomeña; CETIR, Barcelona, SPAIN. Objective Brown fat uptake (BF) may generate 18F‐FDG‐PET scan misinterpretation. Several types of interventions have been proposed to reduce the metabolic activity of BF. However, there is not any clear consensus or protocol to avoid FDG uptake in BF. The aim of this study is to assess whether the local application of heat reduces the 18F‐FDG uptake in BF. Materials and methods First Phase: Over a period of six months, a muscle relaxant (Myolastan ®; single dose; 5 mg; oral administration) was administered to 390 patients suffered from different types of tumours, before FDG injection. In 12/390 (3%) patients the PET/CT had to been repeated due to the presence of 18F‐FDG uptake in BF. These second PET/ CT were conducted again in less than 72 hours under the same basal conditions and including the application of corporal warmth using a thermal blanket before the injection and during the FDG uptake period. Second Phase: Noting the results obtained in the first phase it was decided to change the protocol in our unit. Muscle relaxants (Myolastan ®) were not administered and thermal blanket was applied to women <45 years and men <40 years. The new protocol was applied to new sample of 867 patients. Results First Phase: All 12 studies repeated showed complete disappearance of uptake in BF. In 5/12 (41.7%) patients abnormal FDG uptake remained, corresponding to tumour infiltration
Poster Presentation
PET/CT examinations. All patients had previously received the appropriate treatment (surgical excision, chemotherapy, radiotherapy). Patients were referred for residual or recurrent disease. All had been evaluated by conventional imaging (MRI, CT, Bone scan, Radiograph). We separated the patients in 3 groups. Group A: patients with sarcoma Ewing (12 patients‐ 21 PET/CT exams), Group B: patients with sarcoma of bones (8 patients‐10 PET/CT), Group C: patients with soft tissue sarcoma (36 patients‐ 41 PET/CT). We compared the findings of PET/CT with those of anatomical modalities site‐to‐site and in per patient basis. RESULTS: Group A: agreement in findings was observed in 9 cases. PET/CT revealed metastatic disease (nodular, distant) in 2 cases where MRI‐ CT were negative and more metastatic lesions in 1. In 3 patients (4 PET/CT) osteoblastic lesions and small lung nodules were nonmetabolic. MRI‐CT were inconclusive in 5 cases; PET/CT was negative in 1, positive in 4. 2 patients (6 PET/CT) could be evaluated only by PET/CT. Group B: agreement in findings was observed in 8/10 cases. In 1 case small lung nodules were non‐metabolic in PET. MRI was inconclusive in one case, while PET/CT was negative. Group C: agreement in findings was observed in 24/41 cases. PET/CT and MRI‐CT disagreed in 10/41 cases: CT was superior to PET in detecting small lung nodules, but MRI‐CT were inferior to PET/CT in evaluating residual, recurrent disease‐ particularly at the site of the primary tumor, where surgical intervention had provoked major anatomical disturbance‐ soft tissue, nodal metastasis. PET/CT revealed more metastatic lesions in 4 cases. MRI was inconclusive in 3 cases; PET/CT revealed lymph node invasion in 1/3 and was negative in 2/3. In total PET/CT upstaged 7 patients and downstaged 3. Of note, evaluation of disease in 1 patient , with successive PET/CT examinations through years, could only be succeeded by metabolic activity of the tumor, as its size remained almost unaffected. CONCLUSION: PET/CT is a whole body imaging modality, useful in detecting residual or recurrent disease at the primary site of the sarcoma, particularly when major anatomical changes have occurred and conventional imaging is inconclusive. Although attention should be paid in small lung nodules and osteoblastic lesions, it is useful in evaluating nodal invasion and distant metastasis.
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unchanged between the two PET/CT studies. Second Phase: Only 1/867 patients (0,001%) showed FDG uptake in BF. Conclusion The use of thermal blanket during FDG uptake period significantly reduces FDG uptake in BF, improving the visualization of the FDG tumour uptake. In addition, with this type of protocol we may avoid the use of medications and their possible side effects.
P247 End Stage Renal Disease: Impact on Metabolic Activity in the 18 Routine Internal References as Detected by F FDG-PET/CT R. Muzaffar, E. A. Gonzalez, A. Moinuddin, D. Oliver, N. C. Nguyen, M. M. Osman; Saint Louis University, St. Louis, MO, UNITED STATES. PURPOSE: End stage renal disease (ESRD) increases the background activity in various nuclear medicine studies such as bone scans. In FDG‐PET/CT studies, the maximum Standard Uptake Value (SUVmax) in the liver, mediastinum and muscle are frequently used as internal references. However, the pattern of PET/CT abnormalities secondary to ESRD is not well understood. The aim of this study is to evaluate ESRD induced metabolic changes in the routinely used internal references on PET/CT studies. METHODS: Eight patients with ESRD on hemodialysis underwent PET/CT for cancer work‐up were identified. They consisted of 5 males and 3 females; mean age 60 (range 43‐75). Ten normal volunteers with no known renal disease were the control. They consisted of 2 males and 8 females; mean age 47 (range 38‐61). For all 18 subjects, PET/CT studies were retrospectively reviewed and a log was kept to record SUVmax for liver, mediastinum and muscles (psoas muscle and quadriceps). RESULTS: The mean SUVmax in all 3 regions was statistically higher in the ESRD patients than in the controls. The mean mediastinum SUVmax in ESRD patients (1.7 + 0.2 SD) was statistically higher than compared to the control (1.4 + 0.3 SD), p=0.048. Similarly, the mean liver SUVmax in ESRD patients (2.2 + 0.6 SD) was statistically greater than the controls (1.6 + 0.3 SD), p=0.025. Finally, the mean muscle SUVmax in ESRD patients (0.9 + 0.3 SD in psoas and 0.9 + 0.2 SD in quadriceps) was statistically significantly higher than the controls (0.5 + 0.2 SD in psoas and 0.5 + 0.1 SD in quadriceps), p=<0.001 in both muscle groups. CONCLUSIONS: When present, ESRD results in increased metabolic activity in the liver, mediastinum and muscles. ESRD induced metabolic changes may not only affect liver, mediastinum and muscle uptake but also may underestimate uptake in lesions relative to the frequently used internal reference areas. Therefore, care must be taken when using the liver, mediastinum and muscles as an internal reference in the presence of ESRD in 18F FDG‐PET/CT exams.
P29 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT:
central
nervous
system
tumours
scintigraphy
P248 Complex 99mTc(V)DMSA examination suspicion on brain metastases
of
patients
with
S. Makeyev, V. Rozumenko, V. Semenova; Institute of Neurosurgery, Kyiv, UKRAINE. Brain metastases are the most common intracranial tumors in adults. They metastasize in the brain from lungs (26‐50%), breast (15‐20%), melanoma (10‐40%), rens (13%) and large intestine (5%). Aim. Estimation of complex radionuclide examination expediency of patients with suspicion on brain metastases to define the primary tumor and multiple metastases. Material & methods. 78 patients with the brain focuses underwent brain SPECT and whole body scintigraphy (WBS) with 99mTc(V)DMSA. CT/MRI signs of these focuses were similar to metastases. The diagnosis of brain tumors was verified histologically. Also in 26 (33,3%) of 78 patients the additional focuses were revealed outside brain by WBS and in six of them the histological diagnosis of primary tumors was confirmed. Results. The sensitivity of brain SPECT in diagnostics of cerebral focuses was 95,9%. Histologically there were 41 (52,6 %) cancer metastases and 37 (47,4 %) primary brain tumors: 26 (33,3%) gliomas (3 low grade astrocytomas, 9 anaplastic gliomas, 14 glioblastomas), 6 (7,7%) meningiomas and 5 (6,4%) intracerebral abscesses. Brain metastases had clear contour in 29 (70,7%) cases, almost rounded form, high T/B ratio (13,6±7,2) and medium diameter 3,0±1,2 cm. Non‐metastatic focuses had clear rounded contours only in 14 (37,8%) cases, had high T/B ratio (13,0±6,5), but the middle diameter was greater than metastases (3,9±1,4 cm). In 3 patients with low grade astrocytomas brain SPECT did not reveal brain tumors, unlike CT and MRI. WBS diagnosed the non‐cerebral focuses in the 26 (33,3%) patients. In 14 (53,8%) cases they were solitary, in 12 (46,2%) ‐ multiple. Solitary focuses were revealed in the lungs (5), the bones (4), the breasts (2), the rens (2) and in the intestine (1). Multiple focuses were visualized in the bones (9), in the breasts (2) and in the projection of neck (1). In 5 patients with single non‐cerebral pathological focuses, diagnosed by WBS, histological verification testified the presence of cancer of the breasts (2 cases), the lungs (2) and the rens (1). In one patient with the multiple focuses hyperplasia of lymphoid tissue was diagnosed in the neck left‐side and lipoma ‐ in the neck right‐ side. Conclusion. Our results testify that complex radionuclide investigation (99mTc(V)‐DMSA brain SPECT and 99mTc(V)‐DMSA WBS) in patients with suspicion on brain metastases could be useful for clarification of the character of cerebral focus, diagnostics of the primary tumor and multiple metastases.
P249 Comparision computerized tomography and brain SPECT in patients with acute ischemic stroke diagnosis H. Kaya1, G. Kaya Altunci1, Y. Tamam2, C. Can Karahan1; 1Dicle University School of Medicine the Department of Nuclear Medicine, Diyarbakir, TURKEY, 2Dicle University School of Medicine the Department of Neurology, Diyarbakir, TURKEY.
Introduction: Stroke is the most common neurological disorder which appears due to hemorrhage or ischemia at central nerve system. It is very valuable to image cerebral ischemia and infarct along with neurological examination in these patients. In early period computerized tomography (CT) usually can not give information, although brain SPECT can show perfusion defect. Aim: In our study we aimed to evaluate Tc99m‐HMPAO brain SPECT’s value at early diagnosis for affective treatment by comparing acute phase Tc99m‐HMPAO brain SPECT images with acute and subacute CT and magnetic resonance imaging (MRI) results in patients with acute ischemic stroke diagnosis. Material‐Method: Twenty nine stroke patients who diagnosed by clinical examination and laboratory findings with normal brain CT images that administered at admission time included to our study. Their age average was 68.41±9.48 (49‐83). All patients were evaluated by Tc99m‐HMPAO brain SPECT within 6‐72 hours from symptoms onset, and we used NIH stroke scale for prognosis calculation. We noted patients’ age, gender, acute phase brain CT and subacute phase brain MRI/CT images, NIH stroke scales at admission time and Tc99m‐HMPAO brain SPECT images. We compared NIH stroke scales, MR/CT and SPECT findings of individuals. Results: When we compared hypo perfusion or perfusion defect at SPECT images with NIH stroke scale; we determined high NIH stroke scale values togetherness with perfusion defect at SPECT images significantly (p<0,05). Acute phase SPECT and subacute phase MRI images were evaluated by 3 arterial regions for each cerebral hemisphere. We calculated brain SPECT images’ sensitivity 83% and specifity 95% for 138 regions that were fed by these 3 arteries in 23 of 29 patients. While acute phase all brain CT images were normal, brain SPECT images could show perfusion defects.
P30 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: head and neck cancer scintigraphy
P250 Preoperative diagnosis of orbital cavernous hemangioma by means of Tc99m-labeled red blood cells scintigraphy. L. Burroni1, P. Pichierri2, E. Polito2, L. Monti3, A. G. Vattimo1; 1Dept. of Nuclear Medicine, University of Siena, Siena, ITALY, 2Dept. of Ophtalmology, University of Siena, Siena, ITALY, 3Dept. of Neuroradiology, University of Siena, Siena, ITALY. The aim of the study is to evaluate Technetium‐99m red blood cells (Tc‐99m RBC) scintigraphy as a diagnostic tool for orbital cavernous hemangioma and to differentiate between orbital masses on the basis of their vascularization. We performed Tc‐99m RBC scintigraphy on 50 patients (17 F, 33 M; mean age: 47.6 years) affected by an orbital mass previously revealed with CT and MRI and suggesting cavernous hemangioma. In our diagnosis we considered the orbital increase delayed uptake with the typical scintigraphic pattern known as “perfusion blood‐pool mismatch”. The patients underwent biopsy or surgical treatment with transconjunctival cryosurgical extraction, when possible. Single Photon Emission Tomography (SPET) images showed intense focal uptake in the orbit corresponding to radiological findings in 32 patients who underwent surgical treatment and pathological evaluation (29 cavernous hemangiomas, 1 hemangiopericytoma and 2 lymphangiomas). Clinical or histological examination of the remaining 18 patients revealed the presence of 5 pseudotumors, 2 lymphomas, 3 pleomorphic adenomas of the lacrimal gland, 2 lipomas,1 astrocytoma, 1 inflammatory myofibroblastic tumor, 1 organized haematoma, 1 dermoid cyst, 1 opthalmic vein thrombosis and 1 orbital varice. The confirmation of the preoperative diagnosis by Tc99m RBC shows that this technique is the best tool in recognizing a cavernous hemangioma prior to excision (sensitivity =100%, specificity =85% and positive predictive value=89% ). Unfortunately, Tc99m RBC scintigraphy was positive in 1 case of hemangiopericytoma and 2 cases of lymphangioma, which showed increased uptake in the lesion on SPET images, due to the vascular nature of these tumors. Therefore, in these cases, the SPET images have to be integrated with data regarding clinical preoperative evaluation and CT or MRI images. On the basis of our study, a complete diagnostic picture, CT or MRI scans and scintigraphic patterns can establish the preoperative diagnosis of some vascular orbital tumors, such as cavernous hemangioma, lymphangioma and hemangioperycitoma. Moreover, Tc99m RBC is a useful diagnostic tool in excluding tumors with a non‐vascular origin responsible for unilateral painless proptosis.
P251 99m
Tc-MIBI SPECT in laryngeal and laryngopharyngeal cancer diagnosis
R. Zeltchan1, V. Chernov2, I. Sinilkin1, S. Chizhevskaya1, E. Choinzonov1; Cancer Research Institute, Tomsk, RUSSIAN FEDERATION, 2Institute of Cardiology, Tomsk, RUSSIAN FEDERATION.
1
The purpose of the study was to determine a feasibility of single photon emission computed tomography (SPECT) with 99mTc‐MIBI for the assessment of laryngeal and laryngopharyngeal malignant tumors. Materials and Methods: 99mTc‐MIBI SPECT was performed in 25 patients with stage T2‐4N0‐2M0 laryngeal or laryngopharyngeal cancers. Images were obtained 20 and 120 minutes after intravenous injection of 99mTc‐MIBI. Out of the 25 patients, 9 patients underwent additional SPECT examination following 2 courses of neoadjuvant chemotherapy. The control group consisted of 20 healthy subjects. The early and delayed tumor/background indices were calculated. Results: None of the patients of the control group had asymmetric increased radiotracer uptake in the larynx. Pathological accumulation of 99m Tc‐MIBI in the tumor was visualized in 24 out of 25 patients with laryngeal or laryngopharyngeal cances, thus demonstrating 96% sensitivity. In the group of patients who received chemotherapy, 8 patients 99m had decreased in Tc‐MIBI uptake in the tumor and their early and delayed tumor/background indices were also decreased (from 2.05±1.56 to 0.9±0.45 (p=0.01) and from 1.35±1.04 to 0.58±0.35 (p=0.01), respectively). Significant increase in 99mTc‐MIBI uptake in the tumor was revealed in 1 patient demonstrating the disease progression. Conclusion: Single photon emission 99m Tc‐MIBI can be used for the detection of laryngeal and computed tomography with laryngopharyngeal malignant tumors as well as for the assessment of therapeutical response.
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P252
P31 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
A quantitative investigation of brain tumor with Tl-201 and patlak plot method.
Diagnostic Oncology: Planar Scintigraphy, SPECT and
Aim:Tl‐201 scan is useful for diagnosis of brain tumor. Some authors tried to use semiquantitative indexes, including Tumor‐to‐nontumor activity ratio (T/N ratio) and retention index. We hypothesized that pharmacokinetics of Tl‐201 might indicate charactaristics of brain tumors. The purpose of this study was to investigate pharmacokinetics of it with patlak plot method, and to compare the indexes with T/N ratio and retention index. Methods: A total of 13 lesions, in 12 patients with brain tumor, were studied. After an injection of Tl‐201 (111MBq), the dynamic SPECT was performed on a triple‐headed digital gamma camera system for 15 minutes. ROIs were drawn manually over the abnormal uptakes of brain tumors. We analyzed Tl‐201 pharmacokinetics with patlak plot method, and estimated Ku as an index of influx rate constant, Vn as an index of distribution volume. Four hours after the injection, delayed image was acquired to calculate delayed T/N ratio and retention index as semiquantitative indexes. Finally, the correlation between each obtained parameters ware analyzed by a Pearson correlation test. Results: Statistically significant correlations were seen between Vn and T/N ratio in early and delayed phase (P < 0.005 and P < 0.05, respectively).The results were summarized in the table. Conclusions: The pharmacokinetics of Tl‐201 in the first 15 minites after injection had relation to the T/N ratio in early and delayed phase. This quantitative approach might be useful to estimate charactaristics of brain tumors with patlak plot method. Pearson''s correlation coefficients (*p < 0.05, **p < 0.005)
T/N ratio(early) T/N ratio(delayed) retention index
Ku 0.327
0.579
0.580
Vn 0.00492**
0.0161*
0.279
P253 Usefulness of Tc-99m MIBI and TI- 201 SPECT/CT in Brain Tumor Imaging after Surgery and Radiotherapy M. F. Alzayed1, A. Driedger1, J. Urbain2, R. Reid1, I. Rachinsky1, S. Yuoness1, M. Al-Harbi1, T. Belhocine2; 1LHSC, University of Western Ontario, London, ON, CANADA, 2St Joseph Hospital, University of Western Ontario, London, ON, CANADA. Objectives: The differentiation between brain tumor recurrence and post‐irradiation injury remains an imaging challenge. Computed tomography (CT) and magnetic resonance imaging (MRI) cannot always distinguish between the two. The aim of this study was to assess the clinical usefulness of [Tc‐99m] MIBI and TI 201 single photon emission computed tomography (SPECT) and X‐ray transmission computed tomography (CT), performed simultaneously with a hybrid imaging device, to differentiate recurrence from necrosis on brain MRI or fully diagnostic contrast enhanced CT. Methods :A total of 12 SPECT CT studies ( Tc‐99m MIBI (n=6) and 201‐ TI ( n=6) ) for 10 patients (5 men, 5 women) with brain tumor [multifocal glioma ( n=1), oligodendroglioma ( n=4) , metastatic breast cancer ( n=2), metastatic lung cancer (n=2), and metastatic renal cancer ( n= 1)] were evaluated. All patients received external‐beam radiotherapy with or without surgery and /or chemotherapy. Those patients were imaged on an integrated SPECT/ low dose CT scanner ( Infinia TM Hawkey TM ‐1 ( n=1)/‐4 ( n= 11) , GE Healthcare ). The SPECT CT data were compared to brain MRI and fully diagnostic contrast enhanced CT. Recurrence was confirmed histologically after surgery or by growth of the lesion over a 11‐month average follow‐up period, and clinical deterioration. Results: Fused images were found useful for accurate anatomical and functional localization of tumor recurrence, although the contrast resolution of the low dose unenhanced CT from SPECT CT was found inherently insufficient. There were 3 folds increase in the lesion mean counts following CT attenuation correction, which improved the lesion detectability. In 11/12 cases, an abnormally increased tracer uptake appeared in the region that CT and/or MRI indicated as suspicious; in all these cases, recurrence was confirmed histologically or by the lesion growth and clinical deterioration. In contrast MRI initially favored recurrence only in 6 of them. The remaining patient had no tracer uptake in the suspicious region, compatible with radiation injury; this lesion remained morphologically stable in a 13‐month follow‐up period, with no clinical deterioration in the patient’s condition, a course strongly favoring the diagnosis of radiation injury. In that patient MRI favored recurrences initially. Conclusion: SPECT/CT imaging with Tc‐99m MIBI and 201 TI represents a useful clinical tool in brain tumor imaging, both correctly categorizing focal areas near sites of physiological uptake and differentiating recurrence from necrosis on brain MRI or fully diagnostic contrast enhanced CT after radiotherapy and surgery.
P254 Comparaisons of SPECT Bone Scintigraphy and CT for Diagnosing Skull Base Lesion in Nasopharyngeal Carcinoma I. Slim, I. El Bez, I. Yeddes, S. Krimi, B. Letaief, A. Mhiri, F. Ben Slimene; Nuclear Medicine Department, Salah Azaiez Institute, Tunis, TUNISIA. Aim: To evaluate the usefulness of SPECT bone scintigraphy in examining the skull base of nasopharyngeal carcinoma (NPC) patients. Patients and methods: From january 2006 to December 2008, thirty patients (21 men, 9 women, mean age 42 years) with histologically proven NPC had undergone bone scintigraphy with SPECT of the skull and CT of the skull base within 1 month. Results: Bony involvement was demonstrated by SPECT in 23 patients and by CT in 14 patients. Comparison of SPECT with CT showed that SPECT did not miss the lesions detected by CT while CT missed 39% of the lesions detected by SPCET. Conclusion: SPECT of the skull is a diagnostic tool for early detection of skull base involvement of NPC and appears useful in patients with a negative CT study.
SPECT/CT:
thyroid
and
parathyroid
tumours
scintigraphy
P255 Value of Tc-99m MIBI as a screening method for the functional status of parathyroid gland in uremic hyperparathyroidism A. A. Kandeel1, M. A. El-Hawary2, H. S. Ebaid3; 1Kasr El-Ini Hospital, NEMROCK, Cairo, EGYPT, 2Fayoum University, Radiology Department, Fayoum, EGYPT, 3Al-Agouza Hosp., Nephrology department, Giza, EGYPT. Purpose: We aimed in this investigation to study the usefulness of Tc‐99m sestamibi scintigraphy as a screening method to assess the functional status of the parathyroid glands in uremic patients with persistent secondary hyperparathyroidism that cannot be controlled medically to select those who in need for parathyroidectomy. Methods: Dual‐phase Tc‐99m‐MIBI parathyroid scintigraphy was done in 30 patients with chronic renal failure and persistent hyperparathyroidism. Most of them presented with variable frequency and severity of symptoms and complications. In all patients, serum calcium, phosphorus, creatinine and intact PTH were measured. On scintigraphic basis, 13 patients underwent neck exploration and 19 parathyroid glands were removed and histologically examined. Results: MIBI scintigraphy was positive in 17/30 patients (57%) showing 23 positive sites of focal tracer uptake. Mean serum iPTH and mean serum calcium concentrations were significantly higher in patients with MIBI‐positive glands than in those with MIBI‐negative glands (1319±400 versus 345±235 pg/ml for iPTH) and (9.2±0.9 mg/dl versus 8.1±0.7mg/dl for calcium) respectively. Patients with MIBI‐positive scan had statistically significant longer disease duration (111±24 m) compared to those with MIBI‐ negative scans (51±25 m). MIBI scan correctly identified 3 glands with parathyroid adenoma. On histological examination, 12/16 glands (75%) showed nodular hyperplasia with obvious higher MIBI uptake compared to the rest 4 glands (25%) that showed diffuse hyperplasia. Conclusion: Dual‐phase MIBI scintigraphy has the ability to localize hyperfunctioning parathyroid glands in a significant number of uremic patients with persistent secondary hyperparathyroidism that cannot be controlled medically to select those who in need for parathyroidectomy. In addition to biochemical data, Tc‐99m MIBI parathyroid scan can be a useful screening method to assess the functional status of parathyroid glands in uremic patients with secondary hyperparathyroidism as well as to detect functional autonomy (tertiary hyperparathyroidism). Keywords: Tc‐99m‐MIBI; parathyroid scintigraphy; parathyroid hyperfunction; uremic secondary hyperparathyroidism; parathyroid hyperplasia.
P256 Prediction of suspect cytological finding in thyroid hypofunctioning solid nodule by echosonography, color flow Doppler sonography and 99mTc-MIBI scintigraphy Z. Aleksic, A. Aleksic, V. Mitov, D. Nikolic, V. Savija; Health Center Zajecar, Zajecar, SERBIA. Introduction: The reported sensitivity and specificity of fine needle aspiration cytology (FNAC) is as high as 90% and 79% respectively in diagnosing thyroid carcinoma, while imaging modalities ‐ echosonography, color flow Doppler sonography (CFDS), thyroid pertechnetate scintigraphy and 99mTc‐MIBI scintigraphy are of limited specificity. The aim of the study was to assess the value of those imaging modalities in prediction of suspect cytological finding in thyroid nodules. Patients and methods: Thirty one patients (pts), 26 female and 5 male, average age 50.6±11.8 were included in the study. There were 17 pts with solitary solid nodule and 14 pts with multynodular goiter with dominant solid nodule. All investigated nodules were hypofunctioning on 99mTc04‐ scintigraphy. Thyroid echosonography was done on Toshiba Justvision 200 device with 8 MHz rectilinear probe. CFDS was done on Siemens sonoline versa pro device with 7.5 MHz probe. 99m Thyroid scintigraphy was done after 15‐20min of i.v. application of 74 MBq of TcO4‐ or 370 MBq of 99mTc‐MIBI in planar anterior projection on gamma camera Siemens Diacam with high resolution parallel hole collimator. FNAC of nodules were done and smears were prepared using May‐Grunwald‐Giemsa stain. Cytological findings were expressed as nonsuspect (N) and suspect (S). Echosonographic findings were classified as isoechoic (I) , hypoechoic (Hy) and hyperechoic (Hr). CFDS findings were classified as absent vascularity (AV), normal vascularity (NV) and increased vascularity (IV). 99mTc‐MIBI scintigraphy findings were classified as cold (C ‐ decreased uptake of tracer), warm (W ‐ the same uptake as in the surrounding tissue) and hot (H ‐ increased uptake of tracer). Results: Ecosonographical finding could not predict suspect cytological finding (p=0.05;RR=0.9). We found statistically significant (SS) difference in presence of suspect cytological finding in IV versus AV and NV nodules on CFDS (p<0.05; RR=2). We found high statistically significant (hSS) difference in presence of suspect cytological finding in H versus C and W nodules on 99mTc‐MIBI scintigraphy (p<0.001; RR=1.5). Conclusion: Increased vascularity (IV) on CFDS presents 2 times greater risk and increased uptake of 99mTc‐MIBI (H) presents 1.5 times greater risk for suspect cytological findings in nodules. Avascular nodules on CFDS and those with decreased uptake of 99mTc‐MIBI almost exclude the possibility of suspect cytological finding. Key words: thyroid nodule, FNAC, thyroid scintigraphy, echosonography, colour flow Doppler sonography, MIBI
P257 Long-Term Course of Patients With Differentiated Thyroid Cancer. Prognostic Value of Initial Thyroglobulin Levels and First Follow-Up Whole Body Scan M. Alvarez, A. Serena, F. Loira, J. Pou, J. Barandela, L. Campos; Hospital Meixoeiro (Chuvi), Vigo, SPAIN. AIM: To examine the outcome of differentiated thyroid cancer (DTC) after initial treatment, principally patients with discordant findings of serum Tg levels and 131I whole body scan (WBS)
Poster Presentation
M. NAKAYAMA1, A. Okizaki1, J. Sato1, T. Tanaka2, T. Aburano1; Department of Radiology, Asahikawa medical college, Asahikawa, Hokkaido, JAPAN, 2Department of Neurosurgery, Asahikawa medical college, Asahikawa, Hokkaido, JAPAN. 1
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and their predictive evolution. MATERIAL AND METHODS. Retrospective observational study. Review of DCT medical records from 2003‐2008. 697 patients who underwent total thyroidectomy and a remnant radioiodine therapy were enrolled and divided in 4 groups, according to initial (i) and follow‐up (fu) WBS and stimulated Tg levels results. Cases with only radioiodine ablation background (94 patients‐13.5%) were excluded. Correlation with other diagnostic modalities (ODM): Ultrasound, CT, Bone scintigraphy, PET was evaluated. RESULTS: Group I: Successful ablation (fuTg level <1ng/mL and negative fuWBS). 407 patients. 100% of cases with cervical uptake in iWBS. Negative ultrasound in 27 patients. Group II: Persistent elevated fuTg levels and positive fuWBS. 68 patients. iWBS: Cervical uptake in 51 patients; extra‐ cervical uptake in 17 cases. ODM concordant with fuWBS in 51 patients. a) 18 patients had a reduction of fuTg and minimum uptake in fuWBS, with complete resolution only 2. b) 28 patients had a progressive increase of fuTg and extensive uptake in fuWBS; 10 subjects died. c) 22 patients had stable disease. Group III: Persistent elevated fuTg and negative fuWBS. 67 patients. iWBS: only cervical uptake in 51 patients; extra‐cervical uptake in 16 cases. 2 cases with positive Tg‐antibodies levels. ODM: CDT‐related findings in 19 patients. a) 26 patients had iTg <51.3 ng/ml: 20 with progressive reduction of fuTg; Complete resolution only 6. b) 22 patients had an increase of fuTg; 5 subjects died. c) 25 patients had stable disease. Group IV: fuTg <1ng/mL and positive fuWBS. 61 patients. iWBS: only cervical uptake in 55 patients; extra‐cervical uptake in 6. ODM performed in 6 patients, concordant with fuWBS (mainly adenopathies). a) 52 patients with iTg <47.7 ng/ml: Complete resolution in 23; 29 cases with descending local uptake in fuWBS without reaching normalization. b) 9 patients had progressive disease in fuWBS. GROUPS
I
Patients
407 (58.4%) 68 (9.8%) 67 (9.6%) 61 (8.8%)
% Male
17
32
31
18
Age at diagnosis (years)
41,7
55,6
45.5
43.4
Average surveillance (years) 6
9.8
9.1
8.1
Papilar/Follicular
42/26
53/14
49/12
Average total 131I dose (GBq) 339.6
1695.3
1243.5
865
Average initial iTg (ng/mL)
74.6
72.3
18.4
364/43 12.3
II
III
IV
P258 Sestamibi patients
P260 Negative thyroglobulin after total thyroidectomy in Differentiated Thyroid Carcinoma: role in therapy and followup B. Martínez-Sanchis, P. Sopena-Novales, E. Caballero-Calabuig, M. CanoTerol, M. Reyes-Ojeda, P. Abreu-Sanchez, M. Plancha-Mansanet, J. FélixFontestad; Hospital Dr. Peset, Valencia, SPAIN.
CONCLUSION: Most DTC‐patients can successfully be free of disease with surgery and remnant ablation. In patients with discordant findings, deferred normalization of Tg and negative fuWBS is possible. Cases with extensive iWBS uptake and/or iTg levels >50 ng/mL, will have a longer disease and possibility of fatal outcome.
Value of dual-phase 99mTc preoperative assessment of hyperparathyroidism
chromosome 12p13. cycle inhibits inactivaction of the Rb protein and prevents G1 to S phase transition. Aim.We analysed 70 papillary thyroid microcarcinomas wishing to determine prognostic implications of RET mutation and the cell cycle regulators Cyclin D1 and p27 investigating their relation to metastatic spread. Material and methods. Tissues were retrieved from surgical pathology files of the Clinical Hospital Split . Immunohistochemical staining was performed on the formalin‐fixed paraffin‐embedded sections using monoclonal antibody against RET, Cyclin D1 and p27 purchased from Novocastra,Vision Bio System, Newcastle, UK. We used immunohistochemical analysis to investigate their expression in 70 papillary microcarcinomas. Results.Our results on univariate analysis show that overexpression of CyclinD1 (p=0,014) and undrexpression of p27 (p=0,093) predict lymph node metastases in papillary microcarcinomas demonstrating their expression in the inverse proportion. High risk microcarcinomas were Cyclin D1 expressors and p27 nonexpressors, while low risk carcinomas were Cyclin D1 nonexpressors and p27 expressors. RET expression (p=0,459) was not proven to have any statistically significant predictiv value. Conclusion.Immunihistochemical analysis of Cyclin D1 and p27 expression prove to be valuable test for identifying papillary microcarcinomas with metastatic potential. These data might contribute new treatment protocols and facilitate follow‐up of patients.
SPECT/CT in with primary
N. Solar1, K. Taborska1, J. Astl2, P. Libansky3, S. Smutny4; 1Clinic of Nuclear Medicine and Endocrinology Faculty Hospital Motol, Prague, CZECH REPUBLIC, 2Department of ENT and Head and Neck Surgery, Prague, CZECH REPUBLIC, 3Department of Surgery 3, Prague, CZECH REPUBLIC, 4 Department of Surgery Faculty Hospital Motol, Prague, CZECH REPUBLIC. In this retrospective study we evaluate benefit of fusion single photon computed tomography and low dose CT images in localization of abnormal parathyroid glands before operation in patients with primary hyperparathyroidism. Material and methods: A total of 63 surgical patients (52 women, 11 men, age range 28‐78 years) with suspected primary hyperparathyroidism who underwent parathyroidectomy in period 08/2006‐02/2009 at three different surgical clinics and who underwent scintigraphy at our department previously, were included in this study. Retrospectively, we evaluated the blinded fused SPECT/CT slices and surgical findings were used as a standard of comparison. Dual‐ phase sestamibi parathyroid scintigraphy was performed after i.v. injection of 700MBq 99mTc‐ sestamibi, followed by planar scintigraphy of cervical and thoracic area after 15 and 2 hours, SPECT/low dose CT was acquired with Symbia T (130kV, 17mAs, 5 mm slice thickness) at delayed phase. The field of view of the CT scanning was the same as the SPECT acquisition. Results: Surgery was successful in 61 patients (solitary parathyroid adenoma in 58 patients, double parathyroid adenomas in 2 patients, 4 hyperplastic parathyroid glands in 1 patient), in 2 patients no parathyroid adenoma was found, one patient with true negative scintigraphy, the other with false positive finding due to nodule within thyroid lobe. The sensitivity, specificity and diagnostic accuracy calculated for localisation of individual parathyroid glands were 88%, 97% and 93%. Conclusions: Single injection, dual‐ phase 99mTc‐sestamibi is widely used technique in the evaluation of hyperparathyroidism. Fused imaging available on hybrid SPECT/CT camera substantially improve preoperative diagnostic accuracy of locating abnormal parathyroid glands, but the ability of low dose CT slices is lower in differentiation other tissue with MIBI uptake (parathyroid adenoma versus nodular goitre).
P259 RET mutation,Cyclin D1 and p27 in papillary microcarcinoma of the thyroid A. Punda, V. Pesutic-Pisac, V. Marković, I. Glunčić; Clinical Hospital Split, Split, CROATIA. RET mutation, Cyclin D1 and p27 in papillary microcarcinoma of the thyroid Table of Contents Introduction.The term microcarcinoma should be used for a papillary carcinoma which measures 1cm or less in diameter and which is usually found incidentally. According to some authors it has been reported in up to 24% of surgical thyroidectomies performed for disorders unrelated to papillary carcinoma. In children these tumours behave more aggressively, most of them are associated with external or therapeutic irradiation and presence of RET mutation. Located near the thyroid capsule, the tumor is often sclerosing. The smaller ones frequently show follicular pattern and the bigger ones papillary pattern. The prognosis is excellent but sometimes these tumors present with large cervical lymph node metastasis suggesting that this rare lesions have distinct immunohistochemical features including Cyclin D1 and p27. The Cyclin D1 gene is a positive regulator of the cell cycle located on chromosome 11q23. that inactivates Rb protein and allows cell cycle progression from G1 to S phase.Tumor suppressor gene p27 located on
Introduction: Thyroglobulin (Tg) is a very sensitive tracer of the presence of thyroid cells. Non‐ detectable Tg is considered as absence of thyroid tissue and hence, a prove of cancer remission. Nevertheless, in some cases, we find notable thyroid activity in 131I wholebody scan images and non‐detectable Tg. Aim: to demonstrate that non‐detectable Tg should not be taken as the only criteria to rule out the presence of thyroid cells. Material and method: This is a retrospective study (2000‐2008) of 180 patients with differentiated thyroid carcinoma (DTC) sent to Nuclear Medicine department for the administration of ablative 131I dose, after total thyroidectomy. Tg, Tg autoantibodies (TgAb) and 131I scan under TSH > 30 mcU/ml are evaluated. Tg and TgAb under TSH suppression are also determined every 3 months in the first year after initial treatment. We consider negative Tg value when non‐detectable (<0.5 ng/ml). Patients with positive TgAb are excluded. Two whole body 131I scans are performed: after 131I ablative dose and, one year later, after diagnostic dose. Positive scan is considered when cervical and/or distant uptake are present. Results: 180 patients are collected. 10 patients with positive TgAb are excluded. We find detectable Tg (>0.5 ng/ml) in 147 out of 170 patients and non‐detectable Tg in 23 (13.5%). Iodine scan after ablative dose is positive in all of them. All 23 patients with non‐detectable Tg show thyroid remnant and two of them also have lymph node uptake. In none of these patients Tg becomes positive along follow‐up. 17 out of these 23 patients have iodine control scan performed one year later; images are still positive (thyroid remnants) in only one patient; and stimulated Tg remains negative in all of them. Conclusions: Non‐detectable Tg does not exclude the need of radioiodine therapy. Follow‐up of these patients should include 131I scan.
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Semiquantitative Analysis of Tc-MIBI Scan of Hyperfunctioning Parathyroid Glands: Correlation with Histological and Surgical Findings I. Zerizer, S. Welch, A. Al-Nahhas, Z. Win; Hammersmith Hospital, London, UNITED KINGDOM. Aim: To evaluate the performance of a semi‐quantitative analysis method of 99mTc‐ methoxyisobutyl isonitrile (MIBI) scans in differentiating parathyroid adenoma from hyperplasia in conjunction with histology and surgical findings. Method: A review of 46 MIBI Single Photon Emission Computed Tomography scans of patients with suspected hyperparathyroidism was performed. Planar imaging of the neck and thorax was obtained at 10‐minutes (early image) and 90‐minutes (delayed image) after injection of 900 MBq of 99mTc‐MIBI with the patient supine and the neck extended. The images were obtained with a low‐energy, parallel‐hole, high‐resolution collimator and a 20% energy window centered on the 140 KeV peak. A grading of the parathyroid relative uptake from 0 to 3 on both early and late images was performed using the software display on a Hermes Workstation. All patients underwent a parathyroidectomy with a total of 47 glands removed. The combination of histology and surgical finding was considered the gold standard for diagnosis to which the MIBI scan findings were compared. Results: Thirty‐two glands scored 0 to 2 in the 10‐minute scan and 0 to 1 in the 90‐minute scan. These were reported to be scintigraphically negative for a parathyroid adenoma. Twenty‐two (68%) of these lesions were found to be parathyroid adenomas on histology and surgical appearance. Three were normal (9%) and 7 (22%) were hyperplastic glands. Fifteen glands scored 3 in the 10‐minute scan and 2 to 3 in the 90‐minute scan and were reported to be highly suggestive for a parathyroid adenoma. Eleven (73%) were adenomas, 4 (26%) hyperplasia and 1 (7%) gland was normal There was no statistical significance between the negative and positive groups (p>0.05, student t‐test). The positive predictive value of the MIBI scan was 45% and the negative predictive value of 12 % giving an overall sensitivity of 33% with a specificity of 75%. Correlation of the scan findings with the multi‐disciplinary clinical probability score of an adenoma, which includes the biochemical test results was the single most useful tool in making the diagnosis with an increased sensitivity of 75% (p< 0.05). Conclusion: The MIBI scan alone is a poor predictor of the nature of the parathyroid lesion. The scan findings should be carefully interpreted. A multi‐disciplinary approach in conjugation with the clinical findings and biochemical tests is advised to increase the sensitivity and specificity of scan findings.
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Positive Predictive Value of the Parathyroid Scintigraphy with a Multiphase Technique and an Additional Thyroid Scintigraphy. Surgical confirmation U. C. Vera, L. Díez, M. E. Rioja, M. P. Orduña, Á. Crespo; Ramon & Cajal Hospital, Madrid, SPAIN. Aim: To determine the efficiency of the Tc‐99m‐Sestamibi scintigraphy(2‐methoxy‐isobutyl‐ isonitrile) in four phases combined with late thyroid study with Tc‐99m‐Pertechnetate in the diagnosis and localization of pathological parathyroid glands. Material and methods: Between January, 2005 and December, 2006, 252 patients were studied (of which 191 were women and 61 men) because of a clinical suspicion of primary hyperparathyroidism (with a blood PTH, calcium and phosphorus determination). The patients underwent a combined scintigraphy study (Tc‐99m‐MIBI multiphase and thyroid scintigraphy). Among the patients with a positive study, we evaluated the ones referred to surgery and the results of the surgical biopsy. The MIBI acquisition was made after the intravenous infusion of 925 MBq of Tc‐99m‐MIBI, acquiring planar sequential images after 10, 30, 60, 90 and 120 minutes, of the neck and thorax in frontal projection, with the patient in decubitus supine and the neck hyperextended, fulfilling the first one to 600 Kc and the successive ones in time. In the following days a thyroid scintigraphy was made after the intravenous infusion of 185 MBq of Tc‐99m‐Pertechnetate obtaining only one frontal projection, with the patient in the same situation as in the study with MIBI. The images were taken with a low‐energy general purpose collimator, window of 140 KeV and 128x128 matrix. The images obtained were checked by two nuclear doctors, to detect areas of located hypercaptation suggestive of hyperactive glands. The persistent accumulation of the tracer was considered to be a positive finding in the planar study, so long as the image was not concurrent with the thyroid scintigraphy. Results: Of the 252 patients, the combined study was negative for pathological parathyroid glands in 71 patients (28,2 %) and positive in 181 (71,8 %). Of the group of patients with positive scintigraphy, 86 (34,1 %) were referred to surgery, being removed a pathological parathyroid gland in 82 patients (32,5 %), confirmed by means of the biopsy (78 adenomas, of which 3 were ectopic and 4 hyperplasias). In 4 patients with positive scinitgraphy, surgery did not find pathological glands (false positives). A positive predictive value of 95.5% was obtained in the scintigraphy of the patients who underwent surgery. Conclusion: The Tc‐99m‐Sestamibi multiphase scintigraphy associated with a later study of the thyroid gland is a diagnostic tool of high positive predictive value to demonstrate the existence and localization of pathological parathyroid glands, and diminishes the rate of errors induced by associated thyroid pathology.
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Clinical usefulness of Tc-EDDA/HYNIC-TOC scintigraphy in diagnosing and staging of patients with medullary thyroid carcinoma 1
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M. Vlajkovic , S. Ilic , M. Rajic , R. Dzodic , A. Karanikolic , M. Matovic , I. Pejcic5, S. Vrbic5, T. Strahinjic6; 1Department of Nuclear Medicine, Clinical Center, Nis, SERBIA, 2Institute of Oncology and Radiology, Clinical Center of Serbia, Belgrade, SERBIA, 3Clinic for General Surgery, Clinical Center, Nis, SERBIA, 4Department of Nuclear Medicine, Clinical Center, Kragujevac, SERBIA, 5Clinic for Oncology, Clinical Center, Nis, SERBIA, 6Clinic for Endocrinology, Clinical Center, Nis, SERBIA. The aim of the study: Medullary thyroid carcinoma (MTC) is a tumor of neuroendocrine origin and is functional, producing hormone calcitonin. It expresses multiple somatostatin receptors (sst 2‐5), which represent the molecular basis for the clinical use of somatostatin analogues in diagnosis and the treatment of endocrine tumours and their in vivo localisation. No definitive imaging study has been established for MTC, however several modalities have been suggested for the use in detection of residual disease and metastases. The aim of this study was to assess the diagnostic efficiency of 99mTc‐EDDA/ HYNIC‐TOC (Tektrotyd) scintigraphy in the detection and staging of patients with MTC. Patients and methods: Eight patients with sporadic MTC, aged 53‐ 99m 70 years, were submitted to radionuclide investigation. Sequential scintigraphy using Tc‐ Tektrotyd was performed 2 and 24 hours after the injection of 740 MBq of the tracer. All the patients were imaged after the surgery during the follow up (2‐17 years), out of which three were imaged before the surgery as well. Other imaging techniques were also applied and analyzed in individual cases (ultrasonography, computed tomography, 99mTc(V)‐DMSA, 131I‐MIBG, 99mTc‐MDP, 99m MRI) and compared with Tc‐EDDA/HYNIC‐TOC. Results: Out of the 3 patients who were imaged before the surgery, one was found to have increased uptake in primary tumor, while in other two, beside the primary tumor, cervical and axilar lymph node involvement was observed in the scan. In one of these patients, other imaging modalities failed to detect primary tumor and in the other two lymh node metastases. No pathological uptake was visible in one patient after thyreoidectomy, either by Tektrotyd scan or by means of other imaging techniques. Another patient showed an increased uptake in the left lobe after partial thyreoidectomy. Scintigraphy using Tektrotyd detected a significantly greater number of lesions in other four out of 5 patients after thyreoidectomy, so that the patients were upstaged. One of these patients with Tektrotyd avid metastases in bones, lung and lymph nodes was successfully managed using somatostatin analogue (Sandostatin LAR) during 12 months. However, Tektrotyd scan failed to show 4 bone lesions in one patient in whom only mediastinal lymph nodes were detected. Conclusion: It can be concluded that 99mTc‐EDDA/ HYNIC‐TOC is the sensitive technique for diagnosing and follow‐ up of patients with MTC. It can be used both for preoperative staging and for the detection of local recurrence and distant metastases.
P264 Recurrent medullary or mixed papillary and medullary thyroid 99m Tc-Depreotide; correlation with tumor cancer identified by markers P. Valsamaki1, A. Gotzamani-Psarrakou2, E. Molyvda2, V. Papantoniou3, I. Tzitzikas2, A. Zanglis1, G. Fountos4, S. Gerali1; 1“Pammakaristos” General Hospital, Athens, GREECE, 2“Aristoteleion” University of Thessaloniki,
Thessaloniki, GREECE, 3“Alexandra” University Hospital, Athens, GREECE, 4 “Technological Education Institute of Athens (TEI)”, Athens, GREECE. Aim: Hitherto only few clinical studies involve the application of the newer synthetic somatostatin analogue 99mTc‐Depreotide (99m Tc‐D) in medullary thyroid cancer (MTC) follow‐up. Considering the encouraging 99mTc‐D results in papillary thyroid cancer (PTC) as well, we decided to evaluate 99mTc‐D in the localization of recurrent metastatic lesions in patients suffering from MTC or mixed PTC+MTC and statistically assess the functional interaction between tumor marker secretion and somatostatin receptor visualization. Patients and Methods: Our study included 16 patients (6 men and 10 women, 52±17 years old, mean age±SD), post total thyroidectomy, 8 due to MTC and 8 mixed PTC+MTC. All patients presented with clinical and/or laboratory (increased serum calcitonin‐Ct and/or thyroglobulin‐Tg levels) indicators of relapse. The imaging work‐up consisted of whole‐body and case‐adjusted regional (head, neck, chest and/or abdomen) tomographic scintigraphy (SPECT), 120 min after the iv administration of 740 MBq of 99mTc‐D, as well as conventional radiologic examinations (i.e. ultrasonography, computerized tomography and/or magnetic resonance imaging). The verification of the radionuclide imaging results was based either on histology or on concordant radiologic findings. Scan interpretation involved both visual and semi‐quantitative assessment. The Lesion/Background ratio (L/B) was calculated, using regions of interest of the same size and shape. The Uptake Index (UI) was defined as the ratio (L‐ B)/B, and was mathematically corrrelated with the serum tumor marker levels. Results: The 99m Tc‐D scan revealed metastatic lesions in 6/8 MTC and 4/8 PTC+MTC patients. There were three true negative, one false positive and two false negative results. The 99mTc‐D scan exhibited an overall 83.3% sensitivity and 75% specificity. Statistical analysis of the data failed to show any significant linear correlation between the UI and the tumor marker levels (non‐parametric, Spearman rank correlation test). However, a statistically significant non‐linear correlation was detected between the UI and the Ct values (r = 0.994, P = 0.003) in MTC and in mixed TC patients (r = 0.997, P = 0.0046), as opposed to the Tg levels (r = 0.641, P = 0.349) of the latter group. Conclusions: The 99mTc‐D‐scintiscan appears to substantially influence the management of patients with recurrent MTC and mixed PTC+MTC, since both diagnostic and therapeutic guidance may be expected. Our data suggest that the increased expression of 99mTc‐D(+) lesions in MTC and possibly in mixed TC, reflects high‐grade disease. The underlying communications and amendments of the somatostatin receptor subtypes on thyroid cancer cells will further elucidate their scintigraphic status quo.
P32 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: lung cancer scintigraphy
P265 Non small cell lung cancer (NSCLC) staging by simultaneous single photon emission computerized tomography (SPECT) with 67-Ga and 99mTc-MIBI: preliminary results. S. N. Novikov, M. M. Girshovich, S. V. Kanaev, E. V. Levchenko, D. S. Beynusov; N.N. Petrov Inst. Oncol., St. Petersburg, RUSSIAN FEDERATION. Aim of the study: PET has been shown to be an effective staging and follow‐up tool in patients with NSCLC but its restricted availability and low specificity prompt us to test alternative procedures. The aim was to evaluate diagnostic properties of simultaneous double‐tracer SPECT as addition to conventional staging. Material & Methods: Simultaneous scintigraphy with 67Ga and 99mTc‐MIBI was performed in 18 consecutive patients with clinical suspicious for NSCLC. After conventional staging with CT all patients had SPECT with 67‐Ga and 99mTc‐MIBI. SPECT was performed as a single examination with simultaneous registration of both tracers. Acquisition started 48‐74 hr after i/v injection of 130‐175 MBq 67Ga and immediately after i/v injection of 500‐740 MBq of 99mTc‐MIBI. All images for each agent were classified as positive and negative for primary tumor, N1 and N2 lymph‐nodes (LN). Results: according to histology 17 of 18 evaluated patients had NSCLC and one ‐ tuberculosis. SPECT with 99mTc‐MIBI correctly visualized tumor in all 17, 67‐Ga ‐ in 13 cases. Both tracers were true negative in patient with tuberculosis. For primary lesions 99Tc‐MIBI was more sensitive than 67‐Ga and more specific than CT. Histological verification of LN status obtained in 15 patients: N0 revealed in 7, N1‐ 2, N2 ‐ 4 cases. Both tracers correctly discriminate LN ‐ and LN + cases with 100% accuracy. On the contrary, CT was false positive in 2 and false negative in another 3 patients. Differentiation between N1 and N2 LN involvement is crucial for therapy planning. 99mTc‐MIBI and 67‐Ga correctly diagnosed 2 cases with N1 and 4 ‐ with N2 LN involvement verified by postoperative histological examinations. In 2 patients SPECT overestimated extent (N2) of LN involvement. After surgery LN status was changed on N1. In 2 patients results of 99mTc‐MIBI and 67‐Ga was complimentary to each other. Accuracy of LN staging by SPECT with 99mTc‐MIBI and 67‐Ga was 75%. CT accurately determined LN stage only in 2 patients, overestimate ‐ in 4 and underestimate ‐ in 3 cases. Conclusions: In small group of NSCLC patients SPECT with 99mTc‐MIBI and 67‐Ga demonstrated high accuracy in diagnosis of primary tumor and regional LN status. Accuracy of SPECT significantly surpassed results of conventional staging with CT. These preliminary results are very promising but need further confirmation in larger patient group.
P266 The Value Of 99mTc-Depreotide SPECT/CT Imaging For Lymph Node Staging In Non-Small-Cell Lung Cancer. A Study With Histological Confirmation A. Paschali, N. Papandrianos, E. Koletsis, E. Stamou, T. Spyridonidis, C. Savvopoulos, P. Barla, D. Dougenis, P. J. Vassilakos, D. J. Apostolopoulos; University Hospital of Patras, Patras, GREECE. Aim: In the present work we investigated the potential application of 99mTc‐Depreotide scintigraphy in the pre‐operative evaluation of lymph node (N) status in non‐small‐cell lung cancer (NSCLC). Materials‐Methods: 62 patients with NSCLC at a potentially operable stage according to the conventional work‐up (FDG‐PET was not performed) entered the study and
Poster Presentation
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S362 underwent scintigraphy the day before surgery (53 cases) or mediastinoscopy (9 cases). Imaging was performed with a SPECT/low resolution CT system (Hawkeye, GE). Co‐registered SPECT‐CT slices were inspected to determine the exact location of abnormal scintigraphic findings. Depreotide uptake in N1 and N2 node stations was evaluated visually and semi‐quantitatively (using normal uptake in the sternum and spine as reference) on attenuation‐corrected SPECT slices. Findings in particular lymph node stations as well as the ultimate N status of each patient were reported. Surgeons were blind as to the scintigraphic findings. Scintigraphic results were compared to lymph node histology. Results: With reference to 110 N1 and 97 N2 examined lymph node specimens, sensitivity and specificity of scintigraphy by visual interpretation was 86% and 40% for N1 and 88% and 51% for N2 nodes, respectively. As regards staging, N1 stage was accurately predicted in 64% of cases, with positive (PPV) and negative predictive values (NPV) of 52% and 83%. In assessing the ultimate N2 stage, no false negative was found (sensitivity and NPV 100%). Specificity and PPV was 38% and 33%, respectively. It should be noted, however, that the majority of sampled N2 nodes were enlarged (at least mildly) during surgery; specificity of the macroscopically assessed lymph node size was only 18%, whereas sensitivity was, expectedly, 100%. ROC analysis of quantitative scintigraphic data indicated that the best discrimination of disease‐involved from disease‐free lymph nodes was accomplished by setting a lesion‐to‐sternum ratio cut‐off at 1.35 (or lesion‐to‐spine cut‐off at 0.80). Using these cut‐off values, specificity and PPV for N2 status increased in relation to visual evaluation to 76% and 53%, while sensitivity and NPV decreased to 83% and 93%, respectively. Conclusion: 99mTc‐depreotide SPECT/CT seems to have a role in lymph node staging of NSCLC, mainly because of its high sensitivity and negative predictive value for mediastinal lymph node involvement. Specificity appears low, but the particular study design has to be taken into consideration. Quantification of nodal uptake can improve specificity, at the low cost of sensitivity and NPV.
P267 Alveolar edema followed Precision Pulmonary Trans-Arterial Chemoembolization (PPTACE) detected by Ventilation Lung TomoScintigraphy (VLTS) A. Niccoli Asabella1, A. Gaudiano2, C. Gadaleta3, A. Catino3, F. Lauriero2, G. Rubini2; 1Nuclear Medicine, Bari, ITALY, 2Nuclear Medicine - Policlinic of Bari, Bari, ITALY, 3Interventional Radiology Unit, Oncology Insitute G. Paolo II, Bari, ITALY. INTRODUCTION: Radio Frequency Ablation (RFA) under CT is an interesting alternative of local treatment in inoperable cases of primary and metastatic lung tumours; this technique is limited by the air surrounding the intraparenchymal lesions that affords an insulating effect and traps the heat within the target tumours, creating the “oven” effect. TACE is a technique that allow to injected chemotherapic drug into tumours followed by an injection of embolizating permanent material. To over pass the “oven” effect, at Interventional Radiology Unit, Oncology Institute Giovanni Paolo II of Bari, patients with primary or secondary unresectable lung tumours underwent PPTACE before RFA to produce interstizial and alveolar edema induced by citotoxic effect of chemoterapic drugs and ischemic injury, to improve the heat condution developed during RFA treatment. The aim of the study is to verify by VLTS the effects of PPTACE on pulmonary parenchyma, in order to demonstrate the absence of ventilation in the lung region submitted to PPTACE. MATERIAL AND METHODS: We studied eight patients (pts) (2 female and 6 male; median age 64) with histological or cytological demonstrated primary (2 pts) or secondary lung cancer (6 pts) with no extrathoracic or mediastinic diseases evaluated by 18F‐FDG PET/CT, enrolled by thoracic CT to demonstrated and localize the lesion. All patients underwent VLTS pre and post PPTACE with 740 MBq of 99mTc‐DTPA aerosol nebulized trough a Venticis II aerosol delivery system for 15 minutes. A tomographic scan was acquired with a double head gammacamera Acquired images were elaborated to obtained transversal, sagittal, coronal section. For each patients VLTS pre e post PPTACE was analyzed. RESULTS: all patients showed the appearance of a circumscribed defect of ventilation in the lung parenchyma corresponding to area submitted to PPTACE at the VLTS post this treatment,which wasn't present at VLTS pre PPTACE. The ventilation defects involved not only in the lung parenchyma corresponding to the artery distribution territory submitted to PPTACE, but also in a wider area surrounding it. CONCLUSIONS: this pilot study shows the potential utilization of VLTS in the evaluation of alveolar ventilation changes following PPTACE; VLTS is the only non invasive technique able to show in vivo the effect on alveolar ventilation induced by PPTACE, particularly in demonstrating the absence of alveolar ventilation, which is important to exceed the oven effect and to strengthen RFA treatment.
P268 99mTc-tetrofosmin SPECT/CT in lung lesion detection A. Spanu1, F. Chessa1, P. Marongiu1, D. Sanna1, B. Piras1, P. Pirina2, G. Madeddu1; 1Dept. of Nuclear Medicine, University of Sassari, Sassari, ITALY, 2Dept. of Respiratory Diseases, University of Sassari, Sassari, ITALY. Aim. Chest diagnostic CT after contrast medium i.v. injection is widely used in the diagnosis of lung lesions, although it presents some limitations in differentiating benign from malignant lesions. In the present study, we assessed 99mTc‐tetrofosmin SPECT/CT usefulness in patients with lung lesions, correlating the results with those of diagnostic CT. Methods. A consecutive series of 85 patients (50‐84 yrs) with nodules (≤3 cm) or masses (>3 cm) at diagnostic CT were prospectively studied. Within 1 week of CT scan, following 740 MBq of 99mTc‐tetrofosmin i.v. injection, all patients underwent chest SPECT/CT using a rectangular dual head gamma camera integrated with a X‐ray tube for low dose CT. SPECT images were corrected for attenuation and scattering, reconstructed with iterative method and fused with CT. SPECT/CT images were analysed qualitatively and correlated with diagnostic CT findings. Definitive diagnosis was obtained in all cases after scintigraphy: 67/85 patients had malignancy (primary lung carcinomas in 57 cases, metastases in 8 and local recurrences in 2), whereas 18/85 patients had benign lesions. Results. SPECT/CT was true positive in 63/67 patients with malignancy (overall sensitivity: 94%), detecting 27/31 (87%) lesions ≤30 mm and 36/36 (100%) lesions >30 mm, whereas it was false negative in 4 patients, 3 of whom with an adenocarcinoma each (size: 10‐15 mm) indeterminate at CT and 1 with a metastasis (size: 12 mm) positive at CT. SPECT/CT was true negative in 15/18 patients with benign lesions (overall specificity: 83.3%) and false positive, concordantly with CT, in 3 cases, 2 of whom with aspecific inflammation and 1 with Wegner’s granuloma. SPECT/CT was more accurate than diagnostic CT in 17/85 cases (20%), 11 of whom
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 with malignancies (2 adenocarcinomas, 2 bronchioalveolar carcinomas, 2 carcinoids, 2 recurrences, 3 metastases) ranging in size 1‐3 cm and 6 with benign lesions (2 idiopatic fibrosis, 2 chronic alveolitis, 1 antracosis, 1 hamartoma), all indeterminate at CT. SPECT/CT accuracy, positive predictive value and negative predictive value were 92, 95.4 and 78.9%, respectively. Conclusions. 99mTc‐tetrofosmin SPECT/CT proved highly accurate in differentiating malignant from benign lung lesions, playing an important complementary role to diagnostic CT in some cases. The procedure proved also able to detect carcinoid and bronchioalveolar carcinomas which can often result negative on FDG‐PET. A larger clinical application of SPECT/CT, simple and widely available procedure which also gives precise lesion localization, is thus suggested in the management of patients with lung lesions, especially when CT findings are indeterminate.
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The clinical diagnostic valuation of F-FDG SPECT coincidence detection imaging in pulmonary neoplasm R. Wang, X. Lu, Y. Fan, Z. Fu, X. Zhang, J. Zhang, Y. Wang, H. Tian, F. Guo, G. Zhao, Q. Li, M. Zhang; Department of Nuclear Medicine, Peking University First Hospital, beijing, CHINA. Objection: Molecular coincidence detection, manufactured competitively by companies in recent years, is a new technique using dual head SPECT at low cost to perform positron coincidence detection imaging. The aim of this study is to evaluate the clinical value of 18F‐fluorodeoxyglucose (18 F‐FDG) coincidence imaging (SPECT/ PET) for pulmonary neoplasm. Methods: The dual head plus 18 gamma camera was a vertex EPIC MCD /AC. F‐FDG was provided by China Institute of Atomic Energy with purity of radiochemistry >95%. All the patients fasted at least 4 hours. Routinely measured blood glucose level before imaging, the patients whose blood glucose level was high than 9.1mmol /L should be given insulin to regulate it. Imaging was initiated after intravenous injection of 129.5~168.5Mbq of FDG and resting 60 minutes. Imaging localization and bed positions should be determined according to the needs of clinical work, position of the lesions and number of bed positions Using 137Cs of external source for measured attenuation correction, the images with attenuation correction (AC) and without AC(NAC) were reconstructed iteratively. 35 cases of pulmonary nodules patients proved by X‐Ray or CT were performed 18F‐FDG metabolic imaging. The findings of 18F‐FDG metabolic images were analyzed in qualitative and semi‐quantitative ways and compared with pathology. Results: In 35 cases, there were 23true positive cases and 9 true negative cases. A sensitivity of 92.0%, a specificity of 90.0%, and an accuracy of 91.4% were found for detection of pulmonary neoplasm. The positive prediction value (PPV) and negative prediction value (NPV) were 95.8% and 81.8%, respectively. The PPV and NPV of recurrence detected by 18F‐FDG SPECT/ PET were 100 % and 80 %. Conclusion: The present study confirms that 18F‐FDG metabolic imaging are useful in the early detection,clinical staging and clinical treatment of lung cancer. Key Words 18 F‐FDG metabolic images, pulmonary neoplasm, treatment evaluation
P33 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: lymphoma scintigraphy
P270 99m Tc- Tetrofosmin scintigraphy and beta-2-microglobulin in the diagnosis and follow up of patients with non- Hodgkin’s lymphoma D. D. Vassileva1, A. Tzonevska2, K. Nikolova1, E. Piperkova2; 1National Centre of Haematology and Transfusiology, Sofia, BULGARIA, 2National Hospital for Active Treatment in Oncology, Sofia, BULGARIA. 99m Tc‐Tetrofosmin is currently used to study myocardial perfusion, but also has been reported to be localized in various types of malignant tumours. 99mTc‐Tetrofosmin imaging has been used in nuclear oncology, but its role in detecting lymphomas has not been widely investigated. Aim: The aim of this study was to assess the utility of 99mTc‐Tetrofosmin scintigraphy as a diagnostic modality in patients with non‐Hodgkin’s lymphoma and to relate these results with these of tumour marker beta‐2‐microglobulin measurement. Material and methods: Fifty five patients with biopsy proven non‐Hodgkin’s lymphoma (33 men and 22 women) aged between 18 and 72 years in clinical stage IA to IVB were investigated. Scintigraphy was performed 30 minutes after intravenous injection of 740 MBq 99mTc‐Tetrofosmin (Myowiev, Amersham). Planar and SPECT images were obtained on gamma camera Diacam (Siemens) and analysed qualitatively. Serum beta‐2‐microglobulin levels were measured by radioimmunoassay using the Immunotech international microtest. Results: Focal pathological tetrofosmin uptake was seen in 42 from 55 investigated patients. From 81 detected lesions in these patients, 59 were with lymph node involvement in mediastinum(28), neck(8), supraclavicular(7), axillar(9) and inguinal (7) area and 22 extranodal lesions were found‐ with lung(13), bone(7) and breast(2) localization. All these lesions are CT approved. The tumour to background ratio ranged from 1,5 to 2,1. Significant correlation was found in patients with true positive 99m Tc‐Tetrofosmin scintigraphy and increased serum beta‐2‐microglobulin levels. In patients with advanced disease the serum levels of beta‐2‐microglobulin were with mean value 4,3 mg/l . Forty two patients with non‐Hodgkin’s lymphoma had true positive 99m Tc‐Tetrofosmin scan. In 13 patients a true negative scintigraphy was obtained after treatment. In these patients in remission, the serum levels of beta‐2‐ microglobulin were near to the normal range (1,2‐2,4mg/l). Conclusion: 99mTc‐Tetrofosmin is a promising tracer in determining disease activity, site of active lesions and the fellow up of the patients with non‐Hodgkin’s lymphoma. The uptake score correlated significantly with clinical status and stage of disease and with disease activity as determined by beta‐2‐microglobulin.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Comparison Of 99mTc-Depreotide And 67Ga-Citrate SPECT/CT Imaging In Patients With Various Types Of Lymphoma N. Papandrianos, S. Alexiou, A. Paschali, V. Lakiotis, P. Barla, T. Spyridonidis, A. Symeonidis, P. Matsouka, P. J. Vassilakos, D. J. Apostolopoulos; University Hospital of Patras, Patras, GREECE. Aim: To investigate the potential role of 99mTc‐Depreotide imaging in various types of lymphoma. Depreotide was directly compared to Ga‐citrate scintigraphy. Materials and Methods: A total of 146 studies were performed in 102 patients, 46 with Hodgkin disease (HD) and 56 with non‐Hodgkin lymphoma (NHL). Fifty‐one studies were carried out during initial staging and 95 at various time points during follow‐up. The imaging protocol included whole body planar and SPECT/low resolution CT imaging. Depreotide studies were performed first (3‐4 hours post 20 mCi administration), followed by injection of 7 mCi of Ga‐67 and imaging 48 hrs later. The findings of the two methods were compared with reference to the results of the conventional work‐up (FDG‐PET was not included) and the clinical outcome. Ninety‐two patients have completed at least one‐year follow up by now. Results: On a patient basis, the overall sensitivity of Depreotide and Gallium was 91% and 76% and the specificity 73% and 80%, respectively. A notable false positive finding, mostly with Depreotide, was post‐therapy reactive thymus hyperplasia. Different degree of uptake and dissimilar tracer distribution in disease‐ involved sites was noticed in several cases. In the majority of HD, Depreotide was equal or superior to Ga‐67 in terms of uptake, particularly in the nodular sclerosis subtype. Ga‐67 uptake was in general higher in aggressive B‐cell NHL, such as mantle‐cell and diffuse large B‐cell (DLBC). A noteworthy exception was the T‐cell/histiocyte rich subtype of DLBC, where Depreotide uptake exceeded Gallium in all included cases. In the setting of a high‐grade NHL, positive Ga‐67 but absent Depreotide uptake was always predictive of a poor outcome. In marginal‐zone/MALT, low‐grade follicular and some T‐cell NHL subtypes Depreotide imaging was invariably superior to Ga‐67. Regarding Depreotide, focal defects or diffusely decreased uptake in the spleen was a highly sensitive and specific finding for spleen infiltration. Decreased or inhomogeneous bone marrow uptake was specific but insensitive for marrow involvement. Identification of hepatic and abdominal lymph node disease was suboptimal. Conclusion: Due to the high physiological Depreotide concentration in the liver, bone marrow and intestine, the method is of little value for the initial staging of patients with lymphoma. Post‐therapy or during follow‐up, however, Depreotide seems useful in the evaluation of residual tumor as well as early detection of relapse in certain lymphoma types, namely HD and low‐grade NHL, particularly above the diaphragm, in the stomach and spleen and in the inguinal region.
P272 111
90
In and Y-Bremsstrahlung scan in the assessment of Zevalin biodistribution.
F. Cicone, C. Del Mastro, G. Di Santo, A. Tofani, A. Signore, F. Scopinaro; Nuclear Medicine Unit, S.Andrea Hospital, “Sapienza” University, Rome, ITALY. Aim The biodistribution of Zevalin (Z) can be assessed with 111In‐Z scan. Although characterized by suboptimal quality, Bremsstrahlung scan (Brem) might be an alternative technique. Two questions arise: 1) is Brem scan appropriate to image Z biodistribution? 2) how different is the information provided by the two scans?. The aim of our work was to compare qualitative and quantitative data of 111In‐Z and Brem with pre‐therapy PET/CT. Materials and Methods Eight patients treated al S.Andrea Hospital, who had PET/CT, 111In‐Z and Brem scans were included in the study. Z was labelled with 3 to 5 mCi of 111In, obtaining more than 95% labelling yield, as assessed by Chromatoscan. The same yield was accepted for 90Y‐Z labelling; therapeutic doses were chosen according to patient platelets counts. 111In‐Z study was acquired before therapy on a Gamma Camera provided by a 5/8 inch thick crystal and Medium Energy collimator (Forte Philips Holland), 10 minutes, 1, 24, 72, 96 and 144 hours starting from the administration of the tracer. The same Camera and the same collimator were used to acquire Brem scans 10 minutes, 90 24 and 96 hours after the infusion of Y‐Z; the energy window was 80 to 200 kev. Ninety‐six hour 111 In‐Z and Brem images were compared. ROIs were manually drawn on whole body, liver, spleen, lesions and external background using 111In‐Z as scout image. Liver/TB, spleen/TB, liver/spleen, lesion/TB, and lesion/liver count ratios on both 111In‐Z and Brem scans were compared. Only the most evident lesions were used for the analysis. Counts from ROIs were compared with Paired Student’s T‐test. Results Only four out of the eight patients had lesions. All 111 of them were positive for lesions at In‐Z and Brem scan. Twenty six, nine and six lesions were detected by PET/CT, 111In‐Z and Brem scans, respectively. Twelve out of the seventeen lesions missed by 111In‐Z were located in the liver of a single patient. The three lesions missed by Brem and imaged by 111In‐Z, were smaller than 3.0 cm. For all ratios analysed, Student’s T test for paired data showed no significant differences between 111In‐Z and Brem ROIs. Conclusions This preliminary study showed similar ratios for organs and whole body images between 111In‐Z and Brem. 111In‐Z and Brem were less sensitive than PET/CT, however the different sensitivity was mainly due to hepatic lesions. Only lesions larger than 3.0 cm were detected by Brem.
P34 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: colorectal cancer scintigraphy
P273 Radioimmunoscintigraphy of colorectal cancer using a twostep pre-targeting method. F. Aarts1, O. C. Boerman1, R. M. Sharkey2, T. Hendriks1, R. P. Bleichrodt1, W. J. G. Oyen1, D. M. Goldenberg2; 1Radboud University Medical Center,
Nijmegen, NETHERLANDS, 2Garden State Cancer Center, Belleville, NJ, UNITED STATES. Purpose: To explore the potential of pretargeted tumor imaging in colorectal cancer, using a bispecific antibody (bsAb) and In‐111‐labeled peptide. Methods: Non‐randomized trial to optimize pretargeting utilizing an anti‐CEA x anti‐DTPA bispecific antibody and In‐111‐labeled peptide, for diagnostic imaging of CEA‐expressing cancers in patients with colorectal cancer. In three patients safety, pharmacokinetics, and tumor targeting of the peptide alone was studied. The other patients received 5 mg bsAb and 3, 4 or 5 days later 5 mCi In‐111‐labeled peptide was injected to assess the interval between bsAb injection and the peptide. Images were acquired 1, 4 and 24 h postinjection of the peptide. Results: Twelve patients were enrolled in the study. In one patient, pre‐operative imaging with PET‐scanning showed inguinal and para‐aortic lymph node involvement. Adverse events (localized erythema) were seen in two patients. Peptide pharmacokinetics showed enhanced blood levels of the peptide in patients in the 3‐day interval cohort as compared to the other cohorts. The peptide alone did not accumulate in the tumor. The best images were acquired with a 3‐ and 4‐day interval, 24 h after injection of the radiolabeled peptide. Imaging sensitivity was 78%. PET positive lymph nodes were clearly visualized. Tumor to background ratios were 4.5:1‐6.5‐1 in the 3‐day interval group, 6.0:1‐16.6:1 in the 4‐day interval group and 3.9:1‐8.3:1 in the 5‐day interval group. Conclusion: Imaging of colorectal cancer using a two‐step pretargeting system showed best imaging results 24 hours after peptide administration with a three or four day interval between bsAb and peptide injection.
P274 The value of SPECT/CT in diagnosing aberrant abdominal vessels in pre - SIRT evaluation with 99mTc-MAA M. Mustafa1, R. Hoffmann2, A. Haug1, P. Bartenstein1, M. Hacker1; 1Dept. of Nuclear Medicine, Univ. of Munich, Grosshadern, Munich, GERMANY, 2 Dept. of Radiology, Univ. of Munich, Grosshadern, Munich, GERMANY. Aim: Selection of patients most suitable for SIRT is routinely done with multimodal imaging including a 99mTc‐MAA scan which is ‐ besides the calculation of the degree of liver‐lung shunting ‐ employed to demonstrate the absence of access to extrahepatic sites within the abdomen. Embolising vessels like the cystic or duodenal artery and choosing the appropriate catheter position within the hepatic arteries to prevent reflux into other vessels has proved to be one of the practical challenges of SIRT. Aim of this investigation was to evaluate whether the inclusion of SPECT/CT scans of 99mTc‐MAA distribution had a significant effect on the detectability of these aberrant abdominal vessels. Methods: Two weeks prior to SIRT a 99mTc‐ MAA scan was performed as follows: a total dose of 85 MBq of 99mTc‐MAA was administered to (if applicable) both liver arteries via a femoral artery catheter using Seldinger technique. Planar images of abdomen and chest (anterior and posterior views, 4 min. 256x256 matrix), thyroid area and bladder (excluding significant accumulation of unbound 99mTc) as well as SPECT/CT images of the abdomen were performed (hybrid dual‐head SPECT camera, 2‐slice spiral CT in low‐dose technique, SYMBIA, Siemens). Extrahepatic deposition (EHD) of 99mTc‐MAA was assessed on planar images, SPECT images alone as well as SPECT/low dose CT fused images. Results: A total of 116 pts. was examined 03/2008 ‐ 03/2009. Planar images showed EHD in 6 cases (in correlation with corresponding MRI and FDG‐PET/CT data 4/6 unlocalizable, 2/6 gastric). SPECT alone showed EHD in 22 patients (8/22 unlocalizable, 7/22 gastric, 2/22 intestinal, 5/22 projecting on umbilical vessels). SPECT/CT fusion images allowed for the diagnosis of EHD in 33 pts. In 2 cases that were misdiagnosed as EHD with SPECT, SPECT/CT allowed for a correct intrahepatic allocation, therefore SPECT/CT allowed for additional detection of 15 extrahepatic foci (including cases with multiple foci). Precise anatomical allocation was only possible by SPECT/CT in 7 cases to the intestine,in 4 cases to the gall bladder and in 4 cases to the stomach. In 25/33 pts. with EHD depicted by SPECT/CT SIRT was performed, in 7 of these pts. SIRT technique was altered or an additional vessel embolised due to the SPECT/CT results. Conclusion: Although SPECT already allows for a good depiction of EHD, SPECT/CT is clearly superior to planar and SPECT images alone. It has proven to be of most value in differentiating MAA deposition in intestinal structures from neighbouring hepatic tissue.
P35 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: genitourinary cancer scintigraphy
P275 The correlation between prostate-specific antigen and Tc99m-HMDP bone scintigraphy before and after the therapy of prostate cancer M. Momose, S. Yanagisawa, M. Hayashi, M. Kadoya; Shinshu University School of Medicine, Matsumoto, JAPAN. Purpose; To evaluate the use of Tc‐99m‐HMDP bone scintigraphy before and after the therapy of prostate cancer by means of clarifying the correlation between serum prostate specific antigen (PSA) levels and the numbers of bone metastatic lesions on bone scans before and after ordinary therapies. Method; Tc‐99m‐HMDP planar scans and the measurements of serum PSA level were performed within a month for 132 patients with prostate cancers from October 2006 to March 2008. Newly diagnosed patients were 106 and followed patients after ordinary therapies, such as prostate resection or radiation or hormonal chemotherapy, were 26. The software SPSS was employed for statistical calculation of the correlation coefficient between the serum PSA levels and the numbers of the bones with abnormal uptake as metastases. Result; Ten newly diagnosed patients had bone metastases on bone scans (the serum PSA level 416.9 +/‐ 648.7 [mean +/‐ SD] ng/ml; the number of metastatic bones 16.8 +/‐ 20.0), and 96 newly diagnosed patients had no bone metastasis (PSA 29.8 +/‐ 41.1 ng/ml). The correlation coefficient between the serum PSA level and the number of the bone metastases was 0.696 (P < 0.01). Fourteen followed patients after ordinary therapies had bone metastases (PSA 82.6 +/‐ 171.5 ng/ml; the number of metastatic bones 9.7 +/‐ 13.9), and 11 followed patients had no bone metastasis (PSA 22.2 +/‐
Poster Presentation
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S364 45.8 ng/ml). The correlation coefficient between the serum PSA level and the number of the bone metastases was 0.609 (P < 0.01). The difference of the serum PSA levels between the patients with bone metastases and without bone metastasis and the correlation coefficient between the serum PSA level and the number of the bone metastases were smaller in followed patients than in newly diagnosed patients. Conclusion; Although a baseline bone scan may be eliminated in patients with newly diagnosed prostate cancer with low serum PSA levels, a following bone scan should be performed in followed patients with low serum PSA levels to allow the early diagnosis of bone metastases.
P276 Sentinel Node Detection in Renal Cell Carcinoma: A Feasibility Study L. Vermeeren, A. Bex, G. de Windt, W. Prevoo, S. Horenblas, R. Valdés Olmos; Netherlands Cancer Institute, Amsterdam, NETHERLANDS. Aim: Lymphatic drainage from renal cell carcinoma is unpredictable and the therapeutic benefit and extent of lymph node dissection are controversial. We evaluated the feasibility of intratumoral injection of radiolabeled tracer to image and sample draining lymph nodes in clinically non‐metastatic renal cell carcinoma. Material and Methods: Eight patients with cT1‐2 cN0 cM0 (<10 cm) renal cell carcinoma prospectively received percutaneous intratumoral injections of 99mTc‐nanocolloid under ultrasound guidance (0.4 ml, 240 MBq at 1‐4 intratumoral locations depending on tumor size). Lymphoscintigraphy was performed 20 minutes, 2 hours and 4 hours after injection. After the delayed images a hybrid SPECT‐CT was performed. SPECT was fused with CT to determine the anatomical localization of the sentinel node. Surgery with sampling was performed the following day using a gamma probe and a portable mini‐gamma camera. Results: Eight patients, 7 with right sided RCC, were included (6 female, mean age 55 years (range 45‐77 years). Mean tumor size was 4 cm (range 3.5‐6 cm). Six patients had sentinel nodes on scintigraphy (2 retrocaval, 4 interaortocaval, including 1 hilar) with one extraretroperitoneal location along the internal mammary chain. All nodes could be mapped and sampled. In 2 patients no draining nodes were visualized. Renal cell carcinoma were of clear cell subtype with no lymph node metastases. Conclusion: Sentinel node identification using preoperative and intraoperative imaging to locate and sample the sentinel node at surgery in renal cell carcinoma is feasible. Sentinel node biopsy may clarify pattern of lymphatic drainage and extent of lymphatic spread which may have diagnostic and therapeutic implications.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 showed the existence of a multricentric paraganglioma which was not detected before surgery by conventional imaging. In group 2, all patients (100%) had positive pentetreotide scan confirming the diagnosis of residual HNPg on conventional imaging. Five patients had malignant paraganglioma. CONCLUSIONS. Our results show that 111In‐pentetreotide is an useful tool, highly sensitive to detect residual or recurrent paraganglioma in patients who underwent to surgery for HNPg, with more precision than conventional imaging.
P279 Attenuation Correction of Somatostatin Receptor SPECT by Integrated Low-Dose CT: Is there an Impact on Sensitivity? J. Ruf1, I. Steffen2, F. Heuck3, F. Elgeti2, C. Furth1, H. Amthauer1; 1Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Magdeburg A.ö.R, Magdeburg, GERMANY, 2Klinik für Strahlenheilkunde, Charité Centrum 6 für diagn. und interventionelle Rad. und Nuklearmedizin, Campus VirchowKlinikum, Charité – Univ.medizin Berlin, Berlin, GERMANY, 3Medizinische Klinik m. S. Hepatologie und Gastroenterologie, CharitéCentrum 13 für Innere Medizin mit Kardio-, Gastroentero-, Nephrologie, Campus VirchowKlinikum, Charité - Universitätsmedizin Berlin, Berlin, GERMANY.
Bone Scanning in Patients with Newly Diagnosed Prostate Cancer
Aim: Somatostatin receptor scintigraphy (SRS) is an established imaging modality for neuroendocrine tumours (NET). Additional SPECT‐CT not only permits image fusion but also attenuation correction (AC) of SPECT‐data. This study evaluated whether attenuation corrected SPECT‐images [SPECT(AC)] are more sensitive than non‐attenuation corrected SPECT‐ reconstructions [SPECT(NAC)] for the detection of NET‐lesions. Methods: The imaging data (planar scintigraphy and SPECT‐CT) of 50 consecutive patients (28 m; 22 f; age; 34 ‐ 80; mean; 65 yrs.) suffering from NET were included in this retrospective study. SPECT‐data were reconstructed with and without integrated CT‐based AC and then analysed by two experienced readers for the presence of pathological uptake in a blinded consensus reading. Fused SPECT‐CT as well as contemporary CT/MRI served as a reference standard. All foci were rated in both the SPECT(NAC)‐ and SPECT(AC)‐reconstructions for intensity and contrast using a 6‐point‐score (i.e. “0 = not visible” to “5 = very high uptake”). The scores were analysed in a 6x6 contingency‐table using the McNemar‐Bowker‐test. Results: 222 pathological foci were detected by SPECT(NAC) and 227 foci by SPECT(AC), respectively. In 67 of 227 foci (29.5%), focus intensity/contrast increased after AC whereas only 5 foci showed a decrease (p<0.001). Sensitivity increased by 2.2% (p=0.025) as 5 foci were only detected by SPECT(AC). However, as these 3 patients were already diagnosed with systemic disease, there was no influence on the therapeutic strategy chosen. Conclusion: AC of SRS‐SPECT significantly improves focus visualisation and, albeit slightly, increases sensitivity. However, depending on the presence of other metastases, the resulting clinical impact may be limited.
L. Jaukovic, B. Ajdinovic, M. Dopudja, S. Dugonjic; Institute of Nuclear Medicine MMA, Belgrade, SERBIA.
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Background: the routine use of bone scintigraphy in patients with newly diagnosed prostate cancer is still under debate. Aim: the study included 142 patients with newly diagnosed prostate cancer in the period 2006‐2008. Bone metastases were studied for its correlation with prebioptic PSA serum level and Gleason scores from the biopsy specimen. Methods: Tc‐MDP bone scintigraphy was performed in all patients using standard protocol. Bone scan findings were classified as positive (bone metastases), negative (normal and benign) and equivocal. Results: serum concentration of total PSA ranged from 1.73 to 1015 ng/ ml. Gleason score 7 was the most common grade accounting for 60% of patients. Ninety eight (69%) of cases were considered negative for bone metastases. Scan was equivocal in 12 (8.5 %) patients. Bone metastases were found in 32 (22.5%) patients. Out of five patients with positive bone scan and PSA level between 10‐20 mg/ml, two patients had Gleason score of 7. One patient with PSA level of less than 10 ng/ml and Gleason score of 9 was positive for bone metastases.Conclusion: PSA level of less than 20 and Gleason score of 7 and less, as the criteria for excluding the use of bone scanning in newly diagnosed prostate cancer could result in missing the diagnosis of bone metastases in 0.014% of cases.
P36 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: neuroendocrine cancer scintigraphy
P278 111
In-Pentetreotide In The Follow-Up Of Patients Who Had Surgery For Head And Neck Paraganglioma P. Tamayo, A. Muñoz, R. Ruano, P. Garcia-Talavera, D. Garcia, F. GómezCaminero, J. R. Garcia-Talavera; University Hospital of Salamanca, Salamanca, SPAIN. INTRODUCTION. Head and neck paraganglioma (HNPg) are neuroendocrine tumors that express somatostatin type 2 receptors and can consequently be visualized using radionuclide‐labelled somatostatin analogs, specifically 111In‐pentetreotide (octreoscan). The aim of this study was to assess the capability of octreoscan to detect residual or recurrent HNPg after surgery MATERIAL AND METHOS. 35 patients with HNPg who underwent surgery were included in this investigation and divided in two groups. Group 1 consisted of 28 patients with complete tumor removal and group 2 consisted of 7 patients with partial tumor removal. All patients underwent 111In‐ pentetreotide scintigraphy at a mean interval of eight months after surgery. Each patient received a dose of 111 MBq of 111In‐pentetreotide intravenously. Whole body scan and spot images of head and neck were obtained at 6 hr and 24 hr after radiopharmaceutical administration. SPECT of head and neck was adquired at 24 hr after inyection when necesary. The results were compared with the results of conventional imaging techniques (CT and MRI). RESULTS. In group 1, the pentetreotide scintigraphy was positive in 7 patients (25%). In 4 patients residual or recurrent HNPg was confirmed on conventional imaging and in the other 3 patients conventional imaging was not conclusive and the diagnosis of residual HNPg was made on the basis of repeated pentetreotide scintigraphy during follow up. In one patient the scintigraphy
Correlation of IN-111 pentetreotide SPECT, CGA and NSE serum markers levels in neuroendocrine tumors S. Ledda, C. Costanza, N. Pisu, G. Melis, G. Spiga, F. Santagata, P. Chapelle, G. Melis; Azienda Ospedaliera Brotzu, Cagliari, ITALY. AIM Aim of this study was to assess the clinical usefulness of SPECT Somatostatin receptor scintigraphy (SRS) with (111)In‐pentetreotide imaging and chromogranine A (CgA) levels, neuron specific enolase (NSE) levels in patients with neuroendocrine tumours (NETs) and with neuroendocrine pattern of solid tumors . MATERIALS AND METHODS We used somatostatin receptor scintigraphy (SRS) SPECT imaging with (111)In‐pentetreotide. performed using a dual‐ head gamma camera. SPECT images of the chest and abdomen were obtained 24‐48 hours after injection of 5 mCi of In‐111 pentetreotide of the radiopharmaceutical. We used an immunoradiometric assay to determine CgA and NSE levels in blood. The normal range for CgA was 19.4‐98.1 ng/ml; the normal range for NSE was 4.7‐14.7 ng/ml. Seventy‐height patients with known or suspected NET were included in this study. CgA and NSE levels were assessed in 35 patients (pts) with NETs and 43 pts with neuroendocrine pattern of solid tumors. The neuroendocrine assett was established by histologic findings or in vivo SRS receptor imaging. RESULTS Serum CgA values were increased in 19/35 patients with NETs : 3/3 patient with gastrinoma, 2/3 patient with carcinoid of unknown origin, 1/2 patient with large cells lung cancer (LCLC), 3/3 pts with pancreatic well differentiated endocrine carcinomas, 2/8 appendix carcinoids, 2/5 medullary thyroid carcinoma, 5/5 pts with lung carcinoid, 1/1 rectal carcinoid. CgA levels were increased in 34/43 pts with neuroendocrine pattern of solid tumors: 24/28 pts with hepatocellular carcinoma, 6/9 patients with prostatic adenocarcinoma, 1/1 patient with kidney cancer, 1/1 patient with adrenal gland cancer and 2/3 pts with lung adenocarcinoma. Serum NSE was increased just in 1 patient with hepatocellular carcinoma. Somatostatin receptor scintigraphy with (111)In was positive in 3/3 patient with carcinoid of unknown origin, 2/4 Merkel carcinoma, 3/5 medullary thyroid carcinoma, 1/1 ovarian carcinoid, 3/8 appendix carcinoids, 4/5 pts with lung carcinoid, 1/1 rectal carcinoid, 2/3 pts with pancreatic well differentiated endocrine carcinomas, 3/3 patient with gastrinoma, 5/28 pts with hepatocellular carcinoma, 3/9 patients with prostatic adenocarcinoma and 2/3 pts with lung adenocarcinoma. CONCLUSION We found 21/77 pts positivity for Somatostatin receptor scintigraphy scan with (111)In and CgA levels increased. Greater correlation between the two methods was obviously for patients with gastrinoma (100%). NSE doesn’t appear useful in monitoring solid tumors with neuroendocrine pattern.
P281 Somatostatin receptor scintigraphy in the management of patients with neuroendocrine liver metastases treated with liver transplantation. I. Hervás1, P. Bello1, J. L. Vercher1, J. L. Loaiza1, R. Pérez-Velasco1, C. Ruiz1, A. Rivas1, C. Olivas1, J. F. Martí1, A. Moya2, A. Mateo1; 1Department of Nuclear Medicine. University Hospital La Fe., Valencia, SPAIN, 2Hepatic Unit. University Hospital La Fe., Valencia, SPAIN.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 Patients with neuroendocrine tumours (NET) often present with liver metastases not amenable to hepatic resection. For them, liver transplantation has been considered a viable treatment option, especially if hormonal symptoms and pain cannot be controlled medically. Currently all patients with neuroendocrine liver metastases should have CT or MRI and Somatostatin Receptor Scintigraphy (SRS). The latter is the most effective method of screening to confirm or refute extrahepatic metastatic disease. Aim: To assess the influence of SRS in the management of patients with liver metastasis from NET treated with liver transplantation. Materials and Method: 25 SRS (111In‐Octreotide) were performed to 9 patients (5 men, 4 women) aged from 27 to 60 years (mean 44y.;median 43y.) at the moment of diagnosis. The primary NET were: pancreatic carcinoid (n=4), ileal carcinoid (n=2), colon carcinoid (n=1), primary hepatic carcinoid (n=1), glucagonoma (n=1). SRS including planar and SPECT images were performed before (n=9) and after liver transplantation (n=16). Patients were studied and followed‐up using clinical examination, laboratory tests and different imaging modalities including X‐rays, CT, MRI, Bone Scintigraphy and SRS. Results: All patients presented SRS positive for multiple liver metastasis (unresectable liver lesions) and negative for extrahepatic disease before liver transplantation. One patient died within the firs year after the liver transplantation due to other reasons not related with the NET. The rest of the patients are alive (survival months after liver transplantation: 18‐154 m.; mean=86 m., median=54m.). After liver transplantation we obtained 10 positive (one or more lesions) SRS and 6 negative SRS. 3 patients (including the one that died) had negative SRS (clinical examination, laboratory tests, X‐rays, CT, MRI also negative). SRS was positive (multiple metastases) in 5 patients: lymphatic involvement in 4 patients, bone metastases in 2 and liver metastases in other 2 patients. 3 of these patients were treated with 90 Y‐ DOTATOC and/or 177Lu‐DOTATATE. SRS showed a solitary abdominal lesion (mesenteric adenopathy) in one patient that was treated with surgery. Posterior SRS controls were negative. Contributions of SRSS: Confirmation of lack of disease (4 occasions), confirmation of metastases suspected by CT/MRI (4 occasions), diagnosis of new metastases unsuspected clinically or by other imaging techniques (6 occasions) and showing the possible improvement after 90Y‐ DOTATOC/177Lu‐DOTATATE treatment (3 occasions). Conclusion: SRS has an important role in the follow‐up of patients with liver metastasis from NET treated with liver transplantation and should be always included in the management of these patients.
Aim: Cushing syndrome arising from ACTH secretion other than pituitary gland is a rarely seen situation. Generally ectopic ACTH secretion is caused by neuroendocrine tumors localized in lungs. As the dimensions of the tumors get smaller, the localization becomes more difficult (approximately %30 has no focus). The essential treatment is the surgical removal of the tumor. Indium‐111 octreotide scintigraphy (OS), computed tomography (CT) and magnetic resonance (MR) are used for ectopic tumor localization. The results of the OS performed in the patients, who are diagnosed as ectopic ACTH syndrome for the last 8 years, are evaluated and compared by the radiologic methods, operation findings and follow‐ups. Material‐Methods: Between the years 2000‐2008, OS was performed to 8 patients who were diagnosed with ectopic ACTH syndrome ( 4F, 4M, ages between 14‐50 ). For scintigraphic imaging, after 5 mCi In‐111 octreotide intravenous injection, whole body, anterior‐posterior thorax, abdomen static and SPECT images were taken in the 4th, 24th and if needed in 48th hours. CT and MR images of all patients were present. All of the patients’ pituitary gland MR’s were negative. Ectopic mass was seen on 6 of the 8 patients with radiologic and scintigraphic images. Ectopic mass was not found on 2 patients and bilateral adrenalectomy was applied to these patients. Seven thorax CT, 7 OSs and one abdomen MR were performed to those six patients with ectopic mass findings. In 5 of the thorax CTs, 5 of the OSs and 1 of the abdomen MRs, mass was detected. On one of the patients, CT could not detect any mass whereas OS detected mass on the same patient. For this patient, although there was no pathologic activity in his planar thorax image, focal activity was seen with thorax SPECT images. Another patient had negative OS but a mass was seen with thorax CT which was performed after 3 years. Six patients with ectopic mass findings were operated on; 5 of them had lung carcinoid and one had pancreatic neuroroendocrine tumor. Tumor dimensions for lung lesions were 0.8‐2 cm and it was 5cm for the pancreatic tumor. Five of the patients had normal ACTH values after the operation (follow‐ups: 2 month‐5 years) and no relaps were detected. Results: Because the tumors that secrete ectopic ACTH are mostly localized in lungs and the diameters of the tumors are small, the routine thorax SPECT imaging is suggested in order to increase OS sensitivity.
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Diagnostic Oncology: Planar Scintigraphy, SPECT and
Impact of Octreotide Scintigraphy on the Management of Neuroendocrine Tumours
SPECT/CT: adrenal cancer scintigraphy
T. Koc, J. Franklin, K. Miles, A. Webb, S. Dizdarevic; Brighton & Sussex University Hospitals, Brighton, UNITED KINGDOM.
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Influence on management
Confirm
10 (33.3%) 12 (40%) Confirmed planned investigations
Investigation
4 (13.3%) 2 (6.6%)
Biochemical investigation requested
1 (3.3%)
3 (10%)
Imaging investigation requested
4 (13.3%)
Follow‐up octreotide scan requested
2 (6.6%)
Radionuclide octreotide therapy planned 1 (3.3%) Therapy
Alter
4 (13.3%)
Operation performed
4 (13.3%) 5 (16.6%)
Medication changed
P37 ‐ Sunday, October 11, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Utility of I-131 NP-59 SPECT-CT for Investigation of Adrenal Nodules and Hypersecretory Syndromes K. Wong1, M. Komissarova1, A. M. Avram1, L. M. Fig2, M. D. Gross2; Nuclear Medicine/Radiology, University of Michigan, Ann Arbor, MI, UNITED STATES, 2Nuclear Medicine, Department of Veteran Affairs, Ann Arbor, MI, UNITED STATES. 1
Purpose: To present cases of hypersecretory adrenal syndromes investigated by cortical imaging using radioiodinated I‐6‐B‐iodomethyl‐19‐norcholestrol (NP‐59) in which SPECT‐CT assisted image interpretation. The basics of adrenal cortical imaging are reviewed. Subjects and Methods: Four patients (3M:1F) being investigated for adrenal hypersecretory syndromes, with or without adrenal nodules, underwent NP‐59 scintigraphy with SPECT‐CT imaging. Sequential anterior and posterior images of the upper abdomen were acquired between 4 and 8 days following intravenous injection of 37 MBq I‐131 NP‐59. Saturated solution of potassium iodide (SSKI) was given to block thyroid uptake. Three patients with suspected hyperaldosteronism received adrenosuppressive dexamethasone 1mg po qid starting 7 days before radiotracer injection and continuing 7 days post‐injection. SPECT‐CT imaging was performed on a dual‐head gamma camera with inbuilt CT (Symbia T6, Siemens Medical Solutions, IL). Clinical and imaging data were reviewed to evaluate if the additional information derived from simultaneous anatomical localization aided study interpretation. Due to the small number of patients a descriptive approach was adopted. Results: The final diagnoses reached were 1) adrenal hyperplasia, 2) right adrenal hypersecretion with a non‐functioning left adrenal adenoma, 3) physiological biodistribution, and 4) hyperfunctioning left adrenal adenoma (see Table below). SPECT‐CT assisted study interpretation by localizing focal uptake to the adrenal glands, distinguishing physiological bowel activity from left adrenal uptake, and allowing direct assessment of function within adrenal nodules. SPECT‐CT provided additional information to planar and SPECT imaging, which improved confidence of study interpretation. Discussion: SPECT‐CT imaging allows simultaneous, direct registration of function and anatomy, and permits attenuation correction of body background activity. Superior performance of SPECT‐CT over planar and SPECT imaging alone, has been reported with adrenal medulla imaging using radiolabelled MIBG and somatostatin analogues. However, the use of SPECT‐CT for adrenal cortical imaging is not yet well established. Only a single case in which NP‐59 SPECT‐CT allowed the diagnosis of primary hyperaldosteronism due to a hypersecretory adrenocortical micronodule, with negative saline‐ loading test and CT has been reported. In the patients presented in the Table we have found the additional information provided by SPECT‐CT is useful for accurate localization of radioactivities and is likely to assist in problem solving. Care should be taken to ensure that misregistration between functional and anatomic images has not occurred, due to respiratory or body movement between data acquisition. Conclusion: Utilization of SPECT‐CT with NP‐59 scintigraphy may facilitate diagnostic interpretation in a range of clinical scenarios. 131‐I NP‐59 SPECT‐CT imaging of suspected adrenal cortical hyperfunction
1 (3.3%)
Patient Clinical 1. 36M Conn's
SPECT‐CT bilat adrenal uptake
P283
2. 67M Conn's
no uptake in L adrenal nodule non‐functioning L adrenal nodule
Tumor localization with Indium-111 octreotide scintigraphy in cushing syndrome depending on ectopic acth secretion
3. 64M Conn's
LUQ bowel uptake
Table 1. Impact on management (investigations & therapy) of octreotide scan.
D. Balkose1, I. Adalet1, S. Yarman2, F. Aral2, C. Turkmen1, S. Aday1; 1 Istanbul University Istanbul Medical Faculty Department of Nuclear Medicine, Istanbul, TURKEY, 2Istanbul University Istanbul Medical Faculty Department of Internal Medicine, Division of Endocrinology, Metabolism and Nutrition, Istanbul, TURKEY.
4. 55F Cushing's uptake in L adrenal nodule
Diagnosis adrenal hyperplasia physiological biodistribution hyperfunctioning L adrenal nodule
Poster Presentation
AIM: Octreotide scintigraphy has been shown to be effective in the detection of tumours expressing somatostatin receptors (STR) and is complementary to conventional imaging. However, there is limited evidence of the impact of this modality on patient management. We aimed to evaluate the influence of STR scintigraphy on the management of patients in one NHS Trust. MATERIALS & METHOD: This was a retrospective cohort study of 45 STR scintigraphy conducted between September 2006 and October 2008 at Brighton & Sussex University Hospitals NHS Trust. Questionnaires regarding patient management were sent to requesting consultants. Impact on management was classified as (a) no impact, (b) confirmed proposed management or (c) altered management. Respondents were asked to indicate any influence of STR scintigraphy on subsequent investigations and therapy. Statistical analysis was conducted using appropriate non‐parametric tests. P‐value <0.05 was taken to be significant. RESULTS: 30 of 45 questionnaires were returned. 10 of 30 scans (33.3%) were for diagnosis and 20 scans (66.7%) were for staging or detection of recurrence. STR scintigraphy influenced management in 22 patients (73.3%, 95% CI 56%‐86%) (p<0.01); confirming management in 10 (33.3%) and altering management in 12 (40%). 11 of 30 (36.7%, 95% CI 22%‐54%) scans showed octreotide‐avid lesions. All positive scans influenced management compared to 11 of 19 negative scans (100% vs 57.9%; p<0.05). Positive scans generally altered management (9/11, 82%) whereas negative scans tended to confirm management (8/11, 73%) (p<0.01). The nature of impact on investigations and therapy is represented in Table 1. Where the indication was the detection of known or recurrent disease the scan altered management in 11 of 20 cases, compared with only 1 of 10 cases where the indication was diagnosis (p<0.05) mainly through a change in therapy (1/10 vs 10/20, p<0.05). CONCLUSION: STR scintigraphy influences management in nearly three quarters of patients, thus supporting its role in the management of neuroendocrine tumours. Both negative and positive scans have an impact. Positive scans tend to change management, while negative scans generally confirm management. It is reasonable to conclude that confirmatory results may serve to increase diagnostic confidence. Scans conducted in the context of known disease alter management plans in more than half the patients, mainly through influence on therapy, suggesting that it is in this condition that STR scintigraphy has the most valuable impact.
S366
P285 Neuroblastoma: staging and evaluation of the treatment evaluation and recurrence detection by MIBG scintigraphy W. El Ajmi, A. Sellem, N. Elkadri, H. Hammami; Military Hospital, Tunis, TUNISIA. Background Neuroblastoma is the second most common solid tumor in childhood. The metaiodobenzylguanidine (MIBG) labelled with 131I or 123I scintigraphy become an standard exam in the management of neuroblastoma. Aim: to asses the role of MIBG scintigraphy for staging and follow up of neuroblastoma Materials & method: This retrospective study included 44 patients (28 boys, 16 girls; age range 2months‐12 years, median: 30 months) with neuroblastoma who underwent 131 I or 123I‐MIBG‐scan. Planars image of the whole body were acquired at 24 and 48 hours after intravenous injection of 131I or 123I‐MIBG. Results: 26 children were sent for MIBG scintigraphy for staging of the tumor.18 patients (69%) had a positive MIBG scan, while 8 patients (31%) had a negative scan. The tumor site were localised in the abdomen in 12 cases (66.6%), in the thorax in 3 child (16.6%) and cervical localisation was seen in 2 child (11.1%). On the last case the primary tumor wasn’t found, but the scan showed a bone morrow involvement. Metastasis was found in 8 patients (44.4%). All of them had a bone morrow metastasis. Hepatic metastasis was seen in 4 cases (22.2%), and one case had simultaneous bone morrow, liver, lymph node and pleural metastasis. This examination was proposed for treatment evaluation in 25 patients. 8 patients (32%) had negative examination and were judged in complete remission. The response was only partial in 8 (32%) patients having residual tumor and/or metastasis. 8 patients (32%) had an evolutive process of the tumor with hepatic, bone, morrow and lymph node metastasis. In the last case we have found a pelvic node‐recurrence in 67 months after complete remission. ConclusionStaging and response to therapy evaluation in patients having neuroblastoma are essential prognostic factors. The MIBG scintigraphy is the most accurate investigation for detection the primary tumor and residual or metastatic disease.
P286 Automated Quantitative Bone Scan Analysis R. Kaboteh; Sahlgrenska Akademy at Gothenburg Univ., Göteborg, Sweden Abstract A quantitative analysis of metastatic bone involvement can either be an important prognostic indicator of survival or a tool in monitoring treatment response in patients with cancer. The purpose was to develop a completely automated method for quantification of whole‐ body bone scans based on the bone scan index (BSI) method as presented by a group at Memorial Sloan‐Kettering Cancer Center. Methods: The quantitative method was based on our recent experience in developing an automated computer‐assisted diagnosis system for the diagnosis of metastatic disease in whole‐body bone scans. New image processing algorithms, new artificial neural networks and a training group consisting of 795 whole body bone scans (600 MBq Tc‐99m MDP) obtained with a dual detector gamma camera were developed. Metastases in the training group were defined as those hotspots, which three experienced nuclear medicine physicians classified as potentially caused by metastatic disease during a re‐evaluation process. The quantification method first detects hotspots, thereafter classifies them either as metastasis or not, calculates the skeletal involvement for each metastasis, and finally calculates the BSI value as the sum of involvement for all metastases for a patient. The quantification method was evaluated using a separate test group of 58 whole body bone scans. Three other experienced nuclear medicine physicians evaluated the test group and assigned 281 hotspots as metastases using the same approach as was done in the training group. Results: The quantification method detected 276 (98.2%) and correctly classified 222 (79.0%) of the 281 as metastases. A total of 514 hotspots were classified as metastases by the quantification method. Ten of the test patients showed BSI values above 1%, the largest being 4.9%. Automatically calculated BSI values were compared to BIS values calculated based on the metastases defined by the three experts in the test group. The BSI values were categorized into four groups and a substantial agreement was found (kappa value 0.61). Conclusion: The completely automated quantification method shows a high ability to detect and classify metastases, and it can calculate BSI in close accord with experienced physicians. The clinical value of the method must be tested in clinical studies.
P287 Bone Metastases in Prostate Cancer Patients Refractory to Hormonal Control S. A. Rogan1, K. Kovacic1, M. Tarle1, G. Stimac2, Z. Kusic1; 1Dpt. of Oncology and Nuclear Medicine, U.H. "Sestre milosrdnice", Zagreb, CROATIA, 2Dpt. of Urology, U.H. "Sestre milosrdnice", Zagreb, CROATIA. Advanced prostate cancer is frequently accompanied by acquired androgen refractoriness and development of bone metastasis. Serum chromogranin A (CgA) has potential as useful serum marker for neuroendocrine (NE) differentiation in prostate cancer patient. It was noted that bone scan patterns in advanced disease are also divergent. The aim of this study was to evaluate the potential of bone scan as a predictor of neuroendocrine differentiation in D3 stage prostate cancer patient. Patients and Methods: 130 prostate cancer pt in D3 stage were followed prospectively during 10 year period (mean 5.6 y). All pts received maximal androgen blockade involving LH‐RH analogue or antiandrogens. Serum prostate antigen and CgA concentrations were longitudinally assessed in serial manner every 6 months. Bone scan (99mTc MDP) was performed at 6‐12 months intervals. The pts were divided according to the CgA values in two groups: A) pts with normal level of CgA (NE non‐ differentiation) and B) pts with increased level of CgA (NE differentiation). Six groups of pts (variables) were formed according to the bone scan considering the number and nature of bone metastases: M0‐without metastases; M1‐up to 10 osteoblastic metastases; M2 10‐20 osteoblastic metastases; M3‐more than 20 osteoblastic metastases, M4‐predominant osteolytic metastases and M5‐aquired osteolysis. In order to evaluate which of these variables could be the best predictor of NE differentiation, crosstabulation and Fisher’s exact test are performed. Results: Groups of pts with osteoblastic and osteolitic metastases showed strong association, statistically significant, with higher values of CgA (Fisher’s exact test: p=0.003; M1‐M5 expected count were 24.0, 5.3, 11.3, 18.8 and 17.3 for group A vs. 8.2, 1.7, 3.7, 6.2 and 5.7 for group B). Test for strength of association between number and type of metastases and level of CgA value was rather low (Cramer’s V test = 0.377). In the groups of pts without metastases disconcordant association with level of CgA value was
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 found (expected count 19.6 for Group A vs. 6.4 for group B), because 46,2% of these pts had elevated CgA value (> 50 ng/ml). Conclusion: Pts in D3 stage prostate cancer with osteoblastic or osteolitic metastases mainly had pathologically elevated values of CgA serum concentrations, but also CgA values could be normal. Our results did not show that the type or the number of bone metastases could reflect NE differentiation. We may conclude that bone scan cannot serve as independent variable for prediction of NE differentiation in prostate cancer patients.
P288 Bone scintigraphy findings in association with tumor markers on the assessment of the effect of zoledronic acid in patients with bone metastases E. L. Ergün, T. Aksoy, N. B. Kanat; Hacettepe University, School of Medicine, Deparment of Nuclear Medicine, Ankara, TURKEY. Aim: Zoledronic acid(ZA), a bisphosphonate, causes reduction in bone turnover; has antiresorptive effect and used for hypercalsemia in malignant diseases, palliation of pain due to bone metastases in breast/prostate cancer. It has anti‐tumoral effect. The aims of this study are to investigate the role of bone scintigraphy(BS) in the assessment of therapeutic effect of ZA in patients who have bone metastases; to compare BS findings with changes in tumor marker levels. Methods:Data of 25 patients (24 breast,1 prostate cancer) who used ZA and had BS were analyzed retrospectively. The inclusive crtiteria for the study are:A)To have baseline BS (BBS) B) To start ZA treatment just after BBS C)To have a second BS after BBS(SBS) C)Having 8‐15 month‐ period between BBS and SBS D)Not having chemotherapy‐radiotheraphy during this period E)Having the plasma levels of tumor markers (TM)[ALP, CA15‐3, CEA]at the same time with BBS‐ SBS. The number of foci of increased osteoblastic activity were counted on BBS and SBS;each foci was interpreted using a visual uptake score(VUS)[0:normal; 1:mild, 2:moderate, 3:increased; 4: significantly‐increased uptake]. The difference in TM levels after and before ZA treatment were calculated; percent ratio of each TM(TM level after ZA/TM level before ZA)was obtained. Correlations between TM findings and the differences in the number of the foci on BS; between TM findings and change in VUS on BBS‐SBS were investigated. BBS and SBS were compared with each other using the number of the foci and VUS in each scintigraphy(paired‐t test). Results:The number of the foci decreased in 5, increased in 8 patients on SBS; no diference was observed in 12 patients. VUS was decreased in 7, increased in 12 patients ; no difference was found in 6 patients. No significant correlation was found between the change in the number of foci and VUS on BBS‐SBS and TM. The highest correlation coefficient was obtained between the change in VUS and percent ratio of ALP(r: 0.51).No significant difference was obtained between BBS and SBS(for number of foci p=0.33,for VUS p=0.12)Conclusion: For the assessment of therapeutic effect of ZA with BS in patients with bone metastases, no correlation between BS and TM was observed. BS findings; TM should be interpreted separately, individually for each patient. Further studies on the basis of clinical outcomes(patient survival/progression, life quality of the patient according to the bone metastases etc) are needed to increase the information regarding to find out which method is more efficient in this aspect.
P289 Usefulness of low-dose single photon emission computed tomography/computed tomography (SPECT/CT) to assess bone metastases in cancer patients D. Cabello García, E. Matínez Gimeno, M. Albalá González, J. Uña Gorospe, M. De Sequera Rahola, C. Cárdenas Negro, A. Allende Riera; Nuestra Señora de Candelaria Hospital, Santa Cruz de Tenerife, SPAIN. Objective: To assess the diagnostic information contributed by low‐dose SPECT/CT in the study of cancer patients with bone lesions suspected of malignancy. Material and Methods: A retrospective study was conducted of 45 patients (30 females and 15 males) with oncological disease (55% breast carcinoma), who underwent bone scintigraphy to rule out metastasis, according to protocol (89% of patients), or due to the presence of suspicious lesions in conventional imaging methods (CIM). Forty nine lesions were detected by means of bone scintigraphy and their study was completed with a low‐dose SPECT/CT examination (120Kv and 50 mAs). Lesions were scored on a five‐point scale: 1, definitely not metastasis; 2 probably not metastasis; 3 indeterminate; 4 probably metastasis; and 5 definitely metastasis. The reference standard was clinical and radiological follow‐up (mean: 14 months). Results: The low‐dose SPECT/CT study showed a single suspected lesion in 91% and two suspected lesions in 9% of patients. The most frequent localizations were dorsal spine (42%) and lumbar spine (36%). Bone scintigraphy identified 18 indeterminate lesions (37% of the lesions): low‐dose SPECT/CT study classified 5/18 as definitely metastasis, 10/18 as definitely not metastasis and 1/18 as indeterminate. The low‐dose SPECT/CT study correctly classified 65% of the lesions as definitely not metastasis and 25% as definitely metastasis. In contrast, bone scintigraphy only identified 12% of the lesions as definitely not metastasis and 0% as definitely metastasis.
Bone Scintigraphy Low‐dose SPECT/CT
Frequency %
Frequency %
1: Definitely not metastasis 6
12.3% 32
65.3%
2: Probably not metastasis 17
34.7% 3
6.2%
3: Indeterminate
18
36.7% 1
2%
4: Probably metastasis
8
16.3% 1
2%
5: Definitely metastasis
0
0%
12
24.5%
Total lesions
49
100% 49
100%
Conclusions: According to our results, low‐dose SPECT/CT study allows the correct classification of a high percentage of lesions observed in bone scintigraphy of cancer patients, contributing further diagnostic information, about anatomical localization and structural features of the lesions. Therefore, its use can avoid additional tests and reduce the delay in the diagnosis of these patients.
S367
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Predictive value of serum Prostate Specific Antigen in detecting bone metastasis in prostate cancer patients K. K. Kamaleshwaran, C. N. B. Harisankar, A. Bhattacharya, B. Singh, B. R. Mittal; Postgraduate Institute of Medical Education & Research, Chandigarh, INDIA. Radionuclide bone scan continues to be the investigation of choice for detecting osseous metastases in prostate cancer. Previous widespread use of bone‐scan imaging was certainly reasonable, even in the asymptomatic patient, as clinicians had no methodology to predict who would or who would not have osseous metastases. Now, in the era of serum Prostate Specific Antigen (PSA) testing, clinicians do have a timely, cost‐effective method to determine those patients who are highly unlikely to have osseous metastases. Objectives: To determine utility of PSA to predict the presence of skeletal metastasis in bone scintigraphy (BS) in prostate cancer patients Methods: Retrospective analysis of medical records of 322 consecutive prostate cancers patients presented during the last 3 yrs was done. 52 cases were excluded due to following reasons: serum PSA not available, hormonal or other therapy given prior to serum PSA measurement and/or bone scan, and symptomatic for bone metastasis. In remaining 270 cases, PSA value and BS were evaluated. BS was performed with 99mTc MDP as per the standard protocol. Results: Of the 322 patients, 270 were included (Mean age 65yrs; range 55‐94yrs). BS was positive in 153 (56%) and negative in 117 (46%) patients. Of those 153 positive cases, 108 (70%) had serum PSA > 100 ng/ml, 42(28%) had PSA of 20 ‐100 ng/ml, only 3(2%) had PSA < 20 ng/ml. All those with PSA >100ng/ml had multiple skeletal metastasis. Of the 117 negative cases, 110 (94%) had a PSA < 20 ng/ml, 5 had 20‐100 ng/ml and only 2 (6%) had PSA>100ng/ml. 97.4% of the cases with serum PSA< 20 ng/ml did not have metastasis.95.5% (150/157) with PSA >20ng/ml had bone metastasis. Using this criterion, 110(40.7%) scans would have been omitted. Conclusions: Serum PSA <20 ng/ml have high predictive value in ruling out skeletal metastasis. Our results strengthen reports from previous studies that bone scan is indicated when PSA>20ng/ml. Using this cut‐off, unnecessary investigation can be avoided. Avoiding bone scans in this group of patients would translate into a significant cost saving and reduction in their psychological and physical burden.
P291 Added Value of SPECT and SPECT/CT in Diagnosis of Single Bone Foci in Vertebrae in Oncology Patients Suspected of Bone Metastasis M. Gorska-Chrzastek1, M. Bieńkiewicz2, K. Kovacevic-Kuśmierek2, J. Kuśmierek1; 1Nuclear Medicine Department, Central Teaching Hospital, Medical University, Lodz, POLAND, 2Department of Quality Control and Radiological Protection, Central Teaching Hospital, Medical University, Lodz, POLAND. Whole‐body scintigraphy is a widely used functional imaging method for detecting a multiple bone metastases. However the differentiation between metastases and benign lesions has been recognised as troublesome for diagnosis ‐ especially in case of detecting only single foci in planar scintigram. Aim: To evaluate diagnostic value of SPECT and SPECT/CT for assessing bone metastases in oncology patients with single foci in vertebrae detected on planar whole‐body scan. Material and Method: Scintigraphic bone examinations of 40 (17F,23M) oncology patients (15‐breast,18‐prostate,2‐lung, 2‐kidney,1‐neuroblastoma,2‐corporis uteri) were analyzed retrospectively. The criterion for selecting patients was a single foci at vertebrae detected in a planar imaging that was further clinically differentiated by radiologic imaging and clinical follow‐ up. Bone scintigraphy: whole‐body scan and SPECT/CT of selected range of vertebrae were performed with Infinia Hawkeye GE, 3h after i.v. administration of body weight adjusted dose of 99m Tc‐HEDP. Tomographic images were reconstructed with scatter correction and attenuation correction based on CT maps. Images were assessed by means of consensus of two experienced specialists in nuclear medicine and radiology. Whole‐body scans, SPECT and fused SPECT/CT were independently reviewed with the criteria of extent of radiotracer uptake, size and location, symmetry and in SPECT/CT‐location and structure. Observed foci of uptake were classified as: ‐ probably metastasis‐high uptake, asymmetric changes in the body of vertebra reaching posterior vertebral arch, in CT visible destruction,osteolytic lesion with soft‐tissue mass or sharply delineated osteoblastic lesion, ‐ probably not metastasis‐symmetric changes in the lateral parts of the vertebral body,increased uptake anterior to vertebral body, in CT visible degenerative changes partial sclerotic lesion with angular or indistinct margin. Results: Assessment of whole‐ body scans correctly indentified 19 benign cases out of 26 verified as non‐malicious (76%) and 8 out of 14 malicious (53%). In SPECT and SPECT/CT number of correct malicious classifications (14/15=93%) was significantly higher (p=0.02), while number of correct benign classifications was significantly lower (p=0.04) in review of SPECT alone (11/25=44%). NPV of SPECT/CT was higher than in whole‐body 95% vs 73% (p=0.07) and significantly higher than PPV=67% (p=0.03).
Sensitivity Specificity Accuracy PPV NPV
WBody 53%
76%
68%
57% 73%
SPECT
93%
44%
63%
50% 92%
SPEC/CT 93%
72%
80%
67% 95%
Conclusions: 1. Applied criteria of single foci diagnostics in SPECT and SPECT/CT have significant clinical value in differentiation diagnosis of malignant vs benign lesions as the negative test result has high reliability. 2. Reliability of detection of malignant lesion was significantly lower than for the benign lesion, however it was higher for fused images than for SPECT alone because of the additional evaluation of lesion’s morphology.
P292
99m
Synthesis and biological evaluation of Tc-DTPAalendronate as a potential probe for bone imaging with SPECT 1
1
1
1
2
D. Sinha , G. Shukla , A. K. Tiwari , K. Chuttani , H. Chandra , A. K. Mishra1; 1Inmas, Delhi, INDIA, 2University of Delhi, Delhi, INDIA.
Aim:‐The purpose of this study was to obtain the easy and convenient synthesis of target specific multidentate chelating agent, DTPA‐bis( sodium alendronate) and radiolabelled it with 99mTc to use as a potential radiopharmaceutical for bone imaging. Materials and Methods: The chelate was synthesised by the covalent coupling of DTPA‐bis(anhydride) with sodium alendronate in the presence of triethylamine as a base to adjust the pH of the reaction mixture at 8. The conjugate was characterized on the basis of IR, NMR and Mass spectroscopy Results: The efficiency of 99mTc radiolabelling was more than 95% and the complex was stable for about 24h under physiological condition. Blood kinetic study of this complex showed a bi‐exponential pattern as well as quick wash out from the blood circulation. Biological t1/2(F) and t1/2(S) were found be 50 min ± 0.001 and 6h 30 min ± 0.001 respectively. Imaging and bio distribution studies showed a significant accumulation of DTPA‐Alendronate conjugate at bone. Bone to muscles ratios were 12.08 ± 0.001 at 1 h, 45.33 ± 0.001 at 4 h and 35.83 ± 0.001 at 24 h after post injection respectively. The receptor binding of the 99m Tc‐DTPA‐Alendronate was established on human bone cell line (Soas‐ 2) revealed Kd = 0.86nM. Conclusions: The preliminary results of the 99m Tc‐DTPA‐Alendronate is encouraging to carrying out further in vivo experiment for targeted bone imaging because of good bone to normal organ contrast.
P293 Morphologic and functional modalities in diagnosis and follow up of chondrosarcoma H. Mhalla, K. Chatti, F. Elouni, M. Guezguez, D. Lihiou, C. Ben Othmene, M. Maitig, N. Ayachi, M. Ben Frej, M. Nouira, O. Bouzouita, H. Essabbah, K. Tlili; Sahloul Hospital, Sousse, TUNISIA. Introduction: Chondrosarcoma is the second most common malignant bone tumor. It affects mainly adults and usually sits in the pelvis and long bone metaphyses. It can be primitive or secondary. Its treatment is surgical. A right and precise diagnosis is necessary since the prognosis is based on the initial findings. The aim of our study is to demonstrate the contribution of morphologic and functional imaging in the management of chondrosarcoma. Materiel and methods : Retrospective analysis of 10 patients ; 5 men and 5 women aged from 10 to 60 years, hospitalized in orthopedic department with chondrosarcoma confirmed by histology ( 2 were grade 2 and the others were grade 1). They were referred to radiology and nuclear medicine departments. All had standard radiographies, 9 had CT, 8 had MRI and all had scintigraphy. Results and discussion: In our series, among the 10 patients, 2 were children. It concerned both male and female at equal parts. Morphologic imaging allowed diagnosis establishment. In fact standard radiographies evocated chondrosarcoma in different locations (femur, pelvis, scapula, tibia) even in the less common ones (fibula, ulna) showing an aggressive bone lesion with lyses of the cortical, calcifications and invasion of soft tissues. It also described both central and periosteal tumor development. CT showed a cartilaginous lesion; it refined the study of cortical, periosteal reaction and calcifications. MRI showed a lobulated tumor with low signal on T1SE fat sat taking gadolinium after injection and high signal on T2SE taking gadolinium heterogeneously. We noticed a high signal STIR which appears more intensive in chondrosarcoma grade 2. Functional imaging allowed the follow up of chondrosarcoma. In fact scintigraphy suspected malignancy of initial benign lesion showing a more intensive and a larger area of uptake. It showed also metastatic bone extension. Conclusion: Our series is original. It included children, primary and secondary forms and unusual locations. Standard radiographies required for pain or swelling often show an aggressive bone lesion. CT refines the analysis of the tumor matrix (calcifications) and search for signs of aggression (periosteal reaction and cortical lyses) but can be replaced by MRI which seems the best exam to confirm diagnosis and precise loco regional extension. Scintigraphy is sensitive but not specific, keeps his place in the bone extension and helps us in the suspicious of malignancy transformation.
P294 Jaws positive bone imaging lesion and dental disease in Chinese patients. W. Cao, R. Jiang, L. Zhang, Z. Huang, B. Cheng, H. Zhang, Y. Zhang; Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, CHINA. Aim: The object was to find out the relation between positive bone imaging lesion of jaws and dental disease in Chinese patients. Methods: 52 patients were randomized selected from patients who performed 99mTc‐Methyl diphosphonate whole body bone imaging in Wuhan. Anterior, right and left lateral images of the jaws were acquired for the patients with positive jaw uptake on bone imaging. Mandible and maxilla were divided into 4 quadrants, left and right halves of the mandible and maxilla, for analysis. Those patients received oral examinations and pantomography within 2 days after imaging. The results of bone imaging and dental examination were compared. Results: 30 of 52 patients with at least one positive jaw uptake lesion (57.7%), including 12 of 16 male patients and 18 of 36 female patients. 54 of 208 quadrants (26.0%) with positive uptake. No positive lesion on jaws was verified to be metastasis in this study. The positive rates of right superior, left superior, right inferior and left inferior quadrants were 8.7% (18/208), 9.1% (19/208), 3.8% (8/208), 4.3% (9/208) respectively. 23 of 54 positive quadrants (42.6 %) found to be periapical periodontitis, 9.3% (5/54) were ill‐fitting dentures, 9.3% (5/54) were tooth extractions, 7.4% (4/54) were dental caries, 1.9% (1/54) were periodontits. Conclusions: The positive bone imaging lesion happened more frequently in maxilla than that of mandible. The most common cause of positive bone imaging of jaw was periapical periodontitis in Chinese patients. Other causes including, ill‐fitting dentures, teeth extractions, periodontits, etc. Oral examinations and pantomography can help the diagnosis of abnormal lesion of jaws on bone imaging.
P295 Bone SPECT/CT in prevention of Osteonecrosis of Jaw in patients planned for bisphosphonates C. De Gaudio1, V. Ciliberti1, M. Pellegrini2, R. Tarchi1; 1Nuclear Medicine Unit - Campo di Marte Hospital, Lucca, ITALY, 2Oncology Unit- Campo di Marte Hospital, Lucca, ITALY.
Poster Presentation
P290
S368 The osteonecrosis of jaws (ONJ) is a specific‐side pathology characterized by a slow‐progression without spontaneous recovery, associated to bisphosphonates therapy. The unknowledge of this complication often produced wrong diagnostic interpretations and treatments, with decrease of the patient's quality of life. As to date it is not available any satisfactory therapeutic protocol, our attention is to perform prevention of necrotic phenomena, by a multidisciplinary evaluation of the patients to obtain a perfect state of oral caves before bisphosphonates. The SPECT/CT evaluation of jaws, more than planar scintigraphy, represents the main approach, to select the pts who need previous dental care to obtain a perfect oral state, before to start bisphosphonates. Since February 2007 to January 2009, 90 pts (28 Males, 62 Females; age ranged 45 to 86 years) were enrolled in our study. All patients, affected by bone metastaes , after a physical examination, underwent whole body scintigraphy and SPECT/CT scan of head by an hybrid gammacamera (SIEMENS Symbia) equipped by generaI purpose collimators and CT device (128x128 matrix, zoom 1.45, scans on 3600 by 64 steps 15 sec/step). After iterative reconstruction where obtained sections and CT fusion image software was applied, so that, all hot spots can be easily disposed in relation to anatomic features of oral caves. A qualitative evaluation grid was obtained and patients was first classified in "positive" and "negative" in base of presence or absence of jaws focal or diffuse tracer fixation. All patients classified "positive" at SPECT/CT were enrolled into a dental care program before to start bisphosphonates. At planar scan evaluation on1y 13/90 (14.4%) of patients resulted "positive", but 63/90 (68.9%) showed a positivity at SPECT/CT examination. 27 pts showed no tracer spot and were classified as "negative". In 23 pts, positivity was "diffuse" and in 40 pts it was "focal"; in these cases the hot tracer spot was perfectly localized, so that subsequent dental care was easily performed. This protocol of ONJ prevention allowed us to reach 0% in the incidence of ONJ occurrence in our group of patients. Instead of another group of 572 pts, treated with bisphosphonates, which not included bone SPECT/CT in hits prevention protocol, showed an incidence of 1.4% of ONJ. In conclusion, a multidisciplinary protocol of ONJ prevention, including the bone SPECT/ CT evaluation of the head, performed before bisphosphonates treatment, resulted very safe to prevent ONJ occurrence in selected patients affected by bone metastases planned for bisphosphonates.
P296 The additional values of diagnostic CT in hybrid SPECT/CT for positive bone scan patients X. Sun; Renji Hospital, Shanghai Jiaotong University, Shanghai, CHINA. Objective: To clarify the additional values of the multi‐slice spiral CT in hybrid SPECT/CT for positive bone scan patients. Methods:238 bone scan patients who had positive lesions in planar bone scan have enrolled in this study. In these patients, 55 had lung carcinoma, 45 prostate carcinoma, 16 breast carcinoma, 13 myeloma, 12 esophageal carcinoma, 10 liver carcinoma, 31 had uncertainty disease in time of scan, 127 other diseases (both not exceeds 10). There are 162 males, 76 females. The average age is 63.3 (19‐89) years old. After planar scan, SPECT/CT tomographic scan were performed on the positive lesions. A team of nuclear medicine and radiology physician interpreted the planar and tomography images separately. The results were recorded as benign, possible benign, undetermined, possible malignant and malignant. If the patients had 1 or 2 lesions, or the lesions detained in one region, we recorded the exact location. If the patients had 3 or more lesions and not detained in one region, we recorded it as multiple. The diagnostic changes and lesion locations were compared and analyzed. Results:There are totally 271 lesions, of which in 142 (52%), CT have additional value. The additional value in costal bone, lumbar vertebrae, thoracic vertebrae and ilium were 66% (38/58), 67% (30/45), 88% (22/25) and 53% (9/17) respectively. Even in patients with multiple lesions, CT has additional values in 12% (7/59). In the 142 lesions which CT had additional value, 45% (64/142) tends to decrease malignance, 49% (69/142) tends to increase malignance and 6% (9/142) had other values (soft tissue mass invasion, exact location of lesion etc.). Conclusion:SPECT/CT has about 52% additional values in traditional bone scan patients.
P297 A Comparison Between the Total PSA Value, the Gleason Score and the Bone Scintiscan Results for Different Age Groups D. Rusu, V. Rusu, C. Stefanescu, M. Rusu, A. Statescu, I. Raileanu; St. Spiridon Hospital, Iasi, ROMANIA. Aim: To compare the results of the 99mTc Medronate bone scintigraphy of prostate cancer patients in different age groups with their total PSA and histopathological test results. Materials and Methods: Of the 180 patients with prostate cancer who were analyzed by scintiscan in the last five years in our laboratory, 86 have a known PSA value, and of these, 55 have a known Gleason Score. The patients were divided into three age groups: 1) ≤ 60 years;2) 60‐70 years and 3) > 70 years. The 86 patients were also classified into five classes according to their PSA value: 1) 4‐10 ng/ml; 2) 11‐20 ng/ml; 3) 21‐50 ng/ml; 4) 51‐99 ng/ml; and 5) ≥ 100ng/ml. It was noted that in this study there were no patients with PSA value ≤ 3 ng/ml. The patients with a known Gleason Score were divided into three groups: 1) Gleason Score < 7; 2) Gleason Score = 7; and 3) Gleason Score > 7. The scintigraphy results included patients in 3 groups: 1) those with bone metastases; 2) those without bone metastases; and 3) those with likelihood (low, medium or high) of bone metastases. The 33 patients with proven bone metastases on the scintiscan whole body images were divided, according to their numbers, into the four Soloway groups. Results: Among the patients with PSA > 20 ng/ml, considered high risk for bone metastases, according to the 2007 guidleliness of CCAFU (French Assoc. Urol), 21 (32.81%) of the 64 patients do not show the presence of bone metastases. For PSA > 50 ng/ml, all 5 patients < 60 years of age have metastases, while only 15 (62.5%) of the 24 patients over 70 years old have metastases, and 1 (4%) has low likelihood. 6 (21.42%) of the 28 patients with PSA ≥ 100ng/ml do not have metastases. 10 (43.4%) of the 23 patients with a Gleason score < 7, considered low risk, do have metastases (6 patients ‐ 26%) or low probability of metastases (4 patients ‐ 17.4%). Conclusion: Our study confirms that the probability of bone metastases for a same high PSA value is reversely proportional to age. In our study 6 patients with a Gleason Score < 7 have bone metastases (of which 3 patients have a Gleason Score of 4; 2 of these have a grade III Soloway score).
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P298 Early breast carcinoma follow up- serum biomarker Ca 15- 3 and bone scan lesions A. Koljevic Markovic, 1964.1, Z. Neskovic, 19501, E. Jaksic, 19502; 1NCRC, Belgrade, SERBIA, 2INMKC, Belgrade, SERBIA. Aim: The aim of this study was to evaluate the bone scan findings, complementary imaging methods and Ca 15‐ 3 in follow up of breast carcinoma patients after neoadjuvant chemotherapy in relation to TNM staging. MM: 63 patients with histological proven breast cancer were included (mean age 58, range 41‐ 82) and followed (12‐ 324, median 72 months). Bone scans were confirmed with either X‐ ray, Ct or MRI. Ca 15‐ 3 values were measured before the bone scan, using the same commercial test over the follow‐ up period. Patients were classified according to suspect malignant bone scan lesions and TNM stages. Bone scans were classified in 6 groups: negative(1), diffuse increased uptake in calvaria(2), solitary hot spot lesion(3), two lesions(4), three lesions(5) and multiple >3 metastasic involvement(6). Results: Bone scan lesions were present in 39 (62%) patients among them in 21 (33%) malignancy patterns were radiologicaly confirmed. Vice versa, in 3 (5%) patients radiological osteolytic lesions did not present on bone scan (normal findings). Typical localizations were on: vertebra (38%), ribs (5%), pelvis (19%), femur (2%) and sternum (2 %).The most frequently lesions in our group were presented as solitary‐ 18 patients or multiple‐17 patients. There is significant incidence of bone metastasis in lower stages and no statistical difference in correlation between postoperative T and N category. Metastasis were present in 20 (37%) patients before bone scan: lung 7 (11 %), liver 11 (17 %)‐ in this group 3 patients had metastasis in skeleton and liver; skin 1(2%) and brain 1(2%). Number of patients in bs groups 1 to 6 was: 13, 5, 18, 6, 4, and 17 respectively and had mean Ca 15‐3 value U/ml: 18; 13; 74; 93; 53 and 405. Five patients in group 6 had normal Ca 15‐3‐ values. The statistical difference was not evident in groups 1 vs. 2+3+4+5 but was excellent (p
P299 Whole Body Bone Scintigraphy in Assessment of Therapeutic Effect of Biphosphonates in Patients with Bone Metastases E. Takacs1, A. Radacsi1, E. K. Toth2, J. Kocsis2, M. Szucs3, G. Banfi3, I. Szilvasi1; 1Semmelweis University, Dept. of Nuclear Medicine, Budapest, HUNGARY, 2Semmelweis University, Dept. of Internal Medicine, Budapest, HUNGARY, 3Semmelweis University, Dept. of Urology, Budapest, HUNGARY. BACKGROUND: The aim of this retrospective study was to evaluate the role of whole body bone scintigraphy (WBS) in the monitoring therapeutic effect of biphosphonates in patients with documented multiple bone metastases. MATERIALS AND METHODS: 24 patients (7 male and 17 female, aged 51 to 83 years) were studied. 13 of them had breast cancer, 5 had lung cancer and 6 had prostate cancer. Two WBS (after iv.injection of 740 MBq Tc‐99m‐MDP) were performed in each patients: the first one before the start of the treatment with new‐generation biphosphonates (ibandronic acid, zolendronate or pamidronate) and the second one 6 months thereafter. Number and intensity of scintigraphic lesions were compared in all patients. RESULTS: After biphosphonate treatment no bone lesions were visualized in 3 (12,5%) patients; the number and/or the intensity of the lesions were decreased in 9 (37.5%) patients; no change was seen in 5 (21%) patients. 7 (29%) patients showed progression on bone scintigraphy. CONCLUSIONS: A total of 50 % of patients had a complete or partial scintigraphic improvement after biphosphonate treatment. The whole body bone scintigraphy is a useful imaging modality for assessment the effect of the biphosphonate therapy in patients with bone metastases. The clinical significance of bone scintigraphic remission needs further investigations.
P300 Utility of sentinel lymph node biopsy in malignant melanoma. E. Arroyo, P. Lievano, M. Añaños; Hospital Universitario Miguel Servet. Servicio de Medicina Nuclear. Zaragoza. España, Zaragoza, SPAIN. Introduction: The main prognosis factor in the patients diagnosed of malignant melanoma is the existence of lymph node metastasis. Their presence decreases survival by 40%. The technique of sentinel lymph node biopsy in melanoma, allows to know the state of lymph node, offering a better staging, avoiding further unnecessary lymphadenectomy. Objective: To analyze the value of selective lymph node biopsy (SLNB) in patients with malignant melanoma and Breslow thickness> 1 mm or minor with ulceration, or Clark> III and negative extension study. Material and methods: We studied 49 consecutive patients from September 2006 to March 2009, diagnosed with melanoma (32 men and 17 women) with aged between 23 and 82 years (average age 57.12 years). The location of melanomas is shown in Table 1 MELANOMA LOCATION NUMBER Lower limb
14
Backstroke
12
Upper extremity
10
Head‐neck
7
Tórax
3
Abdomen
3
Table 1 The lymphoscintigraphy was made to locate the sentinel lymph node the same day of the surgery, after a intracutaneous injection of 1mCi of Tc99m‐labelled albumin nanocolloids, around the tumour or the tumour's excision scar, distributed in 4 injections. Dynamic images were obtained during 60 minutes and then static images in anterior, posterior and / or lateral, depending on the location of the sentinel node. Subsequently proceeded to intraoperative detection using a hand‐held gamma probe, the excision and anatomopathological study deferred.
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P39 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: lymphoscintigraphy, lymphatic mapping and sentinel node
P301 Physiotherapeutic stimulation: early lymphedema prevention in axillary lymph node dissection of breast cancer A. J. Sarri1, S. M. Moriguchi1, E. T. Rocha1, S. V. Peres1, E. T. Silva2, R. L. Haikel3, G. Z. Mathes4, K. H. Koga5, R. Dias6; 1Cancer Hospital - Pio Foundation, Barretos, BRAZIL, 2University of Campinas (UNICAMP), Campinas, BRAZIL, 3Cancer Hospital - Pio XII Fundation, Barretos, BRAZIL, 4 Cancer Hospital - Pio XII Fundation, Barretos, BRAZIL, 5Sao Paulo State University, Botucatu, BRAZIL, 6São Paulo State University(UNESP), Barretos, BRAZIL. Objective: To confirm the effectiveness of the precocious physiotherapy stimulation (PS) in the progression of the lymphatic flow in patients with breast cancer submitted to axillary dissection. Methods: randomized experimental study with 22 patients who were submitted to lymphoscintigraphy of the arms at two different moments, being the first one without stimulation while in the second there was randomization into two groups: without physiotherapy stimulation ‐ WPS (n=10) and with physiotherapy stimulation ‐ PS (n=12). The lymphoscintigraphy scan was performed with the administration of phytate‐99mTc in the second digital space of the hand in the same side of the dissected axilla, in three steps: dynamic, static and delayed whole body imaging. The PS was carried out according to Foldi’s technique. Images comparison was accomplished in the two studies of each patient in both groups. The progression of the flow was considered positive when the radiopharmaceutical reached more distant places from the site of injection in the second study. Statistics were performed with analysis of frequency, percentage, measure of central trend and not parametric tests Results: The descriptive analysis shows PS and WPS as similar groups in relation to the mean of age, weight, height, BMI and the number of removed lymphnodes. It was seen statistical significance in the association between PS and radiopharmaceutical progression in the three steps of the study(p<0,0001). Conclusion: This study proves the effectiveness of the precocious PS in patients with breast cancer submitted to radical axillary dissection, indicating this procedure as a prevention measure for lymphoedema.
P302 Sentinel lymph node in breast cancer. Our experience. P. Garcia1, C. Paniagua1, A. Mariana1, A. Balsa1, S. Vasquez1, E. Ramiro2, F. J. Penin1, C. Pey1; 1Hospital Universitario de Getafe, Getafe. (Madrid), SPAIN, 2Hospital Severo Ochoa, Leganes. (Madrid), SPAIN. AIM: Sentinel lymph node biopsy (SLNB) has become the standard method for the accurate surgical staging of the axilla for breast cancer. The aim of this study was to report our experience with SLNB. MATERIAL AND METHOD: Between January 2006 and August 2008, we performed 155 SLNB procedures (all women, mean age: 57. 5 years, min: 32, max:84).In our study group 93 patients were clinically staged T1N0 and 62 T2N0. A lymphoscintigraphy was performed after the peritumoural (61 patients with well palpable tumour) or periareolar (94 patients with non or vaguely palpable tumour, or lesions located very close to axilla) inyection of 111 MBq of 99mTc‐ nanocolloid and a hand‐held gamma‐probe was used to identify hot nodes during the procedure. All lymph nodes with radioactive counts greater than 10% of the ex vivo counts measured in the hottest sentinel lymph node were removed. When sentinel lymph node was affected axillary lymph node dissection was done. RESULTS: sentinel lymph nodes were identified in 154 patients (99.35%). In 2/155 cases sentinel lymph node was not scintigraphically founded however, one of them could be located by intraoperative hand‐held gammaprobe. A total of 290 sentinel lymph nodes were removed (mean per patient 1.88). Metastasic nodal disease was identified in the sentinel lymph node of 30 patients (19.5%) of which, 9 had other lymph nodes affected when axillary lymph node dissection was done. In our group lymph node dissection was avoided in 124 patients (80%). The scintigraphy showed parasternal sentinel lymph node in 18 patients (11.6%) but they were not sought during the SLNB procedure. Patients have been followed for a medial of 22.35 months and, at the time of this study, none of them had developed axillary recurrence. CONCLUSION: Nowadays breast cancer is diagnosed in earlier stages. Sentinel lymph node biopsy is an important technique in the management of this patients reducing surgical morbidity and unnecessary axillary surgery.
P303 The Value of SPECT/CT in Localization of the Unusual Sentinel Nodes Sites in Melanoma G. Cobzac, G. Dindelegan, A. Chirila, G. Andries; Clinical County Hospital Cluj, Cluj-Napoca, ROMANIA. SPECT/CT is a new hybrid tool for fusion between functional and anatomical images. The aim of the study was to evaluate the clinical role of SPECT/CT for sentinel lymph nodes localization in unusual anatomical sites before gamma‐probe guided surgery in melanoma. Material and
Method: 38 consecutive patients with skin melanoma (Breslow 1.5‐6 mm) were examined by planar lymphoscintigraphy and SPECT/CT after intradermai injection of 25 MBq 99mTc‐Nanocoll divided in 4 deposits around the tumour or excision scar. Planar images were obtained at 10 and 60 minutes after injection. 2 hours postinjection we perform the SPECT/CT with a hybrid system (Symbia T2, Siemens). The skin projections of the sentinel nodes were marked. Before surgery Methylene Blue dye was injected around tumor. All radioactive nodes were excised using a hand‐ held gamma‐probe (Neoprobe). Results: The melanoma was located on the trunk in 20 patients, extremities in 16 patients and head and neck in 2 patients. We found 97 sentinel nodes (mean 2.55 per patient) and 16 of them in 10 patients were located in unexpected sites like breast, salivary glands, supra or subclavicular fossa, internal mamary chain, latero‐scapular intermuscle space, popliteal fossa. All these sentinel nodes were visible either on planar images or SPECT/CT‐ fused images, but SPECT/CT identified the precise anatomical location of them. In 7 patients these aberrant lymph nodes were excised, but no metastases were found. These particular located sentinel nodes were found in trunk melanoma in 7 of 38 patients (18%), lower extremities (8%) and head melanoma (3%). Conclusion: SPECT/CT permit exact anatomical localization of sentinel lymph nodes before surgery in skin melanoma with unexpected lymphatic drainage and help the surgeon to choose optimal way for excision.
P304 Sentinel Lymph Node Biopsy in Operable Breast Cancer Patients Treated with Neoadjuvant Chemotherapy. M. Gallego-Peinado1, Á. C. Rebollo-Aguirre1, S. Menjón-Beltrán2, C. Ramos-Font1, A. Salamanca-Ballesteros2, E. Pastor-Pons3, J. GarcíaGarcía2, J. M. Llamas-Elvira1; 1Nuclear Medicine Department. Hospital Universitario Virgen de las Nieves, Granada, SPAIN, 2Gynecology Department. Hospital Universitario Virgen de las Nieves, Granada, SPAIN, 3 Radiology Department. Hospital Universitario Virgen de las Nieves, Granada, SPAIN. Aim: To evaluate accuracy of sentinel lymph node biopsy (SLNB) in operable breast cancer patients treated with neoadjuvant chemotherapy (NAC). Materials and methods: Between January 2008 and December 2008, 34 women, mean age 49 years (range 31‐61), with infiltrating breast carcinoma were studied prospectively. All patients were in stage II (T2,N0‐1,M0). Axillary evaluation included ultrasound of the nodal basin, with ultrasound‐guided core needle biopsy of any suspicious lymph node. Prior to surgery, patients received chemotherapy including epirubicin/cyclophosphamide, paclitaxel, and trastuzumab in Her2/neu‐positive patients. The day before surgery, 74‐111 MBq of 99mTc‐albumin nanocolloid (Nanocoll) in sterile saline (total volume 1.2 ml) was injected into 4 periareolar sites (at the 3, 6, 9, and 12 o’clock positions around the areola). Lymphoscintigraphy was performed in all patients, and SLN were localized in the operating room using gamma probe Europrobe. SLN were examined by hematoxylin‐eosin staining and immunohistochemical analysis using an anticytokeratin antibody AE1/AE3. Results: Nowadays, 21 patients have undergone lumpectomy and SLNB followed by complete axillary lymph node dissection (ALND), 10 had clinical node‐positive at presentation and the remainder was clinical node negative (52%). Mean tumor size was 31 mm (range 22‐50). 17 primary tumors were invasive ductal carcinoma, 2 invasive lobular carcinoma and 2 mixed type carcinoma. The clinical response of primary tumour to NAC (RECIST) was: complete response in 12, partial response in 7, and stable disease in 2 patients. A pathologic complete response was achieved in 7 (33.3%) patients. All patients were clinically node‐negative after NAC. The SLN identification rate was 90.5% (19/21). The 2 patients in whom SLN was not found had clinically positive axilla before NAC. The mean number of SLN removed was 1.7 (range 1‐3). SLN accurately represented the axillary status in 94.7% of patients (4 true positives, 14 true negatives). In 3/4 (75%) patients, the SLN was the only positive node. The only false negative case occurred in a patient with clinically negative axilla before and after NAC, ALND revealed 3 metastatic lymph nodes of 14 analyzed. The mean number of nodes resected from the ALND, SLN or not, was 12.7 (range 3‐21). In the group of patients with complete clinical response in the axilla after NAC, SLNB could be avoided ALND in 6/8 cases. Conclusion: In patients with positive axilla at presentation, SLNB performed after NAC accurately identifies cases that have been down‐staged to node‐negative status, and this approach could reduce the morbidity of ALND.
P305 Radioguided localization of non-palpable breast cancer lesions. A randomized comparison with wire localization in patients undergoing conservative surgery and sentinel node biopsy. M. Solá, A. Mariscal, M. Fraile, S. Vizcaya, J. Julian, V. Vallejos, E. Castellà, J. Fuster, V. Vallejos, M. Milà, E. Calvo; Hospital Universitari Germans Trias i Pujol, Badalona, SPAIN. OBJECTIVE. The aim of this investigation was to determine whether there are differences in effective localization and complete excision of non‐palpable breast cancer lesions using the radioguided occult lesion localization technique compared with a standard wire localization method. PATIENTS AND METHODS. This prospective, randomized study included breast cancer patients scheduled for conservative tumour excision and sentinel node biopsy. Patients were randomized to either radioguided localization or wire localization. Comparative radiologic, surgical and pathologic data were collected and analyzed to establish the duration, ease of use, and accuracy of the two techniques for occult lesion localization. Effectiveness of sentinel node biopsy was also assessed. RESULTS. Among 134 patients, 68 were treated with wire localization and 66 with radioguided localization. Mean radiologic localization time was significantly shorter for radioguided localization (p<0.001). No statistical differences were found for the remaining parameters studied. Radiography of the surgical specimen showed 100% lesion excision with both techniques. Complete tumour excision with tumor‐free margins was achieved in 89.4% patients in the radioguided localization group and in 82.4% patients in the wire localization group. On pathologic study, excised tissue volume was slightly larger (p=0.371) and lesion concentricity was slightly lower (p=0.730) with radioguided localization. Sentinel node detection rate was 91% with radioguided localization and 84% with wire localization. CONCLUSION. The radioguided technique is as effective as the standard wire technique for localization and excision of non‐palpable breast cancer lesions, and is a somewhat faster and simpler procedure.
Poster Presentation
Results: In 48 of 49 patients (97.9%) were visualized lymphatic migration of radiotracer which corresponds to the GC. In 14 of these 48 patients (29.1%), at least one of the nodes removed was positive, performing lymphadenectomy in all. We extracted a total of 123 sentinel nodes, 16 of them were positive for metastasis, 3 for micrometastasis and 1 presented isolated tumor cells. Conclusion: Sentinel lymph node biopsy is a useful technique in the diagnosis and staging of malignant melanoma, which allows to value the lymphatic involvement in order to establish the individual forecast with accuracy, avoiding unnecessary lymphadenectomy. In our review avoided the realization of systematic lymphadenectomy in 34 patients (71%).
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P306 Adequacy of medical terminology used in the informative leaf of sentinel lymph node biopsy (SLNB) in breast cancer patients. C. Cifuentes Morillas, R. De la Fuente Sanchez, L. Plasencia Álvarez, R. Espinosa Fernández, A. Couso Blanco, J. Vicente Martínez, J. Vicente Castañeda; Hospital Universitario La Paz, Madrid, SPAIN. Background: One year ago we implemented in our service an informative leaf (IL) for breast cancer patients underwent SLNB. We observe that IL didn’t resolve all the doubts raised by patients. The aim of our study is verify that this terminology used in the IL is adapted for the comprehension by patients. Material and methods: We studied the first 100 patients who came to our service from June 2008 to February 2009, diagnosed with breast cancer. We performed SLNB to all of them, with mean age 56 years (range 21‐92). The following questions were asked to evaluate their knowledge on the procedure: What is a lymph node? What is the sentinel lymph node (SLN)? Why SLNB is realized? Does the location of the SLN imply malignant disease? Every question was assigned a value in a range of points from 0 to 10 (0 =no knowledge and 10 =maximum knowledge), the answers were analyzed by a doctor and a nurse in an independent way. The mean’s punctuations were obtained to every question in 100 patients.
Mean punctuation Mean punctuation Total mean doctor nurse (doctor+nurse)
What is a lymph node?
1.9
2.8
2.35
What is the sentinel lymph node? 2
3
2.5
Why SLNB is realized?
2.75
3.95
3.35
Does the location of the SLN imply malignant disease?
2
2
2
Conclusions: It is necessary to adapt the terminology used in the IL of SLNB in our service to optimize the comprehension by patients.
P307 Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastases. An update of the multicenter clinical trial. AATRM 048/13/2000. M. Solá1, M. Fraile1, J. A. Alberro2, M. Ramos3, R. Fábregas4, J. Gubern5, P. Culell6, S. Vidal7, J. Solsona8, A. Moral9, E. Veloso10, P. Deulofeu11, J. Janer12, B. Ballester13, P. Puig14; 1Hospital Universitari Germans Trias i Pujol, Badalona, SPAIN, 2Instituto Oncológico, San Sebastian, SPAIN, 3Hospital Universitario, Salamanca, SPAIN, 4Inst. Univ. Dexeus, Barcelona, SPAIN, 5 Hospital de Mataró, Mataró, SPAIN, 6Althaia, Xarxa Assistencial, Manresa, SPAIN, 7Hospital Clinic, Barcelona, SPAIN, 8Hospital del Mar, Barcelona, SPAIN, 9Hospital Santa Creu i Sant Pau, Barcelona, SPAIN, 10Hospital Mutua de Terrassa, Terrassa, SPAIN, 11Hospital Municipal, Badalona, SPAIN, 12Hospital Espiti Sant, Santa Coloma de Gremanet, SPAIN, 13 Hospital de la Ribera, Alzira, SPAIN, 14Hosp. Sant Jaume, Calella, SPAIN. Objective: To asses the impact of SN technique on the performance status of breast cancer patients, specifically targeting the finding of a SN with micrometastatic disease. Method: A randomized prospective clinical trial was devised with two arms. In one arm, patients with SN micrometastases are the subject of clinical follow‐up (study arm). In the other arm, patients are submitted for completion axillary lymphadenectomy (ALND ‐control arm). All patients are intended for a minimun two‐year follow‐up period. Results: The accrual phase has been completed (1st Jan 2002 to 31 Dec 2008). A total of 248 patients have been entered. There have been 14 withdrawals. 113 patients are being followed in the control arm, and 121 in the study arm. In the control arm, 15 completion ALNDs turned out positive (non‐SN metastases), in 13 with only one additional lymph‐node metastasis (a micrometastases in 6 of them). In the study arm, one axillary recurrence has been observed in a single lymph‐node, one year after primary surgery. The follow‐up is not yet completed. However, the observed data after primary surgery treatment suggest that adjuvant radio‐chemotherapy might cure residuary axillary minimal residual disease in those patients not submitted to completion ALND. Primary endpoints analysis, including survival and regional control will have to wait for the study follow‐up to be completed.
P308 The yield of sentinel lymph node in vulvar malignancies. S. Vidal-Sicart, B. Domenech, P. Fusté, J. Lejarcegui, O. Sola, P. Paredes, F. Pons; Hospital Clinic Barcelona, Barcelona, SPAIN. Although sentinel lymph node (SLN) identification is widespread used in melanoma and breast cancer some concerns exist in mapping other malignancies, like gynaecological cancers. This staging method has not been adopted in many centres due to lack or large validation studies. Aim: To evaluate the feasibility and results of SLN technique in vulvar malignancies referred to our institution. Method: We studied 80 patients with vulvar squamous cell carcinoma (n = 70) or vulvar malignant melanoma (n = 10). The first 35 consecutive patients constituted the validation group of the technique (with subsequent uni or bilateral inguinal lymphadenectomy). The remaining 45 patients (application group) were scheduled only to a SLN location and lymphadenectomy only if the SLN was metastatic. The day before surgery a lymphoscintigraphy was performed by injecting 111 MBq of 99mTc‐nanocolloid in several ways depending on the type of cancer studied. Intraoperative detection of the SLN was always performed by using a hand‐held gammaprobe and, in 77 cases, with the aid of blue dye injection few minutes before surgical intervention. In recent times we have applied new techniques such as SPECT/CT and intraoperative gammacamera in 5 cases. Results: SLN was found in 34 out 35 patients in validation group (97%) with 9 metastatic nodes (26%) with only one false negative result. In
application group SLN was harvested in 44 out of 45 patients (98%) being 25% metastatic. No recurrences were observed to date. Although SPECT/CT and portable gammacamera offered SLN localization in all cases, they did not result in a significant advantage in front of classical approach with planar lymphoscintigraphy. The following table shows the overall SLN’s localization percentages in every aspect of the technique as well as the false negative (FN) rate
Lymphoscintigraphy Surgery
Vulva 78/80 (97%)
Blue dye
+ve SLN
FN rate
78/80 (97%) 59/77 (76%) 20/78 (26%) 1/21 (5%)
Conclusion: Lymphoscintigraphy is a relatively simple and useful technique to identify the SLN in these kinds of tumours. Sentinel lymph node biopsy seems to be a reliable technique in vulvar malignancies. The yield of sentinel lymph node applied in these particular tumours offers a 74% reduction in inguinal lymphadenectomy and a diminished morbidity in this group of patients without a high percentage of false negative cases.
P309 Value of sentinel lymph node identification in high risk ductal carcinoma in SITU S. Vidal-Sicart1, A. Rodriguez2, A. Mestre3, M. Ortega4, A. Fernandez5, G. Zanón6, V. Juncà7, M. Segura7, M. Vernet7, J. Solsona7; 1Hospital Clinic Barcelona, CRC-MAR (CRC Corporació Sanitaria), Barcelona, SPAIN, 2 CRC-MAR ( CRC Corporació Sanitaria), Barcelona, SPAIN, 3CRC-MAR (CRC Corporació Sanitaria), Barcelona, SPAIN, 4Cetir Grup Mèdic, Barcelona, SPAIN, 5CRC Corporació Sanitaria, Barcelona, SPAIN, 6Hospital Clinic Barcelona,, Barcelona, SPAIN, 7Hospital del Mar, Barcelona, SPAIN. Introduction: Although sentinel lymph node (SLN) identification have a definite role in breast cancer staging it has not yet been totally accepted for patients with ductal carcinoma in situ DCIS of the breast. Aim: To evaluate the applicability and results of SLN technique in high risk DCIS patients. Method: We studied 200 patients with preoperative diagnosis of high risk DCIS from two tertiary hospitals. The day before surgery a lymphoscintigraphy was performed by using 111 MBq of 99mTc‐nanocolloid in 1 intratumoral, peritumoral or subdermal injection way based on every case. Intraoperative detection of the SLN was performed by using a hand‐held gammaprobe. In 100 cases vital blue dye was used. Results: One hundred and thirty six patients showed a pure DCIS, 45 an invasive carcinoma and the remaining 19 had microinvasion in definitive histology. Lymphoscintigraphy and radioguided surgery identified SLNs in 98% (197/200) of patients. The vital dye injection identified SLNs in 77% of patients. Thirteen patients showed metastatic SLN (10 micrometastases and 3 macrometastases). Eight of them in the group with invasive carcinoma (i.e. metastatic rate 19%). The remaining five presented two micrometastasis and a macrometastasis in the group with microinvasive carcinoma (metastatic rate 16%) and two micrometastases in pure DCIS group (metastatic rate 1.4%) Conclusion: Lymphoscintigraphy is a relatively simple and useful technique to identify the SLN. This method shows a high SLN identification and deserves a special consideration in order to better staging the high‐risk group of patients with DCIS.
P310 The role of atypical sentinel lymph nodes in malignant melanoma M. Papós1, G. Mohos2, M. Lázár3, J. Varga2, E. Kis2, K. Kapitány2, T. Séra1, J. Oláh2, I. Korom2, L. Kemény2, L. Pávics1; 1Department of Nuclear Medicine, University of Szeged, Szeged, HUNGARY, 2Department of Dermatology and Allergology, University of Szeged, Szeged, HUNGARY, 3 Euromedic Diagnostics Szeged Ltd., Szeged, HUNGARY. Background: In patients with malignant melanoma (MM) of the trunk and the extremities the usual localization of the sentinel lymph node (SN) are the cervical, axillary and inguinal regions. Some authors found SN in atypical localization in about 3‐10% of the cases. Aim: The aim of this study was to analyse the frequency of the atypical SN‐s and to investigate the malignant involvement of these SN‐s. Patients and methods: Preoperative SN mapping was performed in 665 consecutive MM patients applying 99mTc‐nanocolloids with gamma camera technique. Intraoperative SN localization was performed using gamma probe method. All patients had MM with a Breslow thickness of more than 1 mm, or less than 1 mm, but a Clark IV, ulcerated or regressed MM. All patients were clinically in N0 stage. Results: Atypical SN was found preoperatively in 54 cases (8%): only atypical SN was detected in 11 cases, both typical and atypical SN‐s were located in 43 patients. Biopsy of the atypical SN was performed in 37 cases. Atypical SN‐s showed MM involvement in 10 cases (27%): in 3 patients only atypical SN was detected, in 6 cases the typical and atypical SN‐s were also involved and in one patient metastatic MM cells were detected only in the atypical SN with negative typical SN. More than two‐year clinical follow‐up was possible in 24 patients: 3 patients died in association with MM (all of them showed MM involvement in both typical and atypical SN‐s). Conclusions: We detected atypical SN‐s with the same frequency as it was previously described. On the basis of the common MM involvement of the atypical SN‐s, we suggest the biopsy of these SN‐s.
P311 Which is the best planar projection in identification of sentinel nodes in breast cancer? The value of anterior oblique view in “surgical position” in lymphoscintigraphy L. Mena Bares, P. Contreras Puertas, A. Benítez Velasco, F. Maza Muret, F. Hidalgo Ramos, C. Pacheco Capote, J. Latre Romero; Hospital Universitario Reina Sofia, Córdoba, SPAIN. Aim: The purpose of this study is to detect and analyze the best planar view in lymphoscintigraphy for sentinel node localization in women with breast cancer, and evaluate the utility of anterior oblique planar image with the arm in the same position as it will be in the surgery room (“surgical position”). Material and Methods: From July 2008 to January 2009 one hundred and seven consecutive breast cancer patients were included in the study. 45.8% of the lesions were located in the upper outer quadrant of the breast. All patients were submitted to
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and 2cm (34’43%). The most common histological group was ductal carcinoma (60’38%) and the most common histology grade was 2 (37’74%). In 91.08% of cases the number of removed SLN was ≤ 5. SLN was positive in 49 patients (23’11%). In 92’45% ≥ to 3 NSLN were removed. In 6 patients (2’83%) the NSLN was positive on histology, and in 3 of them SLN was negative. There was a statistically significant relationship between tumour size and malignant involvement of the SLN and NSLN, the indication of AC and the presence of malignant lymphadenopathy in AC. Moreover, there was a statistically significant relationship between histology grade and number of removed SLN. Conclusion: The local and regional lymph node involvement of disease only showed a statistically significant relationship with tumour size. The number of removed SLN showed a statistically significant relationship with histology grade. It would be advisable to perform an intraoperative histological analysis of all removed SLN and NSLN.
The best projection (Axilla)
Patients (Nº) Patients (%)
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Anterior oblique
54
50.94
Anterior oblique=Anterior=Lateral 22
20.75
Lymphoscintigraphy and radio-guided surgery for sentinel lymph node procedure in patients with prostate cancer
Anterior oblique=Lateral
17
16.04
Anterior oblique=Anterior
13
12.26
In axillary migration none of the lateral and anterior projections demonstrated more lymph nodes than anterior oblique in “surgical position” view. Lymphoscintigraphy showed internal mammary drainage in 25/107 patients and these were observed with anterior and anterior oblique projections. In 7/25 cases were visualized more number of lymph nodes in anterior view than in anterior oblique. Conclusions: The anterior oblique view in “surgical position” is the best projection in lymphoscintigraphy breast cancer, because it provides more information about axillary lymph nodes and it could avoid the acquisition of lateral view. The anterior projection is the best view to show the drainage of internal mammary lymph nodes.
P312 The sentinel lymph node concept in vulvar cancer: feasibility and validation. G. F. L. D'Errico1, F. Anglana2, F. Battaglia2, S. Basile2, V. Valenza1, M. Sturla3; 1Nuclear Medicine Dept - Catholic University of Sacro Cuore, Rome, ITALY, 2Gynaecology and Obstetrics Dept. - San Filippo Neri Hospital, Rome, ITALY, 3Plastic and Reconstructive Dept.- Catholic University of Sacro Cuore, Rome, ITALY. AIM: Vulvar malignancy is a preferentially lymphogenic metastasizing tumour with a well defined direction of drainage to the groin lymph nodes; lymph node status is an important prognostic factor and inguinal lymphadenectomy, unilateral or bilateral, widely used, is often associated with a considerable morbidity. The concept of sentinel lymph node biopsy (SLNB) is well suited to this cancer giving a less invasive lymph node staging. The Authors’ purpose was firstly to determine the reliability of SLNB in predicting regional lymph node status and secondly, applying this technique in the routine clinical setting, to investigate the diagnostic accuracy of the SLNB in these patients. PATIENTS: 15 women with operable vulvar cancer (2 melanoma and 13 vulvar intraepithelial neoplasia) were prospectively studied. The first 6 cases of vulvar cancer were submitted SLNB to validate in this clinical setting (validation group) this technique. Once a satisfactory success rate had been achieved in the validation group, the SLNB technique was applied to the following 9 patients with vulvar malignancies (application group). METHODS: All the patients underwent sentinel node identification (lymphoscintigraphic mapping) with 99mTc‐ labelled nanocolloidal albumin intradermally injection at four sites around the tumour and intraoperative use of a hand‐held probe to find the SLN(s). In the validation group, SLNB was always followed by radical lymph node dissection. In the application group, this procedure was only performed if the SLN was positive for metastases; for pathological staging, samples were evaluated using haematoxylin and eosin and immunohistochemistry. RESULTS: in the first group, lymphoscintigraphy showed monolateral drainage in 4 patients and bilateral in 2; the SLNB showed metastases in the pathology study in 1 patient while the remaining 5 patients with negative SLNB had also regional lymph nodes negative for metastases. In the application group monolateral SLN drainage was in 8 cases, bilateral in 1; 3 patients showed metastases at pathological survey. CONCLUSION: our results are encouraging: SLNB permits the accurate pathological study of regional nodes and could reduce the high morbidity of current surgical treatment in vulvar tumour patients (if adopted on a routine clinical basis).
P313 Sentinel node in breast cancer. Retrospective analysis of 212 patients and factors associated with lymphatic involvement A. López López1, S. Ruiz Solís1, R. De Juan Rubio1, C. M. Hentea1, D. Lora Pablos2, A. Gómez Embuena1, A. Manrique Legaz1, M. J. Tabuenca Mateo1; 1 Nuclear Medicine Department, Hospital 12 de Octubre, Madrid, SPAIN, 2 Research unit of the Hospital 12 de Octubre, Madrid, SPAIN. Goal: To perform retrospective study/review of the sentinel lymph node biopsy (SLNB) technique at our institution, analyzing (the results obtained) the relationship with the patients’ age, tumour characteristics, injection technique, lymph node involvement and local/regional recurrence. Material and Methods: 212 patients were included. 209 patients underwent subdermal periareolar injection (of 99m‐Tc albumin nanocolloid) and peritumoral injection was performed in 3 patients. Lymphoscintigraphy was performed after 15‐30 minutes post‐injection until the sentinel lymph node(s) (SLN) was/were identified, anterior and lateral views were registered. In case of next day surgery protocol, a delayed 24h post‐injection view was registered preoperatively. Skin marking of the SLN location was performed preoperatively. SLN was defined as the one presenting with highest count rate as measured by the intraoperative probe, as well as those with count rate of at least > 10% of the former the remaining resected LN were regarded as non‐SLN (NSLN). A descriptive (and association) analysis of the following variables was performed: age, size and tumour location, histology type and grade, injection technique, number of removed SLN and NSLN, malignant involvement of SLN and NSLN, surgical axillary clearance (AC), malignant lymphadenopathy in AC and axillary recurrence. Results: Mean patient age was 59 (range 32 to 85), mean of removed SLN 2’94; mean of removed NSLN 0’82. The most frequent location was the supero‐external quadrant (45’75%). The size of most tumours was between 1
B. E. Chrapko1, R. Klijer2, W. Białek2, K. Florek1, R. Gołębiewska1, A. Nocun1, K. Bar2; 1Department of Nuclear Medicine Medical University of Lublin, Lublin, POLAND, 2Clinic of Urology and Urooncology Medical University of Lublin, Lublin, POLAND. Introduction: Radical prostatectomy with regional lymphadenectomy is the treatment of choice in localized prostate carcinoma. However, about 30% of the patients develop distant metastases. The procedure which is used to improve the effects of treatment is radioguided sentinel lymph node dissection following lymphoscintigraphy. Aim: The objective of the study was to assess diagnostic value of the procedure in detecting lymph node metastases of prostate cancer in our materials. Materials and methods: A group of 55 patients with T1c‐T2 stage of prostate cancer, aged 56‐71 years, were enrolled for the study. All of them underwent radical retropubic prostatectomy. A day before operation, all patients had USG ‐guided transrectal injection into the peripheral zone of each lobe of the prostate 2x 0.3 ml of 2,7 MBq 99mTc Nanocoll (GE Healthcare, Milan, Italy). Two hours after the injection, SPECT and planar lymphoscintigraphy of the pelvis and abdomen was performed. On the next day, standard lymphadenectomy was performed. Results: The sentinel lymph nodes (SLNs) were detected in the limphoscintigraphy: bilaterally in 34 pts, unilaterally in 16 pts; in 4 pts SLNs were not visualized in the study. In 5 patients, histopatological examination confirmed micrometastases in dissected SLNs. Two sites of metastases in SLNs were detected outside of the region of standard lymphadenectomy, none was detected in the obturator fossa. Conclusion: The results confirmed that SLN‐procedure is a valuable diagnostic examination, useful in detection of lymph node metastases in prostate cancer.
P315 Work-up before pelvic radiotherapy treatment planning using multimodality imaging in prostate cancer: Combined SPECT/CT lymphoscintigraphy and 18F-choline PET/CT C. Steiner, H. Vees, M. Wissmeyer, A. Chouiter, M. Velasquez, S. Namy, R. Miralbell, O. Ratib, F. Buchegger; Univ. Geneva Hosp., Genève, Switzerland Aim: Identify sentinel lymph nodes (SN) by SPECT/CT prostate lymphoscintigraphy and suspicious lymph nodes (LN) by 18F‐choline (18F‐FCH) PET/CT to appreciate the value of this multimodality imaging approach in the work‐up before pelvic radiotherapy (RT) treatment planning in intermediate‐ and high‐risk prostate cancer patients. Patients and Methods: 13 intermediate‐ and high‐risk prostate cancer patients were included in the study. 1.5 hr after transrectal, ultrasound guided injection of a total of 100MBq of 99mTc‐Nanocoll into the 4 prostate quadrants, pelvic SPECT acquisition was performed on a 3 heads gamma camera. Then, using Siemens software, SPECT studies were coregistered with the pelvic planning CTs and the help of fiducial body markers for every patient in the study. Pelvic SN localized on SPECT/CT prostate lymphoscintigraphy were compared to standard pelvic clinical target volumes (CTV). Pelvic LN were also evaluated for malignancy using 3 phase PET/CT criteria after injection of 300 MBq 18F‐ FCH, in 12 out of the 13 patients in the study. Results: A total of 69 pelvic SN were identified on SPECT/CT (mean 5.3; range 3‐9). 23 SN (33%) were located outside standard pelvic clinical target volumes, 15 of them in common iliac and retroperitoneal chains above L5, 5 in para‐rectal fat, and 3 in inguinal bed, respectively. All pelvic SN fulfilled non‐suspicious metabolic and morphologic criteria such as size, shape, and absence of malignant 18F‐FCH behaviour. SPECT/CT lymphoscintigraphy coregistration was able to change pelvic‐CTV and thus treatment plans in 5/13 patients, mostly due to the presence of pararectal SN located outside standard treatment volume. 18F‐FCH PET/CT studies permitted to identify suspicious 18F‐FCH uptake in enlarged iliac lymph nodes in 2 patients that showed unexpectedly missing uptake of 99mTc‐Nanocoll on SPECT/CT. These suspicious iliac LN, whose lymphatic drainage was probably blocked by tumor burden, could benefit from a boost dose. Thus a significant change of RT treatment planning could be expected in 53% (7/13) of the patients. Conclusion: Multimodality imaging combining SPECT/CT prostate lymphoscintigraphy and 18F‐FCH PET/CT identified para‐rectal SN outside standard pelvic CTVs or highly suspicious pelvic LN in 53% of the intermediate‐ and high‐risk prostate cancer patients included in the study, highlighting the potential impact of this approach in the work‐up before RT treatment planning.
P316 Sentinel lymph node mapping in colorrectal and anal cancer. Preliminar results. J. Duch, M. Estorch, C. Balagué, C. Gómez, S. Sainz, A. A. RodríguezRevuelto, E. Rivera, C. Artigas, A. Flotats, M. Camacho, I. Carrió; Hospital de la Santa Creu i Sant Pau, Barcelona, SPAIN. AIM : Lymph node evaluation is an important prognostic factor in colorrectal and anal cancer. A 25% recurrence rate in patients who are node‐negative with current methods suggests that current staging practices in colorrectal carcinoma are inadequate. Sentinel lymph node mapping (SLNM) can improve staging, specially with skip metastasis, and allows the possibility to add adjuvant chemotherapy post surgery in cases with positive sentinel lymph nodes. We performed in vivo and ex vivo studies for ultrastaging of colorrectal and anal carcinoma. MATERIALS &
Poster Presentation
administrate the radioactive colloid the day before of surgery. Three or four 0.15ml doses of 37 MBq 99mTc‐Nanocoll® were injected peritumoral around palpable and no palpable lesions. Ultrasonography helped to localize no palpable lesions. Patients were positioned in supine decubitus and lymphoscintigraphies were obtained from 60 to 180 minutes after injection with dual headed gamma camera with low energy high resolution (LEHR) collimator. Planar images were obtained in anterior (cross arms), lateral (arm above head) and anterior oblique in “surgical position” (shoulder hyperextended 90º). The last two views were acquired with breast fixed with adhesive tape. Two physicians visualized all views and every hot spot was considered as lymph node, choosing the view with the greatest number of lymph nodes as the best projection. Results: Axillary migration of the tracer was present in 106 /107 patients (this patient showed internal mammary sentinel node).
S372 METHODS: As part of an ongoing trial, 4 patients diagnosed with colorrectal (2 patients) and anal (2 patients) cancer underwent in vivo and ex vivo SLNM. The day before surgery, 0.8 ml of 99mTc‐nanocolloid was injected submucosally around the tumor, under endoscopic guidance. Two to 3 hours after injection, planar lymphoscintigraphic and SPECT/CT images were obtained. We used laparoscopic probe and intraoperative portable gamma camera fitted with a pinhole collimator during surgery, for in vivo imaging. After laparoscopic surgery, 4ml of isosulfan blue dye was injected submucosally ex vivo. All sentinel nodes (SN) identified by imaging/counting and by blue dye were examined by hematoxilin and eosin staining, and by immunohistochemical staining with cytokeratin. RESULTS: At least one SN was identified with SPECT/CT in 3 patients. In one of them, an aberrant drainage was observed (interaortocaval region). Laparoscopic probe could not identify any SN, but intraoperative portable gamma camera identify 1 SN (the aberrant drainage referred). With ex vivo study, isosulfan blue dye and gamma probe counting identified SN in 3 patients. SN were positive in 1 patient. CONCLUSION: Sentinel lymph node evaluation from a colorrectal and anal cancer can be performed by in vivo and ex vivo techniques. In vivo technique allows detection of aberrant drainage. Ex vivo technique has more sensitivity for the detection of SN.
P317 Is the use of a portable gammacamera in the localization of the sentinel node really necessary? B. N. Luján, S. Vidal Sicart, B. Doménech, S. Lafuente, O. Sola, F. Pons; Hospital Clinic, Barcelona, SPAIN.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 subdermally. The injection was peritumoral, intratumoral or around the nipple 24 h before surgery. The planar and SPECT‐CT acquisition with hybrid camera were performed 1.5 h after injection. The location of the SNL was marked on patient`s skin using the ink pen. The blue dye was injected 20 min. before surgery. A SLN was defined as node that could be identified by hand‐ held gamma detectors as substantially radioactive beyond the background or as any blue node. Results. In 30 patients results from planar and SPECT/CT imaging were identical in 18 patients (60%). SPECT/CT revealed properly anatomic localization in 24 patients (80%) and additional SLNs were detected in 10 patients (18%). Due to the improvement of the anatomical mapping of SPECT/CT images, it was easier for the surgeons to precisely locate the SLNs in patients with breast cancer. Conclusions. SPECT/CT discovered “hidden” sentinel lymph nodes in 33 % of patients with non‐visualized lesions on the planar imaging. The CT portion of examinations was especially helpful for identification of sentinel lymph nodes during surgery. The additional information of SPECT/CT allows a more accurate characterization of the SLN concerning size, depth and anatomical location.
P320 Sentinel node biopsy in high risk breast ductal carcinoma in situ R. Ruano1, M. Ramos2, F. Gomez-Caminero1, P. Tamayo1, P. GarciaTalavera1, J. Gonzalez-Orus2, J. Garcia-Talavera1; 1Universitary Hospital. Nuclear Medicine Department, Salamanca, SPAIN, 2Universitary Hospital. Surgery Department., Salamanca, SPAIN.
Introduction: The localization of the sentinel node is based, at the moment, in the combination of preoperative images and intraoperatively use of a hand‐held gamma probe as well as, in many centers, blue dye (classical approach). In some circumstances the addition of a"real‐time" image during surgery could help to improve the percentages of localization of the sentinel node. Objectives: To assess the additional information that yields from the use of a portable gamma camera, not only before the intervention (preoperative image) but also during the surgical procedure, in comparison with the classical approach. Methods: Three hundred and six patients have been preoperatively studied with the portable gamma camera and 104 of them during the surgical procedure (Endometrium 5, Vulva 5, Cervix 3, Breast 75, Melanoma 15, Tongue 1). The portable gammacamera preoperative images were acquired just before the second set of classical planar images (2 hrs after injection). During the surgery intraoperative images were continuously acquired according to the protocol developed in our hospital for every particular malignancy and anatomical location. Results: In preoperative group, the conventional images located the sentinel node in 298 of the 306 studied cases (97%) and the portable gamma camera identified it in 275 of these cases (90%). In the surgical group, the gamma probe located a sentinel node in 101/104 (98%) patients, and the portable gamma camera in 88/104 (85%). However, the intraoperative utilization of “real‐time” images was beneficial for a better sentinel node depiction in 12 cases (11%). Conclusions: The use of a portable gammacamera for the localization of the sentinel node is not able, at the current moment, to substitute the classical approach with lymphoscintigraphic images plus gamma probe. Although the portable gammacamera offers advantages in certain anatomical localizations, the gamma probe shows better localization rates of the sentinel node. The combination of both techniques offers the best results.
Background: the use of sentinel node biopsy (SNB) in breast ductal carcinoma in situ (DCIS) is controversial due to its low risk of developing axillary metastases. It is the aim of this study to present our experience in the therapeutic approach of the SNB in patients with high risk DCIS (large, multicentric, high grade or palpable tumors). Methods: we studied 55 consecutive cases of high risk DCIS and performed SNB in the period 2002‐2008. 26 (47%) of them with previous 99m excisional biopsy. Preoperative lymphoscintigraphy was performed with Tc‐colloidal rhenium sulphide (nanocis); the sentinel node was located with a gamma ray detection probe (europrobe) and periareolar isosulfan blue dye (lymphazurin). Axillary lymph node dissection (LND) was completed only when the SLN was positive for metastasis or not located. Results: Our casuistic included 20 large tumors, 19 multicentric, 24 palpable and 30 high nuclear grade, for a total of 55 patients. Mean age 55,18y (range 38‐80). The sentinel node was located in all cases but 2 with previous surgery. Conservative treatment of the breast was feasible in 38/55 (69%) cases. 17/55 (31%) underwent a mastectomy due to extensive DCSI, 11 of them (65%) followed by breast reconstruction. SNB histopathology results were 51 (93%) negative for metastasis, 1 (1,8%) with isolated tumoral cells, and only 1 (1,8%) with metastasis (also with 3 additional metastasis in the lymph chain). This case corresponded to a previous excisioned high nuclear grade with comedonecrosis DCIS. Axillary lymph node dissection was performed and negative for metastasis in the 2 patients were SN was not detected. Conclusion: Routine SNB in high risk breast carcinoma in situ, previously operated or not, will result in a very low percentage of axillary metastasis. Its utility may be controversial, but it might be acceptable as SNB itself represent a low morbidity technique.
P318
Sentinel Node Biopsy in the Ductal Carcinoma in situ (DCIS)
The contribution of lymphoscintigraphy in the accurate staging of patients with melanoma presenting after wide local excision (WLE) X. Geronikola-Trapali1, I. Armeniakos1, P. Karabina1, A. Stefanoyiannis1, V. Lyra1, S. Bakalis1, P. Zotou1, A. Prentakis1, G. Zabakos2, I. Papadopoulos2; 1 University General Hospital “Attikon”, Nuclear Medicine Department, Chaidari, GREECE, 2University General Hospital “Attikon”, 4th University Surgical Department, Chaidari, GREECE.
P321 G. E. Łapińska1, M. Benke1, J. Niewiadomska1, J. Piechocki2, A. Garszel1, M. Bryszewska1, A. Warszewska1, I. Kozłowicz-Gudzińska1, E. Towpik2; 1 Department of Nuclear Medicine and Oncological Endocrinology, Warsaw, POLAND, 2Department of Breast Cancer and Reconstructive Surgery, The Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, POLAND.
Patients have traditionally been considered candidates for sentinel node imaging and biopsy (SNBx) only at the time of wide local excision (WLE). We presumed that patients with prior WLE may also be staged accurately with SNBx and that lymphoscintigraphy may support this procedure as well. Aim: The aim of this study was to highlight the contribution of lymphoscintigraphy to the accurate staging of patients presenting after wide local excision for malignant melanoma (visualization of SLN and further histological identification) . Materials and methods: Our study involved 33 patients (23 males and 10 women ‐ mean age 38,5 9 years ) who had previous WLE for clinically localized melanoma. Lymphoscintigraphy was performed after intradermal injection of 1 mCi (37MBq) of Tc 99m Nanocolloid around the scar .Dynamic flow and static images were obtained. Once SLN was visualized, a mark was set on the skin. After surgical removal which was guided by a handheld gamma probe the node was sent for histopathologic examination (SNBx).Median follow up was 34 months. Results: Intraoperative identification of at least 1 sentinel node was accomplished in 32 patients (96,9%) .The mean number of nodes removed per patient was 2.0 . Five patients (15%) had positive SLN. Among the 27 patients with negative SNBx 1 (3,7%) developed an isolated first recurrence in a lymph node. Conclusions: This study confirms that: 1.SNBx after WLE provides much‐needed outcome data on recurrence after SNBx in these patients, suggesting that accurate staging of the regional lymph node bed is possible in patients after WLE. 2. The incremental value of preoperative lymphoscintigraphy.
Background Ductal carcinoma in situ (DCIS) is being considered as non‐invasive form of breast cancer. However, there is a 0‐18% risk of sentinel lymph node (SLN) involvement in patients suffering from pure DCIS. Aim To evaluate efficiency of SLN diagnostics in patients with DCIS. Material 196 patients aged 44‐83 years (median 55 years) with ductal carcinoma in situ (DCIS), confirmed with vacuum assisted biopsy (VAB) were enrolled in the study. Average area of DCIS was 5,4 cm (2,5 to 12 cm). Methods The day before surgery all patients underwent a lymphoscintigraphic study. The radiotracer (nanocolloid labeled with 99mTc, mean activity 55 MBq) was administered with subdermal injection ‐ subareolar or at the projection site of the lesion. Two hours later lymphoscintigraphic images of the breast and axilla were acquired. In operation room, after anesthetic induction, a blue dye was injected in the same site. The surgical identification of SLN was guided by hand‐held gamma‐probe and visual identification. SLN was removed at surgery and analyzed with HE staining and immunohistochemistry. All patients underwent mastectomy. In cases with positive SLN biopsy the treatment with the axillary node dissection was completed. Results SLNs were successfully localized by using intraoperative gamma‐probe in all 196 patients. One hundred sixty nine patients presented pure DCIS and in 27 (14%) patients metastatic SLNs was identified. After operation, during the final histopathological examination, 26 patients were diagnosed with invasive carcinoma (macroinvasion in 16 pts and microinvasion in 10 pts). Only one patient (0,5%) with pure cancer in situ presented metastatic SLNs. Conclusions Lymphoscintigraphy is a simple and useful method to identify the SLNs in patients with DCIS. This technique enables a better staging in patients with DCIS, and may be the auxiliary method in the selection of the appropriate surgical procedure.
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P322
Hybrid SPECT/CT imaging in localization of sentinel lymph nodes in breast cancer
Various scintigraphic patterns identified during detection of sentinel lymph nodes in breast carcinoma patients
A. Giźewska, Z. Zaręba, Z. Stembrowicz-Nowakowska, A. Dąbek, E. Dziuk; Military Institute of Health Services, Warsaw, POLAND.
M. U. Khan, M. K. Nawaz, I. Munir; Department of Nuclear Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, PAKISTAN.
Introduction: In patients with breast cancer preoperative lymphoscintigraphy may be used to map lymphatic drainage patterns and identify sentinel lymph nodes (SLN).The aim of the study was to evaluate the diagnostic advantages of using SPECT‐CT in patients with breast cancer. Materials and methods. We examined 30 patients with operable breast cancer (stages 1 or 2) with no clinical evidence of lymph nodes. 99mTc ‐nanocolloid 0,2 mL 40MBq was administered
Introduction & Aim: Scintigraphic sentinel lymph node (SLN) detection in patients with breast carcinoma now forms an important part of breast cancer management. This initial study has been undertaken to identify and group various scintigraphic patterns observed during SLN detection. Further studies would be undertaken to assess correlation between these patterns and disease
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P323 Reliability and detection rate of sentinel lymph node mapping using double labeling method in patients with breast cancer M. Vlajkovic1, S. Ilic1, M. Rajic1, M. Visnjic2, P. Kovacevic2, L. Djordjevic2, J. Paravina2, M. Matovic3, V. Artiko4; 1Department of Nuclear Medicine, Clinical Center, Nis, SERBIA, 2Clinic for Plastic Surgery, Clinical Center, Nis, SERBIA, 3Department of Nuclear Medicine, Clinical Center, Kragujevac, SERBIA, 4Institute of Nuclear Medicine, Clinical Center of Serbia, Belgrade, SERBIA. The axillary node status is one of the most powerful prognostic factors to determine recurrence and survival of patients with primary breast cancer. The aim of this study was to assess efficacy of sentinel lymph node (SLN) biopsy following double labeling by 99m‐Technetium human serum albumin colloids (99mTc‐HSA) and vital blue dye, and to evaluate the reliability of labeling and detection of SLNs in patients with T1 and T2 stage breast cancer without clinical evidence of nodal involvement. The status of 52 lymphatic basins in 50 women (mean age 54±12) were analyzed after either mastectomy or lumpectomy and complete axillary dissection. A total of 0.3 ml (50‐74 MBq) of 99mTc‐HSA was injected intradermally, subareolary. Dynamic lymphoscintigraphy was performed followed by early and late static scintigraphy. Blue dye (1%, 3 ml) was injected around the breast mass, 10 minutes before the surgery. The node(s) that were found to be “hot”, colored blue, or both, were considered to be SLNs. During the surgery, a gamma probe was used to localise SLNs. Forty‐five SLNs in 36 basins were detected via both methods. A total of 68 SLNs were detected in 50 lymphatic basins on late static lymphoscintigraphy. Vital blue dye colored 58 SLNs in 48 basins and failed to mark 4 SLNs in 4 patients, in whom SLNs were found by lymphoscintigraphy. All axillary SLNs labelled preoperatively were found during the operation either by collimated gamma probe detector or by eye. The success rate of SLN identification was 100%. All SLNs were examined by frozen section, hematoxylin eosin staining and immunohistochemically. Overall 75 SLNs and 714 non‐ SLNs were removed and analyzed. Seventeen out of the 50 patients (34%) had metastatic disease in the axilla. Out of the 17 patients with metastases, the range of involved nodes was from 1 to 2. The SLN(s) were positive in all patients with metastatic disease (sensitivity: 100%), and no skip metastases were found (false negatives: 0%). The SLNs were the only sites of metastases in 10 out of 17 patients (58%). It can be concluded that SLN biopsy after double labeling method is a highly reliable and accurate procedure for staging and treatment of breast cancer patients.
P324 Comparison of a 1-day and a 2-day protocol for sentinel lymph node biopsy in breast cancer. A. Aliyev1, M. Ozhan1, M. Halac1, H. Sayman1, I. Uslu1, O. Sımsek2, F. Aydogan2; 1Istanbul University Cerrahpasa Medical School,Nuclear Medicine Department, ISTANBUL, TURKEY, 2Istanbul University Cerrahpasa Medical School,General Surgery Department, ISTANBUL, TURKEY. Objective: To compare the identification rate and number of the sentinel nodes (SLN) in a 1‐day protocol versus a 2‐day protocol in patients with breast carcinoma. Materials & Methods: Ninety patients that underwent SLN mapping before breast surgery were analyzed retrospectively. The patients were divided in 2 groups: Group I consisted of those who were injected and mapped on the same day with surgery (n: 35 patients) and Group II consisted of those who were injected the day before surgery (n: 55 patients). For lymphoscintigraphy and intraoperative gamma probe detection 40 MBq of Tc‐99m nanocolloid was injected subaerolar space in both groups. After dynamic images were taken under gamma camera and SLN(s) were identified, patients were transferred to the operating theater and blue dye was also used during the operation. Radioguided surgery was successfully completed by using a gamma probe and samples were sent for histopathological investigation. According to the biopsy result operation is either continued for axillary dissection or completed. Results: The ratio of SLN (+) patients was 97.1% in Group I. In one patient SLN could not be retrieved. The average number of detected SLN(s) was 1.67 and the ratio of SLN metastases (+) patients was 31.4% in Group I. The ratio of SLN was 100% in Group II. The average number of detected SLN(s) was 2.3 and the ratio of SLN metastases (+) patients was 27.2% in Group II. There were no statistical difference between the results obtained in two groups in terms of detection rate and number of SLN. Conclusion: Radiocolloid injection the day before operation is an acceptable alternative and logistically advantageous technique for breast cancer SLN mapping
P325 SPECT-CT and the Sentinel Lymph Nodes in Breast cancer patients: additional diagnostic value of CT slides analysis. P. Bourgeois, C. Garcia, K. Muylle, V. Huyghe, D. Hertens, D. Noterman, F. Deneubourg, I. Veys, J. Nogaret, D. Larsimont, M. Lemort, P. Flamen; Jules
Bordet, Brussels, BELGIUM. Background ; Interest of the combined SPECT‐CT imaging for the anatomical localisation(s) fo the Sentinel Lymph Nodes (SLN) in Breast Cancer patients is well established. However, there are few data about the complementary diagnsotic value of the CT slides analysis. Material and methods : SPECT‐CT imagings of the axillary SLN were obtained using a Symbia system in 28 patients 3 to 18 hours after the intra‐mammary and peri‐tumoural deep injections of 99mTc labeled naosized HSA colloids. The removed SLN (in 26 cases) and non SLN (in 14 cases) were pathologically assessed using HE and immuno‐histochemical stainings as well as RT‐PCR technique. Axillary SLN and Non SLN on the CT slides were visually assessed and defined as positive or negative according classical criteria. Results: Among the 18 patients with CT axillas reported as negative, the SLN were microscopically positive (pNmi) in 1, only RT‐PCR positive in 1 and, in a third patient, one non SLN was pNmi. Among the 10 patients with CT axillas reported as positive, 5 patients had the SLN pathologically positive (pN1a in 3, pNmi in 1 and RT‐PCR positive in 1), one patient had one non SLN pN1a (with falsely negative SLN) and the seventh patient in whom the SLN was not visualised also had a pN1a status. Sensitivity of the CT analysis was thus 7/10. CT analysis corrected one false negative conclusion of the SLN and demonstrated a pathologically invaded LN in one patient in whom the injections failed to demonstrate the SLN. Conclusions: Although based on a limited series, these preliminary results are encouraging. Analysis of the CT slides appear to be complementary to the SLN technique and might correct it in several cases. Further studies on larger populations are however requested as well as additional analysis such as inter‐ and intra‐ observer recevability, effect of the learning curve or of dual reading. (Updated results will be presented).
P326 Is complete axillary lymph node dissection always necessary after a positive sentinel node biopsy? A. C. Hernandez Martinez, J. Sanchez Mendez, R. Couto Caro, M. D. Marín Ferrer, C. Escabias del Pozo, S. Rodado Marina, M. Coronado Poggio, L. Martin Curto; La Paz Hospital, Madrid, SPAIN. AIM The standard of care for breast cancer patients with sentinel lymph node (SLN) metastases includes complete axillary lymph node dissection (ALND). However, in up to 50‐65% patients SLN is the only disease‐positive node of the ALND. In these cases complete ALND will not give us additional information or increase survival. The aim of our study is to establish which patients with breast cancer and positive SLN will not profit from complete ALND. MATERIAL AND METHODS From November 2001 to September 2008, 430 patients (p) with breast cancer (mean age 56.8, range 26‐92) underwent SLN biopsy in our hospital. In 100 cases SLN was positive and ALND was completed. We retrospectively applied the Memorial Sloan‐Kettering Cancer Center (MSKCC) Normograma, that uses a multivariable logistic regression to predict the likelyhood of additional disease in non‐SLNs. The Normograma asses: age (20‐91), tumor size (0.1‐11cm), histology type and tumor grade (ductal I‐II‐III, lobular), lymphovascular invasion, multifocality, estrogen‐receptor status of the primary tumor, method of detection of SLN metastases, number of positive and negative SLNs. Each of these features is assigned a value in a range of points. The total amount of points reached for every patient is correlated with a predicted probability of non‐ SLN metastasis (0.2‐92%). RESULTS 398 out of 430 p were histologically studied. Positive SLN resulted in 119p (29,9%), and complete ALND was performed in 100 of them. We found non‐SLN metastasis in 32%. MSKCDC (%)
n 0‐5 6‐10 11‐15 16‐20 21‐25 26‐30 31‐35 36‐40 41‐45 >45
Non‐SLN‐ (nº p) 68 1
8
22
19
8
4
3
3
0
0
Non‐SLN+ (nº p) 32 0
0
1
9
14
3
1
2
1
1
If we applied the Normograma and established the cut‐off at 11%, 9% of complete ALND free of disease would have been prevented, and none positive non‐SLN would have been found. If the cut‐off was at 16%, only one patient (3%) with additional disease in the non‐SLNs would have undergone lymphadenectomy. We would obtain Sensitivity=96,88%, Specificity=48,53%, Positive predictive value=46,97% and Negative predictive value=97,06%. 31% of unnecessary ALND would have been avoided. CONCLUSION In our group, if we applied the MMSKCC Normograma considering a cut‐off at 16%, unnecessary ALND would be avoided, obtaining high sensitivity and negative predictive values. However, it is necessary to individualize every case with collaboration of the patient, as well as participate in clinical trials, to stablish definitive conclusions.
P327 Sentinel lymph node biopsy in breast cancer after cancer after excisional biopsy. Preliminary results. A. C. Hernandez Martinez, R. Couto Caro, C. Escabias del Pozo, S. Rodado Marina, M. Coronado Poggio, M. D. Marin Ferrer, J. Coya Viña, L. M. Martin Curto; La Paz Hospital, Madrid, SPAIN. AIM In Murcia´s consensus (Spain, 2007) it was established that excisional biopsy in patients with breast cancer does not contraindicate sentinel lymph node biopsy (SLNB) if it is done before a month and in abcense of exclusion criteria. The aim of this study is to evaluate the usefulness of SLNB in patients with breast cancer and previous excisional biopsy in our hospital. MATERIAL AND METHODS We have studied the first 33 patients with breast cancer who underwent tumorectomy in the previous month and came to our department for SLNB from December 2007 to February 2009. The radiotracer was injected in 3 ways: periareolar (PA), subdermal (SD) or mixed (M): periareolar and subdermal simultaneously. We performed the usual protocol for scintigraphic detection and radioguided surgery. RESULTS 57,6% of patients had a tumor removed in their right breast and 42,4% in their left breast. 36,4% of patients had the tumor located in the superior‐external quadrant (SEQ). 78’8% of the removed tumors were T1 and 15’2% were T2. Histological type were infiltrating ductal carcinoma (IDC): 72.7%, ductal carcinoma in situ (DCIS): 3%, infiltrating lobular carcinoma (ILC): 9.1% and others (O): 12.1%. 15 out of 33 patients (45,5%) were injected PA, 11 (33.3%) SD and 7 (21.2%) M. The median and interquartilic interval number of SLN detected in scintigraphy was 2 (1‐2). The global scintigraphic visualization rate was 97.3%: 94% axillary and 12,1% internal mammary. In one patient drainage was exclusively to the internal mammary. SLN was not detected during the surgical intervention in 5p (15.15%); these patients underwent complete axillary lymph node dissection, finding additional disease in non‐SLN in 2/5p. From the analyzed SLN, 28 were negative (84.8%), 2 of
Poster Presentation
prognosis. Materials & Methods: 412 scintigraphic procedures for SLN detection were performed in the Nuclear Medicine department from December 2006 to April 2009 on histo‐pathologically proven cases of carcinoma breast. Patients included one male while rests were female. Age range: 20‐85 years (Mean Age: 47.84years). Procedure was performed with intra‐dermal injections of Tc‐99m Nanocolloid given at 3, 6, 9 & 12O’Clock peri‐aeriolar sites (Mean Cumulative dose: 84.73MBq). Delay between injection and surgery was 16‐18 hours. Imaging was done at 45min post‐injection and morning prior to surgery. Static views acquired of Ant‐Chest, lateral & oblique‐300. Scintigraphic patterns were categorized and grouped as follows: I [Single sentinel node], II [Sentinel node(s) with second tier node(s)], III [Sentinel node(s) &/or Internal mammary chain node(s)], IV [Sentinel node(s) with track(s) visualization], V [Multiple nodes with multiple tracks], VI [Bilateral sentinel nodes in bilateral carcinoma breast], & VII [Non‐ visualization of sentinel node]. Results: Group I pattern was seen in 166(40.3%), Group II in 90(21.9%), Group III in 12(2.9%), Group IV in 76(18.5%), Group V in 14(3.4%), Group VI in 7(1.7%) and Group VII in 47(11.3%) patients. Conclusion: Seven different scintigraphic patterns have been identified and categorized in our experience of sentinel lymph node detection. However, further studies are contemplated to assess whether these patterns have correlation with disease prognosis or not.
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them showed metastasis (6’1%), 2 micrometastasis (6.1%) and 1 isolated tumoral cells (3%). CONCLUSIONS We found that previous excisional biopsy does not influence scintigraphic detection of SLN in patients with breast cancer, in accordance with the published literature. For superficial injection, axillary and internal mammary lymphatic drainage are comparable to other series published in breast cancer. The lower rate of metastasis in SLN in our group compared to the literature seems to be in relation with the predominance of small tumors.
P328 Contribution of the portable gamma camera when detecting the sentinel node in breast cancer during surgery. A. Prieto Soriano, J. Cardona-Arboniés, J. Mucientes Rasilla, L. Izarduy, M. Merchan Morales, G. Salazar Andía, A. Gonzalez Maté, R. Delgado-Bolton, J. Román Santamaría, J. Carreras Delgado; Hospital Universitario Clínico San Carlos de Madrid, Las Rozas de Madrid, SPAIN. Introduction The usefulness of the portable mini gamma camera in the operation theatre has been proven in surgeries such as the intraoperative mean of detection of the sentinel node in both colon and prostate (via laparoscopy) cancer, as well as in parathiroids adenoma, ROLL and SNOLL. Aim The main aim of this study is to show our experience using the portable mini gamma camera (Sentinella) during surgery, when detecting the sentinel node in breast cancer. Material and Methods The sentinel node detection technique included 46 women diagnosed with breast cancer. This study was carried out by means of the periareolar intradermal injection of 4 syringes of 37 MBq and 0.2 ml 99mTc‐ labelled nanocolloid. Planar images and SPECT/CT were acquired 60 minutes after the injection. The following day the detection of the sentinel node was performed during surgery by means of a portable probe and the portable mini gamma camera. This gamma camera (Sentinella S102, GEM Imaging, Valencia, Spain) has a 4 cm x 4 scintillator crystal CsI (Na) that will enable taking images during surgery. One minute exposure time images were taken of the injection points, anterior axillary line projection, and lateral axillary line projection. Once the sentinel nodes had been removed, anterior and lateral projections were taken again. Results The images acquired with the portable gamma camera were useful for all patients in order to asses the correct removal of all the sentinel nodes. In 4 out of the 46 cases the portable gamma camera gave relevant information during the procedure. In two cases it located a sentinel node that had not been observed in the presurgical images and in other two cases it oriented the surgeon to locate low activity sentinel nodes when the probe screening had not been effective. Conclusions The use of the intraoperative portable gamma camera when detecting the sentinel node in breast cancer patients is useful in order to ensure, regardless of the surgeon, that all sentinel nodes have been removed. It can as well help to guide the surgeon in the event of a single low activity sentinel node.
P329 Factors that influence scintigraphic detection rate of sentinel lymph node biopsy in patients with breast cancer A. C. Hernandez Martinez, R. Couto Caro, S. Rodado Marina, M. Coronado Poggio, M. D. Marin Ferrer, C. Escabias del Pozo, J. Coya Viña, L. M. Martin Curto; La Paz Hospital, Madrid, SPAIN. AIM The usual scintigraphic detection rate in the sentinel lymph node biopsy (SLNB) is approximately of 95%, in accordance with our experience. We would like to establish if some factors, such as age of patients, size and tumor type have an influence on axillary scintigraphic detection of the sentinel lymph node (SLN). MATERIAL AND METHODS From February 2005 to September 2008, 405 breast cancer patients who came to our department during the clinical application phase of SLNB have been studied. All of them were injected techmetium‐99m‐labeled albumin nanocolloid and images were obtained following the usual protocol. Patients were divided retrospectively in two different groups according to gammagraphic detection of axillary drainage: group A (non visualization) and group B (visualization). In both groups we compared: age (mean: 56.8, range: 26‐92); tumor size: T in situ (TS), T1, T2≤3cm (T2.1), T2>3cm (T2.2), previous excisional biopsy (T0); and histological tumor type: infiltrating ductal carcinoma (IDC), ductal carcinoma in situ (DCIS), infiltrating lobular carcinoma (ILC), others (O). Axillary scintigraphic detection rate (ASDR) was evaluated in groups of age: a (20‐30), b (31‐40), c (41‐50), d (51‐60), e (61‐70), f (71‐80), g (81‐92). RESULTS FACTORS
TOTAL
A
P
405
19 (4,7%) 386 (95.3%)
B
AGE
56.8
63.68 *
IDC 323 (79,8%) 17 (89.5%) 306 (79.3%)
56.46
DCIS 32 (7.9%)
1 (5.3%)
31 (8%)
HISTOLOGY ILC 28 (6.9%)
1 (5.3%)
27 (7%)
O
22 (5.4%)
0 (0%)
22 (5.7%)
TS
31(7.7%)
1 (5.3%)
30(7.8%)
T1
227 (56%) 5(26.3%) 222(57.5%)
SIZE
T2.1 111(27.4%) 10(52.6%) 101(26.2%)
T2.2 12(3%)
1 (5.3%)
T0
2(10.5%) 19(4.9%)
21(5.2%)
11(2.8%)
* p<0.05 ASDR according to group of age: a (5/5P,100%), b (36/38P, 94.7%), c (106/108P, 98.15%), d (95/99P, 95.96%), e (82/86P, 95.34%), f (47/52P, 90.38%), g (15/17P, 88.23%). CONCLUSIONS We have found statistically significant differences (p<0.05) between both groups only when the age of the patients is analyzed, showing a higher mean age in group A than in group B. Smaller tumors (T in situ and T1) show higher ASDR, without statistically significant differences. We do not objectify differences in the ASDR according to the histological tumor type. Although our ASDR is adequate, the small size of the non visualization group makes it difficult to establish statistically significant conclusions.
P330 Comparison between diferent injection techniques of the radiotracer in the sentinel lymph node biopsy in breast cancer: our experience R. Couto Caro, A. C. Hernandez Martinez, M. Coronado Poggio, M. D. Marin Ferrer, C. Escabias del Pozo, S. Rodado Marina, J. Coya Viña, L. M. Martin Curto; La Paz Hospital, Madrid, SPAIN. AIM It is accepted that the isotopic tracer injection for the sentinel lymph node biopsy (SLNB) must be preferably intra‐peritumoural, even though the periareolar and/or subdermal injection are also considered as a beginning option. The objective of this study is to assess the efficacy of the different tracer injection techniques in the SLNB in breast cancer in our hospital. MATERIAL AND METHODS From March 2005 to December 2008, we performed SLNB to 400 breast cancer patients (p). The mean age was 56.8 (range 26‐92). Tumor size were; T0 (previus excisional biopsy): 24p, T in situ: 29p, T1: 225p, T2≤3cm: 110p, T2>3cm: 12p. The radiotracer was prepared following the usual procedure. Injection was individually choosen for every case; peritumoural (PT): 243p, periareolar (PA):108p, subcutaneous in the tumour area (SC): 34p, or mixed (M), combining both peritumoural and subcutaneous / periareolar: 15p. Cases without scintigraphic visualization of SLN were reinjected (periareolar / subdermal) and limphoscintigraphy was adquired. We evaluated the existence of axillar and internal mammary (IM) lymphatic drainage. RESULTS SLN was detected in 96.3% from the 400 patients: 94% axillar drainage, 16.2% IM drainage. In 80% of the cases the drainage was only axillary, in 14% it was both axillary and MI, in 2.2% it was only MI. In 3.7% of the 400 patients no lymphatic drainage was detected. INJECTION
P(number) P(%) Total SLN(%) Axillar SLN(%) IM SLN(%) non‐DT(%)
PA*
109
27,3 96,3
95,4
2,8
3,7*
PT*
243
60,8 90,9
88,1
22,2**
9,1*
SC
33
8,3 97,0
93,9
18,2**
3
M
15
3,8 93,3
93,3
6,7
6,7
400
78,6
7,1
14,3
RE‐INJECTION 14*
3,5* 85,7
In PT and SC injection techniques, the IM detection rate was statistically higher than in the rest of the injection forms (p<0.05)** CONCLUSIONS PT and M injection techniques show the lowest global lymphatic drainage visualization rate in our group. PA and SC injection techniques show the highest rate. MI detection rate is statistically higher with PT and SC injection techniques. In our group, M technique does not improve the lymphatic drainage detection rate, although it was only used in a small number of patients, so this result is not conclusive. Re‐injection allows detection of lymphatic drainage in a considerable number of patients that otherwise would be candidate to complete axillary lymph node dissection.
P331 Unusual tonsil metastasis of melanoma despite surgical excision, Sentinel Node Biopsy and Complete Lymph Node Dissection C. De Gaudio1, R. Cecchi2, V. Ciliberti1, R. Tarchi1; 1Nuclear Medicine UnitCampo di Marte Hospital, Lucca, ITALY, 2Dermatology Unit-Pistoia Hospital, Lucca, ITALY. 1 Melanoma metastases may develop by three metastatic pathways: in‐transit, regional lymph node, or distant. The development of melanoma metastasis to the palatine tonsil is very rare, generally associated with advanced‐stage disease and poor prognosis. We report a patient affected by malignant melanoma of the right shoulder, who developed a metastasis to the palatine tonsil six months after the surgical excision of melanoma, a sentinel lymph node biopsy (SLNB) and a complete lymph node dissection (CLND). A 29‐year‐old man was submitted to surgical excision of a malignant melanoma of the left shoulder and SLNB. Histology of the tumour revealed a nodular melanoma with ulceration, Breslow thickness 1.7 mm, Clark level III. The patient was submitted to lymphoscintigraphy that showed a sentinel lymph node in left axilla. Subsequently a SLNB was performed by an hand‐probe and the sentinel lymph node removed resulted involved by metastasis. The intra‐nodal metastasis was 5 mm, subpsular and parenchymal. The patient underwent CLND of the left axilla, that showed no further metastasis out of 15 harvested lymph nodes. Staging investigations, including PET, showed no evidence of metastases, and the routine follow‐up resulted unremarkable. Six months later the patient was referred to Otolaryngology where the right palatine tonsil appeared enlarged for the presence of a not‐ulcerated, nodular lesion and a biopsy specimen revealed melanoma metastasis. A PET showed multiple focal spot in the right palatine tonsil, hilar and paratracheal lymph nodes, upper abdomen, and left liver lobe. Nevertheless the evidence of distant metastases, a palliative removal of the involved tonsil was delivered in an attempt to prevent further local complications. Afterwards underwent chemotherapy but he developed disseminated disease 5 months after tonsillectomy and died. The palatine tonsils are secondary lymphoid organs, composed of lymphoid tissue arranged in follicle structures but, unlike lymph nodes, they do not have afferent lymphatic vessels. Therefore, the development of a tonsil metastasis is due to blood route spreading and is usually associated with advanced stage disease. The palatine tonsil is an uncommon site of metastasis, with an overall reported incidence of 0.8% among all malignancies. Metastases to the oral cavity and the palatine tonsil from melanoma are an extremely rare event, with less than 40 cases up to now reported in the literature. In conclusion, our case appears noticeable, since the tonsil metastasis was the first clinical sign of melanoma recurrence despite the surgical excision of the primary tumour, SLNB and CLND.
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Our experiences with lymphoscintigraphy and sentinel node detection with patients with prostate cancer I. Balogh, A. Páczelt, J. Varga, A. Medveczki, Z. Galler, K. Pócza; Uzsoki Hospital, Budapest, HUNGARY. Methods: All patients were in clinical stage T1‐2, N0, M0. Transperineal ‐ intraprostatic administration of 100‐150 MBq of Tc‐SentiScint was performed 24 hours before the planned operation. Gamma camera images were taken 3 and 24 hours after the administration of the radiopharmaceutical from anterior, posterior, left and right lateral direction. In the last 5 years together with the 3 hour image SPECT examination was also performed and in 6 cases low dose CT has been made in an other institute with the purpose of better localization of the SN. (For the SPECT and CT fusion images MEDISO‐Interview XP software was used.) During the operation a gamma probe (Navigator) was utilized for localize the lymph nodes found with lymphoscintigraphy. The lymph nodes found and excised with the help of the gamma probe were forwarded separately for detailed pathological processing. Results: In 6 cases out of 91 there was no lymph node detected. Except of the 3 lymph nodes with presacral localization all other lymph nodes were excised. In the obtural triangle (OT) in 27, beside of this triangle (along with the iliacal arteries, iliacal bifurcation) in 32 cases were excided SNL lymph nodes. In 10 cases both inside and outside the OT SNL was detected. In 9/85 cases could be found micrometastasis in SNL during the pathological processing. Only one of this cases were localized inside the OT, the other 8 cases could be found outside of it. Conclusions: According to our results micrometastasis can occur also in very early stage of prostate cancer (9/85) what emphasizes the importance of SN detection. The occurance of SNL outside of the OT is a common finding (32/85). In conclusion it is necessary to examine the presence of micrometastasis with our method even in the early phase of the disease for longer survival. We have to expect that the metastasis does not occur in localization we had known before and instead of the expected 2% it appears with ~11% prevalence.
P40 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT:
single
photon
radiopharmecuticals
in
prediction/assessment of tumour response
P333 Synthesis, Characterization and Biological Evaluation of 99m Tc-DTPA-Amino acids Conjugates as a Potential Probe for Tumor Imaging with SPECT D. Sinha; University of Delhi, Delhi, INDIA. Aim: ‐ In recent years It has been observed that most tumor cells show an increased uptake of amino acids as compared to normal cells and malignant transformation increases the use of amino acids for energy, protein synthesis, and cell division. Keeping these considerations, Novel 99m Tc‐DTPA‐Amino acid conjugates have been synthesized and evaluated as potential radiopharmaceuticals for tumor imaging. Materials and Methods: The compounds were synthesized by the condensation reaction of DTPA bis anhydride with different optically active heterocyclic L‐amino acids in the presence of triethylamine in DMF. The compounds were characterized by spectroscopic techniques (FTIR, NMR and mass spectroscopy) . Results: The 99m radiolabelling efficiency with Tcwas more than 95% and the complexes were stable for about 24h under physiological conditions. Blood kinetics study of all the DTPA‐Amino acids conjugates showed a bi‐exponential patter as well as rapid clearance of radioactivity from the blood. The biological t1/2(F) and t1/2(S) were found to be 45 min for DTPA‐(His)2, 20 min for DTPA‐(Trp)2 and 18 min for DTPA‐(5HT)2 and t1/2 (slow) 6h 30 min, 5h 45 min, 5h 30 min for DTPA‐(His)2, DTPA‐ (Trp)2, and DTPA‐(5HT)2 respectively. Tumor imaging was performed in mice bearing EAT tumor . The mice depicted the beginning of the accumulation of activity in tumor at 30 min, which reached to maximum at 90 min and remained almost stable for 4 h. Biodistribution study of DTPA‐(His)2 and DTPA‐(5HT)2 in normal rabbit showed significant accumulation in the brain. Whereas biodistribution study of DTPA‐(His)2 and DTPA‐(Trp)2 in mice bearing EAT tumor showed remarkable localization at tumor site. The receptor binding study of the compounds on established human tumor cell line (U87‐MG) showed KD=1.08 nm, 1.4 nm and 1.55nm for DTPA‐ (His)2 DTPA‐(Trp)2 and DTPA‐(5HT)2 respectively by Scatchard plot analysis. Conclusion: Novel radiotracers can be produced in high radiochemical yield and high radiochemical purity from stable precursors and are potentially valuable agent for imaging brain and other tumors with SPECT. Biodistribution studies of the compounds showed rapid and persistent accumulation of radioactivity in tumors , which warrants their further in vivo evaluation for clinical applications.
P334 Development of a new, semi-quantitative I-123 mIBG reporting method in high risk neuroblastoma V. Lewington1, Z. Bar Sever2, T. Lynch3, F. Giammarile4, A. McEwan5, B. Shulkin6, A. Staudenherz7, R. Ladenstein8; 1Royal Marsden Hospital, Sutton, UNITED KINGDOM, 2Schneider Childrens Cancer Centre, Petach-Tikva, ISRAEL, 3Belfast City Hospital, Belfast, UNITED KINGDOM, 4CHU, Lyon, FRANCE, 5Cross Cancer Institute, Edmonton, AB, CANADA, 6St Jude Childrens Research Hospital, Memphis, TN, UNITED STATES, 7University Medical Centre, Vienna, AUSTRIA, 8CCRI, Vienna, AUSTRIA. Aim: A straightforward, standardised reporting method is required to assess the potential of I‐ 123 123 metaiodobenzyl guanidine [ I mIBG ] as an independent prognostic indicator in high risk neuroblastoma. Pre‐requisites for an appropriate, semi‐quantitative scoring method include low inter‐observer error and reproducibility across the expected disease spectrum. We report the development and testing of a new score method by an international panel of 7 nuclear medicine
specialists. Method: Patterns of skeletal 123I mIBG uptake were assigned numerical scores within 12 body segments. Uptake intensity was not assessed. 328 anonymised 123I mIBG scans stored on the SIOPEN R NET high risk neuroblastoma database were scored independently as 82 unblinded pairs [pre‐ and post‐induction chemotherapy] and as 164 data sets in random order as a blinded study. Intraclass correlation coefficients [ICCs] were calculated to determine inter‐ and intra‐ observer error for the blind and unblinded scores. Results: 1968 data sets were reviewed. ICCs for pre‐ and post‐chemotherapy in the unblinded study were 0.95 and 0.98 respectively and 0.95 and 0.99 respectively in the blinded study. Skeletal score at diagnosis strongly predicted skeletal response to induction chemotherapy [Spearman rank coefficient 0.341, p<0.007]. Conclusions: The score method developed is reliable and reproducible in high risk neuroblastoma, valid across the expected spectrum of disease and avoids subjective assessment of uptake intensity. The method is sufficiently robust to evaluate the potential of 123I mIBG scintigraphy as a prognostic indicator in high risk neuroblastoma and will be applied prospectively in the SIOPEN R NET high risk neuroblastoma trial. Research support: This work was sponsored by an educational grant from the Adam's Hats Charity.
P41 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: radioguided surgery
P335 Breast cancer and negative sentinel node biopsy. A follow-up study up to 9 years D. Ramal Leiva, A. Benítez Segura, M. T. Bajén, J. Mora, Y. Ricart, R. Ortega, T. Soler, M. Gil Gil, A. López-Ojeda, C. Masuet, J. Martin-Comin; Hospital Universitari de Bellvitge, Hospitalet de Llobregat, SPAIN. Aim: To analyze the rate of axillary recurrence, distant disease and free survival disease rate in breast cancer patients (p) with negative sentinel lymph node (SLN) biopsy. Methods: From a prospective data base of 702 p who underwent breast cancer (cT<3cm) surgery and SLN biopsy from June’00 to December’04, 417p with negative SLNB without axillary lymph node dissection were retrospectively analyzed. Mean age: 54 years (27‐85y). Follow‐up was done up to 9y. 27p were excluded because of lack of follow‐up. SLN biopsy was performed with albumina radiocolloidal and a portatil gamma probe. SN pathologycal analysis: intraoperatively with citological imprint (Diff‐Quick); delayed evaluation with hematoxylin/eosin staining, immunohistochemistry and molecular analysis (RT‐PCR). After surgery all patients underwent a clinical examination (the first 3 years at 4 monthly interval, every 6 months for 2 more years and annually afterwards). Adyuvant treatment was indicated according the hospital protocol. Axillary recurrence, distant disease and free survival disease (Kaplan‐Meier method) is analyzed. Results: After a median follow‐up of 66,47 months (m) (15‐105 m) only 4/390 p (1%) developped nodal axillary recurrence (after 8, 11, 32 and 37 m of surgery), 1 out of these 4p in the context of a breast recurrence. All of them are alive.11p died during the following: 2 p because of breast cancer multiorganic metastases, 4 p because of a second neoplasm and 5 p because of non neoplasic disease. The 9‐year overall survival rate was 97,2%. Conclusions: The results obtained in this serie of patients support the SLNB as an accurate technique in axillary stratification in early breast cancer patients. SLN negative provides a safe axillary control at 9 years follow‐up.
P336 The role of radioguided surgery in the surgical treatment of small bone tumours H. Kaya1, C. Can Karahan1, A. Kapukaya2, S. Altindag1, O. Cetinkaya1; Dicle University School of Medicine the Department of Nuclear Medicine, Diyarbakir, TURKEY, 2Dicle University School of Medicine the Department of Orthopedic and Trauma Surgery, Diyarbakir, TURKEY.
1
Introduction: Osteoid osteoma which occurs in the small bone tumours typically inducing night pain. This osteoblastic tumour consists of a round or oval mass commonly called nidus associated with a surrounding zone of sclerotic bone. It has traditionally been treated with operative excision. An accurate localization and complete removal of the lesion is difficult and result in high reccurence rate. Aim: The purpose of this study was to evaluate intraoperative detection of small bone tumours with hand held gamma probe. Material‐Method: In this study,20 patients who had presumptive diagnosis of benign bone tumour were included. There were 7 woman and 13 men, ranging in age from 6‐32 years (mean 17,3). Dose of 740 MBq Tc99m MDP was injected 3 hours before operation and hand‐held gamma probe was used for the intraoperative detection of the lesion. Radionuclide imaging was obtained immediately prior to operation to confirm good visualization of the bone lesion.Success of the procedure was confirmed by histology. Results: The intraoperative mean ratio of lesion activity to background activity was detected as 4/1. After resection we found a mean decrease of the count rate at the tumour site of %60. histological analysis of the bony pieces excised established the diagnosis of osteoid osteoma in 16 patients. Different diagnosis including chronic osteomiyelitis(2 patients), enchondroma(2 patients) were established in 4 patients. All patients were relieved their symptoms. The radionuclide method generally greatly reduced the need for removal of normal osseous substance. Conclusions: Radioguided surgery is safe, simple and useful technique for localization of benign small bone tumours at surgery. Thus, the removal of bone can be guided, allowing limited but complete surgical resection of the tumour.
P337 Role of SPECT/TC in preoperative assessment of patients before minimally invasive radioguided parathyroidectomy G. Manca1, E. Biggi1, M. Arganini2, E. Filidei1, F. Pesella1, F. Cocco1, G. Boni1, M. Grosso1, S. Chiacchio1, E. Borsò1, B. Dell'Anno1, D. Volterrani1, G. Mariani1; 1Regional Center of Nuclear Medicine, Pisa, ITALY, 2Surgery Unit, Hospital of Versilia, Viareggio, ITALY.
Poster Presentation
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Primary hyperparathyroidism (PHP) i.e. autonomous overproduction of parathyroid hormone, is caused in 80%‐90% of patients by a single adenoma. Pre‐operative imaging for localization of parathyroid adenomas is critical for successful surgery, especially in the case of minimally invasive parathyroidectomy (MIRP). Aim: Our purpose was to evaluate the accuracy of an optimized scintigraphic protocol [based on planar imaging with dual‐phase, dual‐tracer scintigraphy (99mTc‐Sestamibi/99mTcO4), plus an early SPECT/CT study], in locating the parathyroid adenomas in a selected group of patients affected by PHP to be submitted to MIRP. Another goal was to assess in the same patients the incremental diagnostic value of preoperative early SPECT/CT study as compared with planar imaging alone. Methods: We evaluated 29 patients with biochemical diagnosis of PHPT and high likelihood of a solitary parathyroid adenoma (6 M, 23 F; age 57.9±12.4; range 27‐76). All patients underwent planar and SPECT/CT parathyroid scintigraphy 2‐5 days before MIRP. Anterior planar images of the neck and chest were acquired for 10 min, 10 and 150 min after intravenous injection of 740 MBq 99mTc‐Sestamibi. A SPECT/CT study was carried out immediately after the first planar image. In addition, after acquiring the late (ca 150 min) 99mTc‐Sestamibi image, dual‐isotope subtraction was performed using a 10‐min image obtained after injection of 370 MBq 99mTc‐pertechnetate. MIRP technique consisted in injecting 37‐110 MBq 99mTc‐Sestamibi 30 minutes before the start of the surgery in patients in whom the preoperatively 99mTc‐Sestamibi scan showed for a solitary parathyroid adenoma. Through a skin incision < 1.5‐2 cm, dissection of the adenoma was guided by a 14‐mm collimated gamma‐probe. Patients were given the choice of general or local anesthesia. Results: Our scintigraphic protocol identified a solitary adenoma in all patients (Sensitivity 100%) even in cases of ectopic localizations (about 20% of the cases), which were successfully removed in all patients by MIRP. Average time for radioguided surgery was 32 ± 14 (range, 10‐50 min). Planar imaging correctly identified 23 adenomas (sensitivity 79%), while SPECT/CT correctly identified 27 adenomas (sensitivity 93%) offering more precise localisation (7/23 ectopic) and evident improvement in diagnostic accuracy. No patient presented persistent hypercalcemia during long‐ term postsurgical follow‐up, and therefore was considered to be cured. About 10% of the MIRP procedures were performed under local anaesthesia. Conclusion: Our data indicate that early preoperative SPECT/CT in PHP patients is essential for accurate localization of parathyroid adenomas and for the selection of patients who are candidates for MIRP.
P42 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Diagnostic Oncology: Planar Scintigraphy, SPECT and SPECT/CT: miscellaneous
P338 Preparation and biodistribution of a novel potential agent for multimodality imaging
99m
Tc-DTPA-Gd as a
Y. Chen, Z. L. Ding, Z. W. Huang, W. Zhang, F. G. Han; Affiliated Hospital, Luzhou Medical College, Luzhou, Sichuan, CHINA. Objective The purpose of this study was to observe the biologic characteristics of the magnetic resonance contrast enhancement of gadolinium diethylenetriamine‐pentaacid (Gd‐DTPA) labeled with technetium‐99m. Methods The labeled compounds were prepared by reducing 99mTc in the presence of Gd‐DTPA with stannous chloride. The labeling efficiency was accessed by TLC. The plasma protein binding rate was measured by the trichloroacetic acid method, the biodistribution in mice was observed by the blood sampling and other major organs that were taken out from mice at 1min, 5min, 10min, 15min, 30min, and 60min after intravenous injection of labeled compounds, and renal dynamic scintigraphy in rabbits were administrated. All of the experimentations were compared with 99mTc‐DTPA. Results The labeling efficiency of 99mTc‐Gd more than 98%, and stable at room temperature within 6h. The plasma protein binding rate of 99m Tc‐DTPA‐Gd and 99mTc‐DTPA were (3.80±0.25)% and (3.48±0.26)%, respectively, and has not significant difference. The uptake of the blood were the highest level at 1min after injection of two labeled compounds, (14.79±9.77)% and (10.65±14.28)%, respectively. Heart, liver, spleen and lung have a little distribution of radiopharmaceuticals, and brain has the lowest level uptake less than 1%. The deposition of 99mTc‐DTPA‐Gd in almost all major organs were less than 1% at 30‐60min after injection. Renal dynamic scintigraphy showed that two labeled compounds were quickly excreted by kidney, and the time to peak is about 5min, the half time of clearance is about 20min. Conclusion The magnetic resonance contrast agent of Gd‐DTPA may be labeled with technetium‐99m. 99mTc‐DTPA‐Gd may become a novel multimodality imaging agent detected by multimodal imaging device SPECT/MRI.
P339 Thallium-201 scintigraphy in soft tissue tumors H. Otsuka1, Y. Otomi2, N. Morita2, K. Terazawa2, T. Taniwaki2, S. Takao1, M. Harada1, H. Nishitani1; 1Tokushima university, Graduate school of Medicine, Tokushima, JAPAN, 2Tokushima University Hospital, Tokushima, JAPAN. Objective We report the findings of 201Tl scintigraphy and consider how to use this technique to evaluate the character of soft tissue lesions. Patients and Methods We enrolled 91 consecutive patients (45 males and 46 females, age range 8‐91‐years‐old). 19 patients were malignant and 72 were benign. Patients were scanned 15 minutes and 3 hours after thallium‐201 injection. More intense uptake in the lesion in than in the normal side was considered as ‘positive’, the same degree of uptake was considered ‘iso’, and decreased uptake was ‘low’. The retention index (RI) was calculated in 9 patients in the malignant group and in 16 patients in the benign group. Results In malignant tumors, 15 of 19 patients showed positive uptake in both the early and delayed phases. One malignant fibrous histiocytoma patient was positive only in the delayed phase and 1 liposarcoma patient was positive only in the early phase. Two liposarcoma patients showed an iso uptake in both phases. One of these patients was pathologically diagnosed as a myxoid type. In benign lesions, no lipoma showed increased uptake. All neurogenic tumors except for 2 demonstrated increased uptake. All 3 ganglions of the lower extremities showed iso uptake. Most inflammatory diseases showed increased uptake. Clinically‐considered benign patients consisted of tumorous lesions or inflammatory disease. Only 2 patients were considered ‘low’, and these were diagnosed as intramuscular hematoma and cyst. RI was variable in both malignant and benign lesions and no significant statistical difference was seen between
malignant and benign lesions by t‐test (p=0.72). Conclusions A thallium positive lesion is more frequently seen in malignant tumors, but regardless of whether the tumor is benign or malignant, according to the histopathological variety, the thallium uptake pattern can not be the only indicator to differentiate malignant from benign tumors. We ultimately need to evaluate the nature of tumors by a combination of several imaging techniques.
P340 Comparison of dynamic contrast-enhanced MRI parameters with 99mTc-sestamibi uptake ratios in malignant bone and soft-tissue tumours. A. Sarikaya1, N. Tuncbilek2, S. Altaner3, N. Torun1, Ü. Korkmaz1, E. Yalnız4; Trakya University Medical Faculty Department of Nuclear Medicine, Edirne, TURKEY, 2Trakya University Medical Faculty Department of Radiology, Edirne, TURKEY, 3Trakya University Medical Faculty Department of Pathology, Edirne, TURKEY, 4Trakya University Medical Faculty Department of Orthopedics, Edirne, TURKEY.
1
OBJECTIVE. It is known that the contrast enhancement patterns on dynamic contrast‐enhanced magnetic resonance imaging (DCE‐MRI) are influenced by tumor angiogenesis.The aim of this study was to investigate DCE‐MRI for the noninvasive measurement of malignant bone and soft‐ tissue tumours angiogenesis by correlation with Tc‐99m sestamibi uptake. MATERIALS AND METHODS. The study group included 11 patients (8 males,3 females; mean age:43.6) with various malign bone and soft‐tissue tumours. They all had proven malignant tumours [osteosarcoma (6), liposarcoma (1), fibrosarcoma (1), malign mesenchymal tumor (2), dermatofibroma protuberans(1)]. Patients were examined using DCE‐MRI and Tc99m sestamibi scintigraphy. Hemodynamic parameters obtained by DCE‐MRI included peak time enhancement in the first minute (Emax/1) after contrast administration, second minute (Emax/2), third minute (Emax/3), fourth minute (Emax/4), and fifth minute (Emax/5), maximum peak enhancement (Emax), and the steepest slope. Early and late 99mTc‐sestamibi uptake ratios (EUR and LUR) were measured semiquantitatively ( maximum tumor‐to‐nontumor ratios). RESULTS. The mean EUR, LUR, Emax/1, Emax/2, Emax/3, Emax/4, Emax/5, Emax and steepest slope were 4.93+/‐2.80, 3.97+/‐2.03, 137.0+/‐57.2, 134.5+/‐56.0, 131.0+/‐49.0, 130.7+/‐48.9, 112.9+/‐39.1, 149.8+/53.2 and 5.29+/‐1.72, respectively. Emax/3, Emax/4 and Emax/5 were found to have a statistically significant correlation with LUR (p < 0.05 and r=0.68, 0.63 and 0.62 respectively). A correlation was also seen between steepest slope and EUR (p < 0.05, r=0.62). CONCLUSION. According to results of this preliminary study, the biochemical mechanisms of uptake and retention of 99mTc‐sestamibi in malignant cells may be related with angiogenesis.The preoperative evaluation of musculoskeletal tumours with DCE‐MRI and 99mTc‐sestamibi scan could predict tumor angiogenesis and may possibly be used as prognostic indicators. .
P341 Repeatability of 3D Fusion Imaging of Myocardial Perfusion SPECT and CT Coronary Angiography K. Hwang1, B. Lee2, W. Kang3; 1Gachon Medical School, Gil Hospital, Incheon, REPUBLIC OF KOREA, 2Chonnam National Univ. Hwasun Hospital, Hwasun, REPUBLIC OF KOREA, 3Yonsei Medical School, Severance Hospital, Seoul, REPUBLIC OF KOREA. Purpose Myocardial perfusion SPECT is one of the widely used diagnostic imaging modality to assess the myocardial perfusion in the patients with coronary artery disease. With the advance in multislice CT technology, CT coronary angiography has been increasingly used in the evaluation of coronary artery disease. The cardiac fusion imaging is currently raising the question of its technical feasibility and clinical usefulness. We evaluated the repeatability of the fusion imaging of myocardial perfusion SPECT and CT coronary angiography. Methods The image data of 60 patients who underwent both myocardial SPECT images and CT coronary angiography were used. The 3D fusion images of myocardial SPECT images and CT coronary angiography were generated by the workstation software. Three experienced readers interpreted the myocardial perfusion SPECT, CT coronary angiography and the fused 3D images, respectively and the repeatability of the interpretation was measured using kappa statistics. Results The kappa values in the interpretation of the 3D fused images were higher than those of myocardial SPECT images and CT coronary angiography. However, all the kappa values were in the range of moderate agreement. Conclusion The repeatability of the interpretation was improved by the 3D fusion of myocardial perfusion SPECT and CT coronary angiography, but it was not significant. However, the 3D fusion images provided more useful information for the interpretation. Further studies are warranted.
P342 The use of serum amino-terminal propeptide of type I procollagen and osteocalcin as indicators of the presence of bone metastases in prostate cancer patients M. Siabanopoulou1, T. Vasiliadis1, I. Iakovou2, S. El Mantani Ordoulidis3, E. Zaromitidou4, G. Moustakas1, A. Sioundas5, A. Gotzamani-Psarrakou5; 1 Theagenio Cancer Institute, Thessaloniki, GREECE, 23rd Nuclear Medicine Dpt. of the Aristotle University, Thessaloniki, GREECE, 3Biomed Diagnostics, Thessaloniki, GREECE, 4Kavala General Hospital, Kavala, GREECE, 5AHEPA University Hospital, Thessaloniki, GREECE. Introduction: The major structural bone protein is type I collagen. The carboxy‐terminal (PICP) and amino‐teminal (PINP) propeptide of type I collagen are thought to be markers of early bone formation, appearing during osteoblast proliferation. Osteocalcin (OC), also known as Gla protein, is a marker of late bones formation, during the mineralization phase. Aim: The aim of this study was to evaluate the level of bone turnover markers PINP and OC and evaluate their clinical use as indicators of the presence of bone metastases in patients with prostate cancer. Method: Bone formation markers were measured in total 90 patients (mean age 65, range 49‐ 81years) with prostate cancer (CaP). 25 patients (group A) with skeletal metastases and 65 without (group B) were enrolled. Group A was under hormone treatment at the time of sampling. 30 healthy men with no history of prostate cancer (CaP) or metabolic disease were enrolled as
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P343 MicroRNAs in Human Hepatocarcinoma and Their Potential Use as Therapeutic Agents: an Experimental Animal Model and Preliminary Imaging Evaluation M. Giganti1, S. Sabbioni2, M. Negrini2, C. Cittanti1, L. Uccelli1, S. Panareo1, N. Prandini1, V. De Biasi1, M. Roncali1, V. De Cristofaro1, L. M. Feggi1; 1 Nuclear Medicine S. Anna Hospital, Ferrara, ITALY, 2Experimental and Diagnostic Medicine Department, University of Ferrara, Ferrara, ITALY. Numerous microRNAs (miRNAs) are deregulated in human cancers, and experimental evidence indicates that they can play roles as oncogenes or tumor suppressor genes. It has been recently proved that miR‐221 is commonly up‐regulated in hepatocellular carcinoma (HCC). MiR‐221 previously emerged as commonly up‐regulated also in glioblastoma and thyroid cancer, suggesting its oncogenic role in at least three different human neoplasms. Aim of the study is to prove the oncogenic role of miR‐221 in HCC models. To this purpose, in vitro and in vivo experiments have been carried out. HCC cell lines overespressing miR‐221 has been transfected with anti‐miRNAs (AMOs) against miR‐221 to study the effect of miR‐221 downregulation in vitro. A transgenic mouse model over‐expressing miR‐221 in the liver has been produced. These models are characterized by molecular and cellular analyses (histo‐pathological analyses, genome‐wide microarray investigations, cell‐cycle and apoptosis assays). To asses if miR‐221 cooperates with other oncogenes in HCC development, transgenic mice expressing c‐myc under the control of a liver‐specific promoter will be mated with the miR‐221 model. A second aim of this study is to use the HCC models to establish methods for anti‐cancer therapy based on short non‐coding RNAs. Viral vectors expressing short non‐coding RNAs will be used for their delivery in vivo to the liver. Furthermore, by taking advantage of the fact that the liver is one of the organs that are more easily targeted by in vivo delivery of short oligonucleotides, we will investigated by the delivery of AMOs against miR‐221 using other approaches, such as hydrodinamic and nanoparticles administration. Based on molecular characterization, other targets might emerge in the course of the studies. So far, the first generation of transgenic mice has been studied by means of ultrasound imaging and a dedicated animal SPECT‐CT scanner with 99mTc‐nanocolloids to detect the eventual development of hepatocellular carcinoma. None of the mice showed until now the presence of HCC, despite they confirmed at the histologic analysis the over‐expression of miR‐221. In conclusion, a suitable animal model and a multimodality imaging system has been setup. The future generation of transgenic mice expressing c‐myc under the control of a liver‐ specific promoter, mated with the miR‐221 model, will be studied for the assessment of cancer development and the evaluation of the eventual therapeutic effect of the treatment.
P43 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Neurology/psychiatry: dementia
P344 Differential diagnosis for dementia with Lewy bodies and Alzheimer's disease using combined MRI and brain perfusion SPECT K. Ishii, H. Goto, T. Uemura, N. Miyamoto, T. Yoshikawa, K. Shimada, S. Ohkawa; Hyogo Brain and Heart Center, Himeji, JAPAN. Purpose: To evaluate the usefulness of combining magnetic resonance imaging (MRI) and single photon emission computed tomography (SPECT) imaging to discriminate mild dementia with Lewy bodies (DLB) from Alzheimer disease (AD). Methods: Nineteen patients with mild DLB and 19 age‐ and cognitive decline‐matched patients with mild AD underwent both SPECT and MRI. Hippocampal, occipital and striatal volume and SPECT count ratios were compared. Linear discriminant analysis and ROC analysis were performed using the parameters of striatal volume and the occipital SPECT ratio. Results: The striatal volume ratio in the DLB group was significantly lower than in the AD group. The occipital SPECT ratio in the DLB group was lower than in the AD group. The mean area under the ROC curve (Az) from combined MRI and SPECT (Az = 0.898) was higher than from MRI (Az = 0.679) or SPECT (Az = 0.798) alone. Conclusions: By combining MRI and SPECT, we were able to distinguish DLB from AD patients with a high level of accuracy. Our findings suggest that combining MRI and SPECT imaging modalities is a useful and practical approach for diagnostically differentiating DLB from AD.
P345 Quantitative brain SPECT. Value of Short Portable Mental Status Questionnaire. Spanish Version (SPMSQSV) M. Gomez, F. G Gallardo, J. Cobo; Hospital Carlos III, Madrid, SPAIN. 1 The aim of this study was to study the correlation between the Pfeirffer¨s Short portable Mental Status Questionnaire (Spanish Version) (SPMSQSV) and the quantitative findings of the brain SPECT. SUBJECTS& METHODS: We studied 199 correlative subjects that had been evaluated for cognitive impairment (middle age 67.2±11, 112 women 56.5%). Subjects were administered an intravenous injection of 925MBq 99mTc‐ECD (ethylcysteinate dimer) in a rest condition. Images were obtained as usual and volumetric regions of interest (VROI) analysis was performed in both
hemispheres using a regional cerebral blow flow quantification program. RESULTS: The data were compared with a normal data base that had been previously performed with 17 subjects. These subjects met the following criteria; they had been studied for loss of memory but they showed normal brain SPECT images, normal SPMSQSV, normal other images modalities and they remained without alterations for a time nor less than 28 months (mean 32.7 ± 4.5). Quantitative perfusion was 71.8%±2 in right hemisphere and 71.7%±2 in left hemisphere. Middle age in this group was 63.8±10 years and there were not differences in quantitative brain perfusion data between women and men. According to the data base the SPECT was considered normal if quantitative data was >69.5%. Seventy eight patients of the 199 had pathological explorations (mean perfusion 67.7%±2 in right hemisphere and 67.4%±2.2 in left hemisphere p NS) the SPMSQSV showed higher number of errors in patients with pathological SPECT (2.49±0.2 vs 3.99±0.32 p<.000). The multivariate analysis showed an inverse relationship between the SPMSQSV score and the percentage of perfusion in left hemisphere (p=.001). There was relationship between the SPMSQSV score and the age (p<.000) and the SPMSQSV score and the sex, the score was higher in women (p=.004) .CONCLUSIONS: Quantitative analysis related to a normal data base helped in brain SPECT interpretation. We find a high level of agreement between the SPMSQSV score and the quantitative data in brain SPECT. For a correct SPMSQSV utilisation, age and sex (probably due to the educational level) must be taken in consideration.
P346 Lewy Body Dementia. Nuclear Medicine assesment. P. Paredes Rodríguez, M. Rioja Martín, J. Castro Beiras, Á. Crespo Díez; Hospital Ramón y Cajal, Madrid, SPAIN. INTRODUCTION Lewy Body Dementia (LBD) shows common symptoms with Alzheimer Dementia (AD), although with less memory loss but often visual space impairment, consistent persistent visual hallucinations, abnormal Parkinson like movements and behaviour disorders during REM sleep. The correct differentiation with AD is of a great importance due that LBD has a good response to cholinesterase inhibitors and presents adverse reactions to neuroleptics. PET (glucose) and perfusion SPECT shows occipital decrease of metabolism and perfusion, better perfusion in temporal lobes than in DA, and temporal‐parietal hipoperfusion can be found in both entities. PURPOSE Confirmation of LBD in our series according to perfusion SPECT, DATSCAN, IBZM in some cases and radiological findings. MATERIAL AND METHOD ‐31 patients with clinical suspected LBD, Parkinson associated Dementia or difficult differential diagnosis of AD vs. LBD, ‐18 Females/13 Males. ‐ Mean age 74.8 (58‐87) ‐ Brain perfusion SPECT with 20‐25 mCi 99mTc‐ECD in 29 patients. ‐ Dopamine transport SPECT with 5 mCi, 123‐I‐DATSCAN in 30 patients. ‐ Dopamine receptor SPECT with 5 mCi‐I‐IBZM in 5 patients. ‐ Radiological study in 13 patients. RESULTS ‐ Brain Perfusion SPECT: . Parietal‐occipital, temporo‐occipital, and/or occipital hipoperfusion: 16 patients. . Normal: 3 patients . Cortical atrophy: 2 patients . Frontal hipoperfusion: 2 patients . Bitemporal‐biparietal hipoperfusion: 6 patients. ‐ DATSCAN . Pathological: 27 patients, 1 of them mild findings, decrease in putamen uptake in all of them. . Normal in 3 patients (2 had cortex atrophy and 1 bitemporoparietal hipoperfusion in perfusion SPECT) ‐ IBZM . Performed in 5 patients. 4 were normal, 1 pathotogical. ‐ Radiological study no significant findings in all cases in which Nuclear Medicine suspected LBD, except in one with basal ganglia calcifications. ‐ FINAL DIAGNOSIS . LBD 23 / 31 patients. . No findings 2/31 patients. . Frontal dementia 1/31 patients. . AD 1/31 patients. . Parkinsonism 1/31 patients. . Doubtful 1/31 patients. CONCLUSION Nuclear Medicine studies, specially SPECT of Dopamine Transport and Brain Perfusion are of a great value in the diagnosis on clinical suspected LBD dementia and differentiation of other degenerative dementias. In patients with suspected LBD a perfusion brain scan should be performed initially and if it shows findings of the suspected diagnosis a DATSCAN will support it. Occipital reduced perfusion linked with pathological findings in dopamine transport scan is highly indication of LBD also temporoparietal hipoperfusion found in AD can be present, in this case DATSCAN is of a great help.
P347 Regional cerebral blood flow single photon emission computer tomography (rCBF SPECT) in Dementia with Lewy Bodies (DLB), Parkinson’s Disease with Dementia (PDD) and Alzheimer’s Disease (AD). B. Brockhuis1, J. Slawek2, D. Wieczorek3, E. Sitek4, P. Lass1, J. Teodorczyk1, M. Dubaniewicz5; 1Medical University in Gdansk, Department of Nuclear Medicine, Gdansk, POLAND, 2Department of Neurology, St. Adalbert Specialistic Hospital in Gdansk, Poland and Department of Public Health Medical Univ. in Gdansk, Gdansk, POLAND, 3Medical University in Gdansk, Department of Rehabilitation, Gdansk, POLAND, 4Medical University in Gdansk, Department of Public Health, Gdansk, POLAND, 5 Medical University in Gdansk, Department of Radiology, Gdansk, POLAND. Aim: The purpose of the study was to perform rCBF study in patients with DLB, PDD and AD, to find the characteristic pattern of perfusion, typical for this three groups of patients, which allow to distinguis DLB/PDD and DLB/AD. Material: 50 patients, age 54‐88: 13 with DLB, 18 with PDD, 19 with AD and controls (N=14). All patients were recruited according to established clinical diagnostic criteria. DLB patients have fulfilled criteria for probable DLB. Methods: All patients were examined by neurologist specialized in extrapiramidal diseases and by neuropsychologist. In all of them MRI was performed. SPECT study was performed after injection of 20 mCi Tc‐99m‐ ECD (FAM, Lodz, Poland) with three head gammakamera Multispect (Siemens, Erlangen, Germany). Statistical analysis of radiotracer uptake was estimated for 16 regions of interest (8 for each hemisphere) and the perfusion was assessed semiquantitatively using the cerebellar perfusion as the region of reference. To assess possibility of differentiation of patients with DLB, PDD and AD discriminant analysis was conducted. Results: In all patients perfusion was statistically significantly decreased in all regions of interest (with some exceptions of subcortical structures) when compared to controls. DLB patients demonstrated hipoperfusion of left parietal region in comparison with AD. Comparing with PDD group, in DLB patients hipoperfusion in right parietal region, left temporo‐occipital border and left striatum was observed. Discriminant analysis allowed proper classification in 68% of all patients: PDD was classified the most accurately (83%) and DLB the least precisely (46%). Conclusions: rCBF SPECT examination does not allow to differentiate between DLB, PDD and AD what may suggest their common pathogenesis (continuum of neurodegeneration).
Poster Presentation
controls (group C). Blood samples for all patients were taken before any diagnostic procedure. PINP and OC serum levels were analyzed by radioimmuniassay. CaP was diagnosed histopathologically after biopsy or at radical prostatectomy. PSA evaluation and bone scan (BS) were performed at the time of serum sampling. BS was validated as normal and metastatic. Results: High PINP levels were detected in 76% of group A vs 32% of group B, while OC was elevated just in 28% of group A. BS confirmed metastatic bone involvement. The correlation of OC and PSA was not significant. Both PSA and PINP were elevated in 24,5% of patients. Higher PINP and PSA values seem to correlate with the extend of bone involvement and disease progression. Conclusion: High levels of PINP are associated with the presence of skeletal metastases. PINP combined with PSA, seems to be a promising marker in monitoring CaP patients with bone metastatic disease.
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Result table Characteristic
DLB n=13
AD n=19
PDD n=18
Age
73,76 (4,45) 74,73 (6,98) 71,66 (3,27)
MMSE
16,92 (±6,56)
14,52 (±5,76)
19,05 (±4,49)
Years of education
10,53 (±3,23)
10,56 (±4,47)
9,27 (±4,07)
P348 Cerebrovascular Reserve In Healthy And Mild Cognitive Impaired Subjects: A Single Photon Emission Study C. A. Sánchez Catasús1, M. Pagani2, J. Samper3, R. Díaz1, L. Galán4, A. Aguila1, L. Alvarez González5, J. Llibre Rodríguez3, Y. Fernández4, P. Valdés Sosa4; 1Department of Nuclear Medicine, CIREN, Havana, CUBA, 2 Institute of Cognitive Sciences and Technologies – CNR, Rome, ITALY, 3 Deparment of Clinics, University Hospital “Carlos J. Finlay”, Havana, CUBA, 4 Department of Cognitive Neuroscience, Cuban Neuroscience Center, Havana, CUBA, 5Clinic of Neurodegenerations and Movement disorders, CIREN, Havana, CUBA. Our aim was to compare healthy subjects and patients with mild cognitive impairment (MCI) concerning global and regional cerebrovascular reserve (CVR). The patients group was composed of 22 clinically diagnosed MCI subjects (CDR= 0.5; GDS= 3). The healthy group comprised 22 healthy volunteers (CDR= 0; GDS= 1). Both groups did not differ significantly in age, gender composition, educational level and vascular risk factors (limited). Psychometrically, the MCI group classified as amnestic MCI plus other impaired cognitive domains. Global cerebral blood flow at rest (gCBFRest) and post‐administration of acetazolamide (gCBFAcz) were calculated in ml/min/100g by spectral analysis of non‐invasive radionuclide angiographies, using a rectangular camera double‐head SPECT system. Bolus injections of 555 MBq and 900 MBq of 99mTc‐ECD were administered at rest and 20 minutes post Acz, respectively. For each condition, ten minutes after the radionuclide angiography, cerebral SPECT imaging was carried out. A decay‐corrected subtraction of the basal image from the second SPECT image was performed, and this image was defined as the post‐Acz SPECT image. Rest and post‐Acz images were converted to rest and post‐ Acz quantitative CBF images using gCBFRest and gCBFAcz, respectively, by the application of Lassen's correction. Quantitative SPECT CBF images were segmented in 116 volumes of interest (VOI) using a probabilistic anatomical map. Global CVR was defined as follows: gCVR (%) = 100x [gCBFAcz ‐ gCBFRest] / gCBFRest. In a similar way, regional CVR (rCVR) was calculated for the 116 VOIs. Although there was a tendency toward lower gCVR values in the MCI group (gCVR= 19.6 ± 8.6 %) compared to the healthy group (gCVR= 23.8 ± 9.3 %), this difference was not statistically significant. However, rCVR in 15 VOIs were significantly lower in the MCI group in comparison with the healthy group (p< 0.05, independent t‐test). These VOIs corresponds to 9 regions from the left cerebral hemisphere (4 in the prefrontal cortex, superior temporal pole, post central region, angular gyrus, precuneus and posterior cingulate); 3 regions in the right cerebral hemisphere (precuneus, posterior cingulate and pallidum); and 3 regions in the right cerebellum. Reduction of regional cerebrovascular reserve observed in our MCI patients cannot be explained by a clear cerobrovascular cause or related to aging. Such decrease seems to be more related to a brain regional microvascular compromise, in concordance with emerging findings in the scientific literature which indicates that neurovascular factors play an important role in the neurodegeneration in Alzheimer disease.
P349 Brain perfusion correlates of visuoperceptual deficits in preclinical and mild Alzheimer’s disease J. Fuertes1, I. Roca1, M. Alegret2, L. Rubio3, G. Torres3, A. García-Burillo3, M. Boada2, G. Vinyes-Junqué2, G. Cuberas1, P. Martínez-Lage2, S. Valero2, I. Hernández2, L. Tárraga2, J. Castell1; 1Vall d'Hebron Hospital, Barcelona, SPAIN, 2ACE Foundation, Barcelona, SPAIN, 3Corachan Clinic, Barcelona, SPAIN. Introduction: Visuoperceptual processing is impaired early in the clinical course of Alzheimer’s disease (AD). The 15‐Objects test (15‐OT) is a visual discrimination task similar to the Poppelreuter test, but more complex and with higher sensitivity to detect visuoperceptual deficits in the preclinical and mild AD stages. The aim of the present study was to compare the 15‐OT performance and the abnormal cerebral perfusion between subjects with mild cognitive impairment (MCI), mild AD and normal aging. Methods: Fifty‐one mild AD patients, 48 subjects with MCI and 49 healthy elderly controls (EC) underwent a 99mTc‐ethyl cysteinate dimer brain perfusion SPECT and were administered the 15‐OT, out of the neurological and neuropsychological examinations for diagnosis. Brain SPECT were quantified individually (Neurogam®, using a local normal database as reference) and between groups. SPM5 analysis was used to carry out group comparisons as well as correlation between 15‐OT performance and regional cortical uptake. Results: Brain SPECT patterns and the 15‐OT performances were significantly different between groups. MCI scored on the 15‐OT between AD and EC. Compared to controls, the regional brain perfusion was significantly decreased in the temporoparietal regions of AD patients, and in the posterior cingulate and medial temporal of MCI. A statistically significant correlation was found between a worse performance on the 15‐OT and a reduced perfusion on several brain regions, mainly precuneus, posterior cingulate and hipocampal regions. Conclusion: Preclinical and mild AD patients differed from controls in the 15‐OT visuoperceptual performance and in some regional brain perfusion. Moreover, a worse execution on the 15‐OT was found to be related to a reduced regional cerebral blood flow (rCBF) in some specific temporoparietal areas.
P350 The contribution of 123-I MIBG cardiac sympathetic scintigraphy in the differentiation of diffuse Lewy Body
X. Geronikola-Trapali1, I. Armeniakos1, T. Doskas2, P. Karabina1, A. Stefanoyiannis1, V. Lyra1, S. Bakalis1, P. Zotou1, A. Prentakis1, G. Stampoulis2; 1University General Hospital “Attikon”, Nuclear Medicine Department, Chaidari, GREECE, 2University General Hospital “Attikon”, Department of Neurology, Chaidari, GREECE. Diffuse Lewy Body Disease (DLBD) is known to be the second frequent disease to cause dementia in the elderly. Syncope or hallucination are characteristic symptoms of DLBD but its differentiation from Alzheimer’s disease is often difficult in clinical settings. Severely reduced 123‐I MIBG accumulation has been observed in patients with idiopathic Parkinson’s disease ,where a generalized Lewy body type degeneration in the brain has been identified. Aim: To assess the role of 123‐I MIBG cardiac imaging in the differentiation of diffuse DLBD from Alzheimer’s disease. Materials and method :We performed cardiac sympathetic myocardial scintigraphy using 123‐I MIBG in patients with DLBD and Alzheimer’s disease . Patients underwent planar imaging (15 min and 4 hours ) after slow intravenous injection of 185‐222 MBq . A region of interest (ROI) was drawn over the whole left ventricle as well as a rectangular ROI over the upper mediastinum on early and delayed images for the quantitive assessment of the adrenergic innervation. Results: Cardiac activity in five patients ,with typical DLBD symptomatology was almost null , while normal cardiac accumulation was observed in patients with Alzheimer’s disease.Conclusion: Cardiac sympathetic scintigraphy using 123‐I MIBG could be a useful and noninvasive diagnostic tool for the differentiation of DLBD from Alzheimer’s disease in cases showing dementia.
P351 Anatomical regions mediating denial of deficits in dementia syndromes. V. Valotassiou1, J. Papatriantafyllou2, P. Georgoulias1, A. Fothiadaki3, K. Makrypoulias3, C. Zerva3, N. Sifakis3; 1Department of Nuclear Medicine, University Hospital of Larissa, Larissa, GREECE, 2Memory & Cognitive Disorders Clinic, Neurology Department, “G.Gennimatas” Hospital, Athens, GREECE, 3Department of Nuclear Medicine, “Alexandra” University Hospital, Athens, GREECE. Aim: Denial of illness (anosoagnosia) is a frequent symptom in dementia syndromes. The aim of our study was the correlation between anosoagnosia and perfusion abnormalities on 99mTc‐ HMPAO Single Photon Emission Computed Tomography (SPECT). Material‐Methods: We studied 81 patients. Twelve patients had the diagnosis of Mild Cognitive Impairment (mean age 71 years, mean Mini Mental State Examination‐MMSE 26.5), 24 patients had Alzheimer’s Disease (mean age 73, mean MMSE 20.2), 7 patients had Lewy‐body Dementia (mean age 75 years, mean MMSE 23), 35 patients had Frontotemporal Dementia (mean age 64.7, mean MMSE 17.4), 1 patient had Vascular Dementia (age 77.5 years, MMSE 26.5) and 2 patients had Parkinson’s Dementia (mean age 68 years, mean MMSE 24.5). All the patients underwent a battery of neuropsychological tests, an MRI of the brain and 99mTc‐HMPAO SPECT. The regional Cerebral Blood Flow (rCBF) was measured from regions of interest (ROI). We used the automated program SEGAMI to measure rCBF. The ROI’s were measured in 29 left and 29 right brain regions based upon Brodmann’s map and included the following areas: 4‐11, 17‐25, 28, 31, 32, 36‐40, 44‐47. We considered in our analysis 24 on each hemisphere. The mean counts of every region were divided by the mean counts of a reference ROI over the cerebellum (least affected by these disorders). A ratio with value below a threshold of 0.7 was considered to be abnormal. For the estimation of anosoagnosia we used the Anosoagnosia‐Questionnaire‐Dementia which consists of 30 questions, 23 screening intellectual function and 7 screening behavior. The answers used a 4 point Likert scale. The caregiver and the patient answered the same questions regarding the patient. The difference (caregiver‐patient) provided the total score. Results: We used Pearson’s correlation analysis with Bonferroni correction and found that regions 20 and 24 of the right hemisphere and region 24 of the left hemisphere significantly correlated with anosoagnosia. We proceeded with factor and regression analysis for each hemisphere and found 2 groups of regions correlated strongly to anosoagnosia: 20, 21, 32 on the right hemisphere and 21, 22, 37, and 40 on the left hemisphere. Conclusions: Hypoperfusion in multiple cortical regions of both hemispheres is associated with anosoagnosia. Dysfunction in key anterior frontal and temporal regions appears to underlie anosoagnosia in the setting of dementia. Further study is required to determine the neuroanatomical underpinnings of anosoagnosia.
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Ioflupane SPECT in dementia differential diagnosis: a 3D quantitative analysis S. Nuvoli1, A. Nieddu2, A. Rotondo2, R. Salvo2, E. Rubattu1, M. E. Solinas1, F. Chessa1, A. Spanu1, G. Madeddu1; 1Nuclear Medicine DPT, University of Sassari, Sassari, ITALY, 2Geriatrics DPT, Policlinico Sassarese, Sassari, ITALY. Aim: We investigated whether a new 3D quantitative analysis of 123Ioflupane SPECT may be useful in dementia differential diagnosis. Material and Methods: We studied 44 consecutive patients, 23 F and 21 M, aged 52‐84 yrs, with cognitive disorders for 12‐36 mths and clinical criteria doubtful for both Alzheimer’s Disease (AD; NINCDS‐ADR‐DA) and Lewy Body Dementia (LDB; LBD Consortium International Workshop); Parkinson’s disease was excluded and CT/MR were normal or non specific. All patients underwent Brain SPECT, 3‐4 hrs after 148 MBq 123 Ioflupane (DaTSCAN®, GE Healthcare Medical Diagnostic) i.v. injection, by a dual head gamma camera with fan beam collimators. SPECT images were evaluated by both qualitative and quantitative analysis, the latter by a dedicated software (NEUROTRANS 3D; Segami Corp.) which quantifies specific dopaminergic activity expressed as Binding Potentials (BP) in the striata applying attenuation and partial volume effect corrections. The volume of interest (VOI) of caudate and putamen nucleus was obtained by degrading Talairach atlas with the point spread function of SPECT acquisition system. Caudate and putamen BP normal value (cut off of 3.3) was previously calculated in 20 sex‐age matched normal subjects (mean values: 4,9±0,71 and 4,6±0,67 for caudate and putamen, respectively). Results: At SPECT qualitative analysis the uptake in striatum was normal in 31/44 (70.5%) patients (Group A) with BP >3.3 in 88/88 (100%)
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P353 Cerebral 18F-FDG PET Imaging of Neurodegenerative Disorders: Diagnostic Patterns with Statistical Parametric Mapping K. Wong, K. A. Frey, R. K. J. Brown, N. Bohnen; Nuclear Medicine, University of Michigan, Ann Arbor, MI, UNITED STATES. Purpose: To present common diagnostic patterns on cerebral 18F‐fluorodeoxyglucose positron emission tomography (FDG‐PET) imaging of neurodegenerative disorders. To review the role of statistical parametric mapping and computer assisted diagnosis in this area. Subjects and Methods: Patients referred to our department with cognitive deficit, memory loss, and symptoms suggestive of neurodegenerative disorder, demonstrating a spectrum of diagnostic patterns on cerebral 18F‐FDG PET imaging, were selected for this educational exhibit. Reorientation of tomographic data, and statistical parametric mapping to a normal database was performed using a software program, MIMS 4.0 (beta version). Significant regions of cerebral hypometabolism, were displayed using a color map scaled to the number of standard deviations (SD) below the normal range. Cases presented include Alzheimer’s disease, frontotemporal dementia, dementia with Lewy body, and vascular dementia, at various levels of severity, and also less common neurodegenerative disorders. Discussion: Diagnostic patterns of hypometabolism for neurodegenerative disorders have been extensively described in the literature. The greater availability of 18F‐FDG PET imaging allows evaluation of cerebral metabolism with higher spatial resolution and more realistic models of attenuation correction, than can be achieved with cerebral perfusion SPECT imaging. Computer assisted interpretation using statistical parametric mapping programs are commercially available. Tomographic data is re‐orientated and reformatted allowing comparison to a normal control brain template. Statistical deviation can then be displayed using a numeric color scale using 3‐D surface rendered or 2‐D images. Similar to ‘expert readers’ for myocardial perfusion imaging which are widely utilized, these programs could assist readers at centers with low numbers of studies. Potential benefits may be reduction of interobserver variability, greater reader confidence in study interpretation, and increased rate of learning by trainees. Conclusion: Computer assisted diagnosis using statistical parametric mapping improves quality of interpretation of cerebral F18‐ FDG PET imaging for neurodegenerative disorders.
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[ F]FACT PET is Useful for Noninvasive Detection of Amyloid Plaques in Alzheimer’s Disease K. Sugi1, N. Okamura1, S. Furumoto1, M. Tashiro2, K. Furukawa3, Y. Funaki2, H. Arai3, Y. Kudo4, R. Iwata2, K. Yanai1; 1Tohoku University School of Medicine, Sendai, JAPAN, 2CYRIC, Tohoku University, Sendai, JAPAN, 3 IDAC, Tohoku University, Sendai, JAPAN, 4Innovation of New Biomedical Engineering Center, Tohoku University, Sendai, JAPAN. Aim: Depositions of amyloid‐β protein in the brain is one of the neuropathological hallmarks in Alzheimer’s disease (AD). In vivo detection of amyloid in the brain enables early diagnosis of AD. To evaluate clinical usefulness of 18F‐labeled ethenyl‐benzoxazole derivative [18F]FACT as an amyloid‐imaging probe, we evaluated the binding characteristics of this compound in AD pathology and performed clinical PET study using this tracer in AD patients. Materials & Methods: Binding ability of FACT for amyloid‐β protein was evaluated using amyloid‐β protein fibrils and postmortem AD brains. Blood‐brain barrier permeability of FACT was assessed using normal mice. In vivo binding ability of FACT to brain amyloid deposits was also assessed by intravenous administration of FACT to APP transgenic mice. Clinical PET study using [18F]FACT was performed in eight AD patients and six aged normal volunteers. Dynamic PET images were obtained for 60 min after administration of 185 MBq of [18F]FACT. The ratio of regional to cerebellar standardized uptake value (SUVR) was calculated as the index of [18F]FACT retention. Results: FACT showed high binding affinity for both synthetic Aβ fibrils. FACT displayed distinct staining of amyloid plaques in AD brain sections. A biodistribution study of FACT in normal mice exhibited excellent brain uptakes and fast clearance in normal brain tissue. Intravenous injection of [18F]FACT in APP transgenic mice demonstrated specific in vivo labeling of amyloid deposits in the brain. Clinical PET study using [18F]FACT demonstrated significantly higher SUVR in the neocortex of AD patients, compared to aged normal controls. Regional distribution of [18F]FACT correlated with that of [11C]BF‐227 and matched the reported post‐mortem distribution of amyloid plaques. The ratio of cortical to cerebellar uptake became constant by 40 min after the injection of [18F]FACT. Conclusion: [18F]FACT is a useful 18F‐labeled agent for imaging amyloid plaques in AD patients.
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[ C]BF-227 PET Study in Protein Conformational Diseases N. Okamura1, S. Furumoto1, M. Tashiro2, Y. Funaki2, A. Kikuchi1, Y. Shiga1, K. Furukawa3, H. Arai3, K. Doh-ura1, R. Iwata2, K. Yanai1, Y. Kudo4; 1Tohoku University School of Medicine, Sendai, JAPAN, 2CYRIC, Tohoku University, Sendai, JAPAN, 3IDAC, Tohoku University, Sendai, JAPAN, 4Innovation of New Biomedical Engineering Center, Tohoku University, Sendai, JAPAN.
Aim: Alzheimer’s disease (AD) and many other neurodegenerative disorders belong to the family of protein conformational diseases, characterized by protein self‐aggregation and deposition. The tissue deposits observed in the brains contain an enriched β‐sheet structure, suggesting a potential target for non‐invasive imaging by amyloid‐binding agents. The purpose of this study is to evaluate PET amyloid imaging agent [11C]BF‐227 as an agent for in vivo detection of misfolded protein in various protein conformational diseases. Materials & Methods: [11C]BF‐227 PET study was performed in 67 patients with protein conformational disease including AD, frontotemporal dementia (FTD), dementia with Lewy bodies (DLB), multiple system atrophy (MSA), sporadic Creutzfeldt‐Jakob disease (sCJD) and Gerstmann‐Straussler‐Scheinker disease (GSS). After intravenous injection of 211‐366 MBq of [11C]BF‐227, dynamic PET images were obtained for 60 min. Standardized uptake values of [11C]BF‐227 were measured by normalizing tissue concentration by injected dose and body weight. Regional to cerebellar or pons standardized uptake value ratios were calculated as an index of BF‐227 retention. Total distribution volumes of BF‐227 were additionally estimated by Logan plot. Results: AD patients showed neocortical retention of [11C]BF‐227 and were clearly differentiated from normal controls. Regional distribution of [11C]BF‐227 matched the reported post‐mortem distribution of senile plaques in AD patients. FTD and sCJD patients showed no cortical retention of [11C]BF‐227, however DLB and MSA patients showed the elevation of [11C]BF‐227 uptake in both cortical and subcortical brain regions. GSS patients additionally showed higher uptake of [11C]BF‐227 in the cerebellum, basal ganglia and cerebral cortex than normal controls. Selective binding ability of BF‐227 to senile plaques, Lewy bodies, glial cytoplasmic inclusions and prion protein plaques was confirmed by microscopic examination of human brain sections. Conclusion: [11C]BF‐227 PET would be useful for in vivo detection of amyloid‐β, α‐synuclein and prion protein deposits in the brain.
P356 Structural and functional neuroimaging in 10 cases of logorrhea is a initial symptom M. Garrido1, A. Sanchez-Salmon1, A. Robles2, J. Barandela3, J. Cortes1, X. Rodriguez-Osorio1, J. Fernandez-Ferro1, D. Santos4, A. Ruibal1; 1Hospital Clinico Santiago, Santiago de Compostela, SPAIN, 2Hospital La Rosaleda, Santiago de Compostela, SPAIN, 3HOSPITAL MEIXOEIRO, Vigo, SPAIN, 4 Hospital Arquitecto Marcide, El Ferrol, SPAIN. Aim: Logorrhea is a neurological symptom that can be caused by multiple diseases. The symptom has a high relation with the topography, and less with the nature of the injury. Fronto temporal dementia can deal with logorrhea but it is an uncommon finding. Little is known about the neuroanatomy of logorrhea. Our aim was finding a common brain imaging finding which could be related to logorrhoea. Methods: We studied 10 people (7 women and 3 men), aging ranged between 61 and 80 year old, (average, 72 year old) diagnosed as “logorrhea patients” in which several test were performed in the department of Neurology according to parameters obtained of 53 subjects of a control group. Clinical evaluation, MR/CT, and brain 18F‐FDG‐PET and SPECT were also performed. Blood samples were analyzed to detect metabolical or infectious disease. Results: After evaluation of structural disease, nine of them had no vascular or evident lesions such us tumors, hydrocephalus... One had some lacunar subcortical bilateral lesions. After clinical evaluation, RM/CT and SPECT/PET imaging, diagnosis of Frontotemporal Degeneration was established in all cases, with a mild subcortical vascular component in 33%. According to the results of the neuroimaging, cortical prefrontal and anterior temporal areas were the most commonly involved. Inferior and mesial cortical temporal hypometabolism or hypoperfusion in the right lobe was detected in all of the patients (100%). Conclusions: 1.‐ According to the neurological tests a major intervention of the temporal not dominant lobe in the genesis of this disorder, could be suspected. 2.‐ When structural neuroimaging has no helpful findings, functional imaging should be performed. 3.‐ Although logorrhea is an uncommom finding in fronto‐temporal dementia, SPECT and 18F‐FDG PET imaging can be helpful in patients with logorrhea to reach a diagnosis in early stages. 4.‐ Our study group is very little, nervertheless, in cases of logorrhea by degenerative or vascular alteration inferior and mesial involvement of the cortical temporal regions in the non‐dominant brain hemisphere is the most common finding.
P357 Determination of Cerebral Glucose Metabolism in Patients With Alzheimer’s Disease and Mild Cognitive Impairment Using Positron Emission Tomography N. A. Selcuk1, T. Toklu1, G. Ekinci2, I. Midi2, S. Celik1, A. Dura1, N. Tuncer2; Yeditepe University Hospital, Department of Nuclear Medicine, Istanbul, TURKEY, 2Marmara University Hospital, Department of Neurology, Istanbul, TURKEY.
1
Introduction: Measurement of regional cerebral glucose metabolism using FDG PET has become a standard method in neurological research, especially in diagnosis of early Alzheimer’s Disease (AD) and differential diagnosis of dementia. The aim of the study is to introduce cerebral glucose metabolism differences in patients with AD and Mild Cognitive Impairment (MCI) from age matched healthy groups. Methods: A total of 30 patients were included in the study. Ten AD patients (mean age 77.2±7.2 years; m/f:5/5), 10 MCI patients (mean age 70.2±5.2 years; m/f:5/5) and 10 healthy patients (mean age 71.7±7.1 years; m/f:5/5) were determined by neuropsychological tests. All patients underwent 20‐minute PET/CT scan after injection 292±37 MBq 18F‐FDG and 45‐minute uptake time. All the images were aligned to template image using Statistical Parametric Mapping. Volumes of interests were drawn on hippocampus, inferior and superior temporal, frontal cortex and posterior cingulate gyrus, and parietooxipitall lobe. ANOVA test is used to compare patient groups in each region using SPSS. Results: In AD and MCI patients, statistically meaningful reduction of cerebral glucose metabolism was observed all the regions in comparison with healthy patients (p<0.05). Observed mean hypometabolism rate for both AD and MCI patient groups were 73.8% and 58.2% respectively in all interested regions. Conclusion: This study demonstrates that both AD and MCI patients have decreased metabolic activity in all regions of interest. Reduction of cerebral glucose metabolism in patients with AD is more than MCI patients. This result suggests that FDG PET imaging may provide an objective and sensitive support to the clinical diagnosis in early dementia.
Poster Presentation
caudate and in 84/88 (95.4%) putamen and<3.3 in the remaining 4 (4.6%). SPECT was pathological in 13/44 (29.5%) cases (Group B) in whom there was a low uptake in 9/26 (34.6%) caudate and in 19/26 (73%) putamen, while BP was <3.3 in 18/26 (69%) caudate and in 26/26 (100%) putamen and >3.3 in the remaining 8 caudate (31%). BP mean values of caudate and putamen of Group A were not statistically different than controls, while they were significantly lower in Group B caudate and putamen (1.68±0.36, p<0.0000001 and 1.26±0.58, p<0.000001, respectively). Globally, qualitative and quantitative analysis were concordant in classifying AD in 27 cases (61.3%) and LBD in 13 (29.5%). The tests were discordant in 4 further pts (9.2%) in whom only quantitative analysis correctly classified LBD. Conclusions: 123Ioflupane SPECT proved more reliable than clinical parameters in discriminating LBD from AD dementia in our cases; moreover, 3D quantitative analysis with BP calculation better defined dopamine transporter uptake in respect of qualitative analysis, especially in the initial phase of the disease when the diagnosis appeared unclear.
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P358 Iodine-123-IMP brain perfusion SPECT investigation of the relationship between Alzheimer's disease and normal-tension glaucoma K. Utsunomiya1, T. Sugiyama2, T. Ikeda2, H. Akagi2, Y. Narumi2, Y. Harima1, K. Ikeda1, A. Komemushi1, S. Kawa1, S. Sawada1; 1Kansai Medical University, Moriguchi, JAPAN, 2Osaka Medical College, Takatsuki, JAPAN. OBJECTIVES: To investigate cerebral blood flow (CBF), using iodine‐123‐IMP perfusion SPECT, in patients with normal‐tension glaucoma (NTG) and to further investigate the effect of donepezil hydrochloride, an Alzheimer’s disease (AD) treatment drug, on patients with AD‐like decreased CBF perfusion patterns. METHODS: Autoradiography normalized iodine‐123‐IMP SPECT data were acquired in forty NTGs [mean age: 65.2 ± 17.6 yrs, 16 male, 24 female, mean Mini‐Mental State Examination score: 29.1]. Regional CBF (rCBF) in the frontal, parietal, temporal, occipital, cerebellar hemisphere, etc. was automatically calculated using three‐dimensional volume of interest templates non‐rigidly registered to match each patient brain. Visual field stage (classification of Aulhorn) and optic nerve appearance of NTGs were assessed. The NTG SPECT images and quantitative CBF data compared with normal Controls. Five NTG patients were enrolled in a follow‐up study with donepezil hydrochrolide (5mg/day) prescribed for each patient over a period of 12 months. Intraocular pressure (IOP), mean deviation (MD) of the Humphrey visual field, optic nerve head (ONH) circulation, and rCBF were measured before and every six month during the treatment. RESULTS: Visual inspection: nine of 40 cases (22.2%) exhibited AD perfusion patterns with a parietal and temporal lobe decrease in rCBF along with more visual field defects than the remaining NTGs with normal AD perfusion patterns. Quantitative assessment: rCBF in left central, precentral, and parietal regions of NTGs was significantly lower than that of the Controls (p<0.05). The rCBF of NTGs with focal ischemic or senile sclerotic discs was significantly lower as compared to NTGs with myopic glaucomatous or degeneralized enlargement of the opeic cup disc. Occipital blood flow was correlated to the visual field stage (r=0.57, p<0.01) although it is not significantly lower as compared with the Controls. No correlation between CBF and ocular tension was found. In the five patient follow‐up donepezil hydrochloride study, IOP did not change significantly. MD, ONH circulation, and rCBF improved significantly at six months. No deterioration in these parameters was observed at 12 months. CONCLUSION: Some NTGs exhibited AD perfusion patterns ‐ a decrease in parietal perfusion values, notably the posterior singulate gyrus, which may suggest that some NTGs will develop AD. Oral administration of donepezil hydrochloride for 12 months resulted in a visual field improvement and an increase in ONH circulation and rCBF. These results suggest a relationship between AD and NTG.
P359 Relation between regional brain perfusion changes and neuropsychological tests in posterial cortical atrophy B. Donmez Colakoglu1, G. Capa Kaya2, P. Kurt1, G. G Yener1; 1Dokuz Eylul University School of Medicine Department of Neurology, Izmir, TURKEY, 2 Dokuz Eylul University School of Medicine Department of Nuclear Medicine, Izmir, TURKEY. Posterior cortical atrophy (PCA) is a rare type of progressive dementia of unknown etiology which is characterized progressive atrophy of occipital and parietal cortical areas. Aim: The aim of this study to investigate whether the relation exists between regional cerebral blood flow (rCBF) changes obtained with Tc‐99m HMPAO brain SPECT imaging and neuropsychological tests in PCA. Materials: Six patients with the diagnosis of PCA were included in this study. The mean age at onset was 57.5 ± 2.6 years. We found that all the patients had early age onset and depression along with distinctive visuo‐spatial deficits, such as Gerstmann's and/or Balint's syndrome. Neuropsychological tests and Tc‐99 HMPAO brain SPECT to examine rCBF were performed. 296‐ 414 MBq Tc‐99m HMPAO was injected. Images were obtained with triple head gamma camera equipped with high resolution collimators. A total of 128 frames were obtained in 64x64 matrix, 35sec/frame and 360°. Transaxial slices were transformed into plane images. Transvers, sagittal and coronal images were generated. Regions of interest were drawn and region/cerebellum ratios were calculated. Images were evaluated visually and semiquantitatively. The correlation between regional cerebral blood flow and neuropsychological tests were investigated in 5 patients by calculating Pearson correlation coefficients. Results: In visual evaluation, hypoperfusion was observed on the right parietal cortex in 3, on the left parietal cortex in 5, on the right occipital cortex in 3, on the left occipital cortex in 3, on the right temporal cortex in 2 and on the left temporal cortex in 3 patients. All patients had unilateral or bilateral hypoperfusion on parietal cortex. In two patients with diffuse hypoperfusion on parietal, temporal and occipital cortices had severe impairment in neuropsychological tests. Perfusion changes were asymmetric in 4 patiens. We found significant correlations between digit span test and right temporal hypoperfusion(r=0.88, p=0.05); semantic language test and left parietal hypoperfusion (r=0.88, p=0.05); abstraction and left temporal hypoperfusion (r=0.89, p=0.04). Conclusion: When there is clinical suspicion of PCA in patients with progressive visual spatial deficits, SPECT may be used to support the clinical diagnosis.
P360 Quantitative analysis of I-123-Ioflupane SPECT images based on Statistical Parametric mapping for identification of hypocaptation areas in patients with initial stage and with different staging scales of Parkinson ’s disease L. Bellesi, G. Navanteri, C. Maini, R. Sciuto, S. Rea, L. Strigari; Regina Elena National Cancer Institute, Rome, ITALY. Aim: statistical Parametric Mapping (SPM) can be used to find the hypo‐uptake Parkinson Disease (PD) related regions. The primary aim was to validate the method using 123I‐Ioflupane SPECT images and SPM2. The second aim was to discriminate initial versus advanced PD stage in patients, where the results were uncertain or borderline when using a conventional approach. Material and Methods: sixty three patients (34 women, 29 men) with uncertain movement disorders underwent in vivo dopamine transporter (DA‐T) status characterization with 123I‐
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 Ioflupane SPECT (180 minutes after i.v. administration of 185 MBq on a triple‐headed gamma‐ camera and back‐projection reconstruction method). SPM2 was used to analyze the images. The final clinical diagnosis was obtained after a follow‐up of at least 6‐12 months. Ten patients were considered healthy, and their images were used to standardized the normalization templates. The remaining 53 were classified according to PD stage, from 1 (Essential Tremor) to 4 (Atypical Parkinson). Seven patients (PD stage‐1) and two (PD stage‐2) were included in an initial stage PD group, and the remaining 44 patients composed the advanced stage group. The image parameters initially were 128x128xn (with a number of slice “n” ranging from 60 to 85). Images were realigned, normalized using the template and smoothed for pre‐processing. The final image format was 16 bits, 91x109x91 voxels with a size of 2x2x2 mm3. The two‐sample t‐test was performed to compare groups (advanced versus initial stage). A p‐value≤0.001 was used as statistically significant, considering a cluster of 10 voxels. The Talairach coordinates obtained by SPM2 were converted in anatomical regions (Talairach client tool version 2.0). Results: statistically significant differences were found in the cerebral hypo‐captation areas close to the putamen and caudate nuclei, comparing ill versus healthy patients, validating the method, as well as advanced versus initial stage PD. These areas were located close (≤1mm3) to the putamen, central nuclei and disease‐related regions (left / right cerebrum, frontal lobe, inferior/middle frontal Gyrus, gray matter, Brodman area‐47 and 11). Conclusions: 123I‐Ioflupane SPECT images and SMP2 analysis permit the evaluation of the degeneration of the nigro‐striatal dopaminergic pathway, differentiating initial versus advanced stage PD and improving PD diagnosis in cases of dubious initial diagnosis
P361 Frontal Blood Flow Reduction Symptoms in Alzheimer’s Disease
May
Reflex
Depressive
F. Sedaghat, E. Dedousi, S. Spyrides, I. Baloyannis, V. Costa, A. S. Dimitriadis, S. J. Baloyannis; AHEPA University Hospital, Thessaloniki, GREECE. Depressive symptoms of varying severity are common in Alzheimer disease (AD) and often result in greater cognitive decline and burden for caregivers. Previous studies have suggested that hypoperfusion in the prefrontal cortex and anterior cingulate gyrus are involved in the pathophysiology of depression. We aimed to determine the neural correlates of depression in our patients with AD. Twenty‐nine patients who met criteria for probable AD are studied. Depressive symptoms based on caregiver reports were assessed and patients were divided into two groups of depressed AD (n=14) (age 69±9yr) (MMSE 11±7) and non‐depressed AD (n=15)(age 72±10 yr)(MMSE 14±8). Data obtained from Technetium‐99m HMPAO single photon emission computed tomography (SPECT) were analyzed for regional cerebral blood flow in different regions. Patients with depressive symptoms showed less perfusion in bilateral superior frontal(p<0.000 for right frontal, p<0.006 for left frontal) and right prefrontal regions (p<0.002) compared with non‐depressed AD group. Our findings are consistent with previous studies of primary depression suggesting that these regions are involved in affect and emotional regulation.
P44 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Neurology/psychiatry: epilepsy
P362 Differences in Regional Cerebral Blood Flow in Children with Headache, Epilepsy and Anorexia Nervosa using 99mTcHMPAO S. A. Rogan1, M. Zigman1, R. Gjerga Juraski2, L. Sojat Cvitanovic2, P. Hrabac3, Z. Kusic1; 1U.H. "Sestre milordnice", Dpt. of Oncology and Nuclear Medicine, Zagreb, CROATIA, 2U.H. "Sestre milordnice", Dpt. of Pediatrics, Zagreb, CROATIA, 3Croatian Institue for Brain Research, School of Medicine, Zagreb, CROATIA. Purpose: the aim of this study was to examine the differences in regional cerebral blood flow (rCBF) in a group of children with neurological diseases. Patients & Methods: We compared the different rCBF patterns in four groups of children: A) 15 children with headache in a symptom‐ free period (mean age of 12.3 years); B) 29 children with stabile partial epilepsy (mean age 12.8 years); C) 19 children with intractable epilepsy (mean age of 12.2 years) and D) 10 young women with anorexia nervosa (mean age 15.3 years). All patients were subjected to general and neurologic assessment, as well as psychological evaluation. Basic or interictal 99mTC‐HMPAO SPECT was done in all patients. All data collected were analyzed using semiquantitative method including regional perfusion index (mean value is normalized on whole brain cortex). ANOVA and post‐hoc statistical tests were used to comparison of data between groups. Results: All patients in group A, C and D had normal MRI/CT, whereas two children in group B had small periventicuar cysts. The data showed the lowest values of rCBF in group D in frontal lower regions left and right, as well as in upper right frontal cortex, which shows statistically significant difference compared to groups A, B, and C (p=0,012; p=0,003; p=0,000). Children with headache reveals higher rCBF values for left parietal and upper frontal regions compared to children with epilepsy or anorexia nervosa (p=0,001; p=0,005; p=0,010). For children with stabile epilepsy, intractable epilepsy and headache rCBF values showed significantly lower values in right temporal region compared to the group with anorexia nervosa (p=0,001; p=0,000; p=0,000). Lower rCBF in temporal cortex in the children with both type of epilepsy is expected because those children predominantly had temporal lobe epilepsy. Conclusions: Our observations suggest that interictal SPECT may have utility not only in children with epilepsy, but also in children with headache or anorexia nervosa. The most obvious finding was regional frontal hypoperfusion in girls with anorexia nervosa which give little support to a vascular hypothesis of disease pathogenesis or we may point that those girls could suffer from depression more often than they show it. Moreover, our data showed significant lower values of rCBF in temporal cortex in the group with headache, so we can suppose that these children could have also epileptic potential and they should be monitored more often with EEG then those with normal perfusion.
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Influence of Sodium valproate, Levetiracetam and Topiramate on the P-glycoprotein transporters: evaluation with 11Cdesmethylloperamide in mice L. Moerman, L. Wyffels, S. De Bruyne, F. De Vos; Laboratory of Radiopharmacy, University Ghent, Ghent, BELGIUM. Aim In vitro studies already demonstrated that several anti‐epileptics exhibit an inhibitory effect on the P‐glycoprotein efflux pump (Pgp‐pumps), in doses higher than the therapeutic ones. The aim of this study was to investigate the in vivo interaction of sodium valproate, levetiracetam and topiramate on Pgp‐pumps both in therapeutic dose and in high dose, using 11C‐ desmethylloperamide. Materials and methods 11C‐desmethylloperamide was synthesized by methylation of didesmethylloperamide with 11CH3I. Wild‐type mice (n = 3) were injected i.v. with 11 C‐desmethylloperamide, respectively 30, 60 and 90 min after i.p. administration of sodium valproate (50 mg/kg and 200 mg/kg), levetiracetam or topiramate (40 mg/kg and 160 mg/kg). To investigate the maximum brain uptake of 11C‐desmethylloperamide mdr1a knock‐out mice were injected with 11C‐desmethylloperamide. All mice were killed 10 min after tracer injection. Brain and blood were isolated and counted for radioactivity. Plasma was collected and analyzed for sodium valproate, levetiracetam and topiramate. To study the influence of these anti‐epileptics on metabolisation pattern of 11C‐desmethylloperamide, plasma and brain were analysed by HPLC. Results Mean RCY of 11C‐desmethylloperamide was 35.0% ± 12.05%. Radiochemical purity was always > 95%. S.A. averaged around 80 GBq/µmol. Wild‐types Anti‐epileptics
Sodium valproate
Mdr1a Knock‐outs Blood (%ID/g)
Brain (%ID/g)
Blood (%ID/g)
Brain (%ID/g)
Therapeutic Higher dose dose
Therapeutic Higher dose dose
Therapeutic Therapeutic dose dose
0.31±0.06
0.26±0.06 1.69±0.20
1.28±0.16 2.40±0.09
1.47±0.17
Levetiracetam 0.12±0.03
0.31±0.05 0.94±0.13
1.11±0.20 2.06±1.19
1.15±0.62
Topiramate
0.31±0.04 1.01±0.09
1.15±0.19 2.42±0.42
0.93±0.03
0.14±0.01
Brain uptake of 11C‐desmethylloperamide in knock‐out mice was significantly different from uptake in wild‐types for all anti‐epileptics studied. In Wild‐types, pretreatment with levetiracetam and topiramate at high dose resulted in an increased brain uptake compared to therapeutic dose, while brain activity after pretreatment with sodium valproate demonstrated no difference in brain uptake between high dose and therapeutic dose. The blood activity remained the same after treatment with all anti‐epileptics in all doses. No change in metabolisation pattern both in brain and blood was seen after pretreatment with anti‐epileptics. Plasma concentrations of anti‐epileptics at 40 mg/kg and 50 mg/kg were within the therapeutic range, while at 160 mg/kg and 200 mg/kg they were 3.7 to 8.5 times higher. Conclusion Within the therapeutic range of levetiracetam and topiramate, the influence on the brain uptake of 11C‐desmethylloperamide could not be demonstrated but at high concentrations a small but significant different increase could be measured. These results demonstrate that levetiracetam and topiramate are weak modulators of P‐glycoproteins at the blood‐brain barrier. Sodium valproate shows no interaction with the P‐glycoproteins neither at therapeutic dose or high dose.
P364 Can FDG-PET substitute invasive EEG in planning surgery in hippocampal sclerosis with discordant pre-surgical data? S. Tepmongkol1, C. Locharernkul2, T. Srikijvilaikul3, J. Loplumlert2, C. Limotai2, S. Lerdlum4; 1Division of Nuclear Medicine, Department of Radiology, and Chulalongkorn Comprehensive Epilepsy Center (CCEP), Faculty of Medicine, Chulalongkorn University, Bangkok, THAILAND, 2 Division of Neurology, Department of Medicine, and CCEP, Faculty of Medicine, Chulalongkorn University, Bangkok, THAILAND, 3Division of Neurosurgery, Department of Surgery, and CCEP, Faculty of Medicine, Chulalongkorn University, Bangkok, THAILAND, 4Division of Diagnostic Radiology, and CCEP, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, THAILAND. Purpose: To evaluate the usefulness of FDG‐PET for surgery planning in patients with unilateral or bilateral hippocampal sclerosis (HS) with discordant presurgical data. Subjects and methods: Interictal FDG‐PET studies were performed in 18 patients, 8 with unilateral HS and 10 with bilateral HS. All patients had discordant clinical semiology, interictal EEG, ictal EEG, and MRI. Surface EEG was monitored before and during FDG uptake period. PET/CT scan was performed 30 minutes after FDG injection. Images were interpreted using visual analysis and comparison with normal patient file in equivocal cases. Area(s) of hypometabolism on PET scan were compared to EEG from bitemporal strips recording. Concordant rate of PET with bitemporal strips EEG was analyzed. Results: Concordant rate of PET hypometabolism with EEG was 14/18 (77.8%); discordant rate was 4/18 (22.2%). Eight patients had unilateral temporal hypometabolism, 6 of these had EEG onset ipsilateral to the hypometabolic side, 2 had bilateral EEG onset. In 10 patients with bilateral temporal hypometabolism, 6 showed more severe hypometabolism on the ipsilateral side to EEG ictal onset area, 1 showed more severe hypometabolism on the ipsilateral side to more frequent EEG ictal onset area (This patient had bilateral EEG onset), 1 showed symmetric bitemporal hypometabolism which were concordance with bilateral equal temporal ictal onset by EEG, 2 showed bitemporal symmetric hypometabolism but EEG showed only unilateral temporal onset. When incorporating MRI data, there was MRI‐PET‐EEG matching in 9 patients. MRI leaded to incorrect lateralization but PET leaded to correct lateralization in 6 patients. Both PET and MRI leaded to incorrect lateralization in 1 patient. MRI was concordant with EEG but PET showed bitemporal abnormality in 1 patient. PET showed unilateral hypometabolism, while MRI and EEG showed bilateral abnormalities in 1 patient. Conclusion: In temporal lobe epilepsy with questionable ictal onset side by other presurgical evaluations, FDG‐ PET shows high concordant rate with bilateral temporal strips EEG recording in 78% of patients. The side of more severe temporal hypometabolism usually indicates the EEG ictal onset zone.
PET is more helpful than MRI in localizing ictal onset area. In some instances, invasive EEG can be obviated by using FDG‐PET.
P365 Tc-99m HMPAO Brain SPECT Findings in Clinically Seizure Negative Patients with Abnormal Sleep EEG. T. Sucak1, N. I. Karabacak1, E. Arhan2, A. Özçelik2, K. Gücüyener2, A. Serdaroğlu2, N. Gökçora1; 1Gazi University School of Medicine, Department of Nuclear Medicine, Ankara, TURKEY, 2Gazi University School of Medicine, Department of Pediatric Neurology, Ankara, TURKEY. Aim: To investigate regional perfusion abnormalities in electrical but nonclinical form of epilepsy by Tc‐99m HMPAO brain SPECT and compare the location of epileptic discharges measured by simultaneous scalp electroencephalography (EEG) recordings. Methods: Sixteen pediatric patients (8 female, 8 male) between ages 5‐15 years (mean 9.22±3.07), without clinical epileptic seizures, but with sleep EEG abnormalities presenting discharges longer than 10 seconds during sleep EEG were evaluated. Two patients had been diagnosed with ESES (electrical status epilepticus in sleep). The remaining 14 were followed up due to sleep EEG abnormalities in the absence of clinical seizures. Eleven patients were under anti‐epileptic drug medication during the study period. SPECT imaging was performed with Tc‐99m HMPAO being injected during the discharges observed under sleep EEG recordings. SPECT results were interpreted visually by two nuclear medicine physicians blinded to location and evolution of EEG change, as reflected by simultaneous EEG. Sleep EEG, awake EEG (performed within ±1 month of brain SPECT), and clinical data were analyzed. Results: All 16 patients had abnormalities in sleep EEG's while 3 patients had discharges in awake EEG as well. In 15 patients SPECT images showed areas of hyperperfusion, which were predominantly located in the frontal, temporal, and parietal regions. In one case SPECT revealed no area of focally abnormal rCBF while in EEG there was generalized abnormal activity pattern. In two cases crossed cerebellar activation contralatetal to the focally abnormal cortical rCBF area was observed. In 2 patients frontal activation ipsilateral to the focally abnormal cortical rCBF area was seen.When SPECT and EEG findings were evaluated, in 12 patients (75%), EEG abnormalities showed a predominant localization via SPECT, and the regions on sleep EEG and SPECT were found to be concordant. Conclusion: The results of this preliminary study indicate that SPECT reveals focal cortical areas of abnormal rCBF which correlate generally to the predominant sites of EEG abnormalities in this subgroup of patients. This approach may provide identification of abnormal foci in children and perhaps support evidence for indication of therapy in management of electrical but nonclinical form of epilepsy.
P45 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Neurology/psychiatry: cerebro-vascular
P366 Topic: "Semiquantitative evaluation of r-CBF in some cerebral disorders using a dedicated SPECT system". A. Arya; Sanjay Gandhi Post Graduate Institute Of Medical Sciences, Lucknow, INDIA. Abstract The present brain SPECT study was done using a hybrid emission advanced dynamic tomograph ‐ HEADTOME ( Shimadzu Co., Set ‐ 031, Kyoto, Japan) to establish values of semiquantitative regional cerebral blood flow(r‐CBF) analysis in normal controls and to apply these parameters to assess blood flow abnormalities in patients of stroke, Tubercular Meningitis (TBM) and Japanese encephalitis (JE). The SPECT parameters were compared with CT &/or MRI findings to assess their importance in these group of patients. Methods :‐To establish the standard values for semiquantitative analysis of r‐CBF, 7 normal controls were taken with no past history of any neurological deficit. 11 pts. of stroke were included with no previous history of stroke,brain tumor,ICSOL & those admitted after 15 days of event.10 pts.with Japanese encephalitis were included with 2‐3 mo history of onset of disease with post encephalitic sequelae. 9 new/partially treated & confirmed cases of tubercular meningitis were included for the study. Results & conclusion :‐ A group of normal volunteers were studied to establish standard values of r‐CBF using 99mTc‐ECD by mean count rate ratios between various parts of brain and cerebellum. The values varied from 0.68 ‐ 0.99 and served as standard for comparison with other group of patients. 9 patients of TBM showed increased r‐CBF in cortical regions which may be due to vasculitis. 10 patients of JE did not reveal much of perfusion abnormality except for 3 cases with frontal lobe hyperperfusion. Most patients revealed non‐visualization of B/L thalami. 11 patients of stroke revealed visual and quantitative abnormalities which matched with CT &/or MRI. In addition crossed cerebellar diaschisis and luxury perfusion was seen in some cases.
P367 Simple and convenient assessment of possible hyperperfusion after CAS surgery by cerebral vascular response to acetaqzolaminde (ACZ) stress measured by I-123 IMP SPECT Y. Kawamura1, T. Shinozaki1, H. Sugimoto1, M. Hirai2, T. Numajiri2, K. Nishikawa3, M. Kato-Azuma3; 1Department of Radiology, Jichi Medical University, Tochigi Prefecture, JAPAN, 2Department of Radiology, Tsuchiura Kyodo General Hospital, Ibaraki Prefecture, JAPAN, 3Imaging Information Technology Center, Nihon Medi-Physics Co. Ltd., Tokyo, JAPAN. Objectives: For birateral carotid artery stenting (CAS) procedoures, the pre‐operative acetazolamide (ACZ) stress test for brain perfusion is widely accepted as an important measure especially in the cases of lowered cerebrovascular reserve capacity which often causes relatively high risk of hyperperfuion after CAS. We developed a simple and convenient method without arterial sampling by measuring the increase of I‐123 IMP SPECT count value for rest and ACZ stress in one‐day protocol at two independent hospitals. Material and Methods: The five (5) min
Poster Presentation
P363
S382 continuous SPECT acquisition was repeated ten (10) times after the first administration of I‐123 IMP at rest. ACZ was injected at 15 min, and then the second I‐123 IMP (same radioactivity as the first one) was given at 25 min. We developed an empirical estimation method for the brain time‐ activity curve beyond 15 min by using the SPECT count obtained at 5, 10 and 15 min after the first I‐123 IMP dosing to give the estimated SPECT counts for 40 min at rest, and also to give estimated "true counts" after the second I‐123 IMP with ACZ stress to obtain the estimated "true SPECT count increase" with ACZ stress. Results: We have first evaluated this method with 5‐min continuous SPECT for 8 times, and the 8th actual values were compared with the estimated ones in two independent hospitals (n=110, 31) to find very good results of estimation (R2= 0.995, 0.998). Then we tested the method for one‐day rest‐rest studies (n=20, 0) to compare the total brain SPECT counts for rest‐1 and reset‐2 to give good correlation of R2= 0.983, y=1.027‐3.115 (ml/min). In birateral patient cases (n=41, 15) we found the SPECT count increase at the healthy side of the brain to be 49.8±13.4% and 41.7±12.4%,where neither hospital experienced less than 27% increase. In the application to the clinical cases of before CAS operation (n=57,0), we found 19 cases (33%) of poor CAZ response (<10% ) in the birateral disorder brain side, and among the 19 cases the "steal" phenomena was observed in 8 (14%) cases. Conclusions: With this method we found poor (<10%) ACZ response in 33% of the pre‐CAS patients suggesting precautions for hyperperfusion. Our current simple and convenient empirical estimation without arterial blood sampling could be effectively applied in assessing/predicting the risk of hyperperfusion associated with the CAS surgery.
P368 Bain SPECT in evaluation of cerebral perfusion in patients with arterial hypertension and metabolic syndrome: correlation with cognitive function N. Y. Efimova1, V. I. Chernov1, I. Y. Efimova1, Y. B. Lishmanov1, E. M. Idrisova2; 1Institute of Cardiology, Tomsk, RUSSIAN FEDERATION, 2 Siberian Medical University, Tomsk, RUSSIAN FEDERATION. Aim: to estimate and compare the regional cerebral blood flow (rCBF) in patients (pts) with arterial hypertension (AH) and metabolic syndrome (MetS) Material and methods: The study involved 23 pts with moderate essential hypertension and 50pts with MetS. All pts were investigated by perfusion brain SPECT with 99mTc‐HMPAO and comprehensive neuropsychological testing. Brain SPECT slices were divided into 14 symmetrical (right and left) regions of interest per patients: inferior and superior frontal lobes, temporal, anterior and posterior parietal, occipital lobes and cerebellar hemispheres. Regional cerebral blood flow (ml/100g/min) in these regions was calculated. Results: It was revealed less rCBF in MetS pts in left posterior parietal cortex , in right and left temporal brain regions, in left and right occipital cortex on 6.3% (p=0.005), 5.5% (p=0.009), 7.1%(p=0.001), 9.2% (p=0.00001) and 8.1%(p=0.00007), correspondingly in comparison with AH pts. Also we observed deterioration of immediate verbal memory on 15.6% (p=0.02) in pts with MetS in comparison with the AH pts. Relationship between rCBF and cognitive function was found. Deterioration of immediate verbal memory in AH pts and MetS pts correlated well with decrease in rCBF in left posterior parietal region (R2=0.225; p=0.035, R2=0.3; p=0.0002, correspondingly), in right and left temporal regions (R2=0.20; p=0.048, R2=0.22; p=0.002, R2=0.262; p=0.021, R2=0.13; p=0.020, correspondingly), as well as with right and left anterior parietal regions(R2=0.216; p=0.002, R2=0.94; p=0.043). Attention impairment in AH pts related to diminution in cerebral perfusion in right posterior parietal region (R2=0.27; p=0.022), left superior frontal region (R2=0.33; p=0.011), right temporal region (R2=0.346; p=0.008), in right and left occipital regions (R2=0.279; p=0.02, R2=0.24; p=0.033), correspondingly. Significant correlation was shown between psychomotor slowing in AH pts and rCBF in right temporal region (R2=0.21; p=0.042), left inferior frontal region (R2=0.201; p=0.047), right anterior parietal region (R2=0.352; p=0.015). Visuognosis impairment in MetS pts correlated well with decrease in rCBF in right and left anterior parietal regions (R2=0.149; p=0.011, R2=0.139; p=0.014), in right and left posterior parietal cortex (R2=0.203; p=0.003, R2=0.243; p=0.0009) and in left occipital region (R2=0.251; p=0.0007), as well as with rCBF in right occipital region (R2=0.206; p=0.043) in pts with AH. Conclusion Our results suggest that brain SPECT is useful technique for evaluation the cerebral perfusion and understanding of cognitive disorders mechanisms in patients with AH and MetS. Cerebral perfusion as well as immediate verbal memory was significantly decreased in MetS pts in comparison with AH pts.
P369 Hypoperfusion and Ischemia in Cerebral Amyloid Angiopathy Documented by Tc-99m-ECD Brain Perfusion SPECT Y. A. Chung1, I. R. Yoo2, S. H. Kim1, H. S. Sohn1, S. K. Chung1; 1Incheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Incheon, REPUBLIC OF KOREA, 2The Catholic University of Korea, College of Medicine, Seoul, REPUBLIC OF KOREA. Purpose: Cerebral amyloid angiopathy (CAA) is known as an important cause of spontaneous cortical‐subcortical intracranial hemorrhage in normotensive elderly persons. However, patients with CAA can also manifest leukoencephalopathy, brain atrophy, and ischemia secondary to hypoperfusion. Our goal was to verify cerebral hypoperfusion and ischemia in patients with CAA using Tc‐99m‐ECD brain perfusion SPECT. Materials & Methods: A total of eleven patients (M: 5, F: 6, age range: 48‐75 years (65.0 ± 13.3)) with clinically and radiologically proven probable CAA who underwent Tc‐99m‐ECD SPECT were included in the patient cohort assessed in the present study. Tc‐99m‐ECD SPECT scans were also obtained for 13 age‐matched healthy control subjects (M: 7, F: 6, age range: 60‐79 years (66.7 ± 6.4)) for comparison. The relative rCBF obtained for patients and normal controls were compared using SPM2 software. Results: Compared with normal controls, patients with probable CAA showed hypoperfusion areas as follows: an inferior parietal lobule of both parietal lobes (BA 40), a middle temporal gyrus of the left temporal lobe (BA 39), a postcentral gyrus of the right parietal lobe, a superior temporal gyrus of the right temporal lobe (BA 22), a superior temporal gyrus of the right fontal lobe (BA 10), an inferior temporal gyrus of the left temporal lobe (BA 20), and both caudate bodies (p < 0.001, t = 4.65). Conclusion: Cerebral perfusion decreased significantly in patients with probable CAA. These findings are very informative for predicting the risk of cerebral hypoperfusion resulting in leukoencephalopathy, atrophy, and ischemia in patients with CAA.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P370 Cystosine arabinoside induced brain perfusion changes in leukemic patients R. Modzelewski1, S. Lepretre1, O. Martinaux2, D. Hannequin2, P. Vera1; Henri Becquerel Center, Rouen, FRANCE, 2University Hospital, Rouen, FRANCE.
1
Objectives: high‐dose (HD) cytosine arabinoside (araC) is a major treatment in acute myeloblastic leukemia (AML) that can lead to cerebellar complications, although EEG, CT and MRI remain normal. We conducted a prospective study to evaluate brain perfusion with SPECT in adult patients receiving araC. Methods: 43 patients were pre‐included, 19 reached a complete remission. These 19 patients were definitively included and underwent 3 HMPAO SPECTs with a double‐head camera: SPECT1 at AML diagnosis, SPECT2 after induction (conventional araC dose) and SPECT3 during HD araC treatment. All the included patients underwent 6 series of neurological and cognitive examinations: N1, N2 and N3 at the time of SPECT1, SPECT2 and SPECT3 respectively; N4 during HD araC treatment; N5 (at 10 days); N6 during follow‐up (at 6 months). Statistical Parametric Mapping (SPM2) was used to show perfusion changes. A specific method based on Random Walk (RW) was used to analyze diffuse brain perfusion heterogeneity. Results: No neurological adverse effect was observed and all neurological and cognitive examinations remained normal. Between SPECT2 and SPECT1, SPM2 analysis showed a decrease in grey matter around the cerebellum, around the occipito‐parietal cortex, and in the thalamus. No significant difference was observed between SPECT2 and SPECT3, nor between SPECT1 and SPECT3. RW analysis showed no significant difference in perfusion heterogeneity between the three SPECTs. Conclusions: HMPAO SPECT demonstrated a decrease in thalamus, cerebellar and parieto‐occipital perfusion after conventional doses of araC in AML patients, although the neurological examinations were normal and the patients had no neurological adverse effects.
P371 Acetazolamide challenged HMPAO SPECT is reliable in assessment of Intracranial Vasodilatory Reserve in patients with severe steno-occlusive disease of internal carotid or middle cerebral artery disease A. K. Sinha, V. Sharma, V. Chong, T. Hock, B. Ong, C. Ning, B. Chan, C. Hao, M. Tong; NUHS, Singapore, SINGAPORE. Background: Circle of Willis provides collateral pathways to perfuse the affected vascular territories in patients with severe steno‐occlusive disease of major arteries. The collateral perfusion may become insufficient in certain physiological circumstances due to failed vasodilatory reserve and intracranial steal phenomenon, the so‐called ‘Reversed‐Robinhood syndrome’. It is important to determine the degree to which underlying disease has exhausted the normal RCBF reserve capacity and the degree to which collateral supplies have been recruited as a countermeasure. Measurement of the cerebrovascular reserve may be particularly effective in assessing the need for acute intervention following stroke or the risk status for secondary strokes. We evaluated cerebral hemodynamics and vasodilatory reserve in our patients with symptomatic internal carotid (ICA) or middle cerebral artery (MCA) severe steno‐ occlusive disease with HMPAO SPECT. Subjects & Methods: Diagnostic transcranial Doppler (TCD) and TCD‐monitoring with voluntary breath‐holding according to a standard scanning protocol were performed by neurologist in patients with severe ICA or MCA steno‐occlusive disease. The steal phenomenon was detected as transient, spontaneous, or vasodilatory stimuli‐induced velocity reductions in affected arteries at the time of velocity increase in normal vessels. Patients with exhausted vasomotor reactivity and intracranial steal phenomenon during the breath‐ holding were further evaluated with acetazolamide‐challenged HMPAO‐SPECT. Results: 48 patients (age: 30‐74 years, 41 males) fulfilled our TCD criteria for exhausted vasomotor reactivity and intracranial steal phenomenon during the standard vasomotor testing by breath holding. Acetazolamide‐challenged HMPAO‐SPECT demonstrated significant hypoperfusion in 46 patients in affected arterial territories, suggestive of failed vasodilatory reserve. A breath‐holding index of less than 0.3 on TCD was associated with an abnormal acetazolamide‐challenged HMPAO‐SPECT. Conclusions: Acetazolamide challenged HMPAO SPECT is reliable in assessment of Intracranial Vasodilatory Reserve in patients with severe steno‐occlusive disease of internal carotid or middle cerebral artery disease. Identification and quantification of failed vaso‐dilatory reserve, coupled with cerebrovascular ultrasonography helps in identifying a target group of patients for non‐ invasive ventilatory support in stroke prevention as well as selecting patients for possible revascularization procedures.
P372 The role of anatomic and functional imaging in the diagnosis of neuropsychiatric involvement in systemic lupus erythematosus (NPSLE) J. Kubinyi, V. Peterova, M. Olejarova, C. Dostal, L. Rysova, K. Kupka; Charles University Prague, Praha, CZECH REPUBLIC. Neuropsychiatric involvement (NP) occurs in 30‐70% cases of systemic lupus erythematosus (SLE). Diagnosis of NPSLE is based on neuropsychiatric symptomatology and diagnostic imaging. The aim was a) to assess potential contribution of HMPAO SPECT to anatomical information obtained from MRI, b) to study HMPAO distribution patterns in the patients with definitive diagnosis of SLE, and c) to assess potential correlation of HMPAO patterns with clinical symptomatology and the type of NP. Methods: The study has been performed in 47 patients with verified diagnosis of SLE and NP symptoms corresponding to the international diagnostic criteria. The total duration of SLE at time of the first SPECT examination ranged from 1 to 20 years. Neurological symptomatology was focal in 26 patients and diffuse in 21 patients. The patients have been examined by MRI including Gd‐DTPA enhancement and HMPAO (Ceretec)‐SPECT. Assessment of regional cerebral blood flow was performed visually and semiquantitatively using ROI method and Neurogam Segami software. Interval between SPECT and MRI examination was shorter than 4 weeks. Results: a) Abnormal HMPAO distribution pattern was found in all 47 patients. In all of them, the number of significant perfusion defects was greater than 1 (the average number was 4.2). The perfusion defects were predominantly localized in frontal and
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 temporal lobes of the left hemisphere. b) Abnormal MRI was found in 41 patients. Predominant finding was focal T2 hyperintensity and FLAIR with maximum in frontal and parietal lobes. In 6 SLE patients, MRI finding was normal at the time of the first examination. All normal findings were converted into abnormal in the next 1‐2 years. c) No difference has been found between perfusion patterns in patients with focal and diffuse diseases. Conclusion: Perfusion abnormalities were found in all NPSLE patients. The pattern of abnormal perfusion has not correlated with the type of NP symptoms. In early stage of the disease, perfusion abnormalities preceded MRI symptoms and may represent a useful predictive sign.
P375
Aim: Aim of this retrospective evaluation is monitoring whether and how much clinical demand has changed in the course of time in the approach to this imaging tecnique on the basis of our 6‐ years experience. Methods and patients: We reviewed 877 DaTscan (DS) studies, carried out in our Department since 2003 until the end of 2008, sent by various Neurology Departments and, in a small amount, by Geriatrists and Psychiatrists. We divided them year by year and then on the basis of the clinical question, which was then compared to imaging results. 26 pts received a second Imaging test, among them 4 a third one. I) The largest group includes really diagnostic imaging tests, where result gave final answer to clinical question, even changing initial diagnosis (309). II) The second group includes pts. with high probability of Parkinson’s Disease (PD), almost all of them already in therapy (288). III) Pts. with clinical doubt of Atypical Parkinsonism were 61. IV) We had 58 cases of Drug Induced Parkinsonism (DIP), with normal DS pattern. V) We classified Vascular Parkinsonism mostly on the basis of clinical and morphological imaging data than on the variable DS results (52). VI) We grouped high probability Essential Tremors (ET),DS negative (45). VII) Differential Diagnosis of Dementia (30). VIII) Dystonia (4). Results and Conclusion: A) The first remark to be pointed out is gradual, significant reduction of tests in high probability of PD in the course of the years: maximum 72 pts in 2003, minimum 28 pts in 2007. Patient is sent earlier, not yet in therapy, in order to reduce time to diagnosis. B) We checked a progressive increase of DS tests in real or potential DIP, due to a major consciousness of the potential iatrogenic damage of many dopaminergic receptor‐blocker drugs. C) Accesses for Parkinsonism on vascular basis have decreased, suggesting an higher confidence of Clinicians with morphologic imaging, whereas DS is not fully satisfactory. Nowadays use of DS proves to be evaluation of presynaptic dopaminergic damage when vascular aetiology is strongly suggested. E) The trend of Group I is to become the largest one : from 35 pts of 124 in 2003 (28 %), we passed to 57 of 112 in 2007 ( 50%). These data suggest that Clinician is prone to expect a conclusive answer from this still appreciated technique and has reached the goal of better selection of his patients.
Neurology/psychiatry: movement disorders
P373 Molecular imaging of postsynaptic D2 receptors with I-123IBZM in patients with degenerative parkinsonism. T. Aggelopoulou1, G. Gerasimou1, S. Bostanjopoulou2, M. Arnaoutoglou3, Z. Katsarou2, N. Lytras1, E. Dedousi1, E. Hilidis1, G. Liaros1, E. Moralidis1, N. Papadimitriou1, E. Papanastasiou1, V. Kosta3, N. Taskos4, A. GotzamaniPsarrakou1; 1Institute of Nuclear medicine-AHEPA Hospital, Thessaloniki, GREECE, 23rd Neurologic Clinic-Papanikolaou Hospital, Thessaloniki, GREECE, 31st Neurologic Clinic-AHEPA Hospital, Thessaloniki, GREECE, 4 2nd Neurologic Clinic-AHEPA Hospital, Thessaloniki, GREECE. Patients with degenerative parkinsonism (DP) develop atypical symptoms or an abrupt deterioration of their clinical status, despite the fact that they are under L‐Dopa treatment. This fact can be attributed to Parkinson‐plus syndrome. Iodobenzamine labeled with iodine‐123 (I‐ 123‐IBZM) is a radioligand which enables imaging of cerebral postsynaptic dopamine D2 receptors availability. This can be used in order to determine increased or reduced D2 receptors’ density in idiopathic Parkinson’s disease (IPD) and Parkinson‐plus syndromes (PPS) respectively, and blocking of receptors during treatment with neuroleptics. The aim of the study is to investigate the usefulness of IBZM‐SPECT molecular imaging in patients with DP being suspect of developing PPS. A total of 15 patients with DP and an initial diagnosis of IPD were studied with IBZM. Inclusive criteria were: 1) clinical signs of DP with a positive I‐123‐DaTSCAN and 2) atypical clinical symptoms and/ or lack of response to medical treatment. IBZM SPET study was performed 75‐90 min after iv injection of 185 MBq of the radiopharmaceutical. One‐hundred twenty projections were acquired with 20 sec per view. After reconstruction and reorientation of the data, report was performed based on qualitative criteria. A positive IBZM scan was found in 13 (86.6%) of the patients. In these patients the final diagnosis according to the clinical neurologists after evaluating IBZM study plus clinical image, was PPS, and treatment was adjusting accordingly to the report of depletion of D2 dopaminergic receptors. In the remaining two patients with a normal IBZM scan reevaluation and clinical follow‐up was done, keeping in mind that this molecular procedure can be normal in very early stages of PPS. We can conclude, that IBZM‐SPET study is useful in the evaluation of patients with DP, an initial diagnosis of IPD with atypical symptoms and a sudden and abrupt lack of response to L‐Dopa, in terms that in PPS lack of availability of post‐synaptic D2 receptors can increase side effects of anti‐parkinsonian treatment and a reevaluation of these patients is necessary.
P374 Diagnostic accuracy of 123-I-IOFLUPANE spect from the first moment of his implantation E. Goñi1, A. Camarero1, C. Estébanez1, J. Muruzabal2, M. E. Martinez1, J. L. Martinez1; 1Hospital de Navarra, Navarra, SPAIN, 2Hospital Virgen del Camino, Navarra, SPAIN. AIM: The object of our work is the retrospective evaluation of the first results obtained after implantation of DAT‐SCAN SPECT in our department. MATERIAL AND METHODS: We have studied 108 patients received consecutively between December 2003 and September 2007, which were followed by a period minimum of 18 months. 8 patients were excluded (four because they didn’t want to do the study, two for iodine allergy, one for patient movement and one for patient’s death). Therefore, we analysed 100 patients (51 women and 49 men) with ages between 23 and 83 years (x = 66.3). All SPECTS were undertaken after the intravenous injection of 185 MBq of 123I ioflupane. Images were acquired three hours later using a DST‐XL dual head gammacamera (General Electric) equipped with low energy ultra‐high resolution collimators describing an circular orbit as close as possible to the skull. The total acquisition took 45 minutes and consisted of 128 projections acquired for 40 seconds into a 128x128 acquisition matrix. As statistical methods we have used contingency tables and Pearson chi‐square test to compare our results with the final diagnosis. RESULTS: We couldn’t obtain a final diagnosis in three cases, which are actually under study, and had been excluded from the statistic evaluation. Image was pathologic in 64 cases, 61 of them diagnosed as primary parkinsonism (PP), and normal in 33, related mostly to essential tremor, pharmacologic parkinsonism and vascular parkinsonism. One case was a false negative, finally diagnosed as PP. Sensitivity and specificity were 98% and 91% respectively, with PPV of 95% and NPV of 96% ( p <0.005).
Non‐Primary Parkinsonism Primary Parkinsonism Total
Normal Image
32
1
33
Pathologic Image 3
61
64
Total
62
97
35
CONCLUSIONS: In our experience we have confirmed the known high sensibility and specificity of this study but, what we find more important is its high diagnostic accuracy from the first moment of his clinical use. Visual analysis has been enough to diagnose the existence of true presynaptic dopaminergic lesion. We observed that this study has been increasingly requested which we interpreted as an indirect confirmation of its clinical utility in the daily management or patients with doubtful Parkinson disease diagnosis. Therefore we support its inclusion in the diagnostic protocol of clinically uncertain parkinsonism.
I. Pasquin, M. Zuffante, D. Grigolato, P. Braggio, M. Cavaggioni, P. G. Giorgetti; Department of Nuclear Medicine, Major Hospital of Verone, Verona, ITALY.
P376 123I-FP-CIT single photon emission computed tomography in Lewy bodies dementia (DLB): quantitative comparison in patients with DLB and non-DLB clinical diagnostic D. Ramal Leiva, J. Mora, L. Rodriguez Bel, Y. Ricart, M. T. Bajén, A. Benítez Segura, R. Reñé, J. Martin-Comin; Hospital Universitari de Bellvitge, Hospitalet de Llobregat, SPAIN. Aim: To determine the utility of the 123I‐FP‐CIT single photon emission computed tomography (SPECT) quantification in the diagnosis of patients with possible Lewy bodies dementia (DLB). Methods: A 123I‐FP‐CIT SPECT was performed in a total of 34 patients, 21 male (61.8%) and 13 female (38.2%) with DLB clinical suspicion. The striatum/background ratio (s/b ratio) was calculated individually in both sides of all patients, taking the occipital region as background. Images were also evaluated by two experienced nuclear medicine physicians as normal or abnormal. After 1 year of follow‐up, an expert neurology physician diagnosed each patient, following universal clinical criteria, of DLB or non‐DLB. Results: The following table shows the results:
N
Mean age
DLB
16p (47%)
74.9 +/‐ 10p (62.5%) male 6p 5.7y (37.5%)female
3.83 +/‐ 0.96
1p (6.25%) normal 15p (93.75%) abnormal
Non‐ DLB
18p (53%)
72.9 +/‐ 11p (61.1%) male 7p 6.8y (39.9%) female
5.06 +/‐ 1.22
12p (66.6%) normal 6p (33.3%) abnormal
Gender
Mean s/b Visual evaluation ratio
The chi‐square statistical analysis shows significant differences between s/b ratio in DLB and non‐DLB groups (p=0.0029). Both sides analyzed individually show differences too (p=0.0032 on the right side; p=0.0035 on the left side). Conclusions: In patients with DLB there is a significant decrease of dopamine transport. Our study confirms the usefulness of the 123I‐FP‐CIT SPECT in the diagnosis of DLB, showing a good relationship between clinical diagnose and 123I‐FP‐CIT SPECT uptake. Thus, 123I‐FP‐CIT SPECT may be helpful in early DLB diagnosis.
P377 123
I-FP-CIT (DaTSCAN) scintigraphy in the diagnosis of Parkinson`s disease K. Liepe1, F. Sixel-Döring2, C. Trenkwalder2; 1GH Kassel, Kassel, GERMANY, 2Hospital Paracelsus-Elena, Kassel, GERMANY. Aim: Imaging with 123I‐FP‐CIT SPECT (DatScan) is a marker of nigrostriatal neuronal integrity, allowing differentiation of Parkinson`s disease (PD) with loss of dopaminergic terminals from essential tremor (ET) without nigrostriatal degeneration. Materials & Methods: In this retrospective study we investigated 69 patients with 123I‐FP‐CIT SPECT and compared the findings with the primary clinical diagnosis of Parkinson`s disease (41 patients) or essential tremor (28 patients). Additional, the diagnosis was verified with the clinical follow‐up over 2 years. All patients were investigated from one trained neurologist. Striatal radioligand uptake was graded visually as normal or abnormal, and semi‐quantitative ratio the striato‐occipital ratio, ratio of caudatus and putamen to background (occiput), and the ratio of putamen to caudatus was calculated. The study group included 29 female and 40 male with a mean age of 62± 11 years. Results: Two of 41 patients with PD showed visual a false negative finding, all of ET patients were corrected negative (sensitivity of 95%, specificity of 100%). The mean striato‐occipital ratio of the most affected side were significant lower in PD (1.49± 0.53) compared to ET (2.33±0.32) (p>0.001). Similar lower uptake in putamen to occiput was found in PD (1.21± 0.54) compared to ET (2.23± 0.34) (p>0.001). Also the ratio of uptake in putamen to caudatus was lower in PD (0.71± 0.14) compared to ET (0.91± 0.10) (p>0.001). In PD patients, lower striato‐occipital ratio were
Poster Presentation
P46 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Has Clinical approach to Imaging with 123I-Ioflupane changed? A 6-years experience on 877 cases (847 patients).
S384 found contralateral to the clinically most affected side (1.49± 0.53 versus 1.71± 0.52, ipsilaterally). In the clinical follow‐up the primary diagnosis were confirmed in all patients Conclusion: 123I‐FP‐CIT SPECT showed a high sensitivity and specificity in the diagnosis of PD. Patients with PD had a significant lower uptake in mean striato‐occipital ratio compared to patients with ET.
P378 123-I MIBG scintigraphy and 123 I-FP-CIT SPECT: a combined study in early Parkinson’s Disease X. Geronikola-Trapali1, I. Armeniakos1, T. Doskas2, A. Stefanoyiannis1, P. Karabina1, S. Bakalis1, V. Lyra1, P. Zotou1, A. Prentakis1, M. Travassarou2, L. Stefanis2; 1University General Hospital "Attikon", Nuclear Medicine Department, Chaidari, GREECE, 2University General Hospital “Attikon”, Department of Neurology, Chaidari, GREECE. Aim: To asses the sensitivity of 123 I‐FP‐CIT SPECT and 123‐I MIBG scintigraphy in the detection of relevant degeneration of both nigrostriatal and cardiac sympathetic neurons even in the early stages of Parkinson’s disease (PD). Materials and methods:The study involved 14 patients with IPD(Hoehn and Yahr stage 1) 4 women and 10 men mean age 53 ± 12 years and a control group which consisted of 15 age ‐matched healthy volunteers. All patients were examined by neurologists experts in PD according to the United Parkinson’s Disease Rating Scale (UPDRS).Cerebral MRI findings were normal. Patients with cardiac,thyroid ,psychiatric disorders as well as with diabetes mellitus and cerebrovascular events were excluded. Thyroid blocking preceded both studies. Cerebral SPECT imaging was performed after i.v injection of 110‐185 MBq 123‐I FP‐CIT (DaTscan).For quantification purpose the striatal /posterior lobe binding ratio was calculated. 123‐I MIBG scintigraphy was carried out 15 minutes and 4 hrs after slow i.v injection of 180‐250 MBq. H/M was calculated by drawing a rectangular ROI over the upper mediastinum and a ROI over the whole left ventricle. Delayed myocardial analysis was visually assessed as normal,decreased and no tracer accumulation. The striatal /posterior lobe ratio in normal volunteers was 3.35±0.35 The cerebral binding was considered pathological when the ratio was below 2.41. The H/M ratio in normal volunteers was 1.94± 0.11 Results: In 4/14 patients 123‐I FP‐ CIT was normal .10/14 patients showed markedly reduced or asymmetric striatal tracer accumulation.2.46 ± 0.74 (tremor dominant : n= 2),2.0 ± 0.55 (equivalent : 3)and 1,54 ± 0.6 (akinetc‐rigid n=5). MIBG scintigraphy revealed pathological results in 8/14 patients .reduced tracer accumulation H/M : 1.57± 0.18 (n=2),missing accumulation H/M:1.19 ± 0.07 (n=6). There was no dramatic correlation between the H/M ratio and the motor part of UPDRS. Conclusions: In our study pathological results of striatal FP‐CIT and MIBG scintigraphy correlated significantly. The functional loss of nigrostriatal and cardiac sympathetic neurons seems closely correlated. Consequently, the combination of 123‐I FP‐CIT SPECT and 123‐I MIBG scintigraphy may contribute to the early diagnosis of PD.
P379 123
I-Ioflupane SPECT in diagnosis of patients with movement disorders B. Paghera, E. Premi, G. Merli, S. Gabanelli, S. Lucchini, E. Puta, G. Magri, A. Padovani, R. Giubbini; Spedali Civili di Brescia, Brescia, ITALY. Introduction: in parkinsonism nigrostriatal projections loss gives a decrease of dopaminergic transporters; literature data assess that brain SPECT with a dopamine transporter radioligand (123I‐Ioflupane) is an important diagnostic tool in the evaluation of patients with movement disorders. Aim of the study: the study was conducted to assess the diagnostic value of the striatal uptake of 123I‐Ioflupane in subjects with movement disorders by a visual analysis. Materials and methods: 130 patients (70M, 60F, age 64±11 yrs) were enrolled at the Centre for Aging Brain and Neurodegenerative Disorders, University of Brescia, Italy because of parkinsonism (tremor, rigidity, bradichinesia). All patients underwent MRI/CT and a clinical and neuropsychological examination; 99/130 patients were available at clinical follow‐up. Images acquisition started at 3‐5 hours after i.v. injection of 150‐185 MBq 123I‐Ioflupane using a dual‐ 123 head gamma‐camera according to standard protocols in all patients. Visual assessment of I‐ Ioflupane striatal uptake was performed and images were classified as normal, abnormal unilaterally or bilaterally in respect to the symmetric or asymmetric reduction of tracer uptake in striatum (one/both putamen or whole striatum). 123I‐Ioflupane data were correlated with definite diagnosis at follow‐up. Results: 99/130 patients were clinically definitely diagnosed after follow‐ up. In 35/99 patients the 123I‐Ioflupane striatal uptake was normal, suggesting that their parkinsonian syndrome could be related to a benign condition in fact they were diagnosed as 22 essential tremor (ET), 4 drug induced parkinsonism (DIP), 1 vascular parkinsonism (VP), 2 Alzheimer’disease (AD), 2 mild cognitive impairment (MCI). Four patients with disagreement between a normal scan and a clinical diagnosis strongly suggesting a parkinsonian syndrome, need further evaluation. In 64/99 patients the 123I‐Ioflupane SPECT was abnormal and a mild, medium or severe unilateral or bilateral decreased striatal uptake was observed with a good correlation with the definite diagnosis; in fact at follow‐up, independently from the results of brain scans, patients were classified as 35 idiopatic Parkinson’s disease (IPD), 4 atypical parkinsonian syndrome (APS), 9 Lewy body dementia (LBD), 1 progressive supranuclear palsy (PSP), 11 corticobasal degeneration (CBD), 4 multiple system atrophy (MSA). Conclusion: our data indicate a great agreement between the striatal uptake of 123I‐Ioflupane and the definite diagnosis at follow‐up and confirm the strong clinical impact of this procedure suggesting that 123 I‐Ioflupane could be used as a routinary tool in the clinical practice to support the diagnosis of patients with parkinsonism and to differentiate parkinsonian syndromes from other conditions such as ET, VP or DIP.
P380 Comparison of 123-Ioflupane SPECT with clinical evolution in patients receiving pakinsonism inducing drugs I. Casáns Tormo1, R. Pérez Velasco2, A. Tembl Ferrairo3, E. Caballero Calabuig4, S. Palao Esteve5, J. A. Burguera Hernández6, J. A. Dominguez7; 1 Medicina Nuclear. Hospital Clínico Universitario, Valencia, SPAIN, 2 Medicina Nuclear. Hospital Universitario La Fe, Valencia, SPAIN, 3Medicina
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 Nuclear. Hospital de la Ribera, Alzira, SPAIN, 4Medicina Nuclear. Hospital Universitario Dr Peset, Valencia, SPAIN, 5Neurología. Hospital Clínico Universitario, Valencia, SPAIN, 6Neurología. Hospital Universitario La Fe, Valencia, SPAIN, 7Neurología. Hospital de la Ribera, Alzira, SPAIN. AIM: In patients with suspected drug‐induced parkinsonism, it is essential to confirm or exclude a real nigro‐striatal degeneration, to allow a correct diagnostic and therapeutic approach. The results of 123I‐Ioflupane SPECT to assess the integrity of dopamine transporters (DAT‐SPECT) were compared with clinical evolution of patients after follow‐up. METHODS: We have studied 76 patients (51 women, age 36‐89, mean 68+/‐10, 71% older than 65) receiving parkinsonism potentially inducing drugs, all them with parkinsonism clinical signs. The DAT‐SPECT was obtained 3‐4h after i.v. administration of 123I‐Ioflupane, with qualitative assessment of transversal slides, considering results as normal, abnormal or uncertain. Clinical follow‐up was carried out to correlate DAT‐SPECT results with evolution of patients and its relation with drug withdrawal. RESULTS: Tremor was the most frequent parkinsonism sign, detected in 61/76 (80.2%). Only one symptom was showed by 51/76 (67.1%) of patients. Two or more signs were present in 25/76 (32.8%). Neuroleptics was the drug taken by 63.8% of patients, calcium‐channel‐antagonists by 15.2%, litium 9.7%, and others in the rest, like antidepressants, antiepileptics, vasodilators. One drug was received by 83.3% of patients and 16.6% of them received 2 or 3 of these drugs. The treatment began from 10 years to one month before DAT‐SPECT and clinical signs from 6 years to one month before. The drug was stopped in 76% patients, but it was not possible in the rest. There were normal DAT‐SPECT results in 40 patients, abnormal in 29 and uncertain in 7. Follow‐ up was available in 69 patients (3 months to 7 years, mean 18+/‐8 months). 70.2% of patients with normal DAT‐SPECT showed clinical improvement when drug was retired, the rest maintained symptoms, but in 63% of them it was not possible to stop drug. In patients with abnormal DAT‐SPECT, symptoms remained in 66.6%, although drug could be retired in 48% of them. Drug withdrawal had been possible in all 8 patients with abnormal results and clinical improvement. There were 7 patients with early improvement and late worsening, 4 of them despite of stop drug. CONCLUSION: DAT‐SPECT provides an objective method to detect real dopaminergic involvement in patients with suspected drug‐induced parkinsonism. It is essential the early detection, especially in the elderly, as cessation of responsible drug results generally in clinical improvement, and also avoid unnecessary treatment and side effects of dopaminergic agents. Moreover it is possible the identification of previous true parkinsonism, worsened or clinically evidenced by these drugs.
P381 Comparison among qualitative versus semiquantitative analysis of dopamine transporters using 123I-FP-CIT-SPECT in patients with movement disorders M. Suarez-Piñera1, J. D. Gispert2, A. Mestre1, A. Rodriguez1, L. Prat3, E. Miralles1; 1Hospital del Mar .CRC-MAR, Barcelona, SPAIN, 2Instituto de Alta Tecnología (IAT). Parque de Investigación Biomédica de Barcelona, Barcelona, SPAIN, 3Hospital General de Catalunya. Sant Cugat del Valles, Barcelona, SPAIN. Background: Functional images as SPECT with 123I‐FP‐CIT has the ability to demonstrate disturbances of presynaptic dopamine system through the study of dopamine transporters (DAT) in neurodegenerative Pakinsonian syndromes (PS). The correct analysis of the 123I‐FP‐CIT SPECT images is relevant for an adequate interpretation of presynaptic dopamine disturbances and to properly contribute in the PS diagnosis. Aims: To compare qualitative and semiquantitative analysis of 123I‐FP‐CIT SPECT images in a sample of patients with movement disorders and PS suspicious. 2. To evaluate the tool and the benefit of these methods of analysis in the clinical practice. Methods: 30 patients (12 F, 51‐88 yrs) with movement disorders and PS clinical suspicious underwent a baseline 123I‐FP‐CIT SPECT while free of medication. Scan acquisitions started 4 hours after single injection of 185 MBq (5 mCi ) of 123I‐FP‐CIT. Qualitative analysis was the result of a consensus obtained after the visual interpretation of the image by two individual observers. SPECT images were classified using the following scale: normal=0 or positive for PS: slight=1; moderate=2 and severe=3. This classification was based on visual analysis of the intensity of the tracer in the striatum. Semiquantitative analysis was calculated as specific uptake (caudate, putamen and striatum) versus non specific uptake (occipital) . Regions of interest (ROIs) were drawn on the caudate, putamen, striatum and occipital SPECT images. Data were compared using 1‐ ANOVA test followed by a Bonferroni post‐hoc test and 2‐ a correlation between qualitative (0,1,2,3) and semiquantitative analysis. Results: Semiquantitative data showed significant differences (p<0.05 ANOVA test) between normal and positive for PS (slight, moderate or severe) in putamen and striatum, but not in caudate. Bonferroni post‐hoc test did not show major differences between control and slight PS in none of the regions studied. Significant correlation between qualitative and semiquantitative analysis was obtained in putamen and striatum but not in caudate. A negative slope: indicative of gradual hypocaptation proportional to the severity of the disease was obtained in putamen and striatum but not in caudate. Conclusions:1.Using both methods of analysis, presynaptic dopamine disturbances indicative of PS was found in the putamen but not in the caudate. 2.Qualitative and semiquantitative analysis were properly correlated indicative that both methods of analysis can be used in the clinical practice. 3.However, based on our preliminary data semiquantitative analysis is not able to discriminate between “slight” PS and normal.
P382 Significance of myocardial 131 I-meta-iodobenzylguanidine (MIBG) scintigraphy in the diagnosis of Parkinson’s disease T. Samardzic, R. Petrovic, S. Telarovic, N. Klepac, M. Relja, S. Tezak; University Hospital Zagreb, Zagreb, CROATIA. Aim of our ongoing investigation is to evaluate the usefulness of myocardial 131 I‐ metaiodobenzylguanidin (MIBG) scintigraphy in the diagnosis of Parkinson's disease. Parkinson's disease is resulting from loss of nigrostriatal dopamine terminals in the brain. Almost all patients with PD, however, have symptoms of dysfunction of the autonomic nervous system such as orthostatic hypotension. Several recent studies of the sympathetic noradrenergic component of the autonomic innervation of the heart have shown that PD is not only a movement disorder but also a form of dysautonomia. Materials and methods: Twelve patients clinically diagnosed to
S385
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P383 Brain FDG PET Imaging In The Differential Diagnosis Of Parkinsonism L. O. Kapucu1, U. O. Akdemir1, K. Unal1, N. I. Erdoğmuş2, A. B. Tokçaer2; Gazi University School of Medicine, Department of Nuclear Medicine, Ankara, TURKEY, 2Gazi University School of Medicine, Department of Neurology, Ankara, TURKEY. 1
Aim: We evaluated the specific brain metabolism findings in patients with diseases presenting with parkinsonism by visual evaluation and quantitative analysis of brain FDG PET images. Methods: Twenty‐three patients presenting with parkinsonism had brain FDG PET scans between November 2006 and September 2008. After a mean follow‐up period of 18 months final clinical diagnoses were established in 16. FDG PET images were visually evaluated by two physicians who were blind to patients’ diagnoses. Additionally, each patient’s brain data were quantitatively analyzed by comparing the data with an aged‐matched normal group to detect hypometabolic regions using the NeuroQ software. Results: Final clinical diagnoses were idiopathic Parkinson’s disease (IPD) in 6, progressive supranuclear palsy (PSP) in 4, multi‐system atrophy (MSA) in 3, corticobasal degeneration (CBD) in 2, and Lewy‐body disease (LBD) in 1 patient. Findings on visual evaluation and NeuroQ analysis were similar in three IPD patients: One patient had normal findings and two patients had parietotemporal, frontal and occipital hypometabolic regions both visually and quantitatively. Findings were discordant in the other three IPD patients: One patient with normal visual findings had frontal and parietal hypometabolism on quantitative analysis. Two patients with bilateral basal ganglia involvement on visual evaluation had parietal and temporal hypometabolism on quantitative analysis. Patients with PSP showed concordant cortical hypometabolism in frontal and parietal lobes on visual evaluation and quantitative analysis. However, asymmetrical hypometabolism in basal ganglia and thalamic nuclei which were visually observed in three patients were not evident on quantitative analysis. On the contrary one patient had left caudate and thalamic nuclei hypometabolism which were detected only by quantitative analysis. Patients with MSA had frontal, basal ganglia and cerebellar hypometabolism. Findings were concordant in two patients; however, in one patient the basal ganglia and cerebellar involvement were not detected on quantitative analysis. In patients with CBD and LBD, metabolic findings were concordant on both visual evaluation and quantitative analysis: The two patients with CBD had hypometabolism bilaterally in parietal, frontal cortices, cerebellum, asymmetrically in basal ganglia and thalamic nuclei. Cortical hypometabolism in parietotemporal, frontal and occipital regions were detected in the patient with LBD both visually and quantitatively. Conclusion: Brain FDG PET imaging provided useful information regarding differential diagnosis in patients presenting with parkinsonism. Results of quantitative analysis were found to be more concordant with findings of visual evaluation in detection of cortical hypometabolism, whereas quantitative analysis was found to be less sensitive to subcortical hypometabolism.
P384 Brain SPECT with 123I ioflupane(FP-CIT)-DATSCAN in the differential diagnosis of Parkinson’s disease 1
2
2
2
1
L. Brajkovic , V. Kostic , E. Stefanova , M. Svetel , S. Pavlovic , D. SobicSaranovic1, V. Artiko1, V. Obradovic1; 1Institute of Nuclear Medicine, Belgrade, SERBIA, 2Institute of Neurology, Belgrade, SERBIA. Clinical diagnosis of Parkinson’s disease (PD) is difficult, especially in early stage of disease, in young onset of Parkinson’s disease, in some patients with atypical clinical signs and border simptomatology. Some of Parkinsonian syndrome (PS) sings (tremor,rigor,bradykinesia, postural instability) are present in other movement disorders(MD) (Dystonia, Essential tremor(ET). Brain SPECT with 123I ioflupane DaTSCAN‐ imaging is used to asses nigrostriatal dopaminergic system integrity and degeneration detecting loss of presinaptic nerv terminals in the striatum of patients with clinically uncertain PD. . Purpose: To evaluate usefulness of SPECT‐DaTSCAN in differential diagnosis of PD. Method: We performed brain SPECT‐DATSCAN in 39 patients (26 males, 13 females) age 21‐77 with initial unclear diagnosis of PD. Study was performed 3‐4 hours after intravenous injection 145‐185MBq 123 I ioflupane by Mediso Nuclear spirit two headed gamma camera. SPECT were reconstructed by Filtered back projection method, with Butterworth filter (cut off 0,5, order 7) and attenuation correction (Chang method, factor 0,12). We evaluated data by visual and semiquantiative analysis. For the analyses of striatal binding, the ratio of specific (striatal) to non specific (occipital) binding was calculated. Regions of interest (ROIs) were positioned on the reference transaxial slice on both striatal (nucleus caudatus, putamen) and occipital regions, and calculated ratio. Results: In 26 patients DATSCAN confirmed PD diagnosis detecting loss of functional dopaminergic neuron terminals in the striatum (reduction of 123I ioflupane accumulation). Degree of reduction accumulation in striatum (especially in putamen) depends of stage of PD(8 patients with young onset of Parkinson’s disease, 6 patients in early stage of disease) Two patients with autonomic dysfunction and suspected MSA, two patients
with suspected PSP, and two patients with Dementia Lewy body have reduction of accumulation 123 I ioflupane in striatum. Three patients with suspected Dystonia and four patients with atypical statoposturokinetical tremor and uncertain diagnosis‐Parkinsonian syndrome or Essential tremor have normal DATSCAN, and confirmed diagnosis Dystonia and ET. Conclusion: Our preliminary results indicate that DATSCAN is an objective molecular functional neuroimaging method for differential diagnosis of PD. DATSCAN is a very useful diagnostic procedure for differentiation young onset Parkinson’s disease patients and Dystonia patients with atypical clinical presentation. Accurate diagnosis determines medical treatment and prognosis of the disease. .
P385 The first experiences in dopamin transporter imaging with 123I-ioflupane (DaTSCAN) in patients with movement disorders R. Petrovic, T. Samardzic, S. Telarovic, N. Klepac, M. Relja, S. Tezak; Clinical Hospital Centre Zagreb, Zagreb, CROATIA. Aim: to evaluate the effectiveness of brain SPECT with 123I‐ioflupane as a useful and effective diagnostic tool in detection of the loss of dopaminergic nigrostriatal neurons in patients with previously clinically proven diagnosis of movement disorder. Materials and methods: In carefully selected group of 45 patients, 30 men and 15 women (majority scanned from November 2008 until March 2009), identified by strict predefined criteria from experienced neurologist, with clinical diagnosis of: Parkinson disease (PD) (22), essential tremor (ET) (6), progressive supranuclear palsy (PSP) (2), hepatolenticular degeneration (11), extrapyramidal symptoms (EPS) (2), multiple system atrophy (MSA) (1) and Lewy body disease (1) a dose of 185 MBq of 123I‐ ioflupane was administered and SPECT imaging conducted 4 hours after radiotracer injection. Images were reconstructed and reoriented on Odyssey FX820 workstation and analyzed visually and semiquantitatively using region‐of‐interest based method. The ratio of the mean specific‐to‐ nonspecific striatal binding for the entire striatum (S/NS) was calculated in all patients and compared with those from literature. Results: In a group of six patients diagnosed as essential tremor the 123I‐ioflupane brain SPECT was normal in 2 patients while 4 others showed mild to moderate pathologic reduction in striatal uptake. This findings resulted in immediate therapy change for those 4 patients with pathological scans. In 24 of 26 patients with final diagnosis of Parkinsonian syndromes pathologic reductions were found in striatal 123I‐ioflupane uptake, thus achieving 92% sensitivity. Clinical disease severity of those patients was assessed using the Hoehn and Yahr (H&Y) rating scale. Striatum, caudate and putamen uptake ratios were significantly reduced [S/NS ‐ 0,49 (range 0,10‐0,82)], even in early stage of disease. Within the PD group S/NS ratios correlated with the disease severity assessed by H&Y rating scale, and with the duration of disease. Also, in group of 11 patients with hepatolenticular degeneration apparent loss of the 123I‐ioflupane uptake in the striatum was found [S/NS ‐ 1,1 (range 0,86‐1,5)], suggesting significant damage in presynaptic nigrostriatal dopaminergic nerve terminals. In 2 patients with EPS scans demonstrated severe decrease in striatal uptake forcing clinicians to change diagnosis. Conclusion: Our experiences shows that 123I‐ioflupane brain SPECT have an important role in detecting and monitoring nigrostriatal dopaminergic degeneration and could be routinely used in clinical practice to support the diagnosis of PS with dopaminergic deficit (PD, PSP, MSA) and to differentiate between other conditions. Also, 123I‐ioflupane could be significant diagnostic aid in detection and follow‐up of patients with hepatolenticular degeneration.
P47 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Neurology/psychiatry: psychiatry
P387 Decrease of prefrontal metabolic activity secondary to Subthalamic High Frequency Stimulation in obsessive compulsive disorder: a PET study F. Le Jeune1, B. Millet2, D. Drapier2, L. Mallet3, J. Peron4, M. Verin4; 1Centre Eugene Marquis, Rennes, FRANCE, 2Guillaume Régnier Hospital, Rennes, FRANCE, 3APHP, Paris, FRANCE, 4Pontchaillou Hospital, Rennes, FRANCE. Using the cross‐over, randomized and double blind methodological procedure of the STOC’s study, patients who were treated with a bilateral subthalamic nucleus (STN) Deep Brain Stimulation (DBS) underwent a 18FDG‐PET scan investigation in order to highlight the neural substratum of such a therapeutic approach. Methods A 18FDG PET study was done in ten patients with highly refractory OCD operated by high frequency bilateral STN DBS. PET analysis included three main effects: 1.Comparison of OCD patients on “Off stimulation” status with healthy control (HC) to determinate the modifications of glucose metabolism in refractory OCD; 2. Comparison of “On stimulation” and “Off stimulation” conditions to determine direct STN DBS effects; 3. Comparison of “responders” (decrease > 25 % at the Yale Brown Obsessive Compulsive Scale (YBOCS)) versus “non responders”. Results In “Off stimulation” condition, an hypermetabolism in OCD patients was observed in the right orbito‐frontal cortex right parietal lobe post central gyrus and in the bilateral putamen. When comparing to HC. Comparison of “On stimulation” versus “Off stimulation” conditions showed a significant decrease of cerebral metabolism in the left limbic lobe: cingulate gyrus and in the left frontal lobe: medial gyrus. Comparison of “responders” versus “non responders” groups showed significant hypo metabolism in the “responders” group in the right orbito‐frontal gyrus. Conclusions STN DBS would have a beneficial impact via circuits connecting subthalamic nucleus and OFC.
Poster Presentation
have idiopathic PD, 2 patients suspected to have PD, 5 patients with extrapyramidal symptoms and one patient with suspected multiple system atrophy underwent MIBG scintigraphy. Planar chest MIBG imaging was performed 15 min, 2, 3, 4 and 24 hours after tracer injection. Myocardial MIBG activity was quantified by means of a heart to mediastinum ratio (H/M ratio). Ratio over 1.8 was considered normal, between 1.8‐1.3 decreased, and less than 1.3 severely decreased. Normal H/M ratio was calculated from large group of patients who underwent MIBG scintigraphy because of various non‐neurological neither cardiological related conditions. None of these patients had clinical findings that suggested heart disease. Also, any drugs with known effect on the uptake of MIBG had not been administered to our patients. Results showed that H/M ratio from early and delayed MIBG scintigraphy were severely decreased (<1.3) in majority of patients diagnosed as IPD (9 of 12), in 1 of 2 patients suspected to have PD and in 2 of 5 patients with extrapyramidal symptoms. One patient with idiopathic PD, one with extrapyramidal symptoms and one with suspected PD have decreased H/M ratio (1.3‐1.8). Five of 20 patients were considered normal (2 with clinical diagnosis of IPD; 2 with extrapyramidal symptoms and one with multiple system atrophy; >1.8). Conclusions: It seems that myocardial MIBG imaging can be powerful, yet simple and affordable method in diagnosing impaired adrenergic activity present in PD, thus greatly assisting in differentiation of PD from other disorders with rigid akinetic symptoms. Additional studies with more patients are needed to clarify those findings and evaluate effects and impact of myocardial MIBG imaging on clinical diagnostic procedures and therapy of PD.
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P388 The Changes of the Brain Perfusion Pattern in Schizophrenic Patients in Relation to Symptom Improvement after Treatment with Olanzapine B. Fallahi1, D. Beiki1, F. Pooyafard2, S. M. Assadi2, H. Amini2, A. FardEsfahani1, N. Shahmansouri2, M. Eftekhari1, M. Saghari1; 1Research Institute for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF, 2Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF. Aims: SPECT studies in schizophrenia revealed inconsistent changes of regional cerebral blood flow (rCBF). Dopamine D2 blocking typical antipsychotic drugs are known to change the cerebral perfusion patterns of schizophrenic patients. Recently, atypical antipsychotics such as olanzapine have been shown to be more effective in the treatment of schizophrenia symptoms. However, there is a little information about the pattern of changes in rCBF and its relationship with symptom improvement after treatment with these drugs. The aim of this study was to evaluate the rCBF of the schizophrenic patients treated with olanzapine in a within‐subject design. Methods:Twenty‐one patients with schizophrenia participated in the study. Each subject was scanned and assessed according to PANSS and CGI in a medication‐free state and after 4 weeks of 15 mg/day fixed dose olanzapine treatment. Also a group of 12 cases without any history of neurological or psychological disorder was enrolled as a control group for comparing of the SPECT data. The changes in pattern of regional perfusion were evaluated between control and patient subjects and also in the patients group before and after treatment. The correlation between clinical improvement and the pattern of rCBF changes after treatment was also analyzed using Jonckheere‐Terpstra test. Results: A significant clinical improvement for all groups of psychopathological, positive and negative symptoms was seen in the patients (p<0.001). In different patients, hyperperfusion (mainly in the inferior prefrontal and temporal regions) as well as hypoperfusion patterns (mainly in the cerebellar, parietal and dorsolateral prefrontal regions) in comparison with control group were found. Most of the positive symptoms were correlated with hyperperfusion in frontal and temporal regions and several negative symptoms were correlated with hypoperfusion in these areas. A correlation was found between some symptom improvement and rCBF changes after treatment with olanzapine. The magnitude of increased rCBF before treatment may be considered as a predictor of clinical improvement in positive symptoms after treatment. However such a result was not met for negative and psychopathological symptoms. Conclusion: Different symptoms of schizophrenia may be related to the hyperperfusion or hypoperfusion pattern in the brain. Hyperperfusion in the frontal and temporal regions is mostly correlated with magnitude of positive symptoms before treatment and also degree of improvement in such symptoms after treatment with olanzapine. So it may be possible to use SPECT data for guessing about the patients’ response to treatment with olanzapine mainly for prediction of positive symptom relief.
P389 In vivo serotonin transporter (SERT) availability as a link between obesity and depression S. Hesse1, A. Villringer2, K. Naegler3, A. Bresch1, P. Schönknecht3, G. A. Becker1, J. Luthardt1, M. Patt1, M. Stumvoll4, U. Hegerl3, O. Sabri1; 1 University of Leipzig, Department of Nuclear Medicine, Leipzig, GERMANY, 2 Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, GERMANY, 3University of Leipzig, Department of Psychiatry, Leipzig, GERMANY, 4University of Leipzig, Medical Department III, Leipzig, GERMANY. Aim: Serotonergic mechanisms are implicated in both eating behaviour/obesity and depression. However, a possible interaction has not been demonstrated yet with in vivo neuroimaging. We used PET and C‐11‐DASB to measure SERT availability in correlation with BMI as a marker of obesity in depressive patients and healthy controls. Material and methods: Fourteen patients with neuropsychiatric disorders (age 35±14 years, 8 females, BMI 25±4) and 11 age‐ and gender matched healthy volunteers (BMI 26±3) underwent dynamic PET after IV injection of 520±145 MBq C‐11‐DASB. Volume‐of‐interest analyses of parametric images of distribution volume ratios (DVR) were performed after co‐registration of DVR maps with the individual 3D MRI data sets. Results: In healthy controls, DVR and BMI correlated significant in SERT‐rich brain regions (midbrain r=0.70, p=0.01, left thalamus r=0.71, p=0.01 and left head of the caudate r=0.70, p=0.08). In patients with depression, negative correlations were found between the head of the caudate (left r=‐0.60; p=0.03), the hippocampus/amygdala (r=‐0.702, p=0.007), hypothalamus (r=‐0.73, p=0.01) and raphe nucleus (r=‐0.64, p=0.02). Conclusion: The association of in vivo SERT availability and BMI in either obesity or depression indicates that a dysregulation of the brain serotonergic system (particularly in the hippocampus/ amygdala) is responsible for both. The positive correlation between SERT availability and BMI indicates a higher serotonergic activity in healthy subjects with increasing BMI. The inverse association in depressive patients suggests, however, a decompensation of this serotonergic mechanism at higher BMI, which probably leads to negative mood states.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 AIM: To evaluate the microvascular density (MVD) in low‐grade astrocytomas (LGA), anaplastic astrocytomas (AA) and glioblastoma multiforme (GBM) by immunohistochemistry technique using anti‐CD34, correlated with SPECT‐MIBI uptake parameters. Methods: This is a cross‐ sectional study with retrospective assessment data which evaluated 48 subjects, ages ranging from 20 to 73 years, all with diagnosis of brain tumors known as LGA (only diffuse type), AA and GBM who were admitted to the Hospital de Cancer da Fundação Pio XII de Barretos. The SPECT‐ MIBI images were initially classified as normal or altered by visual analysis. Then they were also considered for semiquantitative analysis through drawing of anatomical regions of interest (ROI) resulting in an index to correlate with the MVD parameters. DMV was determined with the use of monoclonal antibody anti‐CD34. Results: GBM, AA and LGA represented 50%, 16.7% and 33.3% of the sample, respectively. Thirteen images were visually normal, while 35 were considered abnormal. There were significant differences in MVD between AA and LGA (p = 0.04), but not between the normal and abnormal SPECT‐MIBI. The mean counts obtained by semiquantitative analysis from SPECT‐MIBI showed no correlation with MVD. Among GBM subjects it was not seen any significance, except for being most likely to find this histological test as abnormal. Conclusions: MVD had relationship with the histological grade between AA and LGA, but there was no correlation with SPECT‐MIBI.
P391 The value of 99mTc-Tetrofosmin SPECT scintigraphy in the grading of brain tumors having as gold standard the histopathological tumor grade. M. Daboudi, S. Koukouraki, M. Stathaki, I. Klinaki, N. Karkavitsas; University Hospital, Heraklion, GREECE. Aim: the aim of this study was to evaluate the role of 99m Tc tetrofosmin scintigraphy in the grading of brain tumors having as a gold standard procedure the postoperative histopathological findings. Materials and methods: 13 patients with clinically suspected brain tumors were included. All of them underwent a brain SPECT scintigraphy preoperatively. 25mCi of 99m Tc Tetrofosmin were injected i.v and tomographic images were taken 30 min p.i with a tomographic γ‐camera (Optima NX). Qualitative and semiquantitative analysis was performed using a Xeleris version 2 functional imaging workstation for the reconstruction of the images. Qualitative analysis was based on the visual analysis of the images in the transaxial, coronal and sagittal axis. For semiquantitative analysis the regions of interest (ROIs) method was used. ROIs were drawn around the lesion with high uptake of the radiotracer (Tumor) and on the contralateral side (background). Tetrofosmin Index (Tin) was calculated taking the tumor to background ratio (T/b). Results: Postoperative biopsy revealed high grade gliomas in 10/13 patients (group I). In the rest 3 out of 13 patients (group II) the brain lesion was characterized as low grade. The T/b ratio in all patients of group I was relatively higher (mean range 5.6‐62.6) compared to those with low grade (<3.77). Conclusion: Tetrofosmin index revealed from 99m Tc tetrofosmin tomographic scintigraphy could be a possible preoperative useful index in the grading of brain tumors.
P392 The role of the combined 99m Tc Tetrofosmin scintigraphy and MR perfusion in the grading of brain gliomas. M. Daboudi, S. Koukouraki, E. Papadaki, V. Stylianaki, M. Stathaki, A. Vakis, N. Karkavitsas; University Hospital, Heraklion, GREECE. Aim: The aim of this study was to evaluate the role of 99mTc‐Tetrofosmin scintigraphy in the grading of brain gliomas compared to MR perfusion technique and histopathological findings. Materials‐Methods: 12 patients with clinically suspected brain tumors were included. All of them underwent MR with a dynamic susceptibility contrast (DSC). MR perfusion technique and cerebral blood volume (CBV) maps were generated. The higher CBV values at the side of the tumor (CBVt) and the contralateral white matter (CBVwm) were measured. The CBVt/CVBwm was calculated {relative CBV (rCBV)}.Two‐three days later a brain SPECT scintigraphy was 99m performed. 25mCi of Tc‐Tetrofosmin were injected i.v and tomographic images were taken 30 min p.i with a tomographic γ‐camera (Optima NX). Qualitative and semiquantitative analysis was performed. For semiquantitative analysis the regions of interest (ROIs) method, around the lesion with the high uptake of the radiotracer (Tumor) and on the contralateral side (background) was used. Tetrofosmin Index was calculated taking the tumor to background ratio (T/b). Possible correlation between rCBV and Tetrofosmin Index was examined by linear regression analysis. Results: Histopathological findings showed 10/12 patients (group 1) high grade (grade III, IV) and 2/12 (group 2) low grade gliomas (grade II). All patients of group 1 demonstrated a scintigraphic Τ/b ratio (mean range 5.6‐62.6). MR perfusion revealed, rCBV value (mean range 1.59 ‐2.10). Regression analysis between MR and SPECT data were statistically significant (p value: 0.001). Conclusion: Besides the limited number of patients, 99mTc‐Tetrofosmin brain scintigraphy and MR perfusion technique may have a possible correlation in the preoperative grading of gliomas. These are the preliminary results of a prospective study.
P49 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Neurology/psychiatry: receptors / transporters
P48 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Neurology/psychiatry: tumours
P390 Spect-MIBI data assessment in astrocytomas in adults correlated with microvascular density S. P. Cavalcante, J. R. W. Almeida, C. Clara, M. J. Santos, S. Peres, S. M. Moriguchi, E. T. Rocha; Hospital de Cancer - Fundação Pio XII, Barretos, BRAZIL.
P393 Role of 123-I -FP-Brain SPECT studies in clinical management of Parkinsonian Syndromes. I. Kotsalou1, I. Karfis1, P. Georgoulias2, G. Aygoustatos3, A. Zoumboulidis1, N. Dimakopoulos1; 1NIMTS Hospital, Nuclear Medicine Dept., Athens, GREECE, 2Larissa University, Nuclear Medicine Dept., Larissa, GREECE, 3 NIMTS Hospital, Neurology Dept., Athens, GREECE. PURPOSE : Parkinsonian syndromes are caracterised by progressive degeneration of specific dopaminergic neurons, taking place in molecular level, which can be prematurely imaged by 123‐ I‐FP‐ scintigram as nigro‐ striatal neural loss. The aim of our study was to identify the role of 123‐I ‐ FP‐Brain studies in clinical management of Parkinsonian Syndromes, comparing the known
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P394 SPM Spatial Template for Dopamine Transporter Image Processing J. Trnka, K. Kupka; General Teaching Hospital, Praha, CZECH REPUBLIC. INTRODUCTION: There are several spatial templates for purposes of image spatial normalization presented in SPM. Only two of them ("PET.nii" and "SPECT.nii") apply to nuclear medicine. Both 123 TM assume perfusion scans. Unfortunately, it is hard to transorm an I‐Ioflupane (DatSCAN ) image onto perfusion template. The aim was to create a SPM template for DaTSCAN images, which is currently not available even in the SPM5 version. METHOD: Spatial normalization of a chosen DatSCAN image to all available SPM templates has been performed. The template which visually matched best the DatSCAN image has been chosen for further manipulation. A group of DatSCAN images of normal subjects have been normalized to that template. The mean image of this normalized group has been used as the new template for DatSCAN images. This basic procedure has been repeated for various groups of normal subjects. The resulting templates have been used in testing analyses via SPM. RESULTS: As the template which matched best particular DaTSCAN images has been chosen the SPM5 T1 template. Three groups of normal subjects defined according the age (less than 50 years, from 50 to 70 years, more than 70 years) have been normalized to T1 template in order to obtain the final DaTSCAN templates (mean images). Several analyses of DatSCAN examination between test subjects and the corresponding reference normal group (two sample t‐test) using the corresponding template have been performed. In all cases, the template provided very good reference for spatial normalization and inter‐group comparison. CONCLUSION: The T1 template included in the SPM5 package is a suitable reference for creation of dopamine transporter image spatial template.
P395 SPECT imaging of the Dopamine Transporter in normally behaving Dogs S. Vermeire1, K. Audenaert2, A. Dobbeleir3, E. Vandermeulen1, S. Janssens1, T. Waelbers4, K. Peremans1; 1Department of Veterinary Medical Imaging and Small Animal Orthopaedics, Faculty of Veterinary Medicine, Ghent University, Merelbeke, BELGIUM, 2Psychiatry and Medical Psychology, Faculty of Medicine Ghent University, Ghent, BELGIUM, 3 Department of Nuclear Medicine, University Hospital, Ghent University, Ghent, BELGIUM, 4Clinical Biology and Medicine of Small Animal, Faculty of Veterinary Medicine, Ghent University, Merelbeke, BELGIUM. Aim The dopaminergic system is involved in several neurological, psychiatric and behavioural disorders in humans and animals, including Parkinson’s disease, schizophrenia, human obsessive compulsive disorder and canine stereotypic behaviour. The dopamine transporter (DAT) regulates the synaptic dopamine concentration throuh presynaptic re‐uptake of dopamine. Since the expression of DAT’s is predominant in striatal dopaminergic axon terminals, functional imaging of striatal DAT binding index can be used as a biomarker to study the dopaminergic innervation. Single photon emission computed tomography (SPECT) and the specific radioligand [123I]‐FP‐CIT are widely used in human medicine to assess the availability of dopamine transporters in vivo in patients with neurological disorders. The aims of this study were to assess the striatal DAT ratios and the pseudo‐equilibrium of these DAT ratios in the brain of normally behaving dogs. Material & methods Nine healthy and normally behaving dogs (4 female, 5 male; mixed breeds; mean age 26.4 months) were used. Dogs were scanned at 5 different time points (3.5h; 4h; 4.5h; 5h; 5.5h) after the IV injection of the tracer (7.37 ± 2.58 [123I]‐FP‐CIT MBq/ kg bodyweight), under general anaesthesia. The time points were based on the pseudo‐equilibrium found in humans. SPECT imaging was performed with a triple head gamma camera (Triad, Trionix, USA), equipped with LEHR parallel hole collimators. Data were acquired for 30 minutes in step‐ and‐shoot mode and reconstructed with filtered back projection and application of a Butterworth filter. Image analysis was performed using region of interest (ROI) analysis with the Multimodality software of Nuclear Diagnostics (Nuclear Diagnostic, Sweden). Regions of interests were manually drawn over the left and right striatum as well as one covering the whole brain and using a previously described resolution‐independent method to define the DAT ratio (Dobbeleir et al., 2005). Results The obtained DAT ratios (mean ± SD) were at 3.5h, 4h, 4.5h, 5h and 5.5h respectively 14.82 ± 2.08, 14.65 ± 0.35, 16.05 ± 3.04, 16.35 ± 0.21, 16.15 ± 2.33. No statistical difference (at p< 0.05) was noticed between all time points. Consequently a pseudo‐equilibrium was observed between 3.5h and 5.5h after tracer administration. Over this time period a mean ratio striatum/background of 14.56±1.94 (± SD) was noticed. Conclusion By determining the
pseudo‐equilibrium and creating a dopamine transporter ratio database of normally behaving dogs, this study offers the opportunity for future research on the relationship between abnormal canine/human behaviour and a disturbed dopaminergic neurotransmitter system.
P396 I-123 ß-CIT-SPECT and Transcranial Sonography in Parkinson's Disease and in Atypical Parkinsonian Syndrome R. Lorenz1, D. Weise2, A. Schirbel1, J. Classen2, C. Reiners1; 1University of Würzburg Department of Nuclear Medicine, Würzburg, GERMANY, 2 University of Würzburg Department of Neurology, Würzburg, GERMANY. Aim: Reduced striatal Uptake in I‐123 β‐CIT‐SPECT is a well known finding in patients with presynaptic loss of the dopamine transporter. In a high rate of patients with Parkinson’s disease newer investigations showed an abnormal enlarged expansion of a hyperechogenic signal of the substantia nigra in transcranial sonography (TCS). The aim of this study was to investigate the relationship between the dysfunction of the dopaminergic neurotransmitter system and the sonographic abnormalit of the substantia nigra in patients with Parkinson’s disease (MP) and in patients with atypical parkinsonian syndrome (APS). Material and Methods: In retrospective, blinded study design 31 patients with MP (8 women, 23 men, age: 58.7±11.8 years) and 9 patients with APS (3 women, 6 men, age: 67.7±8.6 years) were evaluated. In each case a β‐CIT‐ SPECT (MultiSPECT III or E.cam duet, Siemens) and a TCS (Sonoline Elegra, Siemens) were performed. For both modalities a quantitative analysis was carried out. For TCS: Determination of the surface of the hyperechogenic area in the substantia nigra with the program GIMP (GNU image manipulation program). For β‐CIT‐SPECT: Calculation of the specific binding in the striatum with standardised ROIs in the respective transversal slice with the highest uptake using the medical image processing software OsiriX (OsiriX Medical Imaging software). Results: In the TCS the hyperechogenic area of the substantia nigra was increased in patients with MP more often (71%) than with patients with APS (13%); (p = 0,005; Fischer's exact test). In the β‐CIT‐SPECT a visually reduced uptake was found in all patients with MP (100%) and in all patients with APS (100%). The size of the hyperechogenic area of the substantia nigra correlated vice versa with the specific striatal binding in patients with MP (r =‐0.408; p = 0.023) in the linear regression analysis, but showed no correlation in patients with APS (r = 0.116; p = 0.670). Conclusion: In patients with MP the degeneration of the neurons of the substantia nigra leads beside a decrease of the specific binding to the dopaminergic system mostly also to an enlarged hyperechogenic area of the substantia nigra. Both methods β‐CIT‐SPECT and TCS can therefore be used in MP as quantitative markers of the neuronal degeneration, but a higher sensitivity was found with SPECT imaging. In patients with APS a neuronal dopaminergic loss was found with β‐CIT‐SPECT but no corresponding morphological abnormality could be demonstrated with transcranial sonography.
P397 Defective cerebral Gaba-A receptor expression in patients with systemic lupus erythematosus and central nervous system involvement. A. Mathieu1, A. Serra2, A. Vacca1, A. Cauli1, G. Loi2, M. Piga1, G. Sanna1, G. Porru1, A. Floris1, T. Figus1, M. Piga2; 1Reumatology-University Hospital, Monserrato-Cagliari, ITALY, 2Nuclear Medicine-University Hospital, Monserrato-Cagliari, ITALY. Aim: The GABA‐A receptor (rGABA‐A) interactions are critical in regulating neuronal excitability and in cognitive functions; several drugs can bind them exerting different effects. 123I‐ Iomazenil, a iodine radiolabelled ligand with high affinity for rGABA‐A and without intrinsic pharmacological effect at the tracing dose, has been utilized to perform brain SPECT in some neuropsychiatric disorders to investigate the cerebral rGABA‐A expression. The aim of this study was to investigate the rGABA‐A brain expression in a small series of patients affected by systemic lupus erythematosus (SLE) with central nervous system (CNS) involvement including recurrent transient episodes of memory loss. Materials and Methods: Nine female patients with SLE and cognitive defects characterized also by episodic memory loss underwent, in parallel, a complete neuropsychiatric evaluation including EEG, cerebral MRI, 99m‐Tc‐ECD brain SPECT and 123‐I‐IMZ brain SPECT. Results: All the patients tested showed diffuse or focal reduced expression of rGABA‐A by 123‐I‐IMZ brain SPECT, more relevant in frontal and temporal cortical regions and most of them reveled neither EEG nor brain ECD SPECT or brain MRI abnormalities. Conclusions: To our knowledge this is the first report in which an impaired cerebral rGABA‐A expression has been found in SLE patients with CNS involvement and cognitive defect in the absence of perfusional SPECT, MRI and EEG abnormalities. We hypothesize that a decrease in rGABA‐A density might be related to the neurological symptoms in our series. Nevertheless this relationship is faraway to be clarified and might be also due to a concomitant neurological condition, vasculitis, presence of autoantibodies or drugs which could interfere with rGABA‐A expression.
P398 Characterization of 4-18F-ADAM in monkey brains using positron emission tomography K. Ma1, W. Huang1, L. Shen2, C. Shiue1; 1National Defense Medical Center, Taipei, TAIWAN, 2Institute of Nuclear Energy Research, Taoyaun, TAIWAN. Objectives: It is imperative to develop a non‐invasive method in monitoring serotonin transporters (SERTs) changes in neuropsychiatric disorders. A new radioligand N,N‐Dimethyl‐2‐(2‐ Amino‐4‐18F‐Fluorophenylthio)‐Benzylamine (4‐18F‐ADAM) was synthesized recently and had been validated as a SERT imaging agent in rat models. However, in non‐human primate, the feasibility of 4‐18F‐ADAM in monitoring the status of serotonergic system is still unknown. In this study, we aim to explore 1) the biodistribution of 4‐18F‐ADAM, 2) image reproducibility of 4‐18F‐ 18 ADAM, 3) the sensitivity of 4‐ F‐ADAM in different dosage of fluoxetine treatment, and 4) the specificity of 4‐18F‐ADAM using 3,4‐methylenedioxymethamphetamine (MDMA) abused model in monkey brain using positron emission tomography (PET). Method: After various treatments in monkeys, they received a dynamic imaging for 3 h after 4‐[18F]‐ADAM (185 MBq) intravenous bolus injection, using a 3D mode PET scanner (EXACT HR+, Siemens, USA). Except for visual inspection, the specific uptake ratios (SURs) of the midbrain (MB), thalamus (TH), striatum (ST),
Poster Presentation
clinical classifications of Parkinsons Disease (PD) with one diagnostic Scintigraphic scale defined by the authors, using specific quantitative criteria. METHODS : 54 patients with clinically known or suspected PD (classified with UPDRS scale, Hoehn & Yahr, 1‐3 stades), matched for age, dopaminergic therapy, disease duration and severity and with normal or aspesific findings at CT/MRI, underwent 123‐I‐FP scintigraphic study. Brain SPECT was performed 3‐4 h post iv injection of 148 MBq 123‐I‐FP‐CIT (DaTSCAN, GE), using a dual head gamma camera. All the provided SPECT images were analysed qualitatively and quantitatively, calculating conventional putamen/occipital (p/o) and caudate/occipital (c/o) ratios compared to normal values provided by the data processing software (normal values p/o≥ 1.80 and c/o ≥ 2.00). RESULTS : The 123‐I‐FP SPECT scan was normal at qualitative analysis in 15 (27%) of 56 patients, excluding the diagnosis of PS and changing the therapeutic management, thus they were all classified at 1‐2 stage of UPDRS clinical Classification. On the other hand, brain study was pathological in 41 (73%) out of 56 cases, from which 6(15%) presented monolateral caudate or putamen reduced uptake (Scintigraphic Stage 1‐SS.1), 5 (12%) showed monolateral caudate and putamen reduced uptake or bilateral caudate or putamen reduced uptake (SS.2), 19 (46%) cases revealed bilateral caudate and putamen reduced uptake (SS.3). Finally, in 11 cases (27%) 123‐I‐FP‐CIT failed to bind to presynaptic dopamine transporters, due to progressed disease, clinically underestimated. Comparison of abnormal studies and clinical classification of patients, matched in 11 cases (20,3%), whereas revealed upstaging and downstaging in 24 (44,4%) and in 4 (7,3%) cases respectively. CONCLUSIONS : 123‐I‐FP SPECT scanning may help the clinical Neurologist to diagnose early and differentiate Parkinsonian Syndromes from other motor system disorders, to estimate the extent of Parkinsons Disease by comparing the clinical PDs Scale with the Scintigraphic Stades and follow up the progression of the disease. This knowledge helps the clinical specialist to stratify the appropriate therapy and define the therapeutical expectations.
S388 frontal (FR) regions in reference to cerebellum were measured. Results were expressed as mean±SD. Results: The SURs of 4‐[18F]‐ADAM in the six normal monkeys are 2.48±0.11 in MB, 1.60±0.17 in TH, 1.34±0.12 in ST, and 0.34±0.03 in FR. The test/retest variability is below 15% in SERT rich areas such as midbrain and thalamus. In the fluoxetine challenge study, the SURs are also significantly decreased in SERT rich areas. The SURs of 4‐[18F]‐ADAM are decreased 40%, 65% and 70% in monkey midbrain after treatment of 0.75mg/kg, 1mg/kg, and 2mg/kg fluoxetine, respectively. We also found the SURs of 4‐[18F]‐ADAM diminished 30% in midbrain and 35% in thalamus in monkey pretreated with MDMA (5mg/kg, twice a day for 4 consecutive days). Conclusion: The 4‐18F‐ADAM is a reliable radioligand for PET acquisition that may be useful for evaluating the status of serotonergic system in monkey brain.
P399 Reproducibility of Brain Dopamine Transporter Binding with Tc-99m TRODAT-1 SPECT in Healthy Younger W. Huang, K. Ma, C. Yeh, Z. Chung, P. Huang; Tri-Service General Hospital, National Defense Medical Center, Taipei, TAIWAN. Objective: 99mTc‐TRODAT‐1 Single photon emission tomography (SPECT) has become a potential means in evaluating dopamine transporter (DAT) related disorders of young subjects. A reliable reference data, however, is needed for clinical management. We evaluated the reproducibility of Tc‐99m TRODAT‐1 SPECT in DAT binding in the healthy younger. Methods: Twelve healthy young subjects with averaged 20 years old were recruited. The test/retest studies were performed 1 wk apart. The SPECT was acquired 4 h after Tc‐99m TRODAT‐1 (740 MBq) injection using a dual‐ headed camera equipped with ultra high resolution fan‐beam collimators (GE, Millennium VG). Specific uptake ratios (SUR) of striatum (ST) and subregions i.e. caudate (CA) and putamen (PU), using occipital cortex as reference, were measured. The test/retest difference ranges and variability were calculated. The reliability of the two measurements between test and retest was assessed by calculating the intra‐class correlation coefficient (ICC; ρ). Variability was expressed as mean ± SD. Results: Bilateral ST uptake could be visually recognized and semi‐quantitatively measured for SUR using a clinically used dual‐ headed SPECT. The maximal ranges of test/retest ranged 2.46% to 12.74% for ST, 0.91% to 33.83 % for CA and 0.34% to 17.36 % for PU, whereas the mean variability of the SUR between test and retest was 5.81 ± 4.00% for ST, 7.91 ± 9.04% for CA and 6.85 ± 4.76% for PU. All revealed good reliability with ρ = 0.86 for ST, 0.79 for CA and 0.81 for PU respectively.Conclusion: Measurements of SUR of the ST and its sub‐regions using Tc‐99m TRODAT‐1 SPECT might provide reproducible and reliable tools in clinical management of younger patients with DAT‐ related disorders.
P50 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Neurology/psychiatry: miscellaneous
P400 Cerebral glucose metabolism quantification in brain PET by SPM5 and CortexID. C. Ghetti, O. Ortenzia, G. Serreli, L. Concari, S. Gardini, P. Caffarra, L. Ruffini; AOU di PARMA, Parma, ITALY. The aim of this study was to compare the differences in quantification of cerebral metabolic rates for glucose (CMRglc) by two softwares SPM5 and CortexID in different types of patients i.e. progressive fluent aphasia, probable Alzheimer’s disease (AD), mild cognitive impairment (MCI). A group of 15 healthy age‐matched adults was also included in the study for comparison. Materials and methods: All brain PET scans were acquired under standard resting conditions using a GE Advantage DST scanner in 3D mode. The PET/CT camera has an axial field of view of 15.4 cm in 47 planes with a plane spacing of 3.27 mm; the axial resolution is 4.8 mm FWHM. Thirty minutes after injection of about 200 MBq FDG‐18F the images were acquired and reconstructed using the CT scan for attenuation correction. PET images were analyzed using SPM5 (http://www.fil.ion.ucl.ac.uk/spm) implemented on Matlab 7.01, the image set was spatially normalized using the SPM5 PET template, images were then smoothed with a Gaussian filter of 8 mm FWHM. Between‐group (patients vs. healthy subjects) differences in CMRglc were assessed on a voxel‐by‐voxel basis using independent sample t‐test with education as covariate when appropriate. Using SPM5 it is possible to identify, using a stereotaxic coordinate system, the hypometabolic clusters with their extension and severity. The quantification of glucose metabolism was also performed by CortexID (GE Healthcare) using the automatic 3DSSP analysis, which includes the reformatting of the orthogonal views to the AC‐PC lines and the comparison to a normal database. CortexID produces a Z‐score surface map that highlights the areas and the degree of glucose hypometabolism. The severity, measured in standard deviations from normal, is displayed in a color scale and a statistical overview is available for different cerebral regions showing the differences between left and right. Results and Conclusions: SPM5 is more accurate than CortexID in defining, spatially and statistically, the areas of glucose hypometabolism even if it requires a group of healthy subjects as controls and it is less user‐friendly than CortexID. Patients with MCI and progressive fluent aphasia showed a decrease of CMRglc systematically greater with CortexID than with SPM5. The results obtained with the two softwares seem to be similar for the analysis of healthy subjects without CMRglc decrement and severe AD patients, whereas the detection of focal clusters of hypometabolism in patients in an early phase of the disease seems to be easier, more reliable and straightforward using SPM5 than CortexID.
P401 Effect of triglyceride load on quantitative CBF measurements with 99mTc-ECD J. P. Soucy1, S. Ménard1, J. Hébert1, J. Teitelbaum2, L. Boucher1, L. Laflamme3, I. Sibon4; 1CHUM, Montreal, QC, CANADA, 2MNI, Montreal, QC, CANADA, 3HMR, Montreal, QC, CANADA, 4Hôp. Pellegrin, Bordeaux, FRANCE.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 We have assessed the effects of an acute triglycerides load on results of absolute CBF measurement with SPECT using a method derived from that of Matsuda et al. Our hypothesis was that by decreasing the brain/blood partition coefficient for 99mTc‐ECD, such a load would artefactually decrease CBF values. Method: Eleven healthy male volunteers (36 ± 11 years) underwent 2 studies using our standardized protocol, within an interval of 2 weeks. On study days, participants drank 235 mL of an energizing drink, with or without (randomized) 50 mL of canola oil. Forty‐five min later, and 2 min before tracer injection, blood was withdrawn to determine triglycerides levels. The subjects then underwent a 60 secs (2 secs/frame) dynamic A‐P acquisition from the lower thorax to the top of the cranium for hemispheric CBF measurements. Results: Canola oil ingestion resulted in an increase of triglycerides levels from a mean of 1,02 mmol/L at baseline to 1,23 mmol/L (p=0,002). Baseline hemispheric CBF (averaged L and R) was 45, 8 mL/100 g/min; while after canola oil ingestion it rose to 47, 6 mL/100 g/min. (p = 0, 02). There is a significant positive correlation between hCBF and triglycerides values (Pearson = 0, 4; p = 0,008). Conclusion: Ingestion of a substantial amount of lipids before hCBF measurement with 99mTc‐ECD resulted in increased values, as opposed to what we initially hypothesized. This suggests that while the increase of circulating triglycerides observed here does not lead to significant “trapping” of 99mTc‐ECD in the blood, it might affect its rheological properties enough to result in slowed transit of blood through a possibly increased number (recruitment) of capillaries, thereby increasing total transfer of the tracer to the brain. Asking patients to fast before such a measurement might ensure more reproducible measurements.
P402 Evaluation of intrathecal infusion drug devices functioning with scintipraphic technique. G. Garraffa, R. Ricapito, G. Arnone, V. Scaglione, F. La Seta; ARNAS Civico M. Ascoli G. Di Cristina, Palermo, ITALY. Introduction. Intrathecal infusion drug devices are currently used to treat pain and spastic diseases. These devices are made of a from a pump with a reservoir containing the drug connected to a catheter which ends in the spinal cavity. In case of symptoms relapse it is not easy to discover whether they depends on pump or catheter malfunction. In Nuclear Medicine, the use of endocanalar tracers which do not pass through channel or cavity where are administered, as 99mTc‐DTPA, can allow precise functioning evaluation of this infusion device. Materials and Methods. 5 patients affected from spastic disease (n=2) or pain resistant to therapy (n=3) were administered of mean 400 MBq di 99mTc‐DTPA, directly with transcutaneous puncture of abdominal reservoir. Planar static abdominal scans were performed every 3 hours, to follow tracer progression along infusion device, ended by “Whole‐Body” scans in case of visualization of spinal liquoral system. Images were analyzed only visually, focusing attention on devices slowing down or obstructions. Results. One patient showed regular device functioning, the remaining four showed pump (n=2) or catheter (n=2) malfunction. Conclusions. Endocavitary direct 99mTc‐ DTPA introduction can be useful in non‐invasive evaluation of functioning of intrathecal infusion drug devices. In order to better localize possible obstruction level, it can be more useful to employ more advanced complex techniques such as SPECT/TC.
P403 Acute effects of Mobile phone on regional cerebral blood perfusion (rCBP) evaluated by 99mTc-ECD brain SPECTinitial experience H. R. S. Farghaly; Faculty of Medicine-Assiut University, Assiut, EGYPT. Objectives: The aim of this study was to evaluate the acute effects of electromagnetic field (EMF) created from mobile phone on rCBP using quantitative brain SPECT. Methods: After written informed consent, 10 right‐handed healthy male volunteers with mean age of 30±3.8 years participated in the study. All the volunteers have been never used the mobile phone before. Each volunteer was subjected to two brain SPECT scans 2 hours apart using 6 mCi 99mTc‐ECD for each scan. Imaging started 30 minutes after injection. The volunteers was instructed not to speak, read or move before, during and 5 minutes after tracer injection. Each volunteer held a mobile phone with frequency of 900 MHZ and removed loudspeaker in the left hand. Exposure started 1 minute before tracer injection and continue for 9 minutes later. Both the injection and imaging were done in a quiet room with dim light for both scan. 25 automated brain regions were used to evaluate rCBP. We compared the average count/pixel of each brain region between the baseline and after exposure to mobile EMF scans. In view of the small numbers, only a descriptive analysis was carried out. Results: Comparing region by region between the baseline and after exposure scans there was a 25.7% decreased rCBP in the left middle and 23.6% in left inferior temporal regions. There was 4.8% decreased rCBP of the left hemisphere comparing to the right. Comparing the whole brain there was insignificant decreased (3.2%) rCBP of the after exposure scan. Conclusions: Except for decreased rCBP at the left middle and left inferior temporal regions may be as they are closer to the antenna, the EMF created from Mobile phones has no significant effect on the rest of rCBP of the brain.
P404 Registration of I-123 ADAM SPECT with MRI: Sequential and two-step methods. W. Yao1, C. Huang2, Y. Sun2, Y. Yang3, L. Shen4; 1Department of Nuclear Medicine, National Cheng Kung University Hospital, Tainan, TAIWAN, 2 Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan, TAIWAN, 3Department of Psychiatry, National Cheng Kung University Hospital, Tainan, TAIWAN, 4Radiation Application Center, Institute of Nuclear Energy Research, Taoyuan County, TAIWAN. Objectives: Usually, analysis of I‐123 ADAM SPECT is performed by drawing regions of interest (ROIs) or direct co‐registration to magnetic resonance images (MRI). Each method has limitations of observer bias or substantial registration bias. We propose a new concept of sequential registration along the time course of sequential SPECT images and a simplified two‐step method for more accurate registration with MRI. Methods: 11 healthy volunteers were recruited for I‐123 ADAM SPECT using a triple‐headed gamma camera with fan‐beam collimators after intravenous
S389
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P405 Low bone mineral density in female patients with multiple sclerosis C. Sioka, A. Georgiou, A. P. Kyritsis, S. Papakonstantinou, S. Tsouli, S. Pelidou, J. Kalef-Ezra, A. Fotopoulos; University Hospital of Ioannina, Ioannina, GREECE. AIM: To investigate the status of bone mineral density (BMD) in female patients with multiple sclerosis (MS) and the site that is predominantly affected. PATIENTS AND METHODS: Sixty two females with definite multiple sclerosis (mean age 38.5 years) and 82 age matched healthy females (mean age 39.2 years) were subjected to dual x‐ray absorptiometry (DXA) in both lumbar spine and left hip. Their DXA results were evaluated with both World Health Organization (WHO) and international Society for Clinical Densitometry (ISCD) diagnostic criteria in total and separately in lumbar and hip. RESULTS: There was a significant association of low BMD in patients with MS compared with control females (p=0.0011, according to WHO diagnostic criteria; p=0.0221, according to ISCD diagnostic criteria). By evaluating separately the results in lumbar and hip there was a significant statistical difference in the two sites between patients and controls according to WHO diagnostic criteria (p=0.011 and p=0.0125 respectively), but only in the hip according to ISCD diagnostic criteria (p=0.036). CONCLUSIONS: Patients with MS have low BMD and screening with DXA scan may be required for the prevention of future fractures. Furthermore, when applying the ISCD diagnostic criteria the most affected site seems to be the hip, result that may be due to patients’ motor disability.
P406 Cerebral FDG PET/CT - validation of Z-scores using healthy controls from our institution. H. R. S. Farghaly1, J. Piper2, A. S. Nelson2, M. M. Osman1, N. C. Nguyen1; Saint Louis University, Dep. Of Radiology, Div, of Nuclear Medicine, Saint Louis, MO, UNITED STATES, 2MIMvista Corp, Cleveland, OH, UNITED STATES. 1
European Cerebral FDG PET/CT ‐ validation of Z‐scores using healthy controls from our institution Objectives: Several normal data bases provide automated Z‐score statistics for brain FDG PET scan. Theoretically, any healthy subject (NC) should have Z‐score distributions very close to 0.0 as compared to a normal data base. We aimed to validate this assumption by using our own NC. Methods: Brain FDG PET images of 10 NC from our institution were extracted from their whole‐body FDG PET/CT scan and analyzed using a commercial software (MIMneuro, MIMvista Corp.) that provided Z‐score evaluation based on single brain or probalistic mapping and had 43 NC as normal data base. Single brain and probalistic mapping were evaluated together. Results: 78 of 83 (94%) locations showed normal distribution. Five (6%) locations were not normal distributed and were located in the anterior frontal lobes, precuneus and precentral gyrus, probably representing individual brain functions during FDG uptake phase. Z‐scores less than ‐2.0 or greater than 2.0 were found in 12.6% regions (n = 830) which was 8.1% higher than expected. But most of these regions (91.4%) showed normal Z‐score distribution. Conclusions: Z‐scores were less than ‐2.0 or greater than 2.0 in several brain regions of the 10 NC which may be due to systematic differences between our NC and the normal data base from MIMneuro. Physicians should be aware of this fact when using automated FDG brain analysis.
P407 The role of I-123 MIBG scintigraphy in the detection of direct cardiac sympathetic denervation in patients with multiple sclerosis (MS) X. Geronikola-Trapali1, T. Doskas2, I. Armeniakos1, A. Stefanoyiannis1, K. Voumvourakis2, P. Karabina1, S. Bakalis1, V. Lyra1, P. Zotou1, A. Prentakis1, G. Stampoulis2; 1University General Hospital “Attikon”, Nuclear Medicine Department, Chaidari, GREECE, 2University General Hospital “Attikon”, Department of Neurology, Chaidari, GREECE. The sympathetic nervous system has great influence on cardiovascular physiology and the importance of cardiac innervation abnormalities in the pathophysiology of various cardiac diseases has been emphasised. Patients with multiple sclerosis manifest autonomic symptoms which may cause significant disability. Aim :The purpose of this study was to evaluate direct cardiac sympathetic denervation in patients with multiple sclerosis (MS) by neurotransmission imaging using I‐123 MIBG in order to verify the correlation of its uptake and clearance with the clinical severity of the disease. Materials and methods: The study group consisted of 11 patients with MS (3 women and 8 men; mean age 38 years range 20‐56years) and a control group of 5 age sex matched healthy volunteers (2 women and 3 men ; mean age 43, range 25‐60). Neurological assessment was performed according to EDSS scale (Expanded Disability Status Scale).Six patients had relapsing ‐ remitting (R‐R) type and four had secondary progressive type (SP). Patients with cardiac, thyroid, psychiatric disorders as well as with diabetes mellitus and cerebrovascular events were excluded. Anterior planar imaging was performed 15 minutes and 4 hrs after slow i.v injection of 180‐250 MBq I‐123 MIBG. H/M was calculated by drawing regions of interest (ROI)s
over the upper mediastinum (M) and the heart (H) on the early and delayed images. The Wash out rate (WR) was calculated by application of the formula: WR=early image (H‐M)‐delayed image (H‐M) X100(%)/early image(H‐M). Results: At 15 minutes there was not a notable difference of the H/M ratio between the patients and the healthy subjects. At 4 hours the H/M ratio was significantly increased in patients with MS (1.57 ± 0.29),compared to that of the control group. The WR in 6/10 patients (R‐R type) was not significantly different from that of healthy volunteers (32.3 ± 16.5) vs (20.1 ± 9.0). However it is important to notice that in 5/10 patients with severe disease (SP type) the WR was remarkably higher (57.5 ± 18.5 vs 20 ± 9.0). Conclusions: We presume that the increase in WR, which is an index of sympathetic activity in relation to the ability of norepinephrine storage, might imply myocardial damage. According to the results of this preliminary study we believe that I‐123 MIBG myocardial scintigraphy may be a useful tool to directly and quantitatively evaluate cardiac sympathetic dysfunction in MS patients and aid in the assessment of disease severity and prognosis.
P408 Use of brain confirmation
perfusion
scintigraphy
for
brain
death
M. Grmek, J. Fettich, C. Groselj, M. Dolenc-Novak; University Medical Centre, Ljubljana, SLOVENIA. Introduction: New legislation where brain perfusion scintigraphy was recognized as a possible instrumental method for brain death confirmation was adopted in Slovenia in 2001. Before that scintigraphy was very rarely used for brain death conformation. Aim: The aim of the study was to review the use of brain perfusion scintigraphy for brain death confirmation in our department. Material and methods: All patients included in the research indicated clinical suspicion of death brain before brain perfusion scintigraphy was done on them. Results of investigations performed between year 2001 and 2008 are presented in the study. Brain perfusion scintigraphy: 600 MBq of 99mTc‐ECD was injected iv after quality control of radiopharmaceutical (more than 90 % 99mTc binding was requested). Tomographic acquisition was performed 20‐40 minutes later using double head gamma camera, equipped with HR collimator, using 128x128 matrix, 1.23 zoom and 90 steps for 20 seconds. Commercial reconstruction and processing software were applied. Results: In eight year period 259 investigations were done; 20 in the year 2001, the number increased to 51 in the year 2006. In 2007 an 2008 39 investigations per year were done. Altogether 253 patients were investigated. In 6 cases, because the cessation of brain perfusion was not confirmed on first study, brain perfusion scintigraphy was repeated 1 to 8 days after.174 (69%) patients were male and 79 (31%) female. They were in average 41±19 years old, the youngest 1 and the oldest 85. 38 patients (15%) were younger than 20. The cessation of brain perfusion was determined in 233 (90%) investigations. In the remaining 26 studies some tracer accumulation in brain was detected, in 15 (58%) patients in different brain areas, in part of cerebrum only in 3 (11%) cases and in cerebellum or brainstem only in 8 (31%) cases. All 6 patients were dead on repeated study. Conclusion: After legislation that brain perfusion scintigraphy is a suitable method for confirming the cassation of brain circulation was adopted, it became interesting in clinical practice. Brain perfusion scintigraphy for brain death confirmation is applicable also in children. All brain including cerebellum and brainstem has to be captured on acquisition.
P409 Relations between cardiac repolarization time interval and striatal dopamine transporter binding during valsalva manouvre E. Kauppila1, E. Vanninen2, T. Kuusela3, S. Kaurijoki2, L. Karhunen2, K. H. Pietiläinen4, A. Rissanen5, J. Kaprio4, J. Tiihonen2, J. Kuikka2; 1North Carelian Central Hospital, Joensuu, FINLAND, 2University of Kuopio, Kuopio, FINLAND, 3University of Turku, Turku, FINLAND, 4Helsinki University, Helsinki, FINLAND, 5Helsinki University Hospital, Helsinki, FINLAND. Background: Cocaine, analogue of dopamine transporter (DAT) imaging agent, and autonomic ganglion blockade lengthen cardiac repolarization time on ECG (QTc interval) in similar manner. If there is significant coupling between QTc interval and striatal DAT binding, QTc interval could possibly be used clinically in evaluation of brain dopaminergic dysfunctions. Aim: To evaluate QTc‐DAT relations in dynamic phases of autonomic challenge (Valsalva test = VAL) in healthy subjects. Material and methods: Thirty healthy subjects were studied (26.5 ± 1.7 yrs, mean ± SD; 15 women). Dopamine transporter (DAT) binding imaging was performed with iodine‐123 labelled 2beta‐carbomethoxy‐3beta‐(4‐iodophenyl) nortropane (nor‐beta‐CIT) single‐emission tomography (SPECT). Each subject performed VAL (15 s, 40 mmHg). Continuous blood pressure (BP) and single lead ECG were recorded getting R‐to‐R interval (RRI), QT interval and BP changes. QT intervals were measured at rest, at the longest RRI just after VAL (IV phase of VAL). RRI correction was calculated using Friedricia’s formula (QTc=QT/RRI1/3). Results: Striatal DAT binding ratio, [(striatum‐cerebellum)/cerebellum], was 2.63 ± 0.31; mean ± SD. Mean VAL ratio [RRImax (post‐VAL)/RRImin (during VAL) = VR] was 2.13 ± 0.44. QTc‐DAT correlation at phase IV of VAL was ‐0.51 (p = 0.008, n = 30). Tendency for relation was seen at rest between QTc interval or VR, and striatal DAT binding. BP changes were not related to striatal DAT. Conclusion: In this study we showed that relation between striatal DAT binding and QTc interval is enhanced under parasympathetic influence on sinus node and cardiac ventricles at IV phase of VAL.
P410 Methodologial comparison between nuclear physician with different levels of experience with Statistical Parametric Mapping in neurological disorders E. T. d. Rocha1, C. A. Buchpiguel2, R. Nitrini2, S. Tazima2, S. V. Peres1, M. J. Santos1, G. B. Filho2; 1Hospital de Cancer - Fundação Pio XII, Barretos, BRAZIL, 2Universidade de Sao Paulo, Sao Paulo, BRAZIL. Introduction: The visual analysis is the most used form of image interpretation, but observer dependent, while the analysis by region of interest technique is laborious. The automated
Poster Presentation
injection of 185 M Bq of I‐123 ADAM. Seven sequential scans were acquired: 10 minutes, and 1, 2, 3, 4, 5, and 6 hours after injection. Reconstructed images were registered to MRI using SPM2 and mutual information with sequential and two‐step approaches. The former uses sequential registration of all time points, while the latter uses 6 hours and 10 minutes images only. The midbrain and cerebellum areas were drawn on MRI. The mean counts of midbrain activity and the midbrain/cerebellum ratio (M/C Ratio) were then calculated for each method and compared to those obtained from direct registration method. Results: The mean counts of midbrain activity showed no difference between sequential and two‐step methods (166.1±4.3 vs.164.2±4.1, p=0.273), and significantly higher than in direct method (132.8±3.7, p<0.001). M/C Ratios also showed no difference between sequential and two‐step methods (4.40±0.37 vs. 4.28±0.34, p= 0.277), and significantly higher than in direct method (1.68±0.16, p<0.001). Conclusions: The sequential method provides better registration of I‐123 ADAM SPECT and MRI than direct method does. However, it is tedious and time‐consuming. The simplified two‐step approach yields similar results and is more practical for clinical I‐123 ADAM SPECT studies.
S390 methods have been employed in the assessment of brain perfusion abnormalities to search differences between groups, but still little explored in individual analysis. Objectives: Comparative analysis of clinical visual inspection by nuclear physicians with different levels of experience compared to the SPM (Statistical Parametric Mapping) for the detection of a varied spectrum of abnormalities in brain perfusion imaging in patients with neurological disorders (ND). Methods: We selected 14 images from various patients with ND, the visual analysis was performed by two nuclear physician (A and B), and initially classified as normal or altered. Sequentially, physicians reported which structures were compromised as well as the intensity of alteration. The images were compared individually with a databank of 32 normal images and the SPM maps generated were compared with the visual analysis. Results: From the 32 images of the normal databank, 4 maps were significant after correction for multiple comparisons, whereas 13 out of 14 images of patients with ND had altered maps, 9 at the voxel level and 4 at the cluster level. The SPM and the physician A completely agreed in 84.37% and 64.28% for the normal databank and ND, respectively. Moreover, the agreement with physician B was of 71.18% and 35.71%. Conclusion: The SPM replicated the findings described by the most experienced nuclear physician. This may suggest a possible use of SPM as a diagnostic aid in the clinical routine .
P411 Declarative memory and brain SPECT: effects of NREM and REM sleep deprivation (SD) on cerebral perfusion during a verbal task- Initial study. A. O. Tantawy1, H. N. El Tallawy2, A. Hussein1, H. R. S. Farghaly3; Education Psychology Dep. Faculty of Education, Assiut, EGYPT, 2 Neurology and Psychology Dep. Assiut University, Assiut, EGYPT, 3Nuclear Medicine Unit -Assiut University, Assiut, EGYPT.
1
Objectives: to evaluate and compare changes in regional cerebral blood perfusion as a result of NREM and REM sleep deprivation (SD) during verbal task retrieval using SPECT 99mTc‐ECD. Methods: twelve right‐handed healthy male subjects with mean age = 18.5 years participated voluntarily in the study after writing informal consents. The intelligence score (IS) of the 12 subjects was measured by Ravin's test. 4 slept normally (NS) and 4 with sleep deprivation from 10:00 PM to 3:00 Am (NREM sleep deprivation) as NREM sleep is more frequent in this period. The other 4 are with sleep deprivation from 3:00 Am to 8:00 Am (REM sleep deprivation) as REM sleep is more frequent in this period). All volunteers took a list of paired associated words to memorize at 10:00 PM. At 8:00 AM each volunteer underwent to baseline and post retrieval SPECT brain scans of two hour interval, using 6 mCi 99mTc‐ECD for each scan. A comparison of the average count/pixel of 25 automated brain regions between both scans was conducted. The non‐ parametric statistics was used in the analysis of the results. Results: 3 in NS, 3 in NREM sleep deprivation and 1 (has IS above 75%) in REM sleep deprivation subjects have high memory performance (HMP) and 1 in NS and 1 in NREM sleep deprivation (both have IS <75%), and 3 in REM sleep deprivation have low MP. During retrieval after NS there was 40.8 % increased activity in bilateral Middle Temporal (MTL) Lobes and 3% to 15% in the rest of brain regions. In case of NREM SD the main increased activity was in the bilateral frontal lobes (FL) 30.3% and in parietal lobes (PL) 21.3 %, compared to 15.5 % of bilateral MTL and 4% to10 % in the rest of brain regions. While in REM SD the main increased activity in the bilateral FL, bilateral PL and MTL showed increased activity of 47.4%, 32.4% and 11.5% respectively Conclusions: Activity in FL and PL were increased more in REM SD than NREM SD as a compensatory process to decreased MTL. These preliminary results suggested that memory performance is affected by level of IS and affected by REM SD more than by NREM SD.
P51 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radiopharmacy/radiochemistry: technetium & halogens
P412 Optimization in the preparation of high-purity 99mTc(V)-DMSA A. F. Sedda1, G. Rossi1, G. Atzei2, C. Cipriani2; 1ENEA, Rome, ITALY, 2S. Eugenio Hospital Nuclear Medicine Dept., Rome, ITALY. Introduction Diphosphonate radiolabelled with technetium‐99m are the most diffuse bone‐ seeking agents with an affinity for areas of active mineralisations. The complex 99mTc(V)‐DMSA has been adopted as imaging agent in medullary thyroid carcinoma, but has shown to be also useful in the imaging of other soft tissue tumors, of osteosarcoma and of bone metastases. The uptake of the tracer in the case of bone metastases shows, particularly in prostate cancer metastases, shows an high target/non target ratio. The exact mechanism of 99mTc(V)‐DMSA accumulation in tumours, bones and bone metastases is unclear. It was also demonstrated that 99mTc(V)‐DMSA has the highest affinity for cortical bone, and bonding was inhibited in the presence of phosphate and was stronger at lower pH. In the preparation of 99m‐Tc labelled compounds, the reduction of 99mTc‐pertechnetate is routinely performed by the addition of stannous cloride.. In order to avoid the presence of Tc(III) in the complex, we have optimized the experimental steps in the preparation of Tc(V)‐DMSA. Materials and methods The DMSA complex was prepared by working at different pH, and by bubbling oxygen analytical grade through the solution, in sterile conditions, at room temperature.The radiochemical purity was determined by TLC. The radioactivity measurements were performed by active phosphor storage screen (Cyclone‐Perkin Elmer) Results The biodistribution in patients affected with medullary thyroid cancer, head and neck tumors, osseous metastases from prostate and breast cancer generally shows a much lesser concentration in liver and a lesser uptake for kidney respect to commercial products.The images obtained 3‐5 h after injection are generally much “cleaner” in the visualization of tumour tissues than those obtained by commercial complexes, and especially for osseous metastases the accuracy is comparable with 99mTc diphosphonate scintigraphy, but with a much reduced uptake from healthy skeleton. Skeletal metastases arising form a wide variety of malignancies were evaluated using (99)Tc(m) diphosphonate bone scanning and 99mTc (V) DMSA scintigraphy. Whole‐body planar scans were obtained at ca. 3 h after injection of 400‐ 600 MBq of the tracer.The results show generally that renal cortical uptake is negligible,consistently with the very low level of 99mTc(III)‐DMSA in the preparation (<0.9 %). The avid 99mTc (V) DMSA concentration in skeletal metastases from a wide variety confirms the potential therapeutic indications for 188/186 Re(V) DMSA.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P413 Synthesis and biologycal behaviour of citrate complex
188
Re(CO)3
+
O. E. Klementieva, G. E. Kodina, V. N. Korsunsky, A. O. Malysheva; A.I. Burnazian Federal Medical Biophysical Center, Moscow, RUSSIAN FEDERATION. Introduction Investigation of chemistry and biological behaviour of 188Re(CO)3+ complexes is rather actual from the development of the novel radiopharmaceuticals point of view. The aim of the work was to evaluate the technology of preparation and accumulation of [188Re(CO)3+]‐citrate in tumors in vivo and tumor cells in vitro. Materials and Methods [188Re(CO)3+] was prepared from Na188ReO4 solution (Obninsk, Russia), K2[H3BCO2] and BH3∙ NH3. Then citrate buffer was added. The final concentration of anions were 5∙10‐3 mole/L. Radiochemical purity (RCP) was tested by TLC on silica gel ‐ MeOH/HCl 99:1. For in vivo experiments melanoma B16 bearing black mice F1 (CBAxC57Bl) were used. The direct radiometry of dissected organs was made in 1 and 3 h post injection. In vitro experiments were carried out with melanoma B 16 and breast carcinoma MCF‐7 cells. Accumulated activity was expressed in kBq/106 cells. Inhibition of cell viability after influence of [188Re(CO)3+]‐Cit3 was defined in the test with trypan blue. The results represented as survival percentage and mean lethal dose (D0). Results We assume, that the structure of the preparated complex can be described by the formula ‐ [188Re(CO)3+]‐Cit3. Radiochemical yield of [188Re(CO)3+]‐Cit3 was about 95%. Biodistribution data in 1 and 3 h post injection of [188Re(CO)3+]‐ citrate were shown below: time after injection, h blood uptake, %/g tumor uptake, %/g tumor/blood tumor/muscle 1
5.5 ± 0.3
12.7 ± 5.1
2,3
25,4
3
2.3 ± 0,3
10.3 ± 3.9
4,4
8,6
188
Na ReO4 was accumulated in cell cultures on practically insignificant level (max 4.7 kBq/106 cells). Maximal cell uptake of [188Re(CO)3+]‐Cit3 was 78.0 kBq/106 for MCF 7 cells and about 60.0 kBq/106 for melanoma B 16 cells. The curve of cell survival rate in a range of dozes from 74 up to 740 kBq/ml is described by the equation y= 81.47 ‐ 0.017x. D0 for melanoma B 16 cells is equal to 502.3 ± 29.5 kBq/ml. Conclusion: From the preliminary results (accumulation in tumors, cell viability and value D0) we can conclude that the investigated citrate complex of 188Re tricarbonyl can be used as promising agent for nuclear medicine.
P414 Labeling Conditions and Biological Behaviour of Nitrogen-Containing Bisphosphonate
188
Re
V. N. Korsunsky, G. E. Kodina, A. O. Malysheva, O. E. Klementieva, A. V. Abolenskaya; A.I. Burnazian Federal Medical Biophysical Center, Moscow, RUSSIAN FEDERATION. Zolidronic acid (ZA) was chosen as the object for investigation due to it therapeutic effect and accumulation in the bone metastases. Aim To investigate the reaction conditions (pH, concentration of SnCl2 and ligand, temperature, reaction time, adding of different antioxidants and carrier) for the preparation of 188Re‐ZA using carrier‐free 188Re from the 188W/188Re generator. Biodistribution of 188Re‐ZA was also studied. Materials and methods Rhenium‐188 was eluted from commercially produced 188W/188Re generator (IPPI, Russia). The labeling was carried out as follows: To ZA aqueous solution, aqueous solution of antioxidant (ascorbic, citric or gentisic acids), SnCl2 (in 1 M HCl), and 188Re eluate were added. The reaction mixture was allowed to react at different temperatures. Radiochemical yields of 188Re‐ZA, 188ReO4‐ and reduced hydrolyzed rhenium were determined by TLC on silica gel in acetone and paper chromatography in saline. Biodistribution of 188Re‐ZA was studied in rats with bone pathology. Results It was found that the labelling yield of 188Re‐ZA was 85 ‐ 90 % in the pH range 1.0‐2.0 at room temperature. The maximum labelling yields of 188Re‐ZA in optimum conditions were 94.4 %, 95.3 % and more than 90 % using ascorbic, citric and gentisic acids, correspondently. The results of 188 Re‐ZA biodistribution was showen in table (%/id):
normal
Organ
1 h
with bone pathology
Blood
11.7 ± 0.1 1.5 ± 0.9 7.7 ± 1.2 6.2 ± 1.0
Liver
2.4 ± 0.3 1.4 ± 0.6 1.8 ± 0.08 1.5 ± 0.3
Kidneys
11.9 ± 0.6 5.4 ± 0.8 10.4 ± 0.3 9.4 ± 0.9
Bladder
48.9 ± 7.1 69.6 ± 3.2 55.7 ± 1.4 65.4 ± 0.6
Femur normal
0.8 ± 0.3 0.6 ± 0.03 0.6 ± 0.04 0.6 ± 0.07
3 h
1 h
3 h
Femur with bone pathology
1.3 ± 0.01 1.0 ± 0.01
CDU
2.2
1.7
Conclusion Optimum conditions for labeling ZA with carrier‐free 188Re were: reaction volume 1.5‐2.0 ml, pH 0.5‐1.5, SnCl2 0.9‐1.0 mg/ml, molar ratio [ZA]/[Sn] 2‐3, concentration of gentisic acid 2.2‐ 2.6 mg/ml, reaction time 30 min at room temperature. The yield of labeling ZA with carrer‐free 188Re was 88‐91 % and about 94 % if carrier was added (0.02 mg Re/ml). Before intravenous injection pH of 188Re‐ZA was adjusted with NaHCO3 solution 188Re‐ZA showed moderate accumulation in the skeleton. CDU was 1,5‐2,4. The development of lyophilized composition for preparation of radiopharmaceitical in one step on the base of 188Re‐ZA are in progress now.
P415 A new procedure for leukocyte isolation and validation of this technique after 99mTc-HMPAO labelling M. M. Serrano Sanchez-Toscano1, F. Vega Martínez1, J. T. Gutiérrrez Coronado1, P. María Miragaya2, E. Hernandez Behm2, J. Daumal Domenech2, C. Peña Viloria2; 1Unidad de Radiofarmacia. Hospital Son
S391
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 Dureta, Palma de Mallorca, SPAIN, 2Medicina Nuclear. Hospital Son Dureta, Palma de Mallorca, SPAIN. AIM: There are many quality control parameters in leukocyte isolation and labelling with 99mTc‐ HMPAO procedure, but none of them explains the acceptable number of platelets on ready for labelling pellet. We follow the rules of the Spanish Agency of Drugs recommended procedure, according to which the cell‐rich plasma (CRP), extracted from whole blood after eliminating red blood cells (RBC), is centrifuged 10min at 150g to obtain the leukocyte pellet. We intend to check if platelet contamination decreases when the relative centrifugal force (CRF) is reduced to 100g, and assess its effect on leukocyte number compared to the usual procedure. Finally we validate all the parameters of this technique. MATERIALS AND METHODS: Blood venous samples of 30 patients were obtained for 99mTc‐HMPAO leukocyte labelling. In the first group (33% patients), CRP was centrifuged 10min at 150g, and for 67% remaining the RCF was 100g. Samples of whole blood, packed red cells waste after sedimentation step with HES, platelet‐rich plasma (PRP) and final supernatant were analyzed on a haemocytometer slide for counting of RBC, leukocyte and platelets for each patient. With corresponding results, we determinate the leukocyte isolation yield, RBC and platelet contamination, labelling efficiency,… RESULTS: ‐ Platelets number on pellet/CRP relationship was lower when RCF was 100g (17.80%±9.79% vs. 23.45%±11.17%). ‐ Leukocytes number on pellet/CRP relationship was also lower at 100g (88.68%±5.82% vs. 96.8%±2.7%). This difference was due to the reduction of the number of lymphocytes, which are not essential on later scintigraphy (75.75%±7.18% vs. 90.79%±4.74%). The variation on granulocytes number was not so high (94.41%±5.02% vs. 99.53%±0.86%). ‐ Obviously, RBC contamination with the modified procedure increases (9.18±9.19 vs. 3.27±0.97) because of lymphocytes loss in pellet with regard to the RBC number, which remains constant according to both procedures. ‐ Relationship platelets/leukocyte in 99mTc‐labelled leukocyte suspension was lower using the modified procedure (2.96±2.77 vs. 4.23±2.37). CONCLUSION: We suggest our alternative method for leukocyte isolation. Platelet contamination on labelled leukocyte suspension obtained was lower without a very significant loss on granulocytes. We hope that image quality will be better, but we will analyze it on a later study.
P416
demonstrated by correlation with mastersizer results). Furthermore, technetium labelling did not alter the characteristics of the NP, thus enabling the in vivo use of the radiolabelled‐NP as surrogates of their unlabeled counterparts for pharmaceutical biodistribution studies.
P418 Abstract withdrawn by authors.
99m
Synthesis of Tc-Citro-Folate for use as a Tumor-Targeted Radiopharmaceutical F. Yurt Lambrecht, B. Altıparmak, E. Bayrak, K. Durkan; Institute of Nuclear Science, Izmir, TURKEY.
P417
99m
Optimization of Tc labelling and quality control procedures of poly-(anhydride) nanoparticles for in vivo imaging P. Areses1, M. Agüeros2, G. Quincoces3, M. Collantes4, I. Bilbao4, E. Prieto1, L. López-Sánchez1, J. Richter1, J. Irache2, I. Peñuelas3; 1Department of Nuclear Medicine, University Clinic of Navarra, Pamplona, SPAIN, 2 Pharmacy and Pharmaceutical Technology Department, University of Navarra, Pamplona, SPAIN, 3Radiopharmacy Unit, Department of Nuclear Medicine, University Clinic of Navarra, Pamplona, SPAIN, 4Small Animal Imaging Research Unit. CIMA-CUN, Pamplona, SPAIN. Aim Nanoparticles (NP) are becoming important vehicles for targeted and maintained delivery of drugs. Poly‐(anhydride) nanoparticles have been suggested to improve the oral bioavailability of numerous drugs although very few biodistribution data in vivo are available so far. In this work, we describe an optimised simple procedure to label poly‐(anhydride) NP with 99mTc, develop a new fast quality control system and study the possible interference of the NP with tin colloids. Methodology NP (10 mg/ml) were labelled with 99mTc by reduction with SnCl2 (0.03 mg/ml) at pH=4.0 using helium‐purged solutions and vials to minimise oxygen content. Radiochemical purity of the preparations (percentage of radiolabelled NP, colloids and free 99mTc‐pertechnetate) was evaluated by a novel one‐strip double‐solvent TLC system. Firstly, the silica strip was developed using methyl‐ethyl‐ketone, was then air‐dried and developed again using 18% sodium acetate up to the middle. Strips were then read in a Mini‐GITA radio‐TLC scanner and quantified using the proprietary software. The size (and percentage) of unlabelled and radiolabelled‐NP and presence of non‐radioactive and radioactive colloids was studied also with a Zetamaster analyser system, used to measure the size and the polydispersion of the samples. Results NP were 99m radiolabelled with Tc with high labelling efficiency as demonstrated by TLC. The labelling conditions were optimized to achieve the maximum percentage of 99mTc‐labelled NP minimizing ‐ the percentage of 99mTc‐ colloids and free 99mTcO4 . The percentage of labelled NP was ≈ 94%, ≈ 6% colloids and ≈ 0% free Technetium. Sep‐pak and Sephadex‐G10 column techniques were also assayed for QC without success. The Zetamaster analyser system results showed a mean diameter of ≈210 nm for unlabelled NP (confirming digital electron microscopy data) and the presence of 2‐5 % of colloidal 2‐3 µm aggregates. Technetium‐labelled NP had a similar mean size and quantitative values confirmed results obtained from TLC: 92% Tc‐NP, 8 % colloids (2‐3 µm peak). Conclusions Optimum conditions for a fast and reproducible 99mTc labelling of poly‐ (anhydride) nanoparticles were obtained, and a novel TLC method developed that permits adequate quantification in one single TLC strip of all the interesting radioactive species (as
P419 Preparation and use experience of pentavalent 99m 99m TC ( Tc-DMSA-V) dimercaptosuccinic acid labeled with M. Molina, R. Iglesia, C. Calvo, A. Bonilla, A. Fernández, M. Camean, J. Castro; H.U.Virgen Macarena, Sevilla, SPAIN. Aim:To describe preparation, quality control and administration phases of 99mTc‐DMSA‐V at University Hospital Virgen Macarena during the last year. Material and Methods: During this 99m period, 5 explorations with Tc‐DMSA‐V have been carried out in patients in whom there was analitical and clinical evidence of medullary carcinoma of the thyroid relapse and negative reults were obtained by other imaging techniques. 99mTc‐DMSA‐V is a radiopharmaceutical drug of proved utility in the diagnosis of medullary carcinoma of the thyroid. As it is not commercially available in Spain, it must be prepared from commercial ready‐to‐use DMSA with a valency of III (which is indicated for renal parenchyma imaging). In the first place, off‐label use of 99mTc‐DMSA‐ V must be requested, this is prescribing pharmaceuticals for a purpose outside the scope of a drug's approved label. For the preparation of 99mTc‐DMSA‐V , RENOCIS© (CIS bio international) was used. Active ingredient: Dimercaptosuccinic acid: 1 mg. Excipients Stannous chloride,dihydrate 0.36 mg Inositol 50 mg Ascorbic acid 0,7 mg; In aseptic conditions, 1 mL of in‐ house prepared NaHCO3 (4.2%) was added to the vials followed by 740‐1480 MBq of 99mTc‐ Pertecnetate in a volume of 3mL. Afterwards, the mixture is stirred and inverted. It is then incubated at room temperature during 10 minutes and 10 minutes with O2 aseptic bubbling and, once quality controls are carried out and it is filtered with 0,22 μm, the drug can be administered to the patient. Quality controls were performed as follows: Stationary phase
ITLC‐SG
ITLC‐SG Whatman 3MM
TLC‐SG
Mobile phase
Metil Etil Cetone
NaCl 0.9%
Butanol: acetic: water (3:2:3)
Butanol: acetic: water (3:2:3)
Rf
0.0
0.9‐1.0
0.0
0.0
Rf
0.0
0.9‐1.0
0.4‐0.6
0.4‐0.6
Rf
0.9‐1.0
0.9‐1.0
0.65‐0.8
0.65‐0.8
Rf
0.0
0.0
0.0
0.0
Radiochemical purity was higher than 95% in all cases. All patients received a dose of 370 MBq 99m Tc‐DMSA‐V. Results:In 4 of the 5 examinations, imaging was positive. In one patient, confirmation of clinical evidence lead to a second intervention. Conclusions: This method could
Poster Presentation
Aim. Folate and folate conjugates possess high affinity for the folate‐receptor positive cells and tissues and are enable to use for diagnostic interest. Folate receptors are known to be responsible for cellular accumulation of folic acid and folate conjugates. In this study, a novel radiopharmaceutical, 99mTc‐citro‐folat, was synthesized and evaluated for its efficacy with in‐vivo studies. Methods. FR (folate receptor) positive carcinoma cells were targeted with a novel 99mTc‐ citro‐folate derivative. First step, achieved the citro‐folate synthesis, then synthesized citro‐folate conjugate was characterized with LC‐MS/MS and NMR. The conjugate was labeled with Tc‐99m. Radiolabeling efficiency was confirmed by RTLC and RHPLC quality control methods. Biodistribution of radiolabeled conjugate was performed in normal Albino Wistar female rats in order to investigate its potential as a diagnostic radiopharmaceutical. Tissue distribution was determined at three different time points. Results. Radiolabeling efficiency was confirmed as 97±1.0% by quality control methods (RTLC and RHPLC). The serum stability results shown that the radiolabeled folate conjugate remained stable in human serum up to four hours. Biodistribution results of 99mTc‐citro‐folat showed that statically high uptake in folate receptor rich tissues such as over and uterus. Conclusion.This study shows that 99mTc‐citro‐folat is probably used for imaging of folate receptor positive tumors.
S392
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
be a very useful, cheap, safe and fast tool in medullary carcinoma of the thyroid diagnosis in those centres where PET technology is not available.
P420 Quality control of 99mTc-DTPA for solid gastric emptying studies G. Pla Gonzalez, E. Moya, M. Quera, B. Soriano, S. Aguade; Hospital Universitari Vall D’Hebron, Barcelona, SPAIN. Aim The aim of the project was to determine wether the radiochemical purity of 99mTc‐DTPA (diethylene triamine pentaacetic acid) was preserved after exposure to heat, liquid egg and different hydrochloric acid (HCl) concentrations, the latter to determine the range of gastric pH (3‐5) in which it could remain stable. Materials and Methods Samples of pure 99mTc‐DTPA (37 MBq/0.2 mL), heated 99mTc‐DTPA at approximately 120ºC and 99mTc‐DTPA mixed with 0.2 mL liquid egg were prepared and incubated at room temperature with an excess of different hydrochloric acid concentrations (0.6 M; 0.4 M; 0.2 M; 0.08 M; 0.04 M; 0.01 M). After incubation instant thin layered chromatographies of the samples were performed. The developed test strips were cut into two sections at the middle pencil line. Each strip section was placed into test tubes and counted in a scintillation well counter (LKB‐Wallac 1282). The assay was performed three times and mean values were calculated. Results Radiochemical purity mean values of 99mTc‐DTPA 99m 99m samples were: 99.74% for pure Tc‐DTPA, 99.86% for Tc‐DTPA with egg and 97.8% for heated 99mTc‐DTPA. Radiochemical purity mean values of 99mTc‐DTPA samples incubated with hydrochloric acid are presented in the table below: 99m
Tc‐DTPA Radiochemical purity (%)
SERIES
0,6M 0,4M 0,2M 0,08M 0,04M 0,01M (pH 2) (pH 0.22) (pH 0.40) (pH 0.70) (pH 1.10) (pH 1.40)
99m
Tc‐DTPA + HCl
44,08
44,71
65,88
96,61
99,28
96,3
99m
Tc‐DTPA + heat + HCl 37,48
41,65
58,86
94,18
93,93
98,39
99m
Tc‐DTPA + egg + HCl 47,42
44,1
95,67
98,78
98,55
98,6 99m
From a hydrochloric acid concentration of 0.08 M (pH 1.10) radiochemical purity of Tc‐DTPA was preserved in all samples. However liquid egg samples extended their stability to 0.2 M (pH 0.70). Conclusion 99mTc‐DTPA keeps its radiochemical purity from acid concentrations of 0.08 M (pH 1.10) to lower concentrations. Moreover the addition of egg increases the stability to higher concentrations. All of this concentrations are higher than standard gastric concentrations.
P421 Genotoxicity effects of 99mTechnetium-MIBI peripheral blood lymphocytes
in
human
S. J. Hosseinimehr1, A. Ahmadi1, D. Beiki2, A. Mahmoudzadeh3, M. H. Babaei4; 1Department of Radiopharmacy, Faculty of Pharmacy and Pharmaceutical Research Center, Mazandaran University of Medical Sciences, Sari, IRAN, ISLAMIC REPUBLIC OF, 2Research Institute for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF, 3Laboratory of Cytogenetics, Novin Medical Radiation Institute, Tehran, IRAN, ISLAMIC REPUBLIC OF, 4Radioisotope Division, Nuclear Research Center, Atomic Energy Organisation of Iran, Tehran, IRAN, ISLAMIC REPUBLIC OF. Aim: Methoxyisobutyl isonitrile‐99mTC (99mTc‐MIBI) has been widely used as a nuclear tracer for myocardial blood flow imaging. The purpose of this study was to investigate genotoxic effects of 99m Tc‐MIBI in human cultured lymphocytes with adjusted radioactivity doses in same to patients. Materials and Methods: The radioactivity doses were determined in patients at five minutes after injection of 20 mci of 99mTc‐MIBI. The whole blood of human volunteers was incubated with 1, 2.3, 4 and 8µ Ci of 99mTc‐MIBI. After thirty minutes incubation, the lymphocytes were cultured with mitogenic stimulation to determine the micronuclei in cytokinesis blocked binucleated cell. Incubation of lymphocytes with 99mTc‐MIBI dose not induce any additional genotoxicity. Results: The increasing of frequency of micronuclei was not more than samples treated with 99m radiopharmaceutical up to two folders (8µ Ci) than concentration of Tc‐MIBI in blood in compare to control blood. Conclusion: With regards to widely usage of 99mTc‐MIBI in diagnostic, there are several studies to assess the genotoxicity induced by this agent on lymphocytes. There were proven the increasing micronuclei in lymphocytes after exposure to high radioactivity of 99m Tc‐MIBI, it was not observed any genetic damage at low doses of this radiotracer. Our study showed that incubation of whole blood cell with different doses of 99mTc‐MIBI same to blood concentration radioactivity in patients, was not showed any genotoxicity on lymphocytes. Key words: Radiopharmaceutical, Genotoxicity, 99mTechnetium‐MIBI, Micronucleus
saline. A total of 800 MBq of sodium technetium pertechnetate was added to each sample and incubated for 20 min at room temperature with regular mixing each 5 min. All samples were then centrifuged at 340g for 5 min at 4ºC. The radioactivity in the supernatant and sediment was measured and radiolabeling efficiency was then determined. Each sample was resuspended in 1 ml normal saline and incubated for 2 hr at room temperature. The samples were then centrifuged at 340g for 5 min at 4ºC and in vitro labeling stability was estimated. Results: The radiolabeling efficiency in group A was 88‐90% and in group B was 95‐99%. The labeling retention in all samples after 2 hr incubation post‐labeling was 95‐97%. Conclusion: In vitro radiolabeling of human erythrocytes using Sodium pyrophosphate diluted in stannous chloride is an efficacious, simple, safe and cost‐effective procedure and may replace the in vivo radiolabeling technique when the kit for the latter technique is not available.
P423 Alternative method of preparation of 99m Tc-Macroaggregated Albumin for pulmonary hypertension A. S. Capacho, M. Filipe, A. I. Santos; Hospital Garcia de Orta, Almada, PORTUGAL. Introduction: Intravenous injection of macroaggregated albumin (MAA) particles constitutes a major risk in patients with pulmonary hypertension (PH), since they are more prone to hemodynamic impairment. Therefore special considerations regarding the preparation of technetium‐99m (99mTc)‐labelled MAA are required, to assure safe pulmonary perfusion scintigraphic studies. The manufacturer’s recommended method of preparation (A) involves labelling with high activities (up to 3700 MBq of 99mTcO4‐) in order to keep an adequate number of particles, maintaining image quality. This method has some disadvantages, namely high radiation exposure and 99mTcO4‐ waste. Aim of the Study: 1) Implementation of a MAA labelling alternative method (B) and its evaluation in terms of radiochemical purity (RCP); 2) Evaluation of the number of particles administered in these patients and compliance with latest guidelines. Methods: MAA kits from GE Healthcare (Macrotec®) were labelled according to Method A (n = 29) or Method B (n = 121). Method A implies labelling with 3330 MBq of 99m TcO4‐ in a 10 ml volume, while Method B is performed as it follows: reconstitution of MAA kit with 10 mL of 0.9% Sodium Chloride, discharge of 5 mL MAA suspension; labelling of the remaining 5 mL suspension with 1480 MBq of 99m TcO4‐ in 1 ml (247 MBq ‐ 375000 particles ‐ per mL). RCP tests are performed in all kits according to the manufacturer’s instructions. RCP of 99m Tc‐MAA obtained by method A and B were compared. The number of particles administered in PH patients (n=128) from April 2007 to January 2009 were also evaluated. Results: Both preparation methods of 99m Tc‐MAA were not significantly different in RCP measurements: Meth A 99,7±0,4%, Meth B 100±0,5% (p= 0,47). The mean number of particles administered were 202554 ± 19273 (recommendation < 200 000 particles). All images obtained were of diagnostic quality. Conclusion: This 99m Tc‐MAA labelling method for pulmonary hypertension patients implies less radiation exposure and less 99mTc‐pertechnetate waste. This radiolabelling method can also be used in patients without pulmonary hypertension, resulting in less kit expenditure and in lower activities handled. On the other hand, our Nuclear Medicine Department complies with guidelines recommendations regarding the number of particles administered in PH patients.
P424
99m
Preparation of Tc-NE-Mem, a potential technetium-99m imaging ligand for NMDA receptor X. Zhou1, J. Zhang1, Y. Liu2, R. Zhang1, G. Cao1; 1Jiangsu Institute of Nuclear Medicine, Wuxi, Jiangsu Province, CHINA, 2JiangNan University, Wuxi, Jiangsu Province, CHINA. Objectives: To develop a new technetium labeled Memantine 99mTc‐ Ne‐Mem as a potential NMDA receptor imaging agent. Methods: A new labeling precursor 1‐N‐[N‐[2‐(S‐thioethyl)]‐N‐[2‐ [N‐[2‐(S‐thioethyl)amino]ethyl]aminoethyl] amino‐3,5‐dimethyladamantane (N‐ethyl‐N2S2‐ Memantine)was synthesized through six‐step reaction. The chemical structures of the labeling precursor was verified by IR MS and NMR. A series of studies were performed to optimize 99m labeling efficiency of Tc‐ Ne‐Mem by varying the pH value, varying the amount of N‐ethyl‐ N2S2‐Memantine,SnCl2∙2H2O,EDTA‐2Na and GH,labeling yield was measured by TLC. Results: The content of labeling precursor N‐ethyl‐N2S2‐Memantine was determined by HPLC(>97%). The optimal amounts of each ingredient were:N‐ethyl‐N2S2‐Memantine:5~10mg,SnC12 2~10mg,EDTA‐ 2Na 10~15mg,GH100~120mg and pH6.5~8.0.99mTc‐ Ne‐Mem was stable up to 6h in aqueous solution and radiochemical purity was over 92% at selected condition. Conclusions: A new technetium labeled ligand 99mTc‐ Ne‐Mem was successfully prepared. Labeling yield and radiochemical purity were all over 92% with good stability.The further study on biological evaluation and Radioligand receptor binding assays will be needed. Research Support: Project supported by National Natural Science Foundation of China (30770602)
P425
P422 In vitro radiolabeling of RBCs as an alternative to in vivo radiolabeling 1
2
2
2
M. H. Abushhiwa , N. S. Salehi , R. McGennisken , G. Wiltonb , K. Rodsetb2, D. Papadopoulosb2, I. Wallnerb2, B. Parry1, M. Lichtenstein2; Melbourne University, Melbourne, AUSTRALIA, 2Royal Melbourne Hospital, Melbourne, AUSTRALIA.
1
Objectives: our aim is to develop a protocol for in vitro radiolabeling of human erythrocytes using TechneScan® PYP® (Mallinckrodt, USA) to be used for heart gated cardiac scan as a cost‐effective and readily available alternative to the in vivo radiolabeling of erythrocytes using the same radiopharmaceutical. Materials and Methods: A total of 20 mL venous blood was collected from three human volunteers into 20 mL syringes containing 100 IU of heparin. Each sample was divided into 2‐mL ten samples and 1 µg of PYP diluted in 100 µl of stannous chloride (Sigma‐ Aldrich, Australia) was added to all samples. The samples were incubated for 15 min at room temperature with regular gentle agitation every 5 min. Each sample was divided into 2 groups; pre‐washed (A) and un‐washed (B). Group A from each sample was centrifuged at 340g for 5 min at 4ºC, the plasma was then removed and the samples were resuspended in 1 mL of normal
99mTc-Stannous colloid-labeled equine leukocytes: in vitro investigation M. H. Abushhiwa1, N. Salehi2, R. C. Whitton1, J. Charles1, P. M. Lording1, P. Finnin1, B. W. Parry1; 1Melbourne University, Melbourne, AUSTRALIA, 2 Royal Melbourne Hospital, Melbourne, AUSTRALIA. Aims: The current study investigates the in vitro behaviour of equine leukocytes radiolabeled in leukocyte‐rich plasma (LRP) with technetium‐99m stannous colloid (99mTcSnC). Materials and Methods: Venous blood samples were collected from ten healthy horses, LRP prepared and radiolabeled with 99mTcSnC following the standard procedure described by the manufacturer (Radpharm Scientific, Canberra, Australia). Leukocytes subpopulations were separated across double density gradient of Histopaque® and the distribution of radioactivity between polymorphonuclear and mononuclear cells was then determined. Other ten samples of equine LRP were divided into control and radiolabeled samples and the phagocytic function of radiolabeled and control leukocytes was then estimated using zymosan particles. In vitro labeling stability of the radiolabeled equine leukocytes with 99mTcSnC was measured in other ten samples at 3, 6 and 7 hr post‐labeling. Results: From the percentage of radioactivity associated with leukocytes, 83.8 ± 0.86% was in polymorphonuclear cells and 16.2 ± 0.86% was in
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P426 99mTc-stannous colloid-labeled equine leukocytes: in vivo investigation M. H. Abushhiwa1, N. Salehi2, R. C. Whitton1, J. Charles1, P. Lording1, B. Parry1; 1Melbourne University, Melbourne, AUSTRALIA, 2Royal Melbourne Hospital, Melbourne, AUSTRALIA. Aims: The current study investigates biodistribution of equine leukocytes radiolabeled in leukocyte‐rich plasma (LRP) with technetium‐99m stannous colloid (99mTcSnC) in normal horses and the ability of these cells to localize induced inflammation. Materials and Methods: A total of 120 mL of Venous blood was collected from seven healthy horses and LRP was then prepared. Approximately 4 GBq of 99mTcSnC (Radpharm Scientific, Canberra, Australia) were added to LRP and the mixture was incubated on a rotating mixer for 20 minutes at room temperature. Autologous radiolabeled leukocyte samples were injected intravenously into the animals. The horses were scanned at 10 and 30 min and at 2, 4, 6 and 24 h post‐injection using a gamma camera. Seven other healthy horses were injected intradermally with heat‐killed bacteria to induce inflammation and, 24 hrs later, intravenously with autologous radiolabeled leukocytes. The horses were scanned at 30 min and at 2, 4, 6 and 24 h post‐injection of the radiolabeled leukocytes. Results: No adverse effects of injection of autologous radiolabeled leukocytes were observed in any horse. In healthy horses, all scans revealed persistent high uptake by lungs up to 24 hr post‐injection and no uptake by other organs. 99mTcSnC‐labeled equine leukocytes in LRP failed to localise induced inflammatory foci in all horses. Conclusion: The current study showed that intravenous injection of autologous leukocytes radiolabeled with 99mTcSnC is a safe technique in horses, but the accumulation of radiolabeled equine leukocytes in lungs prevents them from localizing induced inflammatory lesions in this species.
P427 Consecuences of the Mo-99 supply crisis: A more efficient use is needed A. Zubiarrain, C. Abella, M. Porcar, D. Perez; Iba-Molypharma, Madrid, SPAIN. Aim IBA‐MOLYPHARMA manages in Spain 3 central and 14 (within) hospital radiopharmacies. The last Mo‐99 supply crisis (Petten reactor) has forced us to improve the efficiency of use of the Mo‐ 99/Tc‐99m generators. The outcome to the crisis has been different between the two kinds of radiopharmacies. It has been easier for us to deliver all the doses ordered from our customers in the case of central radiopharmacies (you can´t divide a generator in two parts but you can share the activity between hospitals), but we need some indicators in our balanced scorecard to measure this factor. The central radiopharmacy allows labelling less vials (using less activity) to prepare the same number of doses, but the doses are more precalibrated because is needed to transport them from the facility to the hospital. Materials & Methods We propose, in order to measure the efficiency of use of Mo‐99, this parameter Fe: Fe = Activity Tc‐99m administered / Activity Mo‐99 received We think this parameter really determines the efficiency because shows how many activity you are able to administer to your patients from the Moly you have received. We also control the number of elutions as another way of setting the efficiency. Results This are the figures for Fe, before the crisis (january‐june 2008), for central (C) and hospital (H) radiopharmacies: C1 C2 C3 H1 H2 H3 H4 H5 H6 H7 H8 H9 H10 H11 H12 1.4 1.3 1.2 1.0 0.9 0.9 0.7 0.7 0.6 0.6 0.5 0.5 0.5 0.5 0.5 This results show that the use of Mo‐99/Tc‐99m generators is more efficient, in our experience, in the case of central radiopharmacies. We consider Fe >1 means an efficient use of Mo‐99. The average number of elutions in the case of central radiopharmacies is 9.3, and 5.6 in the hospital radiopharmacies, showing also a better efficiency in the first case. The average value of Fe has grown, during the crisis period, from 0.7 to 0.8 in hospital radiopharmacies, showing a better use is possible. Conclusion The impact of the crisis has been low in Spain (maybe because the major part of doses are prepared in commercial radiopharmacies). However, this impact has been almost null in the case of hospitals supplied from central radiopharmacies because, in our experience, the central radiopharmacies make possible a more efficient use of the Mo‐99. Next step should be to measure (and reduce) the time between manufacturing and use of a generator.
P428 Simplified method for the determination IOFLUPANE radiochemical purity
of
the
123I-
L. Pérez, F. Campos, M. Martin, J. Ribera, A. Roque, I. Navales, F. Pons; Hospital Clinic, Barcelona, SPAIN. AIM: to compare two previously reported methods for the determination of the radiochemical purity (RQP) of DATSCAN (123I‐ioflupane), with a new and faster radiocromatographic method which avoids the use of toxic solvents. MATERIALS AND METHODS: The new method proposed ( method 1) for determination of RQP of 123I‐ioflupane is a radiocromatography on ITLC‐SG ( 6 cm strip ) with distilled water as mobile phase. Method 2 was performed on ITLC‐SG (10 cm) with chlorofom/methanol (9:1). Method 3 consists in a Sep‐pack C‐18 column which was eluted first with 10 ml of water (A) and later with 10 ml of ethanol (B); the radiactivity of the column (C) and both eluates was measured, providing the RQP as B/(A+B+C). A radiocromatograf BIOSCAN AR‐ 2000 was used for the reading of the chomatographic strips.For the determination of the activity of the eluates (method 3) an activimeter Atomlab 200 was employed. Seven mixtures of 123I‐ ioflupane with sodium 131I‐iodide were made to get a collection of RQP points ranging from 16 %
to 99 %. The mixtures were processed 3 times with each of the described methods, to test the reproducibility (coefficient of variation) and the mean time of execution. RESULTS: An acceptable lineal correlation between method 1 and 2 was found (r: 0.982).The method 3 gave a bad correlation (r: 0.88) with both methods 1 and 2, with a constant overestimation of the RQP, because a part of the free iodide was retained on the Sep‐pack C18 column. Retardation factors (Rf), variation coefficients and execution times obtained are showed in the table: Rf Method
Reproducibility (CV %)
1 ‐ ITLC‐SG water
2. 5 %
0
1
2 minutes
2 ‐ ITLC‐SG chlor:metha 1.6 %
1
0.4
4 minutes
3 ‐ Sep‐pack ethanol
131
123
0.4 %
I‐ioflupane
123
I free Execution time
I free in water eluate 5 minutes
CONCLUSION: methods 1 and 2 are reliable for the RQP determination of 123I‐ioflupane in a conventional radiopharmacy, although the new method here proposed ‐ only using water like mobile phase ‐ is faster, inexpensive, easy to perform, and avoids the use of organic solvents mixtures. Method 3 resulted cumbersome, and correlated poorly with the others.
P52 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radiopharmacy/radiochemistry:
PET
radiopharmaceuticals
P429 Is citrate or heparin the best anticoagulant for obtaining high 18 yield of F-FDG labelled leucocytes? C. Eldjarn, M. Wigen Andersen, S. E. Hagve, R. Moen Forfang, K. Rootwelt; Rikshospitalet University Hospital, Oslo, NORWAY. Background: Successful in vitro labelling of human leukocytes with 18FDG was first reported by Danpure and Osman in 1992. They used acid‐citrate without dextrose as anticoagulant. In vivo studies were not performed. In all subsequent in vivo studies by other groups heparin has been used as anticoagulant. Since heparin ‐ as opposed to citrate ‐ can increase granulocyte activation, it might be advantageous to substitute heparin with citrate in the labelling process. Methods: Blood samples were drawn from the authors in euglycaemic state. Leukocyte counts varied between 4.8‐8.6x109/L. Typically 25 mL blood was anticoagulated with isotonic acid‐citrate or with heparin. The citrate and heparin samples were thereafter divided in three vials each. Subsequent labelling was performed as a downscaled version of our routine method for 99mTc‐ labelling of leukocytes, except that the leukocytes were not resuspended/incubated in cell‐free plasma but in isotonic citrate, Ringer acetate, physiological saline or phosphate buffered saline (PBS), and that 99mTc‐HMPAO was substituted with 18F‐FDG incubation at 37°C. 27 subsamples were labelled. Student's t‐test for paired samples was used for statistical evaluation of labelling yield. Trypan blue exclusion test was used for viability check after labelling. One of the authors had a wholebody PET‐scan after reinjection of autologous leukocytes labelled with 18F‐FDG by the use of citrate for anticoagulation and PBS for resuspension/incubation. Results and discussion: Resuspension/incubation in isotonic citrate or Ringer acetate yielded only 5‐13% 18F‐FDG incorporation, and was discarded from further evaluation. The mean labelling yield was 30.2% for citrate anticoagulation combined with NaCl for resuspension/incubation; 31.3% for heparin/NaCl; 36.5% for citrate/PBS; and 38.4% for heparin/PBS. The higher labelling yield with PBS resuspension/incubation compared with NaCl resuspension/incubation was the only statistically significant difference between groups (p=0.036). The trypan blue tests showed more than 99% viable cells. The PET study in the control showed normal leukocyte uptake in spleen, liver and bone marrow, with only low uptake in the brain. Our lower labelling yield compared to the yield reported from studies of patients with inflammatory diseases are explained by the lower leukocyte counts in normals, and that our in vitro studies were performed with decayed 18F‐FDG with low specific activity. Conclusion: 18F‐FDG leukocyte labelling yield is equally good whether heparin or citrate is used for initial blood sample anticoagulation. Because of lack of granulocyte activation citrate anticoagulation should be preferred in nuclear imaging practice.
P430 Comparison of 99mTc-Herceptin and changes in FDG incorporation to predict response of breast tumour cells to anti-EGFR treatment R. Cheyne, L. A. C. Trembleau, A. C. McLaughlin, T. A. D. Smith; University of Aberdeen, Aberdeen, UNITED KINGDOM. Purpose The 25% of breast cancer patients with tumours exhibiting high HER‐2 expression derive clinical benefit from treatment with the antibody Herceptin. However Herceptin is very expensive and ineffective in patients with HER‐2 negative tumours. Currently HER‐2 expression is determined on tumour tissue invasively obtained using surgical biopsy procedures. Here we have examined the potential utility of FDG‐PET and SPECT with 99mTc labelled herceptin for predicting response to herceptin. Materials and methods Breast tumour cell lines exhibiting normal expression (a) MDA‐MB‐468, intermediate overexpression (b) MDA‐MB‐453 and high overexpression (c) SKBr3 of HER‐2 receptor. The dose of herceptin inhibited 20% of cell growth for each cell line determined using MTT and clonogenic assays. Labelling of Herceptin with 99mTc:Herceptin pre‐reduced using dithiothrietol (DTT) in 1:5000 mole ratio (0.5mg herceptin with 2.5mg (DTT)) followed by washing on 50K Da mwt cut off centrifugation filter. Reduced herceptin (0.1mg) mixed with SnCl2 (final concentration 0.1mM) and thiourea (final concentration 0.5mM) in 25µl for 1h at room T then washed on centrifugation filter. Labelling efficiency >98%. Cells incubated with media containing 37KBq/ml 99mTc‐herceptin for 2h, washed uptake determined by gamma counter. FDG incorporation: untreated and cells treated for 6 days with IC20 (6day) doses of herceptin incubated for 20min with 18F‐FDG (37KBq/ml), washed with phosphate buffered saline and uptake determined by gamma counter. Glucose transport: Uptake of o‐methyl‐glucose over 5 second period. HK activity. Results Incorporation of
Poster Presentation
mononuclear cells. The mean ± standard error percentage of phagocytic function of the radiolabeled equine leukocytes was 95.3 ± 0.35% (control = 95.8 ± 0.25%). The labeling retention of equine leukocytes at 7 hr post‐labeling was 95.5 ± 0.39%. Conclusions: Radiolabeling of equine leukocytes in LRP with 99mTcSnC did not cause any adverse impact on the phagocytic function of these cells. Radiolabeled equine leukocytes retained a high percentage of radioactivity for up to 7 hr post‐labeling. As a large percentage of radioactivity was associated with polymorphonuclear leukocytes, 99mTcSnC‐labeled equine leukocytes may be more suitable for imaging acute inflammation than chronic inflammation.
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99mTc by cells incubated with 99mTc‐herceptin: (a) 28±2 (b) 77±13 (c) 389±90 (Units: cpm/mg protein/37KBq). LD20 dose (µg/ml) for cell line (a) 170 (b) 0.015 (c) 0.005 Change in FDG incorporation after LD20 and LD50 (% control) (a) 89±9, ND (b) 98±12, 65±17 (c) 96±15, 110±13 (units: %control). Only MDA‐MB‐453 cells treated with the higher dose of herceptin exhibit a change in FDG incorporation compared with untreated cells. HK activity after LD50 dose of herceptin (% control): (a) 90±17 (b) 41±5 (p<0.005) (c) 71±11 (p<0.005) Glucose transport after LD50 dose of herceptin (% control): (a) 107±12 (b) 76±23 (p<0.01) (c) 88±16. Conclusions Changes in FDG incorporation in herceptin‐treated compared with untreated breast tumour cells do not consistently correspond with response. Decreased HK activity is not always associated with decreased FDG incorporation. Uptake of 99mTc‐Herceptin by untreated breast tumour cells corresponds with sensitivity to herceptin.
P431 Synthesis and preliminary evaluation of Carbon-11-MetaHydroxyephedrine: A false transmitter agent for the hearth neuronal imaging A. Carpinelli1, M. Matarrese1, R. Vannulli1, P. Todeschini1, S. Todde2, S. Stucchi3, L. Gianolli1; 1CNR-IBFM, Scientific Institute H San Raffaele, Milano, ITALY, 2CNR-IBFM, Università Milano Bicocca, Scientific Institute H San Raffaele, Milano, ITALY, 3CNR-IBFM, Università Milano Bicocca, Scientific Institute H San Raffaele, Milano, ITALY. Aim: The aim of this study was to investigate the possible presence of abnormal presynaptic sympathetic nerve function in patients with CSX, as a possible cause of microvascular dysfunction using PET and [11C] metahydroxyephedrine as a tracer. Materials&Methods: 11 [ C]metahydroxyephedrine was synthesized by direct N‐ methylation of metaraminol free‐base with [11C]CH3I, (1 mg of precursor in dimethylformamide, 5 min at 100°C), and purified by semipreparative reversed phase HPLC. A new chromatographic method was developed using a column Synergi Polar‐ RP 80A (250x 10mm, 10μ, Phenomenex). This is an ether‐linked phenyl phase with hydrophilic end‐ capping specifically designed to maximize retention and selectivity for polar and aromatic analytes. The mobile phase was 5% Ethanol/ 95% 0.1 M Ammonium 11 acetate (v/v). [ C]mHED was collected (Rt = 10 min) and sterilised by a 0,22μm filter (Millex‐GP, Millipore) into a sterile vial. No carrier added [11C]CO2 was produced via the 14N(p,α) 11C reaction using an a IBA Cyclone 18/9 cyclotron. [11C]CO2 was delivered to the radiosynthesis modules for producing [11C]CH3I via two distinct methods. The classical “ wet method” was based on reduction of [11C]CO2 with LiAlH4 in tetrahydrofuran and subsequent treatment with hydriodic acid (HI) to give [11C]CH3I, using a modified, fully automated synthesis module, (PET Tracer Synthesiser, Nuclear Interface). The second method was carried out in “ gas phase” and this exploits the conversion of [11C] methane into [11C]methyl iodide by free radical iodination with iodine vapour at elevated temperature (720°C) in gas phase, using a Tracerlab FXC synthesis module (GE‐ Medical Systems). Results: The radiochemical yield was 10% from EOB, not corrected for decay (n=60); specific activity was 1‐3 Ci/μmol. The radiochemical purity of [11C]mHED was > 98% as determined by radio HPLC. The final product was sterile and apyrogenic. The qualitative analysis of the PET ‐ [11C]mHED study showed a homogeneous uptake of the tracer in all myocardial segments in the controls, while it showed a significant reduction in the uptake of [11C]mHED in 5 patients with CSX (71.4%). Conclusion In conclusion 71.4% of patients with CSX showed obvious [11C]mHED uptake focal defects, particularly significant in the mid sections of the heart. The CMR study demonstrated, in the same patients, a subendocardial hypoperfusion during the i.v. administration of dypiridamole. These data confirm that the chest pain may have an ischemic cause; a regional adrenergic tone dysregulation could be the basis of the microvascular dysfunction in some patients with CSX.
P432 [18F] EF5 shows fast metabolism in tumour bearing mice O. Eskola, T. Grönroos, S. Forsback, M. Haaparanta, O. Solin; University of Turku, Turku PET Centre, Turku, FINLAND. Aim: [18F]‐2‐(2‐nitro‐1[H]‐imidazol‐1‐yl)‐N‐(2,2,3,3,3‐pentafluoropropyl)‐acetamide ([18F]EF5) is used for imaging tumour hypoxia with PET. In previous studies in humans and rats [18F]EF5 has shown high in vivo biostability. The aim of this study was to determine the degree of metabolism of [18F]EF5 in the plasma, muscle, liver and tumour of PC‐3 human prostate tumour bearing nude mice. Materials & Methods: [18F]EF5 was synthesized by electrophilic fluorination using high specific radioactivity [18F]F2 gas as labelling reagent. [18F]EF5 was purified with semi‐preparative HPLC and formulated for injection in physiological saline. [18F]EF5 was injected intravenously (3.6±1.2 MBq) into non‐anaesthetised mice and the tracer was allowed to distribute for 120 minutes. Blood and tissues were rapidly removed and plasma was separated from whole blood by centrifugation in heparinised tubes. Mouse tissue samples were homogenised in methanol and centrifuged to separate the supernatant from precipitated proteins. Plasma and tissue homogenate samples were then applied on a silica gel 60 HPTLC plate. [18F]EF5 added to mouse plasma was used as a standard on the plate. The HPTLC plate was developed in chloroform/methanol (70:20), dried and exposed to an imaging plate (Fuji Imaging Plate BAS‐ TR2025) for 4 h. The plate was scanned for radioactivity with a Fuji BAS 1800 scanner Results: The average amounts of unchanged [18F]EF5 in mice plasma (n = 4), muscle (n = 3), liver (n = 3) and tumour (n = 5) at 120 min post injection were 37% (range 32‐41%), 38% (range 34‐46%), 3% (range 2‐3%) and 19% (range 11‐33%), respectively. Polar radiolabelled metabolites were detected in all tissues. Additionally, a metabolite more lipophilic than [18F]EF5 was seen in the liver and tumour. Conclusion: [18F]EF5 is extensively metabolised in mouse plasma and tissues, which is a new finding as compared to previous metabolism studies in rats and in humans, where [18F]EF5 shows high metabolic stability. This might affect the use of mice as experimental animals 18 in PET imaging to differentiate the oxygen‐dependent binding of [ F]EF5.
P433
3
Synthesis of F-18 Labeled N -fluoroalkylated carbonucleoside analogues S. Ahn, G. An, K. Lee, E. Kim, T. Choi, G. Chun; Korean Institute of Radiological & Medical Sciences, Seoul, REPUBLIC OF KOREA.
Introduction : As an extension of our work to develop radiolabeled carbocyclic nucleoside analogs for imaging HSV tk reporter gene expression we have already reported our success of getting PET imaging with I‐124 labeled cyclopentenylIodouracil derivatives. Recently other research group showed that N3‐radiofluoroalkyl substituted thymidine can be a PET imaging radioligand. Here we report our study on the synthesis of N3‐[18F] fluoroalkylated carbonucleoside derivatives. Materials and Methods: We synthesized cis‐1‐[4‐(hydroxymethyl)‐2‐cyclopenten‐1‐yl]‐thymine (carbocyclic 2’3’‐didehydro‐3’‐deoxy thymidine) via Pd (o) catalyzed coupling reaction, then converted to its O‐tetrahydropyranyl ether and then converted to N3‐propyl and ethyl tosylate precursors. 2', 3’‐dihydroxy carbocylic thymine precursors were also prepared by osmium tetroxide oxidation followed by protection of hydroxy group and N3‐propyl tosylation. Radiofluorination of this precursors with nBu4N[18F] or K[18F]/K222 in amylalcohol/Acetonitrile co solvent followed by acid hydrolysis and HPLC purification yielded cis‐N3‐[18F]‐fluoroethyl‐4’‐ hydroxymethyl‐1’‐cyclopenten‐2‐yl‐thymine, cis‐N3‐[18F]‐fluoropropyl‐4’‐hydroxymethyl‐1’‐ cyclopenten‐2‐yl ‐thymine, cis and trans isomers of N3‐[18F]‐fluoropropyl‐4’‐hydroxymethyl‐2',3'‐ dihydroxy‐1’‐cyclopentanyl ‐thymine. The biological evaluation using MCA hepatoma and MCA‐ TK cell lines were performed. Results: The radiochemical yields were 4‐5% for N3‐fluoroethyl derivative and 10% for N3‐fluoropropyl analogue. Radiochemical purity was over 95% and calculated specific activity was > 37GBq/μmol. The invitro cytotoxicity experiment showed that all 4 derivatives are much less toxic than ganciclovir. Cell uptake is currently in progress. Conclusion we prepared 4 analogues of N3‐fluoroalkylated carbocyclic thymidine derivatives as new radioligands for imaging HSV tk gene expression.
P434 Ga-68 DOTA-Nle-Asp-DPhe-Alpha-MSH(4-11) Amide (Napamide) PET For Melanocortin 1 Receptor Targeting In Melanoma V. Rinaldi1, M. Aurilio1, C. Arrichiello1, A. Barbieri2, G. Palma2, C. Arra2, S. Lastoria1, L. Aloj1; 1Nuclear Medicine, Istituto Nazionale Tumori, Fondazione "G. Pascale", Napoli, ITALY, 2Animal Facility, Istituto Nazionale Tumori, Fondazione "G. Pascale", Napoli, ITALY. Malignant melanoma constitutes a great clinical challenge. Early diagnosis and prompt surgical removal are the only currently available cure. Management of metastatic disease is extremely critical as systemic chemotherapy and external beam radiation therapy have proven to be rather ineffective. Targeted radionuclide therapy may provide a means of delivering high doses of radiation to tumor deposits. There are several reports that indicate over‐expression of the melanocortin 1 receptor (MC1R) in metastatic melanoma, and radiolabeled alpha‐MSH analogs, a high affinity ligand for MC1R, are being developed for imaging and therapy. We are developing models to evaluate tumor targeting and treatment efficacy of DOTA coupled derivatives of alpha‐ MSH. We are currently using a short linear DOTA‐alpha MSH analog, [Nle, Asp, D‐Phe, Lys (DOTA)]‐ alpha MSH (4‐11) (NAPAMIDE). This peptide has been labeled with Ga‐68 and we have utilized it in binding and animal imaging experiments. The B16‐F1 murine melanoma cell line has shown an elevated number of binding sites (Bmax ~150000 per cell, Kd 5.3 ± 2.8 nM) for this peptide. These values are in agreement with those reported by other groups. Human cell lines tested (M14 and SK‐MEL5) have shown very poor binding (Bmax <10000 sites per cell) in vitro. In order to assess imaging capabilities for the receptor densities expressed by B16‐F1 cells we implanted cells in the right thigh of C57/BL6 mice and performed PET imaging after 10 days (tumor size .2‐.4 g). Specificity of binding was assessed by co‐injecting 100 fold excess cold compound in some animals. ROI analysis was used to estimate organ and tumor distribution of the compound after imaging that was performed 15‐20 min after injection (1‐2 MBq per animal). Ga‐68‐DOTA‐NAPAMIDE. Tumors were clearly visible on the PET images in the right thigh and significant reduction of intensity was observed in the blocking experiments. SUV values in the tumors (max 0.26 and mean 0.15) were significantly higher than in the blocked tumors (max 0.18 and mean 0.06). Cut‐up experiments in the same animals yielded similar results (unblocked average 5.5 % injected dose/g, blocked 3% injected dose/g). Receptor densities obtained with B16‐F1 xenografts are suitable for PET imaging in animal models. We are currently evaluating how these receptor densities compare to those shown by human melanoma metastases by quantitative autoradiography to determine whether this approach may be useful in clinical studies.
P435 Use of a Modular System for Routine Automated Production 11 of C- Flumazenil without HPLC Purification G. Quincoces1, I. López-Sanchez1, P. Areses2, R. Catalán1, S. Peña1, M. Collantes3, E. Prieto2, I. Domínguez2, P. Garrastachu2, J. Martí-Climent2, J. Richter2, I. Peñuelas1; 1Radiopharmacy Unit. University Clinic of Navarra, Pamplona, SPAIN, 2Department of Nuclear Medicine. University Clinic of Navarra, Pamplona, SPAIN, 3Small Animal Imaging Research Unit. CIMACUN, Pamplona, SPAIN. 11C‐Flumazenil(11C‐FMZ) is useful to estimate central benzodiazepine receptors by PET. 11C‐FMZ has become the ideal radioligand in a variety of pathologies, providing valuable information about the focus localization of the epileptogenic regions in clinical PET studies and also in PET investigations in patients with cognitive impairment. Aim Design and set‐up of a fully automated system and control interface for rapid synthesis and purification of 11C‐FMZ without HPLC. Material and Methods All the synthetic operations were performed using the Modular Lab System (Eckert & Ziegler). The system was configured using 1 motorized syringe, one 6‐way valve, two 3‐way 3‐valve modules and a peltier based reactor used for evaporation of solvents. Radiation detectors on reaction vial, sep‐pak and reactor permitted proper trailing of the activity within the system. As precursor 1 mg desmethyl‐FMZ (3.3 µmol) dissolved in 300 µl dimethylformamide was used. After 2 min reaction with I11CH3, the crude solution was pushed through a sep‐pak Alumina N plus cartridge, previously conditioned by washing with 8 ml CH2Cl2. Dimethylformamide and un‐reacted precursor were washed to waste with 2 ml dichloromethane. Product was eluted to peltier reactor with 4 ml of the (dichloromethane/acetonitrile/ethanol, 100/5/0.625, v/v/v)], where solvents were evaporated in a stream of Argon gas at 100 ml/min during 300 sec at 95 ºC. Product was then dissolved in saline and transferred to the product vial passing it through a 0.22 µm Millex GV filter unit. Results After 57 synthesis runs, the mean production yield was 2.1 GBq EOS radiochemical pure 11C‐FMZ. Three syntheses failed: 1 due to
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 an operator error and 2 due to electromechanical problems with the motorized syringe. Synthesis time from I11CH3 was just 10 min (2’ reaction, 3’ purification and elution, 4’ solvent evaporation and 1’ formulation). Residual solvents (DMF, CH2Cl2, EtOH and MeCN) were below levels stated in PhEur (DMF < 880 ppm; dichloromethano < 600 ppm, ethanol < 5000 ppm and acetonitrile <5000 ppm)as determined by GC [HP Series II 5890 gas chromatograph with a Phenomenex Zorbax‐WAX plus column (30 m × 0.25 mm × 0.25 µm)] Radiochemical purity was determined by radio‐HPLC (HP Agilent 1100 Series, with a Zorbax XDB‐C8 column) Conclusions We have herein developed an automated procedure to synthetise 11C‐FMZ using the modular Lab System without using HPLC. The final product is radiochemically pure (> 95%), sterile and free from pyrogenes.
FE@SUPPY:2 13,1
0,015
Conclusion Differences in Michaelis‐Menten constants and limiting velocities represent differences in steric and electronic properties of the whole structures. Within comparable structured groups, stability differences between methyl‐, ethyl‐ and fluoroethyl substituents are negligible. Therefore, with respect to carboxylesterase stability [18F]‐fluorethyesters are a useful alternative. The project was supported by the FWF (P19383‐B09, Markus Mitterhauser), the OeNB Anniversary Fund (11439, Markus Mitterhauser) and the Austrian Academy of Sciences (DocfFORTE, Daniela Haeusler).
P438
P436
18
1 3
and 1
Quality 1
Control 2
of 2
J. Ungersboeck , , H. Eidherr , S. Li , M. Backer , J. Backer , A. Krivoshein2, M. Mitterhauser1, K. Kletter1, R. Dudczak1, B. Keppler3, W. Wadsak1,3; 1Medical University of Vienna, Vienna, AUSTRIA, 2Sibtech Inc., Brookfield, CT, UNITED STATES, 3University of Vienna, Vienna, AUSTRIA. Aim: Tumor growth is accompanied by angiogenesis to supply tumor cells with sufficient oxygen and nutrients. VEGF (Vascular Endothelial growth Factor) is known to be one of the most important key proteins for regulation of angiogenesis. Radiolabelling of VEGF with PET‐ radionuclides would allow in vivo molecular imaging of angiogenesis and tumor growth at early stages. It has already been demonstrated that pegylation of single‐chain‐VEGF (scVEGF) and subsequent coupling to cyclic chelators, such as DOTA and NOTA, provides a suitable construct for radiolabelling with radiometal‐ions. Thus, the aim of this study was the reliable preparation and quality control of radiolabelled 68Ga@scVEGF‐PEG‐NOTA for future application in µPET and human PET studies. Methods: A 50mCi 68Ge/68Ga generator (6 months in use) was eluted with 68 6ml 0.1N hydrochloric acid. This Ga‐eluate was concentrated using a small anion exchange cartridge (Chromafix 30‐PS‐HCO3‐) that was finally eluted with 3x100µl water. Sodium acetate was added to the second fraction as a buffer to avoid the formation of colloidal Ga(OH)3. A solution of scVEGF‐PEG‐NOTA which was a generous gift of Sibtech, Inc.(USA), in acetate buffer was added; the vial was sealed and allowed to react under varying conditions. The dependence upon reaction time, temperature and amount of scVEGF‐PEG‐NOTA as well as pH was determined. A quality control system was set up comprising radio‐HPLC (SEC column; mobile phase: phosphate buffer 50mM, pH=6.8) and radio‐TLC (ITLC‐SG strips; mobile phase: citrate buffer, pH=5) to determine integrity and radiochemical purity. Results: The recovery rate of the concentrated radioactivity in the second 100µl water fraction was 59.3±6% within 7‐9 minutes (n=14). An activity concentration of up to 4‐6 GBq/ml was achieved. A distinct dependence upon the amount of scVEGF‐PEG‐NOTA and pH was observed. At pH‐values below 4, only incomplete conversion was achieved. An influence of the amount of acetic buffer and reaction time wasn´t observed. Quantitative conversion of [68Ga]GaCl3 to 68Ga@scVEGF‐PEG‐NOTA was found under stirring of the reaction mixture, containing 88,5µM scVEGF‐PEG‐NOTA, for 10 minutes and pH=5 at ambient temperature. Conclusion: We herewith present the rapid and feasible preparation of gallium‐68 labelled scVEGF and its quality control. The radiosynthesis was evaluated regarding different parameters and optimum reaction conditions were determined. Radiochemical yields were sufficient to serve for future applications in µPET or human PET studies.
P437 On the stability of radiolabelled esters: A Carboxylesterase assay L. Nics1,2, D. Haeusler1, L. K. Mien1, W. Wadsak1, D. Ettlinger1, H. ElSamahi2, K. H. Wagner2, R. Dudczak1, K. Kletter1, M. Mitterhauser1; 1Medical University of Vienna / General Hospital of Vienna, Vienna, AUSTRIA, 2 University of Vienna, Vienna, AUSTRIA. Aim Amongst functional groups for radiolabelling, ester functions play an important role. Esters are accessible via direct radiolabelling procedures on the corresponding acid functions or indirectly by suitable leaving groups. Biologically, they are cleaved by ubiquitous carboxyl esterase enzymes. These enzymes belong to the most prominent biocatalysts in Phase I metabolism, yielding in the unlabelled acidic core and the corresponding radioalcohol. Hence, our aim was to access the stability of a series of radiolabelled esters (‐methyl, ‐ethyl, ‐fluoroethyl) to give an estimate and to compare the influence of those different substituents on ester stabilities. Materials and methods Experiments were performed in triplicate (n=3), using different amounts of the particular unlabelled substrates, knowing that the radiolabelled structures exhibit comparable chemical behavior. Experiments were conducted with β‐CIT, FE@CIT, FP‐CIT, MTO, ETO, FETO, FMZ, FFMZ, CFN, FE@SUPPY and FE@SUPPY:2 under physiological conditions (porcine carboxyl esterase 80IU, 37°C, phosphate‐buffered saline ph7.4). The incubation reactions were stopped by adding acetonitrile/methanol (10:1) at 0, 60, 120, 180, 240, 360 minutes, respectively. After centrifugation (10000rpm, 3min) of the reaction mixtures, the obtained supernatant was subjected to HPLC analysis: Agilent 1100 system with a diode array UV detector at a range from 235 to 255nm; stationary phase was a 5µm particle size RP‐18 column, in each case. The mobile phase was a mixture of different amounts of buffered hydrophilic solution and acetonitrile, optimized for the respective substrates. Results The in vitro assays showed Michaelis‐Menten constants (Km) and limiting velocities (Vmax) as follows: Substrate
Km[µM] Vmax[µM/min]
β‐CIT
175,1
0,101
FE@CIT
182,6
0,142
FP‐CIT
521,4
0,131
MTO
162,0
1,470
ETO
168,6
1,351
FETO
115,1
1,543
FMZ
39,8
0,208
FFMZ
54,4
0,245
CFN
2133,0 0,041
FE@SUPPY
20,1
0,038
6-[ F]fluoro-L-dopa metabolism in rat peripheral tissues S. Forsback, T. Kalliokoski, K. Mikkola, O. Eskola, O. Solin, M. Haaparanta; Turku PET Centre, University of Turku, Turku, FINLAND. Aim: The aim of this study was to gain understanding on metabolic pathways of 6‐[18F]fluoro‐L‐ dopa (FDOPA) in rat peripheral tissues by modulating the metabolism by enzyme inhibitors of aromatic L‐amino acid decarboxylase (AADC), catechol‐O‐methyl transferase (COMT), monoamine oxidase inhibitors (MAO A and MAO B) or their combinations. Previous studies have shown that pre‐treatment with AADC reduce the peripheral FDOPA metabolism and improve its uptake in the brain during PET studies. New diagnostic uses of FDOPA for endocrine cancers and for diagnosis of focal hyperinsulism in infancy have aroused interest in understanding its metabolism in detail especially in pancreas. Materials & Methods: Male Sprague‐Dawley rats weighing 250‐300 g were used. This study was approved by the Animal Experiment Board of the Province of Southern Finland. Rats were pre‐treated i.p. either with saline (non‐treated) or inhibitors of AADC, COMT, MAO‐A, MAO‐B or with their combinations. FDOPA (about 35 MBq) was injected i.v. into a tail vein. At 30 min after tracer injection the rats were killed and blood and tissue samples were collected. Radioactive metabolites of FDOPA were analysed from plasma and tissue samples by a radioTLC method. Results: Under non‐treated conditions the main metabolite in plasma, striatum, pancreas and liver at 30 min after the tracer injection, was 3‐O‐methyl‐ [18F]fluoro‐L‐dopa (3‐OMFD). This was also the case after pre‐treatment with the AADC inhibitor. The COMT enzyme inhibitor suppressed the formation of 3‐OMFD in all tissues. With MAO‐B inhibition no changes in metabolic pathways were observed when compared to the non‐treated animals at the same time point. Conclusion: Based on these results and previous reports we conclude that peripheral tissue metabolism of FDOPA can be modulated by different enzyme inhibitors. The effect of these pre‐treatments on FDOPA uptake and tissue distribution needs further investigation. Increased understanding of the metabolism of FDOPA will help in successful tracer utilisation e.g. for pancreatic imaging.
P439 Innovative approach for an automated synthesis of 218 [ F]fluoroethylcholine using a single step template reaction. M. Asti, D. Farioli, M. Iori, C. Guidotti, A. Filice, A. Versari, D. Salvo; Santa Maria Nuova Hospital, Reggio Emilia, ITALY. Aim: [18F]‐labelled choline analogues, such as 2‐[18F]fluoroethylcholine, have suggested to be the new generation of choline derivatives for the imaging of prostate and brain tumors. Herein, an innovative approach for synthesizing 2‐[18F]fluoroethylcholine, in a single step contemporary reaction between the reagents, was developed. Materials and Methods: Automated synthesis of 18 FECH was performed by using an FXF‐N Tracer Lab Synthesizer and by reacting [18F]‐Fluoride with 1,2‐bis(tosyloxy)ethane (diOTsEt) and N,N‐dimethylethanolamine (DMAE). The reaction was carried out in anhydrous condition and in presence of tetrabutylammonium as transfer phase catalyst. The product was obtained in a single step template reaction by adding to the [18F]‐ Fluoride residue acetonitrile solutions containing 15 mg of diOTsEt and 0.03 ml of DMAE respectively. The reaction vessel was heated at 95°C for 10 minutes and then tempered at 50 °C. 18 After labelling, the crude solution containing FECH was filtered by passing through two plus C‐ 18 and two plus QMA cartridges and collected in a bulb vessel. Subsequently, the purified 18FECH solution was trapped into a cation exchange cartridge (plus CM). The cartridge was washed with 10 ml water and 5 ml ethanol, and 18FECH was eluted with 2 ml physiological solution. Quality controls on the final product were performed by means of TLC, GC and HPLC equipped with 18 conductimetric, UV and radiometric detectors. Results: FECH was prepared with an yield of 48 ± 2 % uncorrected for decay (n = 4) in ca. 43 minutes. Radiochemical purity was always greater than 99 %. The DMAE concentration always resulted less than 15 mg/L and was detected with either GC and HPLC with conductimetric detection. The main chemical impurity was due to dimethylmorpholinium ( dMM ), a cationic by‐product derived from the direct reaction and cyclization of diOTsEt and DMAE. The dMM concentration was detected by HPLC with conductimetric detection and always resulted less than 180 mg/L. The absence of tosylated by‐ products or free OTs‐ anions was assessed by HPLC with UV detection. Conclusions: 18FECH radiopharmaceutical was synthesized with an high yield and radiochemical purity by using an innovative approach. The template method described herein, showed superior features respect to the two steps approach in terms of RCY, synthesis time and feasibility.
P440 Whole-body Distribution Kinetics, Radiometabolism and 11 Dosimetry of [ C]PK11195 in Rats - a New High Performance Liquid Chromatographic Method with Online Radiodetection P. Virsu1, I. Laitinen1, S. Suilamo2, K. Någren3, A. Roivainen4; 1Turku PET Centre, University of Turku, Turku, FINLAND, 2Department of Oncology and Radiotherapy, Turku University Hospital, Turku, FINLAND, 3Rigshospitalet, University of Copenhagen, Department of Clinical Physiology & Nuclear Medicine, PET & Cyclotron Unit, Copenhagen, DENMARK, 4Turku Center for Disease Modeling, University of Turku, Turku, FINLAND. Aim: Carbon‐11 labeled N‐butan‐2‐yl‐1‐(2‐chlorophenyl)‐N‐methylisoquinoline‐3‐carboxamide 11 ([ C]‐PK11195) is a peripheral benzodiazepine receptor (PBR) antagonist and a positron emission tomography (PET) radiopharmaceutical for neuroinflammatory imaging. This study was designed to investigate methodology of a new high‐performance liquid chromatography (radio‐HPLC) for
Poster Presentation
Reliable Radiosynthesis 68Ga@scVEGF-PEG-NOTA
S396
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
radiometabolism of [11C]‐PK11195. Materials & Methods: Rat plasma and various tissue homogenates obtained at different time points after intravenous injection of [11C]‐PK11195 were analyzed by reversed‐phase gradient radio‐HPLC method with online radiodetection. In addition, whole‐body distribution kinetics of [11C]‐PK11195 in rats was evaluated by dynamic PET imaging and estimates for human radiation dosimetry were calculated. Results: Five different radiometabolites were detected in rat plasma and the level of unchanged [11C]‐PK11195 decreased from 80% ± 11% (mean ± SD) at 10 min to 44% ± 5% at 40 min after injection. In rat heart, brain, kidney and lung homogenates, more than 90% of total radioactivity originated from intact [11C]‐PK11195. However, in liver the amount of [11C]‐PK11195 was approximately 70% and decreased over time indicating metabolism by liver enzymes. PET imaging of rats showed the highest radioactivity levels in heart, kidney, thyroid gland, liver, lung and brain, respectively. The radioactivity cleared rapidly from lungs and slowly from heart and liver. However, much of the radioactivity retained in kidneys, which was in accordance to the observed low urinary excretion of [11C]‐PK11195. From the rat derived data, the effective dose for a 70‐kg man was 4.2 ± 0.3 µSv/MBq. Conclusions: The new radio‐HPLC method provided in a good separation of [11C]‐ PK11195 and its radiometabolites. [11C]‐PK11195 showed a fast uptake in many rat tissues and it was metabolised relatively fast in vivo. The observed effective dose favors the use of [11C]‐ PK11195 in PET.
P441
11
Synthesis of [ C]Acetate TracerLab FxC Pro module S. Grugni1, G. Tarullo1, K. Marzo1, F. Giurgola1, I. Vaccaro1, E. Cazzola2, A. Chiti1; 1Istituto Clinico Humanitas, Rozzano - Milano, ITALY, 2GE Healthcare, Milano, ITALY. Aim: [11C]acetate was used for the study of myocardial metabolism; more recently, oncologic application of this radiopharmaceutical widened its use for the detection of prostate cancer, hepatocellular carcinoma and, more recently, for renal carcinoma. Considering the short half‐life of 11C, a rapid and efficient method of production is needed. TracerLab FxC is routinely used in our laboratory for [11C]choline and [11C]methionine synthesis. Methods: The synthesis method was developed modifying the commercial TracerLab FxC Pro (Ge Healthcare) module. [11C]acetate is prepared starting from [11C]CO2 produced using an IBA Cyclone 18/9 (20μA for 10 minutes). [11C]CO2 is trapped in molecular sieves, released by heating and bubbled in methyl magnesium chloride solution in THF (0,1M). The isolation of the final product, after the hydrolysis of carbonated methyl magnesium chloride with acetic acid, is achieved using ion‐exchanging purification cartridges (PSH+ and PSAg+) and a solid phase extraction column (Maxiclean SAX). The final product is eluted with 5 ml of isotonic saline solution. Radiochemical purity is assayed by HPLC, which is performed on an anion‐exchange column (CarboPak PA10) with NaOH 0.85M and flow rate of 1 ml/min. Results: Total synthesis time starting from [11C]CO2 production is 14 minutes. Very short irradiations times are needed to produce, on average, 200 mCi of [11C]acetate. Decay uncorrected radiochemical yield of the product is expected to be around 40%, with radiochemical purity over 99%. Data on [11C]acetate synthesis and quality control over the time are under collection. Conclusions: This new application of the TracerLab FxC Pro allows the production of three different radiopharmaceuticals in a routine setting, without the need of different lines of production.
P442 TracerLab FxC versus TracerLab FxC Pro:a comparative analysis of performances and applications S. Grugni, G. Tarullo, K. Marzo, F. Giurgola, I. Vaccaro, A. Chiti; Istituto Clinico Humanitas, Rozzano - Milano, ITALY. 11
Aim: The commercial TracerLab FxC (Ge Healthcare) module is widely used for C labeled tracers production. This system is based on the reaction of methylation of several precursors using dry chemistry method. [11C]CO2 produced by cyclotron is online converted to methane for the following production of methyliodide. The upgrade TracerLab FxC Pro comes with hardware 11 modifications studied to trap [ C]CO2 before the conversion to methane. This new possibility allows to use this system also for carboxylation reactions. Methods: TracerLab FxC module was used in our laboratory for the synthesis of [11C]choline and [11C]methionine. The system produces 11 methane by reduction of [ C]CO2 produced by IBA Cyclone 18/9 cyclotron (0.5 Ci, 20μA/11min). The [11C]CH4 is trapped on a carbosphere under N2 liquid cooling and then released to react with 11 iodine at 720°C to form [ C]methyliodide. The [11C]CH3I can be used for the in loop methylation of DMAE to [11C]choline or for the on‐column methylation of L‐homocysteine thiolactone to [11C]methionine. TracerLab FxC Pro differs for the first step: [11C]CO2 is captured by molecular sieve at room temperature and then released to be converted to [11C]CH4, as in the TracerLab FxC, or directly used for the carboxylation of methylmagnesium chloride to [11C]acetate. Results: [11C]choline and [11C]methionine are produced by TracerLab FxC respectively with yields about 39% and 15% decay uncorrected and radiochemical purities of 99.9% on average. Using the TracerLab FxC Pro we obtain yields about 50% and 30% respectively for [11C]choline and [11C]methionine synthesis. Furthermore, the TracerLab FxC Pro is used also for the synthesis of [11C]acetate. Conclusions: The upgrade TracerLab FxC Pro enhances the flexibility of the module bypassing limits of the original TracerLab FxC and allowing the synthesis of 11C labeled tracers produced by carboxylation reactions. Furthermore this upgrade increases [11C]CH3I production, stability system and synthesis reliability.
P443 Automatically ‘one-pot’ method 18 18 synthesizing F-FDG and F-Acetate
of
synchronously
L. Biao; Nanjing Medical University Affiliated NO1 Hospital, Nanjing, CHINA. Purpose: We intend to automatically synthesize both 18F‐FDG and 18F‐Acetate in one pot, so that we can achieve synchronously injection and imaging of these two tracers on patient by low radiation, cost and time consumption. Method: We used GE TRACERlab FXFN as synthesis platform. Synthesis protocol is a little different from 18F‐FDG synthesis protocol: we added precursors of both 18F‐FDG and 18F‐Acetate in vial 3, hydrolyzed at 60°C for 10 min, then purified the reacted mixture using FDG purification column produced by ABX. Rabbit PET/CT imaging was got at 10min, 30min, 60min, 90min and 120min after injection of 18F‐FDG and 18F‐Acetate (quantity ratio is 1:1). Result: We successfully built ‘one‐pot’ synthesis protocol to get both 18F‐
FDG and 18F‐Acetate by on GE TRACERlab FXFN module. The production time is about 40 minutes and the total yield of 18F‐FDG and 18F‐Acetate is about 40%(decay uncorrected, 50% if corrected), the pH of final product is 7.0. We analyzed the 18F‐FDG and 18F‐Acetate quantity ratio by Radio‐ TLC, when we added 20mg mannose triflate(18F‐FDG precursor, marked as A) and 100mg Benzyl acetate bromide (18F‐Acetate precursor, marked as B), the ratio of 18F‐FDG and 18F‐Acetate was 1:6; when we added 20mg A and 20mg B, the ratio was 1:1; when we added 20mg A and 5mg B, the ratio was 8:1. We applied rabbit imaging using product in which 18F‐FDG and 18F‐Acetate ratio is 1:1, and did PET/CT scan at 10min, 30min, 60min, 90min and 120min after injection. Liver, gallbladder, pancreas, kidney and bladder show clear concentration at 10 minutes; when brain and heart show less concentration. Uptake of liver and kidney decreased after 10 minutes, while uptake of gallbladder, bluestone, pancreas and bladder increased. Conclusion: We successfully built automatical ‘one‐pot’ synthesis method of 18F‐FDG and 18F‐Acetate, which have high yield and is stable. We can also adjust 18F‐FDG and 18F‐Acetate ratio by changing precursor's ratio. Clinical application is easy to access due to SPE separation protocol.
P444 β-amyloid Imaging Agents for PET - Preclinical Evaluation of [11C]PIB and [18F]Flutemetamol A. Pakkanen1, J. Rokka1, I. Wilson2, G. Farrar2, O. Solin1, J. O. Rinne1, M. Haaparanta1; 1University of Turku, Turku PET Centre, Turku, FINLAND, 2GE Healthcare, Medical Diagnostics, London, UNITED KINGDOM. Alzheimer’s disease is a neurodegenerative disorder characterized by extracellular beta‐amyloid (Aβ) deposits in the brain. Aβ deposits can be successfully assessed with positron emission tomography (PET) imaging agents like [11C]Pittsburgh compound B ([11C]PIB). A novel PET tracer for amyloid imaging, [18F]flutemetamol (previously called [18F]AH110690), has recently been developed. The aim of this study was to evaluate the pharmacokinetic properties and dosimetry of these two PET tracers in healthy Sprague Dawley rats. By comparing the results we further estimated the suitability of [18F]flutemetamol for clinical use. Biodistribution of [11C]PIB and [18F]flutemetamol was evaluated with autoradiographic methods, ex vivo tissue counting and in vivo PET imaging. Tracer metabolism and binding to plasma proteins were analyzed with radio‐ TLC and ultrafiltration, respectively. Radiation dosimetry estimates were based on the ex vivo biodistribution data. The pharmacokinetic profile of [18F]flutemetamol resembles that of [11C]PIB. Both tracers crossed the blood‐brain barrier and clearance of free tracer from the brain of healthy animals was relatively fast. [18F]flutemetamol, however, showed slower clearance, especially from white matter containing structures, probably due to its higher lipophilicity. Tracers were largely bound to plasma proteins and rapidly metabolized to numerous polar metabolites. 5 minutes after injection, unmetabolized [11C]PIB and [18F]flutemetamol comprised 67% and 54% of the total radioactivity measured in rat plasma. Except for excreting organs, no significant uptake of the two tracers was observed in the peripheral tissues. For [18F]flutemetamol no significant radioactivity was detected in bone, which implicates that the radioactive label is resistant to metabolic defluorination. Estimated from the rat data effective doses for human subjects from [11C]PIB and [18F]flutemetamol were 2.28 and 6.65 µSv/MBq. Based on its pharmacokinetic profile, [18F]flutemetamol shows high potential as a PET tracer for imaging brain Aβ. Compared to [11C]PIB, [18F]flutemetamol can be synthesized with higher specific radioactivity and the longer half‐life of the 18F‐radionuclide makes the tracer more feasible for clinical settings than 11C‐labelled compounds. Our work will continue with PET imaging of transgenic, Aβ expressing mice to further evaluate the Aβ binding characteristics of the tracers.
P445
68
Preparation of Ga-DOTA-Biotin derivative by an automated synthesis module S. Papi, L. Garaboldi, L. Martano, V. Sirna, G. Paganelli, M. Chinol; European Institute of Oncology, Milano, ITALY. Aim: 68Ga‐PET represents an advantageous diagnostic tool, due to the availability of the 68 Ge/68Ga generator. Among therapeutic radiopharmaceuticals, a 90Y‐DOTA‐Biotin derivative (90Y‐ ST2210®), is currently under investigation in a pretargeting approach. Lacking of γ‐emissions, 90Y is usually associated with a SPECT/PET analogue for dosimetric purposes. In this study we investigated the radiolabelling of ST2210® with 68GaCl3 by means of an automated synthesis module. Materials & Methods: 68GaCl3 was obtained from a TiO2 68Ge/68Ga generator (1.11 GBq), by fractionated elution with 0.1M HCl. 68GaCl3 was reacted with decreasing amount of ST2210® dissolved in NaAc buffer (210 μL, pH 5.0), with specific activities (AS) ranging between 3.7 and 370 MBq/ μg. After 10 min incubation at 95ºC, reaction mixture was loaded on a C18‐SepPak light cartridge, previously conditioned with ethanol 50% and water. After a washing step with saline, 68 Ga‐ST2210® was eluted with 0.2‐0.5 mL ethanol 50% and diluted with saline up to 8 mL. Radiochemical Purity (RCP) quality control was performed over 1) a small aliquot before purification and 2) the C18 purified mixture. Chemical species evaluated were a) free Ga3+ (ITLC SG/Na‐Citrate 0.1M) and b) 68Ga‐colloid (ITLC‐SG in Saline:Acetone 1:1). Stability of the purified 68 Ga‐ST2210® was evaluated at different time points (up to 4h) by Reverse Phase‐HPLC (Vydac Everest 150 x 4.6 mm x 5 μm column, flow 1.2 mL/min, A: H2O 0.1% TFA, B: CH3CN 0.1% TFA, from 82% to 40% A in 9 min). Results: RCP on the raw mixture was found > 95% when AS was below 185 MBq/μg, while it decreased to 82% for AS = 370 MBq/μg. Column purification was found to be effective, giving RCP > 99.5% in the average, even starting from low RCP solutions; elution from C18 column proved to be almost quantitative, with a low (<5%) residue on the column. Overall radiochemical yield (based on theoretical 68Ga amount) was between 50 and 60%, not decay corrected. In some cases colloid amount was found up to 8 %, but was completely retained in the C18 cartridge, with negligible residue (<0.5%) in the purified preparation. HPLC analyses showed a close correlation with ITLC data, finding a single radiopeak of 68Ga‐ST2210® at Rt ≈ 10min. No significative degradation occurred during the first 3 half‐lives at room temperature. Conclusions: The radiolabelling of 68Ga‐DOTA‐Biotin derivative ST2210® proved to be reliable and reproducible, giving quantitative yield of stable radiopharmaceutical which can be potentially interesting for pretargeted PET‐radioimmunoimaging.
P446 In vivo evaluation of reduced dimethylaminoethanol levels in [18F]fluoromethylcholine.
S397
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 D. Slaets, L. Moerman, F. De Vos; Ghent university, Ghent, BELGIUM. Aim: Synthesis of [18F]fluoromethylcholine involves nucleophilic addition of dimethylaminoethanol (DMAE), loaded on a tC18 cartridge, to gaseous [18F]FBrCH2. The crude mixture is commonly purified on a silica based cation exchange cartridge (Accell CM), furnishing [18F]fluoromethylcholine. However, our analyses indicated high remaining levels of DMAE, which might compete with choline uptake in different organs. As this is suspected to reduce tumor uptake of [18F] fluoromethylcholine, it was aimed at reducing DMAE levels. Consequences for pharmacokinetics of [18F]fluoromethylcholine in mice were evaluated. Material and methods Standard preparation of [18F]fluoromethylcholine was carried out by purging [18F]FBrCH2 through a tC18 cartridge loaded with DMAE. The reaction mixture was then purified on an Accell CM cation exchanger (see Table). Our optimized [18F]fluoromethylcholine synthesis was performed analogously, but a WCX Oasis cartridge was substituted for the tC18‐Accell combination. Remaining DMAE levels were determined by HPLC analysis with refractive index detection. NMRI mice (n=3) were injected i.v. with [18F]fluoromethylcholine (1.85 MBq/150µL) and sacrificed after 5, 10, 20, 40 and 60 min p.i.. Organs were isolated and radioactivity was counted.
TC18 + ACCELL CM PLUS (N=3)
Conditioning Accell
WCX (N=3)
(1)
(2)
0.5M HCl
0.5M HCl
H2O
EtOH
Load DMAE
400µL on tC18
400µL on WCX
Wash
10mL EtOH
10mL 6% NH4OH
10mL H2O
10mL 50/50 6% NH4OH/EtOH
10mL EtOH
10mL H2O
Elute
10mL 0.9% NaCl
10mL 0.9% NaCl
no Accell included
P449
64
Cu production, recovery of
64
Ni and
G. Cicoria, D. Pancaldi, F. Lodi, A. Rizzello, C. Pettinato, S. Fanti, S. Boschi, D. D'Ambrosio, M. Marengo; Policlinico S.Orsola-Malpighi, Bologna, ITALY. 64
Cu can be efficiently produced by proton irradiation of a solid enriched 64Ni target. However, chemical processing of the irradiated target needs particular attention: copper should be separated by other metals and purified, while the expensive enriched 64Ni must be recovered. We have developed an automatic device for purification and synthesis of 64Cu tracers, largely based on standard Modular Lab components (Eckert & Ziegler). The solid target uses a gold disc of 32 mm diameter in which 64Ni is electrodeposited using a Pt electrode. Less than 24 hours allows to reliably electroplate 250 mg of 64Ni which provides a (180±20) μm layer. Irradiation is performed using a PETtrace cyclotron. Target download is automatic and allows for safe recovery of the irradiated disc in a shielded container. For the dissolution of the irradiated material, the prototype module uses a dedicated handmade reactor. The irradiated 64Ni is dissolved in 6 ml of HCl 9N with few drops of H2O2 at 120 °C, then evaporated to dryness. The residue is dissolved in 6 ml of HCl 9N and then eluted through a 20x0.8cm Bio‐Rad AG1‐X8 anion exchange column. After 64Ni recovery (25 ml HCl 9N), the column is dried and 64Cu fraction is eluted with water. The water eluent is sent to a cation exchanger PS‐H column to trap 64Cu2+ which is recovered in the reactor with CH3COONa 3M buffer. The reactor was previously loaded with 1 ml of CH3COONa with 15 μg of ATSM in DMSO. The synthesis time was 2 minutes at room temperature. 64Cu‐ATSM was purified by solid phase extraction on C18 column, eluted with 1ml of ethanol and diluted with saline. Depending on the deposited mass of Nichel and on the irradiation conditions, we have obtained saturation yields in the range 40‐70 mCi/μA. The recovery of 64Ni was greater than 95%. The radionuclidic purity of 64Cu is greater than 99.999% at 12h from end of bombardment. The labelling efficiency was greater than 99.0%. The automated separation technique provides 64 Cu with high radionuclidic purity. The elution from PS‐H column with acetate buffer provides 64 Cu suitable for coordination with chelating agents. Either industrial or home made components are integrated and controlled by the same workstation; full log and audit trails of the process are recorded. These preliminary data show that the described system is suitable for the production of 64Cu tracers in clinical practice as well as in preclinical research studies.
P448
18
Improved Recovery of [ F]-Fallypride in Solvent Exchange Procedure N. Pótári, I. Jószai, S. A. Kis, T. Nagy, T. Márián, L. Galuska, L. Trón, P. Mikecz; University of Debrecen Medical and Health Science Center, Debrecen, HUNGARY. Background Dysfunction in dopaminergic neurotransmission has been implicated in a number of neuropsychiatric disorders including Parkinson’s disease, Alzheimer’s disease, schizophrenia, and Huntington’s disease. fallypride radiolabeled with Fluorine‐18 was first synthesized by Mukherjee
G. Ortosecco1, E. Castaldi1, A. Nardelli2, A. Speranza1, G. Storto1, S. Del Vecchio2, L. Pace2, B. Alfano1, M. Salvatore2; 1Istituto di Biostrutture e Bioimmagini - CNR, Napoli, ITALY, 2Università degli Studi "Federico II", Napoli, ITALY. AIM [18F]‐Fluoroacetate is an analogous of [11C]‐Acetate and it could be used as a potential PET radiotracer for tumor imaging especially in prostate cancer. In this respect, the interest in the production of [18F]‐Fluoroacetate has recently grown and its radiochemical synthesis requires standard and reliable procedures which could be optimally achieved with an automatic synthesizer. The aim of the work is to implement a simple, fast and reliable procedure, according to GMP’s, to synthesize and purify [18F]‐Fluoroacetate using a modified TracerlabFX‐FN(GETM) synthesizer. MATERIALS & METHODS Automated synthesis of [18F]‐Fluoroacetate has already been shown in literature using a number of precursors, several synthesizers and purification by Radio‐HPLC or by a solid phase extraction cartridge system. More recently some authors has originally proposed to shift the aqueous basic hydrolysis step from the reactor in to the cleaning cartridge in a way to perform hydrolysis and purification at once. The proposed work, instead, investigated the possibility and the performance of typical two steps [18F]‐Fluoroacetate radiosynthesis using the automatic synthesizer TracerlabFX‐FN(GETM) by the aid of an automated home‐made cartridge purification system opportunely linked. The synthesis is based on a simple nucleophilic substitution which uses Ethyl‐p‐tosyloxy acetate as precursor :1) after the labelling reaction (K2CO3 aqueous solution, K222 in Acetonitrile and precursor in DMSO at 105°C for 5 min) the non‐hydrolyzed product passes from the reactor throughout a C18 cartridge where is entrapped; 2) water rinses the cartridge to eliminate any unreacted fluoride; 3) electromechanical valve system switches allowing the elution of the radiolabelled intermediate product with dichloromethane; the eluted product is collected in the reactor; 4) 1 ml of NaOH 1 M is added to the solution in the reactor at 50°C for seven minutes to hydrolyze [18F]‐ethyl‐ fluoroacetate; 5) a specific time list of evaporation has been created and launched to allow the evaporation of dichloromethane for injection purposes; 6) finally 1 mL of HCl 1N is added to the product, it is diluted with 4 mL of water and it is conveyed into a collect vial containing buffer solution. RESULTS The synthesis time is about 40 minutes and the RCY at end of synthesis is between 10‐15%. CONCLUSION Automated synthesis of [18F]‐Fluoroacetate is proposed using a typical two steps radiosynthesis by modified commercial synthesizer. A cartridge purification system is suggested. This can replace the Radio‐HPLC inside the module and to allow the reactor back up for other steps e.g. hydrolysis and evaporation procedure.
P450 Validation of the process to obtain L-methyl-[ 11C]methionine M. De Arcocha Torres, M. A. Rodríguez Gago, C. Gil Postigo, B. Arenas Avelleira; Ciclotrón IBA-Molypharma, Santander, SPAIN. PURPOSE Validation of the process for obtaining L‐methyl[11C]methionine with pharmaceutical quality according to standards of good manufacturing practice (GMP's) MATERIAL AND METHODS In the first step the qualifications of the installation (IQ) and the operation (OQ) of production equipment and quality control as well as analytical methods were made. The following equipment were validated; Tracerlab methylation module (General Electric), HPLC (KANUER), TLC (Carroll & Ramsey), gas chromatograph (GC Varian 3900), gamma spectrometer (Canberra) and pH meter (Mettler‐Toledo). Afterwards, the validation of the radiopharmaceutical manufacturing process (PQ) started. Positron‐emiting 11CO2 was produced by 14N(p,α)11C nuclear reaction, using a PETtrace Cyclotron of General Electric, and then trapped with liquid nitrogen. Through a series of chemical reactions, 11CO2 was converted to 11C‐methyl iodide. L‐11C‐MET was labeled by S‐methylation of L‐Homocysteina thiolactone. For further purification, solid phase 11 extraction of the C labeled product is carried out (Waters C‐18 Sep Pak light cartridge). Finally, sterile filtration of the product solution was made. The last step was a quality control procedure ( pharmacophea, monograph 1617). The following tests were performed before liberation: Visual inspection, pH determination, Chemical and radiochemical purity by liquid chromatography using a Kromasil 100‐5C18 column, 250 x 4.6 mm as stationary phase and a solution of NaH2PO4 0.01 M as mobile phase at a flow rate of 1 ml / min. Enantiomeric purity by thin‐layer chromatography using a silica Chiralplate as stationary phase and a mixture of methanol / water (50/50) as mobile phase. After this, a ninhidrina staining to reveal the position of amino acids with ultraviolet light
Poster Presentation
* based on w/v Results The WCX method led to significantly lower DMAE levels compared to Accell purification. Biodistribution studies, comparing both methods, showed a favorable, reduced uptake of radiotracer in the kidneys (significant on 3 out of 5 time points) when DMAE contamination was lower. Reduced [18F]fluoromethylcholine uptake was also observed for bladder and liver, but the opposite (significant on 2 out of 5 time points) was seen in brain and lungs. Additionally, Accell purification led to large error bars and random uptake patterns for various organs compared with WCX purification. Conclusion Lower DMAE levels reduce [18F]fluoromethylcholine uptake and, consequently, radioactive load in kidneys. Moreover, due to known saturable choline uptake in the brain and lungs, we can conclude that DMAE acts as a competitive inhibitor for choline transport. This competition most likely leads to impaired tumor visualization, hence new biodistribution studies in xenograft mice will be carried out.
Automatic system for 64 Cu-ATSM synthesis
18
Automatic two-steps radiosynthesis of [ F]-Fluoroacetate by commercial synthesizer
Residual DMAE 432.6 ± 54.6 ppm* 402.2 ± 49.6 ppm* 9.8 ± 1.4 ppm*
P447
in 1995, and is currently being used as a dopamine D2/D3 receptor‐imaging agent in PET studies because of its selectivity, affinity, and reversibility Production of [18F]fallypride involves HPLC separation followed by solvent exchange on a cartridge containing non polar adsorbent material. Due to its high lipophilicity it is difficult quantitatively recover [18F]fallypride from this cartridge. Our aim was to optimize the solvent exchange procedure by variation of the quantity of the non‐ polar solid phase extraction material. Material and methods: We used materials adequate to GMP and the highest purity available for the synthesis of [18F]‐fallypride. The Tosyl‐fallypride was bought from the ABX Company (Radeberg, Germany) and the Sep‐Pak® cartridges came from Waters (Milford, USA). The synthesis was based on the method described by Mukherjee with minor modifications. It was a one‐step nucleophile substitution followed by isocratic HPLC purification, and solvent exchange on a C18 Sep‐Pak® SPE cartridge and formulation. The quality of the [18F]fallypride was investigated with HPLC and TLC methods. Results and discussion: During the solvent exchange using the generally applied C18 Plus Sep‐Pak® cartridge only the 50% the [18F]fallypride could be eluted with 1 ml ethanol. Application of more ethanol could lead greater final volume or an additional evaporation step. Therefore, we decided to utilize C18 Light Sep‐ Pak® cartridge. On this cartridge, what contains nearly 3 times less sorbent than the Plus version (130 mg against 360 mg), if the acetonitrile concentration remained below 3% the [18F]fallypride fully adsorbed and could be quantitatively recovered in 1 ml ethanol, thus allowed to have 10 ml final injection solution. The reaction yield was about 20% without decay correction. The total synthesis time was 1 hour including the 20‐minutes reaction at 85 oC. In a typical experiment from 30 GBq 18F‐ we could produce 7 GBq [18F]fallypride. The specific activity of the synthesized [18F]fallypride was about 70‐200TBq/mmol (1900‐5400 Ci/mmol). The product was tested with small animal model (mice). The animals were investigated with autoradiography method and mini‐PET scanner built in our institute. Application of SPE cartridges with less adsorbent material in case of other highly lipophilic radio tracers could help improve their recovery in the solvent exchange process.
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was performed. Residual solvents by GC (acetone, ethanol), Gamma spectrum, Half‐life determination; The following tests were performed after liberation: Bacterial endotoxins (Limulus Amoebocyte Lysate, LAL), Sterility, RESULTS Quality control results are shown in the following table:
Residual solvents
Radiochemical Enantiomeric purity purity
11C‐ Visual Ethanol Acetone Batch pH MeI Inspection (mg/ml) (mg/ml) (%)
11C‐ Met (%)
D‐ Half‐ Emisión L‐MET Endotoxin MET life peak Sterility (%) (EU/ml) (%) (min) (KeV)
1
OK
6.25 4.900
< 0.1
0.01
99.99
99.90 0.10 20.33 511,3
<175
OK
2
OK
6.50 5.316
<0.1
0.04
99.96
99.89 0.11 20.23 512,1
<175
OK
3
OK
6.43 5.231
<0.1
0.03
99.97
99.85 0.15 20.80 511,5
<175
OK
4
OK
6.45 4.286
<0.1
0.02
99.98
99.92 0.08 20.54 511,8
<175
OK
CONCLUSIONS The results confirm that the manufacturing process of the 11C‐methionine is consistent and repetitive and meets the quality requirements required by the pharmacophea.
P451
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Evaluation of I as a nuclide for PET radioligand with iomazenil and imaging of rat brain by means semiconductor high resolution animal PET scanner.
124
Iof
Y. Kanai1, Y. Funaki2, H. Yamazaki2, Y. Kikuchi3, S. Matsuyama3, M. Imaizumi1, E. Shimosegawa1, K. Ishii3, J. Hatazawa1; 1Osaka University Graduate School of Medicine, Suita, Osaka, JAPAN, 2Tohoku University, Sendai, Miyagi, JAPAN, 3Tohoku University Graduate School of Engineering, Sendai, Miyagi, JAPAN. 124
Objectives: Iodine‐124 ( I) is one of alternative long‐lived PET nuclides attracting increasing interest. Using 124I, we have many researches in oncology, but few in neurology. We investigated the possibility of 124I as a neurological PET nuclide. Methods: We try to radiolabeling of 124I‐ iomazenil with tributylstunnyl precursor. We measured the biodistribution and unmetabolite in the brain and blood with rat to investigate the basic ability of 124I‐iomazenil (IMZ) as a PET radiotracer. Finally we try to imaging of rat brain with high resolution semiconductor animal PET. Result: Result of investigation of 124I‐IMZ radiosynthesis, We got it with high radiochemical yield (73 %) and more than 98% in best condition. The biodistribution and unmetabolite in brain of 124I‐ IMZ in rat was very similar with that of 123I‐IMZ. The PET image of rat brain with 124I‐IMZ showed predominantly higher 124I‐IMZ accumulation in the cerebral cortices, which was consistent with autoradiographic images of rat brain.Discussion: After optimizing the reaction conditions, sufficient radioactivity of 124I‐ IMZ was obtained within a short period. 124I‐IMZ is good radiotracer for radiotracer for the rat brain imaging. The PET images were successfully obtained in the rat brain by the use of a high resolution CdTe semiconductior PET scaner. These findings facilitate the use of 124I‐labeled compounds for the brain PET imaging.
P452 Design, Synthesis & Biological Evaluation of Targeted SPECT/ PET Imaging agents: A Choline derivative DMEA-E-DO3A type Ga(III) complex 1
1
1
1
J. K. Uppal, F , P. Panwar, F , R. Varshney, F , S. Chaturvedi, F , N. K. Kaushik, M2, A. K. Mishra, M1; 1INMAS, Delhi, INDIA, 2University of Delhi, Delhi, INDIA. Introduction:Target specific SPECT/PET radiopharmaceuticals are desirable in the clinical diagnosis of metabolic tumors.[11C/18F]Choline is a novel radiopharmaceutical potentially useful for prostrate and bladder tumor imaging as it is incorporated in the cell membranes as phosphatidylcholine.Malignant tumors exhibit high proliferation and increased metabolism of cell membrane components which leads to an increased uptake of choline. Because of the short half‐ life of 11C (t1/2 =20.38 min), resulting in a limited usefulness for clinical routine,we describe the 67 68 synthesis and biological evaluation of Ga/ Ga labeled DMEA‐E‐DO3A, a novel SPECT/PET imaging agent containing a tetraazamacrocyclic chelating unit(DO3A) which forms stable complexes with most of the lanthanides and transition metals are proposed. Methods:The above Choline analogue was synthesized by reacting dimethylethanolamine with dibromoethane followed by alkylation of 1,4,7,10‐tetraazacyclododecane‐1,4,7‐tris(t‐butylacetate).Gallium 67 Chloride ( Ga, 74 MBq) was added to the vial containing the ligand and heated for 30 minutes. The pH was adjusted to 5.5 with sodium hydroxide solution to get optimim radiolabeling yield. Radiotracer was evaluated in cultured PC‐3 prostrate cancer cells. Blood kinetics in rabbits and biodistribution in mice was studied. The ability of [67Ga] DMEA‐E‐DO3A to target tumor site in vivo was assessed in gamma/positron scintigraphic studies of normal mice and in PC‐3 xenografts. Results:DMEA‐E‐DO3A was fully characterized by multinuclear NMR spectroscopy and mass spectroscopy.The incorporation of 67Ga into the DO3A nucleus was measured at 94%, after the 30‐minute labeling time. DMEA‐E‐DO3A revealed in vitro accumulation in cultured PC‐3 cancer cells was comparable to that of choline. Imaging of athymic mice with PC‐3 xenografts revealed substantial radioactivity at the tumor site. Biodistribution data in normal mice indicated that the excretion of the radiotracer is through the kidneys. Appreciable amount of activity was visualized in liver. Conclusion: Preliminary data with PC‐3 cancer cell line and tumor imaging support further studies to evaluate the utility of DMEA‐E‐DO3A‐67Ga conjugate as an oncologic probe.
P453 New bromo- and radioiodobutyrophenones as potential radiopharmaceuticals 1
1
1
2
J. Schmitz , W. Brandau , K. Leineweber , G. Schmid ; 1 Universitaetsklinikum Essen, Essen, GERMANY, 2Universitaet Duisburg Essen, Essen, GERMANY. Aim: Derivatives of highly effective butyrophenone neuroleptics, e.g. Spiroperidol, labelled with suitable nuclides, have proven of value for the in vivo imaging of the receptor status of
neuropsychiatric patients using PET and SPECT. This survey describes the synthesis, the labelling and the first in vitro receptor binding studies of three new N‐1 benzylised Spiroperidol derivatives. Methods: Starting with butyrophenone, three ortho, meta and para bromo‐ substituted 8‐[3‐(4‐Fluorobenzoyl)‐propyl]‐1‐(bromobenzyl)‐1,3,8‐triazaspiro[4,5]decan‐4‐ones were prepared in six‐stage syntheses and characterised. The labelling of the brominated precursors with I‐124, I‐125 and I‐131 was achieved through Cu(I) assisted non‐isotopic halogen substitution. A method of isocratic HPLC was developed for the chromatographic purification of the labelled products. The bromobenzylspiperones were used in first competitive binding studies on rat brain tissue against the serotonin 5‐HT2A/2C antagonist 125‐iodine‐DOI. In addition displacement studies were accomplished with the 125‐iodine labelled compounds against the selective antagonists Ketanserin (5HT2A), Spiroperidol (Dopamine D2) and SCH23390 (Dopamine D1). Results: The new bromobenzylised butyrophenone derivatives could be labelled in high radiochemical yields of 80 to 95 % with the iodine isotopes I‐124, I‐125 and I‐131 and could be isolated in specific activities of > 70 TBq/mmol. The binding studies against 125‐iodine‐DOI document a high affinity and selectivity of all three bromobenzylspiperones toward the 5‐ HT2A/2C receptor (Ki = 0,4 ‐ 4,4 nM). Displacement studies with the 125‐iodine labelled compounds revealed no significant affinity towards D1 and D2 receptors. Conclusions: With the new bromobenzylspiperones, compounds are available which can be transformed through quick and simple labelling with varying iodine isotopes into a group of promising radioligands for the 5HT2A/2C receptor scintigraphy using PET or SPECT.
P454 A New Synthesis Module and Automation in F-18-FET Labeling M. Li; Institute of Nuclear Energy Research, Taoyuan, TAIWAN. Objectives: Fast implementation of PET into clinical studies and research has resulted in high demands in the automated modules for the preparation of PET radiopharmaceuticals in a safe and reproducible manner. Methods: The purpose of this study is to develop a fully automated controlled system for the synthesis of O‐(2‐[18F]fluoroethyl)‐L‐tyrosine, with a compact synthesizer module. Main procedures of the process include: (1)absorption of [18F]fluoride anion; (2)reaction with fluoride anion; (3)synthesis with precursor; (4)raw product separation and evaporation; (5)hydrolysis; (6)separation; and (7)collection. Results: The advantages of this fabricated synthesizer module are illustrated as follows. Firstly, the whole processes are operated in a closed system with a liquid nitrogen trapper used to condense the release gases of leaked radioactive material and organic solvent that can reduce the environmental radiation. Secondly, the assembly of the module is made as small as possible. Thirdly, this module is functioned with a fully automated control for synthesis of making O‐(2‐[18F]fluoroethyl)‐L‐tyrosine. The process time is about 50mins. Conclusions: The products obtained with purity of greater than 95% is sufficient to meet the requirements of the specifications for PET in nuclear medicine applications. Other than the previous statements, the software designed can be used to execute the process step by step precisely under the command to be called. During the process performance, the temperature, pressure and variation of radiation dose can be monitored and recorded simultaneously to reflect the reaction situation at that time and compliant with the regulation of GLP/GMP.
P455 TE3A-EA based copper, preclinical results S. S. Raghuvanshi; INMAS, Delhi, INDIA. TE3A‐EA ‐based copper (II): Radiochemical aspects and preclinical results Sweta Singh, Rashi Mathur, Nitin Kumar, Anil K. Mishra* INMAS, Delhi‐110054, India. Aim Bifunctional chelating agents (BCAs) contain a chemical‐reactive group for coupling to proteins or other molecules and a strong metal‐chelating group for complexing certain radioactive metals. Cyclam analogue (1‐ aminoethyl‐5, 8, 12‐tri(carboxymethyl)‐Cyclam (TE3A‐EA) represents a new type of bifunctionalized ligands. In this report, we present the design, synthesis and characterisation of Cu‐64 complexes of TE3A‐EA at a tracer level and describe preclinical biodistribution characteristics and elimination pathways of the complexes. Methods: All used chemicals were purchased from commercial sources, while TE3A‐EA was synthesised by starting from Cyclam in 1 13 three step reaction.. Analytical H and C NMR spectra were recorded on a Bruker 400 MHz spectrometer .All experiments were performed at 25 °C. Mass Unit mass determinations were carried out by using a electro spray ionization mass spectrometry (ESI‐MS) on an SL 1200 system (Agilent) with ion trap detection in the positive and negative ion modes. ITLC‐SG chromatography was performed on commercial silica gel impregnated glass fiber sheets (Gelman Science). Detection of ITLC‐SG stripes was carried out on the TLC‐analyzer. 1 mg TE3A‐EA was dissolved in 1 ml deionised water for radiolabeling of TE3A‐EA with Cu‐64 solution. TE3A‐EA was mixed with 0.5 M acetate buffer (pH 5.5) and subsequently 0.02 mCi of radioisotope was added. After incubation at 90°C for 30 min, ITLC and HPLC analyses were carried out to check the radiochemical purity. Biological experiments were performed on male Wistar rats. Results: It was found that the complex formation is dependent on temperature. The optimal temperature range for the Complexation was 60 ‐ 80 °C. The characteristics checked were buffer pH and excess of ligand. The optimal pH interval for rapid complex formation was 5.5 ‐ 6.5 and excess of ligand was necessary. Finally, TE3A‐EA can be easily labelled by Cu‐64 with high radiochemical purity. Biodistribution studies in rats confirmed that radiolabelled complexes under study were rapidly cleared from the blood, other organs and tissues. The main elimination pathway of radioactivity was urinary excretion. No specific accumulation of radioactivity in any organ and tissue was detected. Conclusion: It turned out that Complexation and biodistribution results of radiolabelled TE3A‐EA are comparable to those of TETA. The complex formation is slightly faster. The surveyed ligand could be a good alternative to known macrocyclic ligands.
P456 Imaging of β-Amyloid Plaques and Tau Inclusion: Will Methyl FSB Be a Good Candidate as a PET-Tracer?
11
C-
H. Audrain1, T. Huynh2, M. Simonsen1, A. Lindhardt2, T. Skrydstrup2, D. Bender1; 1PET-Center, Aarhus University Hospital, Nørrebrogade 44, DK8000 Aarhus C, DENMARK, 2Center For Insoluble Protein Structures,
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The search for new tracers for the in vivo imaging of Alzheimers disease (AD) has been highly prioritized in recent years as this disorder is one of the most common dementia among the elderly. AD is characterized by the formation of senile plaques resulting from the fibrillation of β‐ amyloid peptides and inclusion made of hyperphosphorylated tau protein. A few radiotracers are already in clinical or preclinical use in the PET‐field, targeting β‐amyloid plaques ([N‐methyl‐ 11 C]PIB1 and 18F‐BAY94‐91722). Recently, an alternative fibril binder represented by a fluorine containing bis‐styrylbenzene (FSB) was successfully demonstrated to be a potential marker for Alzheimer plaques by MR imaging in mouse models.3 Even though this compound possesses two carboxylic acid groups, it was shown to pass the blood brain barrier after intravenous injection through the mouse tail. In this work, we present a novel and highly efficient synthesis of FSB, exploiting two consecutive Sonogashira reactions and a stereoselective reduction of both alkynes to the trans‐olefins. The synthetic approach is sufficiently flexible to allow for the selective labeling of one of the two terminal hydroxyl groups.4 Monomethylated 11C‐FSB was prepared in high radiochemical yield and high radiochemical purity with 11CH3I in the presence of potassium carbonate in DMF, followed by a simple and rapid hydrolysis step of the protecting groups. With monomethylated 11C‐FSB in hand, we also present the first results obtained with the possible application of this class of compounds as PET‐tracers. The first micropet studies and biodistribution studies are currently under investigation. 1. Klunk et al., Annals of Neurology, 2004, 55, 306‐319. 2. Rowe et al., Lancet Neurology, 2008, 7, 129‐135. 3. Higuchi et al., Nature Neuroscience, 2005, 8, 527‐533. 4. Skrydstrup et al., Organic Letters, 2009, 11, 999‐1002.
P457 Evaluation of a Novel Adenosine 2a Receptor Imaging in Primate Brain with [123I] MNI 420 X. Zhang1, D. Alagille1, A. O. Koren1, J. Batis1, K. Cosgrove2, K. Marek1, J. P. Seibyl1, G. D. Tamagnan1; 1INDD, New Haven, CT, UNITED STATES, 2 Yale University, New Haven, CT, UNITED STATES. Objective: To evaluate the feasibility of imaging adenosine 2a sites in primate brain with [123I]‐ MNI 420. Background: Recent interest in therapy of Parkinson s disease (PD) with drugs acting through adenosine 2a (A2a) receptors has emphasized the need for non‐invasive scintigraphic methods for assessing these biological targets for both new drug development and elucidating pathophysiological changes in PD patients. There are only a few early‐stage radioligands available for imaging adenosine receptors. We have radiolabeled a promising candidate with low nanomolar affinity for A2a, MNI 420 with I‐123 for imaging assessment in non‐human primates. Design/Methods: Dynamic SPECT acquisitions were performed following a bolus injection of 8 10 mCi of [123I]‐MNI 420 in 2 ovariectomized female baboons (Papio anubis) in a series of studies to evaluate: 1) the specific accumulation and washout properties in brain, and 2) the effects of displacing doses of caffeine which bind to A2a and compete with the radioligand for the A2a receptor binding site. Results: Measured lipophilicity at pH 7.4 is 2.17 and analysis of venous plasma demonstrated low protein binding (10% free) with no lipophilic metabolites detectable by reverse phase HPLC. Highest accumulation of radioactivity occurs in the striatum with peak striatal‐to‐cerebellar ratios ranging from 3.5 to 4.0 at ca. 60 min post injection. Administration of caffeine in separate studies at doses of 20 mg/kg iv at 60 minutes post radioligand injection decreased the specifically‐bound activity in the striatum by 90%. Conclusions/Relevance: These preliminary studies suggest that [123I]‐MNI 420 is a promising agent for in vivo imaging of A2a receptors in brain. This radioligand could prove useful in assessing occupancy at A2a receptors for putative therapeutic agents and as a tool for early detection of neurodegenerative disorders.
P458
18
18
Robotic Synthesis of [ F](N-methyl)benperidol ([ F]NMB) for D2 Receptor Studies with PET C. D. Bognar, S. M. Moerlein, G. G. Gaehle, J. S. Perlmutter, R. H. Mach; Washington University, St. Louis, MO, UNITED STATES. 18
18
Aim: [ F](N‐methyl)benperidol ([ F]NMB) is a D‐2 specific radioligand validated for PET measurement of cerebral dopamine receptor binding in vivo. To promote its use for clinical and preclinical studies in human and animal subjects, we have developed a robotic system for production of this useful PET radiopharmaceutical. Methodology: Our previously published synthetic method was adapted to a robotic system. A CRS Catalyst 5 robot (Thermo Electron Corp) was integrated with chemistry stations designed to perform specific synthetic steps. The robotic system was controlled using an interface developed with Visual Basic. [18F]fluoride was produced by the 18O(p, n) 18F reaction using the RDS Eclipse 11MeV cyclotron. All labeling substrates were obtained from ABX (Radeberg, Germany). The general radiosynthetic pathway involves resolubilization of [18F]fluoride into DMSO containing (p‐nitrophenyl)cyclopropylketone, microwave‐facilitated [18F]fluorodenitration, and acid hydrolysis of the labeled cyclopropylketone. Following C18 SepPak purification, the radiolabeled intermediate is dried and used to alkylate 4‐(2‐keto‐3‐methyl‐1‐benzimidazolinyl)piperidine. The radioligand is purified using normal‐phase preparative HPLC, and the final drug product is reformulated in ethanol/ Sodium Chloride Injection, USP (1/10). Analytical HPLC was used to assess radiochemical purity, chemical purity, and specific activity. Results: The robotic system has been successfully used to produce [18F]NMB in useful batch yield and high radiochemical purity, chemical purity, and specific activity. Overall drug preparation time is 140 min, with an overall radiochemical yield of 6‐7%. This non‐optimized radiochemical yield is remarkable considering the many robotic manipulations of small volumes with incumbent mechanical losses. The major losses from the synthetic pathway to product occurred in the first half of the synthesis, where two separate evaporative steps are required. Ongoing production runs are used to adjust reaction parameters to minimize losses and maximize final radiopharmaceutical yield. Conclusions: A robotic system 18 has been developed suitable for routine production of [ F]NMB with high radiochemical yield and purity suitable for D2 receptor studies in human subjects. The system facilitates production of the radioligand for research studies using small animal scanners as well as for clinical use. Because the tracer is labeled with fluorine‐18, the robotic system could be used in centralized radiopharmaceutical production centers for delivery to off‐site PET imaging facilities. This system is also capable of preparation of several additional fluorine‐18 labeled tracers, underscoring the versatility and flexibility of robotics for PET radiopharmaceutical production.
P53 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radiopharmacy/radiochemistry: therapy: alpha - beta emitters
P459 Experiment of AGPNA on depress the k-ras gene expression in pancreatic cancer cell Patu8988 Y. Wu, B. Zhang; The First Affiliated Hospital of Soochow University, Suzhou, CHINA. Antigene peptide nucleic acid (AGPNA) hybridization probes targeting k‐ras 12 point mutation oncogene, with an IGF‐1A peptide loop on the C‐terminus and 188Re chelator peptide on the N‐ terminus was synthesized. Objective To investigate the effect of AGPNA on depress the k‐ras gene and the k‐ras protein expression of human pancreatic cancer cell Patu8988. Methods 1.AGPNA hybridizing k‐ras 12 point mutation DNA was designed and synthesized. 2.Before and after transfected AGPNA, antigene oligonucleotides (AGON), and antisense oligonucleotides (ASON), the expression level of k‐ras mRNA in human pancreatic cancer cell Patu8988 were detected by reverse transcription‐ polymerase chain reaction (RT‐PCR). 3.Before and after transfected probes, the expression ratio of k‐ras protein in cell were detected by flow cytometry. 4.The directly labeling method was adopted to label AGPNA with 188Re. Results 1. The configuration of AGPNA was Gly‐(D)‐Ala‐Gly‐Gly‐Aba‐AEEA‐ GGA GCT GTT GGC GTA ‐AEEA‐c[D‐ Cys‐Ser‐Lys‐Cys]‐CONH2. 2. After transfected 1nmol/mL AGPNA and AGON, the k‐ras mRNA gray scale ratio were (1.00±0.39) and (1.22±0.31). Its was lower than (1.86±0.07) of the control group, and the difference was significant (P<0.01). Among the difference dose of AGPNA, AGON, and ASON group, the difference of the expression level of k‐ras mRNA was not significant (P>0.05). 3. After transfected 1nmol/mL AGPNA, AGON, and ASON, the expression ratios of k‐ras protein were (15.05 ± 5.07)%, (10.20 ± 2.63)%, and (8.80 ± 4.31)%. Its was lower than (24.38 ± 5.40)% of the control group, and the difference was significant (P<0.01). Compared with the difference dose of AGPNA, AGON, and ASON group, the difference of the expression ratios of k‐ras protein 188 was no significant (P>0.05). 4. The labeling efficiency of Re‐AGPNA could reach (89.61±0.91)% and the amount of radiocolloid was (9.40±0.55)%. Conclusion AGPNA can depress the k‐ras gene expression on the mRNA level and depress the k‐ras protein expression of human pancreatic cancer cell Patu8988.
P460 Determination of the optimal abaltive doses in Differentiated Thyroid Carcinoma (DTC) C. De Gracia González, B. Martínez de Miguel, G. Riesco Almarza, E. Martínez Montalbán, L. Martín Curto; Hospital Universitario La Paz, Madrid, SPAIN. INTRODUCTION Differentiated thyroid Carcinoma (DTC) is the most frequent type of malignant thyroid Cancer (80‐90%) which includes Papillary, Follicular and Hürtle Carcinoma. DTC keep capacity to take iodine actively and synthesize thyroid hormone and thyroglobulin. This ability is fundamental to treatment and follow‐up. The treatment involves thyroidectomy and 131‐iodine ablation which produce hypothyroidism. The 131‐iodine is useful in the treatment of the recurrences of DTC, due to its beta and gamma emission. It also allows the treatment metastases. AIM To determine optimal doses of 131‐iodine for ablative treatment according to DTC pathology and reduce the number of ablative treatments in these patients; achieving complete elimination of thyroid tissue remaining after thyroidectomy. PATIENTS AND METHODS 4613 patients were studied and divided in two groups. Group I: 3118 patients who have been collected in period of 14 years. These patients have been treated with doses of 2960 MBq (80mCi) Group II: 1495 patients who have been studied in a period of 5 years. These patients have been treated with doses according to pathology. 3700 MBq (100mCi) for papillary carcinoma, 5550 MBq (150mCi) papillary carcinoma with lymph node metastases, vascular invasion, follicular carcinoma and mixed. Doses of 7400 MBq (200mCi) for lung and/or bone metastases. We have compared these two groups, the number of admission and ablative treatment according to doses. RESULTS Results are summarized in this table. It shows the percentage of patients who have been treated with 1, 2, 3 or 4 ablative doses according to pathology for each group.
One ablative dose Two ablative doses Three ablative doses Four ablative doses
Group I Group II Group I Group II Group I Group II
Group I Group II
Papillary 64.4 % 89.42% 23.5%
8.17%
6.6%
1.44%
5.5%
0.97%
Follicular 54.1%
84.71% 23.5%
11.64%
9.1%
2.94%
15.3%
0.71%
Mixed
56.8%
93.98% 21.6%
4.95%
16.2%
0.88%
5.4%
0.19%
Hürtle
70.5%
100%
0%
6.8%
0%
2.2%
0%
20.5%
CONCLUSION When the patients are initially treated with higher doses and according to pathology, the percentage of patients who do not need second administrations or more, increases significantly. Only nine patients have been studied Hürtle Carcinoma in group II, so the results are not conclusive.
P461 Production of n.c.a. 177Lu at multi-Curie level at the Munich facility C. Barkhausen1, K. Zhernosekov1, A. Türler1, T. Nikula2, M. Harfensteller3, R. Henkelmann3; 1Institute and Chair for Radiochemistry, Garching, GERMANY, 2ITM, Garching, GERMANY, 3ITG, Garching, GERMANY. Reactor produced low‐energy beta emitter 177Lu (T½ = 6.71 d) is successfully used with an increasing demand in clinical targeted radiotherapy in nuclear oncology. Currently 177Lu is commercially available in carrier added (c.a.) form produced via direct nuclear reaction 176 Lu(n,γ)177Lu (176Lu: σ = 2080b) or in no‐carrier‐added (n.c.a) form obtained via indirect nuclear reaction path 176Yb(n,γ)177Yb→177Lu (176Yb: σ = 3b). The amounts of n.c.a. 177Lu currently found on
Poster Presentation
Department of Chemistry, Interdisciplinary Nanoscience Center, Aarhus University, Langelandsgade 140, DK-8000 Aarhus C, DENMARK.
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the market are limited. A disadvantage of the direct production path is the limited specific activity of about 20 ‐ 30 Ci/mg (110 Ci/mg theoretical specific activity)[1],[2] and therefore limited applicability of the radionuclide for preparation of high‐specific activity 177Lu‐ radiopharmaceuticals. Moreover c.a. 177Lu preparations contain up to 0.1 % of relative long‐lived byproduct 177mLu (T½ = 160.1d). The long‐lived radionuclide 177mLu can be a critical contamination in view of the sewage disposal and radiation protection and thus can be a limiting factor for routine use of 177Lu‐radiopharmaceuticals in clinical environment. In contrast to the direct production path, irradiation of 176Yb‐target allows production of n.c.a. 177Lu with the highest radiochemical and chemical purity. The chemical similarity of the two adjacent members of the lanthanide series complicates, however, the isolation of micro amounts of 177Lu(III) from the macro amounts of Yb(III). In this work the indirect production route has been studied to develop a chemical separation method by means of cation‐exchange chromatography. A fully automated system has been installed and is currently in use at the Munich facility for the processing of massive Yb‐targets. Multi‐Curie amounts of high quality n.c.a. 177Lu are produced with an estimated specific activity of about 100 Ci per mg of lanthanides and content of 177mLu less than 10‐5%. References: [1] Z. Dvorakova, Appl. Rad. Isot., 2008, 66, 147 [2] K. Zhernosekov, Appl. Rad. Isot., 2008, 66, 1218
P462 Effect of I-131 labelled magnetic iron particles in breast tumor 1
2
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1
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R. Bekis , Z. Biber , K. Dagdeviren , T. Ertay , P. Unak ; Dokuz Eylul University School of Medicine, Izmir, TURKEY, 2Ege University, Institute of Nuclear Sciences, Izmir, TURKEY. Targeted tumor therapy is selective delivering curative doses of radiation to malignant sites. Radionuclides which have high LET particle emissions conjugated to appropriate carrier molecules are selectively accumulated by tumor cells, deposits lethal doses to tumor cells while no admission occur to normal cells in targeted tumor therapy. Thus, targeted therapy offers the twin hopes of maximizing efficacy while minimizing toxicity. Aim: The aim of our study is to investigate effects of I‐131 labeled magnetic iron particles (MTC) in breast tumor. Method: This study was approved by the institutional review board of the Ege University animal ethics committee. Tumors were obtained from female Albino Wistar Rats, which were given a single gastric dose of 150 mg of DMBA dissolved in corn oil, per kilogram of body weight. Procedure repeated following three months. The formations of tumors were observed in 3 rats after 2 months. The tumors were verified as breast tumors by histopathologicaly and sizes were measured. 8‐Hydroxyquinoline conjugated magnetic iron nanoparticles were synthesized. The iodogen method was performed for the iodination of the complexes. One of the rats was selected as control group. 1.1 MBq and 13,32 MBq I‐131‐MTC was injected in the four‐quadrant to around tumors in other two rats respectively. Magnets were placed close to tumor to help localization of injected active iron particles. Whole body imaging was performed 5 minutes to show whether localized in the injection site of injected particles. Control and experimental tumor sizes were measured again and changes in sizes were detected 1 month after. Results: The tumor sizes in control rat increased 1 month after. But the tumor sizes in experimental rats decreased 33% in low doses, 65% in high dose 1 month after. Conclusions: In this study with limited number of animals, regression of tumor size was shown with peritumoral injection of radioactive particles. The use of magnetic particles with external magnetic field can increase the efficacy of treatment. These particles can be a potential agent for magnetic targeted therapy and need large series experiments.
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Synthesis of Y Radiolabeled Cationic Dextran for Local Therapy of Tumors S. Zhai1, Y. Shen2, L. Zhao3, X. Deng2, J. Du3; 1Department of Nuclear Medicine, Beijing Cancer Hospital, Beijing, CHINA, 2Department of Isotope, China Institute of Atomic Energy, Beijing, CHINA, 3China Isotope Corporation, Beijing, CHINA. Aim: 99mTc radiolabeled cationic dextran and avidin has shown selective accumulation in superficial bladder tumors compared to normal tissue by intravesical instillation. The aim of this 90 study was to synthesis Y radiolabeled cationic dextran conjugate in order to further explore the possibility to treat superficial bladder tumors locally. Materials and Methods: Dextran‐40 was oxidized with sodium periodate and subsequently reacted with lysine and 2‐(p‐NH2‐Bz)‐6‐methyl‐ DTPA (1B4M‐DTPA). The conjugate was then stabilized by reducing Schiff bases with sodium cyanoborohydirde and purified with a Sephadex G25 column. The concentration of DTPA in final cationic dextran conjugate was determined by spectrophotometric method. The cationic dextran‐ DTPA conjugate was then radiolabeled with 90Y. The stability of radiolabeled cationic 90Y‐DTPA‐ dextran conjugate was tested in saline and human serum. Results: The high purity of cationic dextran‐DTPA conjugate was achieved with 80% yield. The molar ratio of DTPA/dextran in final cationic DTPA‐dextran conjugate was 2.5. The radiolabeling yield of 90Y‐DTPA‐dextran was more than 98%. The radiolabeled cationic 90Y‐DTPA‐dextran conjugate was stable in saline and human serum. The studies to evaluate 90Y‐DTPA‐dextran biodistribution in animal tumor xenograft models are in progress. Conclusions: The cationic dextran was successfully radiolabeled with 90Y in high yield and stability. The cationic 90Y‐DTPA‐dextran conjugate could be as a candidate for further studies in local therapy of tumors. Research Support: This work was supported by the National Natural Science Foundation of China (No. 30670584)
P464 Formulation and Physicochemical 177Lutetium-EDTMP Kit
Quality
Control
of
A. Khawar1, S. Jawaid1, M. M. Ishfaque2, M. B. Khan2, S. Saeed1; 1Pakistan Institute of Engineering and Applied Sciences, Islamabad, PAKISTAN, 2 Pakistan Institute of Nuclear science and Technology, Islamabad, PAKISTAN. Owing to the suitable decay characteristics, as well as feasibility of large scale production in adequate specific activity and radionuclide purity, 177Lu could be considered as a promising radionuclide for palliative care in painful bone metastasis. In this study an attempt was made for
the formulation of 177Lu EDTMP kit and assessment of its physicochemical quality control. Materials and Methods: Appropriate quantity of 177Lu, with a specific activity of ~3700 MBq/mg (~100 mCi/mg) and radionuclidic purity of 99.3% was used for labeling of EDTMP kit containing 7.15mg CaCO3, 35 mg EDTMP and 14.1mg NaOH. Labeling efficiency and radiochemical quality control were checked by paper chromatography and electrophoresis. The effects of various parameters like pH, molar ratios, reaction temperature and time on labeling efficiency were assessed to obtain optimum labeling efficiency parameters. For invitro stability the reconstituted kit adjusted at optimum suitable pH, reaction temperature, incubation time and molar ratios was incubated for 5 minutes to 10 days Results: The Paper chromatography resulted in separation of 177Lu‐EDTMP towards solvent front (Rf=0.9‐1) and 177LuCl3 at its origin (Rf=0) where as the paper electrophoresis confirmed the formation and migration of negatively charged 177Lu‐ EDTMP complex towards anode from point of spotting. The labeling efficiency of 177Lu‐EDTMP was found to be >99% at pH 7‐9 and molar ratio between metal and ligand (1:20‐1:100). More than 99% chelation between 177Lu & EDTMP was achieved after 30 min of labeling at room temperature. The complex exhibited excellent in vitro stability up to 10 days at room temperature Conclusion: It is therefore concluded that EDTMP can be efficiently labelled with 177Lu. Hence, the prospects of utilization of 177Lu‐EDTMP for bone pain palliation should be explored.
P465 Synthesis and Characterization of Original Multidentate Bifunctional Chelating Agent to Label Monoclonal Antibody (EGFr) with Ac-225: Derived from Phenylalanine-GDPHA J. Tanwar, A. Datta, S. Chaturvedi, A. K. Mishra; Institute of Nuclear Medicine and Allied Sciences, Delhi, INDIA. Aim: Acyclic and macrocyclic polyaminopolycarboxylate ligands have found important applications in the field of nuclear medicine such as, in SPECT, Positron Emission Tomography imaging (PET), and Radioimmunotherapy(RIT). In Radioimmnotherapy an antibody is utilized which is labeled with a radionuclide to deliver cytotoxic radiation to target cell. For safe and potent RIT, a ligand that can form a stable complex with radioisotope with clinically acceptable complexation kinetics is required. The bifunctional chelating agent will be the best option for the binding of the metal ion. We have synthesized a novel acyclic multidentate bifunctional chelate GDPHA, derived from Glutamic acid and Phenylalanine to form stable complexes with variety of metal ions such as Bi‐212, Bi‐213 and Ac‐225 which shows their potential for use in cancer therapeutic and diagnostic applications. Methods: Amino acid L‐phenylalanine was used as a precursor and its nitro derivative was prepared, the amino group of nitrophenylalanine was further functionalized to increase the denticity forcomplexation of metal ions such as Bi‐213 and Ac‐225 by appending with ‐COOH groups. The nitro group of the functionalized nitorphenylalanine was reduced to amino and the amino derivatives were conjugated with glutamic acid. The final bifunctional chelator was obtained after treatment with TFA followed HPLC purification. The chelator GDPHA possessed an amino group for conjugation with an antibody while ‐COOH groups are useful to hold metal ions with high stability under physiological conditions. Results: The compounds were characterized by spectroscopic techniques like NMR, IR and Mass. UV spectroscopic studies were carried out for complexation kinetics of the ligand with Metal ions Ac(III) and Bi(III). Various parameters that affect the binding of Ac(III) and Bi(III) to the chelate was determined (pH, Ionic strength, Time) and optimized. The binding constant was determined. The thermodynamic parameters of this metal complexation ΔH≠,, ΔS≠ and Ea also supports binding constant data. During complexation two isobestic points shows the nature of complex and its stability with Ac(III) and Bi(III). The rate constant for the forward and backward reaction at equilibrium suggests quantitative binding of Ac(III) and Bi(III) with chelate. Conclusion: The UV Spectroscopic studies shows the good binding of Bi(III) and Ac(III) with the chelate GDPHA. A novel chelate is synthesized which can efficiently bind with α‐emitting metal ions like Bi(III) and Ac(III) for targeted therapy.
P466 188
W production at the high-flux reactor of ILL Grenoble
U. Köster1, Y. Calzavara1, B. Desbrière1, S. Fuard1, M. Samuel1, M. Harfensteller2, R. Henkelmann2, P. Juntunen2, S. Marx2, T. Nikula2, K. Zhernosekov3; 1Institut Laue Langevin, Grenoble, FRANCE, 2Isotope Technologies Garching GmbH, Garching, GERMANY, 3Institute for Radiochemistry, Technische Universität München, Garching, GERMANY. Institute Laue Langevin (ILL) in Grenoble operates a 58 MW high flux reactor. This powerful neutron source supplies intense extracted neutron beams for a great variety of experiments performed at over 30 different instruments. However, the ILL reactor has also in‐pile irradiation positions with a thermal neutron flux reaching 1.5∙1015 neutrons/cm2/s, unrivalled in Western Europe. Previously these beam tubes served mainly for specific cross‐section measurements and for production of small quantities of special radioisotopes for scientific purposes. Recently ILL started the production of radioisotopes for medical applications. The high neutron flux guarantees highest specific activity in single‐neutron‐capture reactions and is particularly useful for double‐neutron‐capture reactions with short‐lived intermediate radioisotopes. Irradiation of highly enriched 186W produces by double‐neutron‐capture 188W. In the high thermal neutron flux of the ILL reactor specific activities above 600 GBq 188W per g of (remaining) tungsten are reached after 50 days of irradiation and 10 days of decay. The produced 188W is shipped to Isotope Technologies Garching and serves for producing 188W/188Re generators for direct elution of 188Re at high concentrations (>10 GBq/ml), permitting direct use without further post‐ concentration. We will present the achieved specific and total activities and the radioisotopic purity of the irradiated tungsten samples. Also the concentration of the eluted 188Re and its 185 185 radiochemical purity (tungsten breakthrough, aluminium content, stable Re content from W decay and other impurities) will be discussed. With four irradiation cycles (50 days each) per year, ILL has the capacity to provide a quasi‐continuous supply of up to 20 TBq 188W per year. In combination with the high quality ITG 188W/188Re generators this assures the required isotope 188 supply for a large‐scale application of endovascular brachytherapy with Re and of therapy with 188 Re labelled radiopharmaceuticals. Prospects for production of other radioisotopes by ILL/ITG will be discussed.
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Medical radioisotopes activation in the JRC cyclotron-driven INBARCA neutron activator L. Maciocco1, S. Buono1, K. Abbas2, G. Cotogno2, N. Gibson2, F. Simonelli2, H. Tagziria2, N. Burgio3, A. Santagata3, G. Mercurio4, J. Taleb5, C. Billotey6; 1 Advanced Accelerator Applications, St Genis Pouilly, FRANCE, 2Institute for Health and Consumer Protection, Joint Research Centre, European Commission, Ispra, ITALY, 3FPN-FISION ENEA, Casaccia, ITALY, 4ENEA, Ispra, ITALY, 5Université Claude Bernard, Villeurbanne, FRANCE, 6 Université Claude Bernard, Hospices Civils de Lyon, Lyon, FRANCE. A compact, accelerator driven, neutron activator based on a modified version of the Adiabatic Resonance Crossing (ARC) concept has been developed, with the aim of efficiently utilising ion‐ beam generated neutrons for the production of radioactive nanoparticles for brachytherapy. The facility has been tested under various experimental configurations, and the activation yields of different materials, measured with γ‐spectrometry techniques, have been compared with those of our Monte Carlo (MCNPX, FLUKA) simulations. In particular two version of the activator were tested: a lead‐graphite and an all‐graphite configuration. Experimental results, in agreement with Monte Carlo calculations, showed that higher activation rates (factor 1.7) are obtained for the isotopes of interest (166Ho (T1/2=26.8h), 186Re(T1/2=3.7d) and 188Re (T1/2=0.71d)) as a result of the improved neutron moderation/confinement effects of the all‐graphite configuration. Experiments showed that a 166Ho saturation yield of 150 MBq/μA/g can be obtained on 125 μm 3 Ho metal foils (99.9% Ho content, density 8.8 g/cm ) at 36 MeV in the all‐graphite configuration. When Ho‐oxide 300 nm nanoparticles are irradiated (87.3% Ho content, variable density depending on nanoparticles conglomeration) a saturation yield of 220 MBq/μA/g can be achieved. An extrapolation from 36 to 40 MeV (the maximum energy of the JRC cyclotron) of the experimental results allows estimating a saturation yield of about 350 MBq/μA/g, which can be considered as the present maximum 300 nm Ho‐nanoparticles activation potentiality of the JRC INBARCA activator. Animal tests carried out in the framework of the INBARCA project showed that therapeutic effects on MAT3B tumours implanted in rats can be obtained with injected activities of the order of 50 MBq, corresponding to the injection of 20 mg of nanoparticles at 2.5 GBq/g. Such specific activity can be obtained 24h after an irradiation of 12 h with the INBARCA activator at 40 MeV and 50 μA. Much higher therapeutic doses (estimated at a factor 70 by Monte Carlo codes) can be clearly obtained with higher energies (70 MeV) and currents (~350 μA) currently available in commercial cyclotrons for medical applications. The demonstration of the possibility to obtain a satisfactory distribution and fixation of nanoparticles after intratumoral injection (brachytherapy) in rats was carried out by using Ho and Re loaded nanoparticles activated in the JRC INBARCA activator and visualised/quantified through in‐vivo SPECT imaging and ex‐vivo g‐counting on single organs.
P468 Enhancement of reaction conditions for the radiolabelling of DOTA-peptides with high activities of Yttrium-90 A. Nardelli1, E. Castaldi1, G. Ortosecco1, A. Speranza1, G. Storto2, T. Pellegrino1, L. Pace3, M. Salvatore3; 1Instituto di Biostrutture e Bioimmagini, Consiglio Nazionale delle Ricerche (CNR), Naples, ITALY, 2IRCCS CROB, Rionero in Vulture, ITALY, 3Dipartimento di Scienze Biomorfologiche e Funzionali, Università “Federico II”, Naples, ITALY. Aim: Peptide receptor radionuclide therapy (PRRT) has recently expanded due to the radiolabelling of DOTA‐peptides, such as the somatostatin analogues [DOTA0, Tyr3] octreotate (DOTATATE). The achievement of high specific activities during procedures has been indicated as the critical factor to consent effective therapy. Several radiochemical factors may negatively impact on reaction procedures such as pH, temperature and time of reaction. Our study was undertaken to explore the influence of radiochemical parameters, such as time of incubation, on 90 reaction kinetics during the radiolabelling of DOTATATE with Y. Materials and Methods: Forty‐ five radiolabelling procedures were carried out using small volumes of Yttrium‐90, tipically 60‐78 μL. At nearly constant pH and temperature two different settings of radiolabelling procedures were implemented removing the products from the heating water bath approximately after 30 min. (group E, early; n = 20) and after 39 min. (group L, later; n = 25), respectively. Quality controls were performed by means of both high‐performance liquid chromatography (HPLC) and 90 thin‐layer chromatography (TLC). Results: Reaction kinetics for Y were found to provide suitable percentage of incorporation at pH 4.5 for both groups. Temperature of reactions was not different between group E and L, respectively. A significant difference was found between the two groups in radiochemical yield which was 95,6% ± 0.8 for group E and 98.2% ± 1.1 for group L (p<0.0001). The specific activity of the final product was 46.9 MBq /nmol. Conclusion: In order to achieve optimal specific activities pH, temperature and time of reaction necessitate careful evaluation and setting. A statistically significant difference in labelling yield was found between set of procedures completed at 39 min as compared to those executed at 30 min, retaining reaction pH and temperature constant.
P469 Preparation of Ho-166 and Lu-177 Loaded Polylactic Acid Microspheres for Radiotherapy M. Kropacek1, M. Tomes1, F. Melichar1, J. Ventruba1, J. Srank1, V. Krizova2; Nuclear Physics Institution, Rez near Prague, CZECH REPUBLIC, 2Institute of Chemical Technology, Department of Analytical Chemistry, Prague, CZECH REPUBLIC.
1
Objectives: The aim of this study was to prepare polylactid acid (PLA) microspheres loaded with beta emitters 166Ho and 177Lu, where particles of a well‐defined size could be trapped in the vascular bed of the tumor tissue while delivering a high dose of radiation in order to destroy both primary and metastatic liver tumors. Methods: PLA microspheres were prepared using solvent evaporation technique. Ho/Lu acetyl acetone complex and PLA were dissolved in chloroform and consequently added to 2% polyvinyl alcohol. Mixture was stirred for at least 12 hours until chloroform was evaporated. The precipitated microspheres were centrifuged, washed with
distilled water and 0.1M HCl and finally collected on a cellulose nitrate filter. Particle size analysis, as well as electron microscope scan was carried out before and after neutron activation. Results: Microspheres (200mg) were irradiated at the neutron flux 1012cm‐2s‐1. Activity of 177Lu reached after 60 minutes ranged from 0.524 to 0.625 GBq, while activity of 166Ho attained within the same time was 1.1‐1.5 GBq. Microspheres mean diameter ranged from 21 to 29 μm and minimally 70% of particles showed an ideal dimension 20‐50 μm. Conclusions: Both 177Lu and 166 Ho loaded PLA microspheres showed relatively good quality after neutron activation, without significant sign of degradation. Higher activity of 177Lu for therapy could be reached by increasing amount of activated microspheres. Research Support: Financial Support: 1) Grant Agency of the Academy of Sciences of the Czech Republic, Project No.: 1QS100480501, 2) IAEA Research Project No.: 13948
P470 A New Re-188 labeled-cyclic-alpha-MSH Peptide for targeted therapy of Melanoma Y. Hong, S. Lee, K. Choi, S. Choi; Korea Atomic Energy Research Institute, Daejeon, REPUBLIC OF KOREA. Obsective(s) : Early detection and treatment of primary melanoma is essential to enhance the patient survival. Melanocortin‐1 receptor (MC1‐R) is an attractive target for therapy of melanoma, because it was expressed over 80% of human metastatic melanoma. Radiolabeled alpha‐MSH peptide analogues exhibit nanomolar MC1‐R binding affinities. In this research, we prepared a new alpha‐MSH peptide for targeting of MC1‐R Furthermore, its radiolabeling study with Re‐188 and biodistribution study were performed. Material & Method(s) : Considering the results on structure‐bioactivity study, His‐dPhe‐Arg‐Trp is fundamental for melanoma targeting. To synthesis the specific targeting peptide of MC1‐R having N2S2 chelator for lableing with Re‐ 188, conventional Fmoc strategy was applied. After synthesizing a linear peptide, Mercaptoacetyl‐Gly‐Cys‐Gly‐Dap‐Glu‐His‐D‐Phe‐Arg‐Trp‐Asp‐Lys‐Pro‐Val‐NH2, cyclisation was performed by applying a amide coupling method between Asp and of Dap. The peptide was labeled with Re‐188 via a glucoheptonate transchelation reaction. Freshly eluted Re‐188 and alpha‐MSH peptide solution were injected to the glucoheptonate kit and reacted for 20min at 90°C. Biodistribution studies were performed using B16/F1 murine melanoma‐bearing C57 mice. The mice were sacrificed 2, 24h (n=5) after injection. Result(s) : We prepared a new α‐MSH peptide containing N2S2 chelator and His‐D‐Phe‐Arg‐Trp in the sequence for targeting of MC1‐R for detection and therapy. The radiolabeling yield was reached over 98% at the concentration of ligand (10‐8 mol). The radiolabeled peptide was applied to animal experiments without further purification. Biodistribution studies demonstrated high tumor uptake and extended tumor retention. Tumor uptake values at 2 and 24 h were 8.42±1.48 %ID/g and 1.66±0.38 %ID/g, respectively. Blockage study using un‐labeled peptide showed a reduced tumor uptake about 25%, demonstrating the tumor uptake was receptor‐mediated. The clearance kinetics was rapid, most of injected radioactivity was measured in large intestine 2 h post‐injection. The tumor‐to‐ blood ratios were 7.0 and 5.4 at 2 and 24 h post‐injection. Conclusion(s) : We prepared a new α‐ MSH peptide for the targeting of MC1‐R. Although Mercaptoacetyl‐Gly‐Cys showed the excellent chelation efficiency with rhenium, the excretion pathway was somewhat different to other ordinary radiolabeled peptides. More sophisticated modification of the chelator sequences should be evaluated to change the excretion. Since the designed and prepared peptide showed possibility to target the MC1‐R positive tumor, after improving in vivo kinetic of N2S2 chelator, we will perform well‐designed research for the evaluation of its potent as a tumor‐targeting therapeutics and diagnostics.
P471 Radiolabeling of molecules using Rhenium-188: Early results from IPEN/Brazil T. Brambilla, C. Dias, J. Osso Jr.; IPEN, São Paulo, BRAZIL. Radionuclide therapy (RNT) is emerging as an important field of nuclear medicine. Apart from the well established 131I, several other promising radionuclides have been identified, among them 188 Re, 90Y and 177Lu that are considered to be the most promising radionuclides for in‐vivo 188 therapy. Re has favourable nuclear characteristics [t1/2 16.9 h, Eβ max 2.12 MeV and Eγ 155 keV (15%) suitable for imaging, dosimetry and biodistribution studies], including the fact that it is carrier‐free and can be obtained cost‐effectively from a generator. The aim of this work was to describe the preliminary studies concerning the radiolabeling of the antibody anti‐CD20 (Rituximab) and the DMSA (V) with 188Re. Anti‐CD20 was reduced by incubation with 2‐ME at room temperature. The number of resulting free sulfhydryl groups (SH) was assayed with Ellman’s reagent. Optimization of radiolabeling was achieved by varying parameters: antibody mass, reducing agent mass, tartrate mass, stability and reaction time, 188Re volume and activity. Radiochemical purity of 188Re‐anti‐CD20 was evaluated using instant thin layer chromatography‐ silica gel (ITLC‐SG). The best labeling efficiency was achieved in the following conditions: 1 mg anti‐CD20; 82.8 mg sodium tartrate; 1 mg SnCl2; 0.25 mg gentisic acid, 1 mL 188Re and reaction time of 1 hour at room temperature. Quality control methods for evaluation of radiochemical purity showed reasonable labeling yield of the antibody but further studies and comparison with tricarbonyl core will be carried out in order to improve the labeling yields and consequently the specific activity of the product.188Re‐DMSA(V) was prepared by two methods. The first method was prepared using a commercial kit of DMSA(III) for labeling with 99mTc at high temperature (100oC). The second method was prepared in a vial containing 2.5mg of DMSA, 1.00mg of SnCl2.2H2O and 30mg of sodium oxalate, in a total volume of 1mL. The pH was adjusted to about 5 with 37% HCl. After labeling the solution was stirred and incubated for 15 min at room temperature. The radiochemical purity was determined using TLC‐SG developed with two different solvent systems. Acetone was used in order to separate ReO4‐ (Rf 1) from 188Re‐DMSA(V) and ReO2 (Rf 0) and 5% glycine was used in order to separate ReO2 (Rf 0) from 99mTc‐DMSA(V) and ReO4‐ (Rf 1). Preliminary results for both methods showed that the labeling yield was >90%. Further experiments are necessary to optimize the labelling methodology.
P472 Development of methodology for the preparation of electrochemical generators at IPEN-CNEN/SP in Brazil G. Barrio, J. A. Osso Junior; IPEN-CNEN/SP, Sao Paulo, BRAZIL.
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Poster Presentation
P467
S402 Yttrium‐90 is is considered one of the most useful and important radionuclides for radioimmunotherapeutic applications and also for radiosynoviorthesis treatments. This radionuclide has a half‐life of 64 h, long‐range beta emissions (maximum energy 2.3 MeV) and it decays to a stable daughter with no undesirable intermediate nuclides. 90Y can be obtained conveniently and inexpensively, in a carrier free form, as a radionuclide generator product by decay of its 28‐yr parent, Strontium‐90 (90Sr). The 90Sr‐90Y generators could be used for several months to several years due to the long half‐life of 90Sr but depending on the type of generator this shelf time can be reduced due to radiolysis effects. The electrochemical generator is a proper solution because there are no significant effects of the radiation on the generator itself. The aim of this work is to show the preliminary results coming from the development of a 90Sr‐90Y electrochemical generator at IPEN‐CNEN/SP. The experiments were performed using a simple electrochemical device, with two Platinum electrodes acting as cathode and anode. The first experiments were performed with non radioactive Sr and Y solutions and several parameters were varied, such as time and current of the electrodeposition, pH of the solution and cation concentration. After that the experiments were performed using the following gamma emitting radiotracers: 88Y (t1/2= 106.65 days) and 85Sr (t1/2= 64.84 days). Both radioactive tracers were prepared irradiating Y and Sr oxides at the IEA‐R1m Nuclear Reactor, respectively. The results so far showed that Sr is not electroplated in any condition and that up to 40% of Y can be selectively electroplated in the following conditions: electrodeposition time of 120 min, current of 60 mA, initial pH of the solution between 3.5 and 4 and low concentration of Y. The pH lowered with the electrodeposition time and it was adjusted to the intial value every 30 minutes. The experiments will continue with the use of the pair 90Sr‐90Y.
P473 Automated procedure for the preparation and injection of 188 radiolabelled Lipiodol with Re for HCC therapy N. Lepareur1, V. Ardisson1, S. Becker1, N. Noiret2, E. Garin1; 1Centre Eugène Marquis, Rennes, FRANCE, 2ENSCR, Rennes, FRANCE. Aim We have recently reported a highly efficient procedure for the labelling of Lipiodol through solubilisation of a lipophilic 188Re chelate, 188Re‐SSS. Since the preparation and formulation of 188 Re‐labelled Lipiodol involves different steps, it induces a significant radiation exposure of the personnel, especially when therapeutic activities are required for the routine treatment of patients. To overcome this problem, we present here the development of an automatic procedure for the remote‐controlled preparation and injection of 188Re‐Lipiodol. Materials and Methods Perrhenate was eluted from a 188W/188Re generator. The starting reagents were provided as sterile, freeze‐dried, two‐vial kit formulations. The final radioactive solution was filtered through a sterile 0.22‐μm filter before mixing with Lipiodol. The radiolabelled Lipiodol could be then emulsioned with physiological before injection. All these operations were remotely controlled through dedicated software packages. Results The procedure consists in four main steps, which have been optimised: (1) elution/concentration of perrhenate, (2) synthesis of the lipophilic complex 188Re‐SSS, (3) purification and mixing of 188Re‐SSS with Lipiodol, (4) emulsion with physiological and injection. Handling of the radioactive solutions is limited to the transfer from one apparatus to the other. The radiochemical purity of the radioconjugate 188Re‐ SSS/Lipiodol, as measured with TLC and HPLC, is over 90 %. ConclusionWe proved that this new automated procedure can provide high activity of 188Re‐labelled Lipiodol in routine for treatment of HCC patients, with reduced radiation burden to the personnel.
P474 Lutetium-177 radiolabeling of the humanized monoclonal antibody h-R3 using macrocyclic and acyclic ligands. D. Beckford1, M. Malkova1, M. Beran1, M. Kopracek1, M. Tomes1, A. Laznickova2, M. Laznicek2, P. Barta2, R. Leyva3, F. Melichar1; 1Nuclear Physics Institute, Řež, CZECH REPUBLIC, 2Charles University Prague, Prague, CZECH REPUBLIC, 3Isotopes Center, Havana, CUBA. Objectives: So far, target specific radiopharmacueticals supply a unique tool for specific delivery of radionuclides to diseased tissues. Humanized anti‐EGFR monoclonal antibody hR3 (Nimotuzumab, commercial name Theraloc) is being studied in many clinical trials for immunotherapy of various cancers. The aims of this study were to develop simple, fast and efficient methods for radiolabelling h‐R3 conjugates with 177Lu for radioimmunotherapy and compare acyclic and macrocyclic ligands. Preliminary biological evaluation was carried out for every conjugate. Methods: Humanized mAb hR3 (CIM, Cuba) was conjugated to bifunctional ligands in aqueous media (0.1 M phosphate buffer, pH=8.5) for 24 hours at 16 °C using DOTA‐ NHS, p‐SCN‐Bn‐DOTA, p‐SCN‐Bn‐DTPA and CHX‐A“‐DTPA (Macrocyclics, Texas). The conjugates were purified by size‐exclusion chromatography on PD‐10 (Amersham Biosciences) desalting column, analyzed using HPLC. The number of chelates conjugated to the MAb was determined using a 111In assay. All conjugates were labelled with 177Lu produced in our laboratory by the neutron irradiation of isotopically enriched 176Lu2O3. Labelling efficiencies and radiochemical purity were determined by ITLC and HPLC with radio/UV detection. Radioimmunoconjugate integrity was also evaluated by HPLC. Biodistribution was tested in Wistar male rats. Results: Humanized monoclonal antibody h‐R3 conjugated with DOTA and DTPA derivatives yielded 4 to 14 chelates per MAb molecule. SE‐HPLC showed that no aggregates or fragments were formed during conjugation reaction. Under optimum conditions the labelling efficiencies were 95% and 70% for DOTA and DTPA conjugates, respectively. After purification the radiochemical purity of every radioimmunoconjugate was higher than 97%. The biodistribution studies showed that the number of chelates per protein molecule modified the in vivo behavior of the MAb radioimmunocnjugates. Conclusions: The methods for synthesis of hR3‐DOTA/DTPA bioconjugates and their labeling with 177Lu have been successfully developed. DOTA‐conjugates showed better labelling efficiencies than DTPA‐conjugates. Research Support: The research was supported by the Grant No.1QS100480501 of the Academy of Sciences of the Czech Republic, the EUREKA Grant No. E08018 ( Czech Ministry of Education ) and the IAEA Coordinated Research Project No. 13948.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 P54 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radiopharmacy/radiochemistry: antibodies - proteins / peptides
P475 Cloning, expression and purification of scorpion toxin BmK CT and indirect labelling of 131I-BmK CT J. Zhao1, W. Qiao1, Y. Zhang1, X. Shao2; 1Shanghai Jiaotong University, Shanghai First People's Hospital, Shanghai, CHINA, 2Shanghai Tongji University, Shanghai, CHINA. BmK CT, a kind of scorpion toxin, can inhibit glioma cell proliferation and tumor infiltration on the basis of specific binding to chloride channels on gliomas cell. The purpose of our research is to investigate wether 131I‐BmK CT could be a novel effective method for “targeted nuclide therapy” and therapeutic monitoring of glioma after labelling BmK CT with I‐131. Methods: According to the mutated cDNA sequence of BmK CT, two primers was designed to synthesize BmK CT. The BmK CT gene was obtained by using a PCR method. After construction of expression vector pGEM‐4T‐1‐BmKCT and expression of fusion protein in E. coli, BmK CT could be obtained by purification and cleavage of fusion protein. Mass spectrometry was used to test the obtained protein. BmK CT was labelled with iodine‐131 by indirect labelling (Bolton‐Hunter method). The experiment of cell conjugation was to invetigate whether 131I‐BmK CT could specifically conjugate with C6 glioma cell. MTT (Methyl Thiazolyl Blue) method was used to detect the growth inhibition rate (GIR) of C6 glioma cells for evaluating the killing effect of BmK CT and 131I‐ BmK CT. Results: After cloning, expression and purification, mass spectrometry indicated that BmK CT was a toxin of 35 residues with four disulfide bridges and the molecular weight was 3749. 131I‐BmK CT was successfully prepared by indirect labelling (Bolton‐Hunter method) with the overall yield to 34.5%. The radiochemical purity of 131I‐BmK CT was 94.0%. The experiment of cell conjugation indicated that the reciprocal of cell conjugation rate is of linear correlation with the reciprocal of cell count (R=0.75). 131I‐BmK CT could specifically conjugate with C6 glioma cell. MTT tests indicated that both BmK CT and 131I‐BmK CT could inhibit C6 gliomas cell growth. The ability of 131I‐BmK CT to inhibit cell growth is superior to that of BmK CT. The growth inhibition rate (GIR) of gliomas cell is 60.5% on the concentration of 2μg/ml with BmK CT. And the GIR of gliomas cell is 71.2% on the radiactivity concentration of 50μCi/ml (concentration is much lower than 2μg/ml) with 131I‐BmK CT. Conclusions: On the basis of cytology experiments, 131I‐BmK CT, prepared by indirect labelling, could specifically conjugate with C6 glioma cell and inhibit the growth of C6 glioma cells. Our research may provide a novel, convenient, highly efficient and minimally invasive method for “targeted nuclide therapy” and therapeutic monitoring of glioma in the future.
P476 In vitro and in vivo evaluation of Anti-ProGRP Monoclonal Antibody E-B5 Z. L. Liu, Q. L. Xu, Y. Yang, Y. M. Shen; The Second Affiliated Hospital of Soochow University, Department of Nuclear Medicine, Suzhou, CHINA. Objectives: Gastrin‐releasing peptide(GRP), a nitrogenous hormone, is highly expressed by virtually small cell lung cancer(SCLC). ProGRP, prosoma of GRP, respects the express of GRP. We studied the radionuclide label method of anti‐ProGRP antibody E‐B5 and the feasibility of 131I‐E‐B5 in detecting SCLC. Methods: E‐B5 was labeled by Chloramine‐T method using 131I.TLC and paper chromatography were used to determine the rabeling efficiency and radiochemical purity. 30 nude mice bearing SCLC were divided into 6 groups randomly. After injection of 131I‐E‐B5, the blood and organs of nude mice were harvested at different time for calculating dose per gram of tissue (%ID/g) and tumor/non‐tumor (T/NT) ratio. Continuous images of 131I‐E‐B5 imaging in nude mice bearing SCLC,lung adenocarcinoma and colon cancer were obtained at different time points 131 after injection of I‐E‐B5 , respectively. ROIs were drawn on the images and T/NT ratios were calculated. Results: The rabeling efficiency of 131I‐E‐B5 was 90.8% and its radiochemical purity was 99.28%. After incubation in water bath at 37oC for 6h and 24h, the radiochemical purity still 131 maintained above 90% and 70%,respectively. At 72h post‐injection of I‐E‐B5, the %ID/g of transplantation tumor and the tumour‐to‐blood ratio in nude mice bearing SCLC were 0.14±0.03 and 1.75±0.64, respectively. At 96h post‐injection of 131I‐E‐B5, the T/NT ratios in nude mice bearing SCLC,lung adenocarcinoma and colon cancer were 5.82±0.07,2.57±0.04,1.29±0.05, respectively. Conclusions: 131I‐E‐B5 is a potential radioimmumoimaging agent for detecting SCLC.
P477 Experimental study on biodistribution of 99mTc labeled ECGuanine in mice Z. L. Liu, J. Tang, J. Yang; The Second Affiliated Hospital of Soochow University, Department of Nuclear Medicine, Suzhou, CHINA. Objectives: To evaluate the bio‐distribution of 99mTc labeled ethylenediysteine(EC) ‐Guanine in mice and investigate the value of 99mTc‐EC‐Guanine for detecting malignant tumor. Methods: TLC and paper chromatography were used to determine the rabeling efficiency and radiochemical purity.48 normal mice and 48 Lewis lung cancer tumor‐bearing mice were divided into 8 groups randomly and given 99mTc‐EC‐Guanine via i.v. injection, respectively.They were sacrificed at different time after injected for calculating the injection dose per gram of wet tissue weight(%ID/g).The ratios of tumor/non‐tumor(T/NT) were calculated.Meanwhile,normal mice,mice bearing different tumors and mice models of inflammation were imaged with SPECT at different time after injection.ROIs were drawn on the images and T/B ratios were calculated in tumor‐bearing mice and mice models of inflammation. Results: The rabeling efficiency of 99mTc‐ EC‐Guanine was 98% and its radiochemical purity was over 95% in 8h.The bio‐distribution in all the samples but kidney decreased rapidly in 30min after injection.Considerable radioactive uptake by tumor was observed,the radioactivity ratios of tumor to blood,tumor to muscle,tumor to lung and tumor to liver increased after the injection,at the 4h the ratios of them were 1.69±0.92,4.54±1.54,1.49±0.68,0.45±0.12, respectively.The tumor was clearly visualized at the 4h after injection in tumor‐bearing mice,T/B was 4.63±0.12 at 4h in Lewis lung cancer tumor‐bearing
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P478 Radioimmunotherapy improves survival of microscopic liver metastases of colorectal origin
rats
with
G. M. De Jong, T. Hendriks, W. J. G. Oyen, S. Heskamp, A. Eek, R. P. Bleichrodt, O. C. Boerman; Radboud University Nijmegen Medical Centre, Nijmegen, NETHERLANDS. Objective: The aim of the study was to assess the efficacy of radioimmunotherapy (RIT) with a Lu‐ 177‐labeled monoclonal antibody (MG1) to treat colorectal liver metastases. Methods: Male Wag/Rij rats underwent a laparotomy with intraportal injection of 1 x 106 CC531 tumour cells. The biodistribution of 111In‐MG1 one day after i.v. injection was determined and compared with that of an isotype‐matched control antibody (UPC‐10). The maximal tolerable dose (MTD) of 177 Lu‐MG1 was determined and the therapeutic efficacy of 177Lu‐MG1 at MTD was compared with that of 177Lu‐UPC‐10 and carrier only. RIT was administered either on the day of tumour inoculation or 14 days later. Primary endpoint was survival. Results: 111In‐MG1 preferentially accumulated in CC531 liver tumours (9.2 ± 3.7%ID/g at 1 day p.i.), whereas 111In‐UPC‐10 did not (0.8 ± 0.1%ID/g). The MTD of 177Lu‐MG1 was 400 MBq/kg body weight. Administration of RIT immediately after tumour induction improved survival compared to administration of radiolabelled UPC‐10 significantly (P=0.009), whereas delayed treatment did not (P=0.940). Early administration of RIT improved median survival and 25th survival percentile from 46 ± 6 days to 177 55 ± 24 days and from 49 ± 3 days to 97 ± 1 days, respectively. Administration of both Lu‐MG1 and 177Lu‐UPC‐10 resulted in a transient decrease in body weight, indicating a non‐specific radiation effect. Conclusion: This study provides proof of principle that RIT can be an effective treatment modality for microscopic liver metastases, whereas RIT is not effective in larger tumours.
P479
177
Preclinical evaluation of Lu complexes of two dendrimers based on a pyridine-N-oxide DOTA derivative M. Laznicek1, A. Laznickova1, V. Biricova1, M. Polasek2, P. Hermann2, I. Lukes2; 1Faculty of Pharmacy, Charles University, Hradec Kralove, CZECH REPUBLIC, 2Faculty of Natural Sciences, Charles University, Prague, CZECH REPUBLIC. Aim Polyamidoamine (PAMAM) dendrimers are highly branched synthetic spherical polymers enabling the attachment of large numbers of chelating agents to a single molecule. Dendrimer conjugates with a macromolecule (such as antibody) with specific biodistribution may deliver a large amount of radiometal ions into the target ‐ mostly for diagnosis and radionuclide therapy of tumours. Bifunctional chelates are generally used to chelate radiometal ions at the surface of such dendrimers. Recently, a new pyridine‐N‐oxide derivative of DOTA (Pynox‐DOTA) has been synthesized and it forms kinetically and thermodynamically stabile radiometal complexes with more rapid complex formation rates when compared with DOTA.The study was focused to the first and fourth generation PAMAM dendrimers (containing 8 and 57 surface amino groups) with Pynox‐DOTA (D8 and D57, respectively) from the point of view of their radiolabelling with Lu‐177 and biodistribution characteristics in rats. Materials and Methods Dendrimer‐Pynox‐DOTA conjugates were mixed with Lu‐177 and non‐radioactive Lu(III) in acetate buffer pH 5.6 and heated up to 40°C for different times. The excess Lu(III) was removed by gel permeation chromatography. Biodistribution was determined in male Wistar rats after intravenous administration of the agents in the dose of 2 μg per animal. Results The complex moiety in the Lu‐177‐D8/D57 dendrimers is electroneutral (unlike most of previously studied dendrimers). Despite its neutrality, Lu‐177‐D8 was very rapidly cleared from the blood and other organs of rats excepting elimination ones. Radioactivity was quickly excreted via the kidney. For Lu‐177‐D57, a moderate clearance from the blood was detected. A relatively high and long‐term radioactivity retention in the liver was found. The main elimination pathway was renal excretion. No significant radioactivity accumulation in other tissues was determined. We can conclude that a biodistribution profile of radiometal‐dendrimer‐chelate conjugate is dependent on the number of chelate groups (the dendrimer size) and/or overall hydrophilicity/charge of the polymer. Conclusion An employment of dendrimer‐functional chelate conjugates represents a promising way for the preparation of radiolabelled tumour‐seeking macromolecules (such as monoclonal antibodies) with a high specific activity. This strategy may overcome a very limited dose of the targeting vector acceptable for human administration. Acknowledgement: The study was supported by the Grant Agency of the Czech Republic, grants No. 305/07/0535 and 203/09/1056, the Czech Academy of Science (No. KAN201110651) and the Long Term Research Plan of the Czech Ministry of Education (No. MSM0021620857). This work was also carried out in the framework of COST BM0608 Action.
P480 Preclinical comparison of two hR3-DOTA derivatives labelled 177 with Lu A. Laznickova1, M. Laznicek1, P. Barta1, M. Beran2, Melichar2; 1Faculty of Pharmacy, Charles University, CZECH REPUBLIC, 2Nuclear Physics Institute, Radiopharmacy, Rez near Prague, CZECH REPUBLIC, Department of Radiopharmacy, Havana, CUBA.
D. Beckford3, F. Hradec Kralove, Department of 3 Isotopes Centre,
Nimotuzumab is a humanized anti‐EGFR monoclonal antibody hR3 with 95% human sequences. Being a humanized antibody it has been approved for indications such as squamous cell carcinoma of head and neck, and glioma. The aim of this study was to compare the stability, in vitro relative immunoreactivity and biodistribution of two 177Lu‐radiolabelled hR3‐DOTA conjugates. Methods Humanized mAb hR3 (CIM, Cuba) was modified either with N‐ hydroxysuccinimidyl‐DOTA (conjugate I) or with amine “activated” p‐SCN‐Bn‐DOTA (conjugate II). Purified immunoconjugates labelled with 177Lu were obtained from the Nuclear Physics Institute, Rez. Radiochemical purity and stability of radiolabelled compound was determined by ITLC or
HPLC with radiodetection. Human skin keratinocyte (HaCaT) and A431 cell lines were used for in vitro testing of immunoreactivity of the 177Lu‐hR3‐DOTA radioimmunoconjugates. The biodistribution and elimination of the labelled antibodies was studied in male Wistar rats. Results: Stability of radiolabelled monoclonal antibodies was determined at 4°C. Radiochemical purity of radioimmunoconjugate I was higher than 90% after 7 days incubation and that for conjugate II was about 99% after 7 days. Affinity to EGF receptors tested in vitro with HaCaT and A431cell lines was significantly lower for conjugate I in comparison with conjugate II. Blood clearance of radioactivity in rats was very slow for both antibodies; radioactivity‐time decrease was somewhat more rapid for conjugate I when compared to conjugate II. Increasing radioactivity accumulation in the liver was found for both compounds under study up to 3 days after dosing. The liver uptake of radioactivity for conjugate I was about one half of that for conjugate II. Partial radioactivity elimination by urine and faeces was more rapid for conjugate I. Conclusions: The results showed that both studied ways of radio‐metal attachment to the antibody affected radioimmunoconjugate stability, its affinity to specific receptors and distribution profile in preclinical experiments. Research Support: The research was supported by the Grant Agency of the Czech Republic No. 305/07/0535 and was performed in the frame of EUREKA, Grant of Czech Ministry of Education No. E08018 and COST Action BM0607 (No. OC08006).
P481 Comparative Radiochemistry and Micro-SPECT/CT Imaging of Two Closely Related Hepatic Receptor Agent : Distinct Asialoglycoprotein Receptor Specificities between Rat and Mice M. H. Wang1, H. M. Yu1, C. Y. Chien1, R. Lee2, Y. C. Lee2, W. J. Lin1; Institute of Nuclear Energy Research, Taoyuan, TAIWAN, 2Johns Hopkins University, Baltimore, MD, UNITED STATES.
1
Aim:Two closely related glycopeptides were synthesized, radiolabeled with In‐111, and subjected to microSPECT/CT imaging. Comparison of their radiochemical characteristics and images are discussed. Method: Two glycopeptides based on nitrilo‐triacetic‐acid (NTA) scaffold were synthesized by similar process. One contains trivalent N‐acetylgalactosaminide (1474.6Da), and the other, hexavalent lactoside(3371Da) made by dimerization of trivalent lactoside, which was synthesized by the same method as the above trivalent N‐acetylgalactosaminide. The glycopeptides were derivatized with DTPA, and mixed with In‐111(1.85 x 107 Bq) in 0.1M citric acid (pH2.1) for 30min. Their radiochemical yield were analyzed by ITLC‐SG using 10mM sodium citrate (Rf values : 111In, 0.9‐1.0; 111In‐glycopeptide, 0.0‐0.2). The SPECT images and CT images were acquired using a micro‐SPECT/CT scanner (X‐SPECT/CT, Gamma Medica, Northridge, CA), with a medium energy parallel hole collimator. Results and Discussion: Both 111In‐hexavalent lactoside and 111In‐trivalent N‐acetylgalactosaminide showed liver targeting characteristics. However, they behaved quite different in radiochemistry. The 111In‐hexavalent lactoside quite easily attained 100% radiochemical purity and more than 1000uCi/ug specific activity under room temperature with 10:1 molar ratio of ligand to 111In. However, 111In‐trivalent N‐ acetylgalactosaminide needed heating to enhance the radiochemical yield, which increased with temperature. For example, 111In‐trivalent N‐acetylgalactosaminide could reach 87% radiochemical purity(RCP) and 5.34uCi/ug specific activity by heating at 90°C. When heated at 100°C, the radiochemical labeling yield is more than 90% and its specific activity is raised to 9.2uCi/ug. Interestingly, we found 111In‐trivalent N‐acetylgalactosaminide with 9.2uCi/ug could be used for liver imaging either for rat and mice, however, 4.6uCi/ug specimen only could be used for liver imaging for rat, but not for mice. We suspect that there may be differences in asialoglycoprotein receptor specificities or capacities between rat and mice. In future, we will test the behaviors of these two glycopeptides on rat hepatocyte (clone 9) and mice hepatocyte (FL83B) to see if the same phenomenon will occur.
P482
131
Radioimmunotherapy with human antibody fragment IAFRA-DFM 5.3 has a strong anti-tumor effect on ovarian tumor A. Coliva1, A. Zacchetti1, E. Luison1, P. Alberti1, F. Martin2, A. Coliva1, E. Bombardieri1, M. Allegretti2, S. Canevari1, M. Figini1; 1Istituto Nazionale Tumori, Milan, ITALY, 2Dompé Pha.r.ma, L'Aquila, ITALY. Aim: 90% of epithelial ovarian carcinomas (EOC) overexpress the folate receptor (FR) stably or even up‐modulated during progression and acquisition of drug resistance. We developed an anti‐ ovary carcinoma murine mAb that recognize the FR. Subsequently, to overcome limits associated to mAbs, using an antibody library from EOC patients combined with epitope imprinting selection methodology, we generated a new human anti‐FR antibody Fab fragment (AFRA), that was genetically and chemically manipulated to obtain the chemical dimer, AFRA‐DFM5.3. Aim of this study was to investigate in animal models the biological parameters and the therapeutic efficacy of 131I‐AFRADFM5.3. Material and Methods: AFRA‐DFM5.3 was radiolabeled with 131I using Iodogen‐precoated iodination tubes by the Chizzonite method. Purified radiolabeled compound was tested for immunoreactivity on FR expressing cells. Biodistribution, pharmacokinetics and uptake of 131I‐AFRA‐DFM5.3 were tested in athymic nude mice bearing measurable s.c FR‐ expressing (A431tFR) or not expressing (A431tMock) human ovarian cancer xenografts. Blood, healthy organs and tumor were collected at serial time points, wet‐weighed and counted for radioactivity. Therapeutic efficacy was tested in the same animal model used for biodistribution studies and subsequently as loco‐regional treatment in an animal model bearing orthotopic xenografts of EOC cells. The efficacy of the treatment was evaluated considering animal weight and tumor reduction where possible or overall survival. Results: 131I‐AFRA‐DFM5.3 (specific activity = 185 ± 18.5 MBq/mg) showed a high immunoreactivity (71.9 ± 4.6 %). In subcutaneous model 131I‐AFRA‐DFM5.3 specifically accumulated only in FR‐expressing tumors and at therapeutic doses significantly reduces tumor growth (average reduction of 60% of tumor volume after administration of 37 MBq; below 20% in controls). Therapeutic experiments on orthotopic model showed a median survival between 30‐35 days for treated animal against 14‐22 days for controls. Doubling treatment with two administrations at about one week of distance with a cumulative activity of 74 MBq improved efficacy and median survival was prolonged till 90 days not reaching the end point. Conclusion: these data point to the suitability of 131I‐AFRA‐DFM5.3 for future clinical application in ovarian cancer.
Poster Presentation
mice.The area of inflammation didn’t uptake 99mTc‐EC‐Guanine,T/B was 1.06±0.05 at 2h. Conclusions: The result indicates that 99mTc‐EC‐Guanine is possibly an imaging agent for detecting malignant tumor.
S404
P483 Investigation of Tc-99m labelling of monoclonal antibody (anty-CD61) to b3 integrin subunit. U. Karczmarczyk1, P. Garnuszek1, M. Maurin1, M. Bilski2; 1National Medicines Institute, Warsaw, POLAND, 2Military Institute of Hygiene and Epidemiology, Warsaw, POLAND. Aim: The field of angiogenesis research is one of the rapidly growing biomedical disciplines. One of the interests in this research is based on the potential of developing the alfaVbeta3 integrin for non‐invasive monitoring of malignant tumors. We recently developed that monoclonal antibody anty‐CD61 radiolabelled with 131I can be useful tool for in vivo imaging of b3 subunit of integrin alfaVbeta3 expression in some experimental tumours and in endothelial cells. Aim of present study was to develop an efficient procedure of anty‐CD61 radiolabelling with 99mTc using HYNIC as bifunctional chelator. Materials and methods: Two substitution ratios of HYNIC to antyCD61 (4:1 and 6:1) were used at the conjugation step. To remove the excess of unbound HYNIC the reaction mixtures were purified on PD‐10 using phosphate buffer containing poloxamer for protection of the mAb from aggregation. 99mTc‐labelling of the conjugates were investigated using various amounts of different coligands (tricine, nicotinic acid, EDTA, etc.). The influence of temperature and pH of reaction on 99mTc‐HYNIC‐antyCD61 yield was also studied. The radiolabelling yield was checked by GF‐HPLC and TLC methods. Results: Generally, the best radiolabelling yields were achieved when HYNIC‐antyCD61 prepared with 6 molar excess of HYNIC to the antibody was used. Tricine applied as single coligand gave a higher efficiency of the preparation comparing with the others coligands, as well as their combinations. In our study the highest radiolabelling yield (ca. 70%) was achieved when the mixture of the conjugate (6:1), tricine, stannous chloride and sodium pertechnetate‐99m was incubated at higher temperature. Purification on PD‐10 column enabled to obtain the monomer of 99mTc‐HYNIC(tricine)‐antyCD61 of radiochemical purity greater than 99%. Conclusions: Our study showed that monoclonal antibody to b3 subunit of integrin alfaVbeta3 can be efficiently radiolabelled with Tc‐99m via bifunctional chelator ‐ HYNIC, and tricine as coligand. The results from the “wet‐radiolabelling” suggest possibility of development of the dry kit for convenient preparation of 99mTc‐labelled antyCD61. Studies on optimization of the freeze‐dried pharmaceutical composition, which will enable one step preparation of the b3 subunit of integrin seeking radiopharmaceutical of appropriate radiochemical purity (>90%), are ongoing in our laboratory.
P484 Radiolabeling of a fully human anti-DR monoclonal antibody with 99m-technetium: a potential new imaging agent for lymphoma and autoimmunity G. Malviya1, R. A. Dierckx1, A. Signore2; 1Department of Nuclear Medicine and Molecular Imaging, University Medical Centre Groningen, University of Groningen, Groningen, NETHERLANDS, 2Nuclear Medicine Unit, IInd Faculty of Medicine and Surgery, “Sapienza” University of Rome, Rome, ITALY. 1D09C3 is a fully humanised IgG4 monoclonal antibody (mAb), due to this it does not have Fc‐ portion‐mediated side effects, which may present in chimeric antibodies. It is known that HLA‐DR protein status predicts survival in patients with B‐cell lymphomas, but it is not yet known whether it is possible to obtain this information in‐vivo by non‐invasive imaging modalities. Furthermore, HLA‐DR antigens are over expressed in situ in a variety of autoimmune diseases, including Rheumatoid Arthritis. Aim: The rationale of the present study was to radiolabel 1D09C3 with 99m‐technetium for the in‐vivo histological characterisation of HLA‐DR +ve cells in lymphoma patients and patients with RA. Materials and methods: For radiolabeling we compared a direct method via 2‐ME reduction of disulphide bonds with a two‐step method using a hetero‐bifunctional linker SHNH/S‐HYNIC (succinimidyl‐6‐hydrazinonicotinate hydrochloride). Binding assay was performed on DR +ve cell line. Several titrations were performed to obtain best labeling efficiency (LE) and specific activity (SA). In‐vitro quality controls included stability assay in plasma, SDS‐PAGE, autoradiography, Cysteine challenge and immunoreactive fraction assay. Results: Anti‐DR mAb (1D09C3) was best labeled with a direct method via 2‐ME reduction with a high labeling efficiency (LE >95%) and high specific activity (SA = 150 mCi/mg) with retained biochemical integrity and binding activity. SDS‐PAGE and autoradiography analysis demonstrated its structural integrity, moreover, Cysteine challenge and immunorective fraction assay also confirms its in‐vitro stability and binding specificity to the HLA‐DR +ve cells. Conclusion: 1D09C3 can be efficiently labeled with 99mTc with high LE and SA, using a direct labeling method with 2‐ME reduction. Radiolabeled 1D09C3 binds to human HLA‐DR antigens, therefore, can be used as a prognostic/diagnostic tool in lymphoma patients or in several autoimmune diseases. In vivo studies are in progress.
P485 Increased tumour versus background ratio of radiolabelled octreotide: intratumoural versus intravenous injection S. C. Dieleman, S. M. Verwijnen, S. C. Berndsen, E. P. Krenning, M. de Jong; Erasmus MC, Dept. of Nuclear Medicine, Rotterdam, NETHERLANDS. Introduction: When treating tumours with e.g. radiolabelled peptides by the conventional intravenous (i.v.) route, both the magnitude of drug exposure to the tumour cells and the duration of this exposure are limited. Locoregional application of radiolabelled peptides is an attractive and logical step to obtain a higher drug concentration in the target tissues. Other important factors determining anti‐tumour effects comprise a long retention time of radioactivity at the tumour site and rapid clearance of radioactivity from non‐target tissues and blood. Aim: 1) To study biodistribution of radiolabelled octreotide after intratumoural (i.t.) versus i.v. injection with special focus on tumour uptake and retention of radioactivity. 2) To study the role of somatostatin receptor subtype 2 (sst2) binding in tumour retention of radioactivity after i.t. injection of radiolabelled octreotide. Methods: Mice were inoculated subcutaneously with sst2‐ expressing H69 tumour cells. Four weeks later, when tumours were palpable, the animals were injected with 111In‐DTPA‐octreotide (2MBq/0.1µg), either given i.v. or directly i.t. To study the
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 role of receptor binding, additional animals received an i.v. injection with an excess (100µg) of unlabelled octreotide (blocking dose), 5 min prior to i.v. or i.t. 111In‐DTPA‐octreotide. SPECT/CT imaging was performed with the NanoSPECT/CT (Bioscan) 2, 4 and 24 hours after injection. Biodistribution was performed at 4 and 24 h p.i. Results: The biodistribution and SPECT scan data showed that the i.t. injection led to > 10 times higher radioactivity concentrations in the tumour as compared to the i.v. application at the different time points (P<0.001). The blocking dose of unlabelled peptide reduced the uptake significantly (P<0.01), showing that the sst2 play an important role in the tumour uptake and retention, also after i.t. application. Interestingly, we did not find significant differences in radioactivity levels in both the sst2 negative and expressing normal organs after i.t. or i.v. administration. Conclusions: This study showed that i.t. injection leads to significantly higher concentrations of radiolabelled octreotide in the tumour than conventional i.v. administration, offering the opportunity to make peptide‐receptor radionuclide therapy (PRRT) more effective. The blocking studies showed the essential role of receptor binding plus internalization of the radiolabeled peptide‐receptor complex in receptor‐expressing tumour cells in tumour retention of radioactivity. These findings support the treatment of intracranial tumours with i.t. PRRT and may be extended towards i.t. PRRT of the primary tumours of pancreatic and prostate origin.
P486 Combination cytolytic viral therapy and targeted radiotherapy with 111In- or 177Lu-DOTATOC enhances killing in vitro of somatostatin-receptor (SSTR2) positive cells Y. Akinlolu1, K. Ottolino-Perry2, R. M. Reilly1, J. A. McCart2; 1University of Toronto, Toronto, ON, CANADA, 2Institute of Medical Sciences, University of Toronto, Toronto, ON, CANADA. Objective: Vaccinia virus has the potential to introduce genes into cancer cells for subsequent therapeutic targeting as well as kill them through a cell lysis effect. Our aim was to study the cytotoxic effects of 111In‐DOTATOC emitting Auger electrons or 177Lu‐DOTATOC emitting β‐ radiation as single therapeutic agents compared to combination therapy with recombinant double‐deleted vaccinia virus (VV‐SSTR) encoding SSTR2 in monolayer or as spheroids. Methods: Human embryonic kidney (HEK‐293) cells transfected with the SSTR2 gene (HEK‐sstr2) and colon cancer cells (MC38) not expressing SSTR2 were exposed to 0.3‐20 ng of 111In‐ or 177Lu labeled DOTATOC (specific activity 6 ‐ 8MBq/ug). For combination therapy, cells were exposed for 15h, 24h, 39h and 48h to VV‐SSTR2 at a Multiplicity of Infection (MOI) of 0.05 and 0.1, treated with 20ng of 111In‐ or 177Lu‐DOTATOC. WST‐ 1 assay was used to measure cell proliferation directly on monolayers or after initial trypsinization of the spheroids and replating. Cytotoxicity was measured on day 5 or day 8 in combination experiments. Results: HEK‐293 cell proliferation reduced in the presence of 111In‐DOTATOC (20ng) by 36 ± 5 % and 88 ± 33% in monolayers and spheroid models, respectively. In the presence of 177Lu‐DOTATOC (20ng) however, proliferation reduced to 46 ± 1 % and 83%. IC50 of 111In‐DOTATOC (10ng) was 2 times greater than that of 177Lu‐ DOTATOC (5ng) in the spheroid model. VV‐SSTR virus alone decreased HEK‐293 monolayer growth by 76.0 ± 0.03% at 48hrs, MOI of 0.1 and 78 ± 28% when combined with 111In‐DOTATOC. 177 Lu‐DOTATOC combined with VV‐SSTR decreased growth by 93 ± 25%. In spheroid models however, VV‐SSTR2 combination therapy with either 111In‐DOTATOC or 177Lu‐DOTATOC reduced cell survival of both HEK‐sstr2 and MC‐38 cells to less than 10%. VV‐SSTR2 alone diminished MC38 cells growth by 83.2 ± 56 %, 111In‐DOTATOC and 177Lu‐DOTATOC as single agents reduced growth by 93.6 ± 1.3 and 93.5 ± 17.1 respectively. Conclusion: We conclude that combining Vaccinia virus therapy with molecular targeted radiotherapy using 111In‐ or 177Lu‐DOTATOC increases the killing of SSTR2 and non‐SSTR2 positive cells. 177Lu‐DOTATOC was more effective than 111In‐DOTATOC. Supported by the Canadian Institutes of Health Research
P487 Labelling of the bispecific trivalent monoclonal antibody TF2 and the TF2 binding hapten IMP288 for in vitro and in vivo investigations in colorectal cancer (Immuno SPET, PET and radioimmuno therapy) B. Meller1, C. Angerstein1, M. Baehre2, J. Meller1; 1Georg-August University, Goettingen, GERMANY, 2Martin-Luther-University, HalleWittenberg, GERMANY. Aim: A high percentage of colorectal carcinoma (CC) express the carcino embryonic antigen (CEA). Pretargeting systems allow the radioimmuno‐mediated SPET and PET based on the affinity of antibodies to the tumor CEA and the quick kinetics of radiolabelled peptides. TF2 is a humanized bispecific trivalent monoclonal antibody (mAb), which has a binding site directed against CEA and at least one other site which binds to the sequence histamine‐succinyl‐glycine (HSG). The HSG peptide IMP288 is DOTA‐linked and should bind to TF2 with high affinity. The aim of our study was to optimize the labelling of TF2 with 131I and the complexation of InCl3 as well as of GaCl3 with IMP288 for in vitro investigation and clinical studies Materials & methods: Iodination of 0.5 mg TF2 antibodies (Immunomedics) was carried out using 50 MBq 131I and Iodogen‐coated tubes. Purity and stability were tested by HPLC (size exclusion, PBS) and TLC (NaCl). The peptide IMP288 (Immunomedics) was coordinated to 111InCl3 (n >20, Covidien) and 68 GaCl3 (n>100, Obninsk, Cyclotron Co. Ltd) from Generator eluted in fractions or after prepurification (ion exchange column) in a synthesis module (Eckhart & Ziegler Eurotop GmbH). The reaction was stopped by addition of DTPA. Influences of peptide amount, activity, reaction buffers, pH, temperature and time were investigated. Quality control was carried out by TLC (ITLC, NaCl, CH3OH/NH3) and HPLC (RPC18, H2O/CH3CN/TFA). Additionally, purification of the product with C18 cartridges was evaluated. Statistical analyses were performed using non‐ parametric tests. Results: The 131I labelling of TF2 antibodies resulted in high yield and purity (>95 %). Complexation of 111InCl3 was carried out in acetate buffer and lead to good yields and purity (pH 5.5, 20 min, 95° C, >90 %). Labelling with 68GaCl3 was more sophisticated and was found to be 68 optimal in HEPES buffer at pH 3.9. Besides DTPA‐bound nuclide, colloidal Ga was a major problem. Neither the amount of the peptide nor of 68Ga was found to have a significant influence on the results. Longer reaction times and temperatures increased the formation of colloidal Ga. Side products could mostly be eliminated by C18 cartridge purification (purity >90 %) but reduced the yield (m =62%). Conclusions: Iodination of the antibody TF2 as well as the complexation of InCl3 with the DOTA‐linked peptide IMP288 could be carried out both in high yield and purity. 68 Ga labelling was more susceptible for side reactions which reduced the yield after purification.
S405
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
L-Phenylalanine alkylator (Melphalan) based Immunoconjugate with Anti-EGFR Antibody ior egf/r3 for targeted Tumor Therapy and Imaging G. Shukla; INMAS, Delhi, INDIA. Conventional cytotoxic therapies of cancer often suffer from lack of specificity, leading to a poor therapeutic index and considerable toxicities to normal organs. An elegant way to overcome this is to selective deliver therapeutics to tumor site by conjugation to carrier molecules. Conjugates specific to the epidermal growth factor, EGFR, are of interest for radionuclide based imaging and therapy. Antibody‐drug conjugate (ADC) were prepared consisting of anticancer drug, Melphalan, that binds to DNA minor grove, to monoclonal antibody (anti‐EGFR ior egf/r3). As selectivity is the ultimate aim of cancer treatment, we here in report the preparation of immunoconjugate by attaching the Melphalan, to the activated ‐COOH of the ior egf/r3 (Mel‐ior/r3). Modified antibody was purified by size exclusion chromatography. Mel‐ior/r3 exhibited quantitative 99mTc‐labeling (>97%) with specific activity of 8‐12 mCi/mg of the protein. Immunoreactivity was determined by flow cytometry. Specific binding was evaluated by receptor ligand assay on human tumor cell line, U‐87MG and Hela, exhibiting Kd= 4.2 nM and 5.6 nm respectively. Blood kinetic data reveals a bi‐exponential pattern of clearance. At 3.2 h 94% of injected activity cleared from blood circulation. The tumor (U‐87MG cell line) grafted in athymic mice were readily identifiable in the $B&C(B images. Biodistribution of the labeled Antibody conjugate in athymic mice grafted with U‐87MG tumor showed high tumor uptake with 5.56 $B!^(B0.16 % ID/g at 4 h and 7.88$B!^(B 0.8 % ID/g at 24 h. Excretion of the conjugate was via hepato‐biliary system. Immunoconjugate showed remarkable regression in established EAT tumor in Balb/c mice. In vitro cytotoxicity was evaluated by MTT assay and macrocolony asaay which revealed enhanced dose dependent cytotoxicity on U‐87 MG and Hela cell line with IC50=1.56$B&L(BM and 12.5$B&L(BM respectively at 24 h. Henceforth, Mel‐ior/r3 revealed targeted delivery to the specific receptor with enhanced and better results, this derived biomolecule is of importance for diagnosis and therapy. Data suggest that Melphalan conjugate with EGFr reactive mAb warrant further investigation as possible clinical candidate.
P489 Design, construction and characterization of trastuzumabconjugated gold nanoparticles (AuNPs) for enhanced Xradiation treatment of locally advanced breast cancer (LABC) N. Chattopadhyay, Z. Cai, B. Keller, J. Pignol, R. Bendayan, R. M. Reilly; University of Toronto, Toronto, ON, CANADA. Purpose: LABC has a high mortality despite its anatomic restriction with only 1 in 2 patients surviving 5 years. Our purpose was to develop a human epidermal growth factor receptor‐2 targeted (HER‐2; overexpressed in 40‐50% LABC cases), nanotechnology‐based platform that may enhance the radiation response in LABC. Theoretically, the X‐radiation dose delivered to tumours could be greatly enhanced by their interaction with high atomic number materials (79 for gold) due to generation of secondary photoelectrons and Auger electrons. Methods: Trastuzumab was derivatized with a novel polyethylene glycol cross‐linker (OPSS‐PEG‐SVA, Mr = 5 kDa) to create trastuzumab‐PEG‐OPSS. The formation of conjugates was assessed by SDS‐PAGE and SE‐HPLC. Further, the immunoreactivity of trastuzumab‐PEG‐OPSS was analysed by FACS using HER‐2 overexpressing SK‐BR‐3 BC cells. The size of trastuzumab‐PEG‐AuNPs was measured by dynamic light scattering and transmission electron microscopy (TEM). The number of trastuzumab‐PEG‐ OPSS molecules conjugated to AuNPs was determined by incorporating 123I‐labeled trastuzumab‐ PEG‐OPSS into the reaction. AuNP surface bound trastuzumab was visualized by TEM by interaction with 5nm anti‐human IgG‐AuNP antibody. Results: Reacting trastuzumab with increasing ratios of OPSS‐PEG‐SVA caused a gradual increase in the molecular weight (Mr) for trastuzumab from ~148 kDa to ~243 kDa, indicating increasing PEG substitution. According to the estimated Mr values, approximately 7 PEG chains were conjugated to trastuzumab at a trastuzumab:PEG molar ratio of 1:25. SE‐HPLC confirmed PEGylation of trastuzumab with the retention time of PEG conjugates decreasing from 6.7 to 5.7 mins. FACS analysis of trastuzumab‐ PEG demonstrated 90% retention in immunoreactivity relative to trastuzumab. It was established that 18.5 ± 2.8, 14.3 ± 2.7, 10.2 ± 1.9 trastuzumab molecules were conjugated per AuNP when 2x1011 AuNPs were reacted with 20 µg, 10 µg or 5 µg of trastuzumab‐PEG‐OPSS, respectively. Hydrodynamic size of the particles increased at each step of the reaction ‐ AuNPs (35.6 ± 1.9 nm), AuNP‐PEG (42.1 ± 1.0 nm), trastuzumab‐PEG‐AuNPs (58.3 ± 1.6 nm). However, the particles remained stable in PBS, pH 7.5 with no increase in size when stored at 4ºC for 14 days. Analysis by TEM confirmed surface localization of 8‐14 trastuzumab molecules per AuNP when reacted with 10 µg of trastuzumab‐PEG‐OPSS. Conclusion: Trastuzumab was successfully cross‐linked to AuNPs resulting in an increase in their hydrodynamic size from 35nm to 58nm but with retention of their immunoreactivity to HER‐2. These results suggest that these AuNPs could potentially target HER‐2 overexpressing human BC cells in vivo for radiosensitized X‐irradiation.
P490 A novel radioiodinated peptide of arginine-arginineleucine(RRL) for tumor angiogenic endothelium imaging R. Wang, M. Yu, C. Zhang, P. Yan, M. Liu, Y. Cui; Department of Nuclear Medicine, Peking University First Hospital, beijing, CHINA. Objective: Tumor angiogenesis is the proliferation of a network of blood vessels penetrating into the tumors to supply nutrients and oxygen and remove metabolic waste products from tumors. Peptides has been shown to detecte tumor‐induced angiogenesis and are good candidates because of their characteristic properties. The purpose of this study is to design and synthesize a radioiodinated peptide of arginine‐arginine‐leucine(RRL) for tumor angiogenic endothelium imaging. The RRL peptide can specifically adhere to tumor angiogenic endothelium. Methods: RRLpeptide(Tyr‐Cys‐Gly‐Gly‐Arg‐Arg‐Leu‐Gly‐Gly‐Cys‐NH2) and the control peptide(Tyr‐Cys‐Gly‐ Gly‐Gly‐Gly‐Gly‐Gly‐Gly‐Cys‐NH2) were assembled by the solid phase method and disulfide bonds between cysteines on each peptide were formed to maintain the cyclic structure. The cysteine at the C‐terminal of the RRL peptide and control peptide was amidated to protect the peptides from the biocatalyst. Radioiodination of the RRL peptides was performed by the chloramine‐T method. 131 I was added to peptide solution in the presence of chloramine‐T(0.9mg/mL) for 1 min at room
temperature. Labeled peptide was separated from free iodine using a sephadex G‐25 column and eluted with 0.05M PBS. The purifiled radioiodine labeled RRL peptides was put in human blood serum at 37°C for 24hr, and radiochemical purities were checked on 1, 2, 4, 8, 24hr. Biodistribution and imaging results in vivo was obtained after 131I labeled peptides were injected through tail vein. Results: RRL peptide was synthesized successfully. The 131I labeling rate of RRL peptide was about 60%. The radiochemical purity was 96.5%. The radiochemical purity of the labeled compound remain 90.3% at 24hr in human blood serum at 37°C. In the biodistribution studies, the 131I labeled RRL peptide accumulated in the tumor to a higher level than in the other organs. The 131I labeled RRL peptide can successfully image the tumor in human prostate carcinoma bearing nude mice. Conclusion: The results suggest that radioiodination of RRL peptide is feasible and the labeled compound is stable in human blood serum at 37°C at 24hr. The 131I labeled RRL peptide is valuable to detected tumors as molecular probe. Key Words: Peptide; Radioiodination; Tumor; Radionuclide image
P55 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radiopharmacy/radiochemistry: miscellaneous
P491 Experimental using iodine 123 beta-methyl iodophenyl pentadecanoic acid (BMIPP) for myocardial metabolism evaluation L. Maslov1, S. Minin1, Y. Tahauova2, E. Makarova1; 1Institute of Cardiology, Tomsk, RUSSIAN FEDERATION, 2Sibirian biophysical research centre, Tomsk, RUSSIAN FEDERATION. The aim experimental researches of functional suitability of 123I‐BMIPP for myocardial fatty acid metabolism evaluation. Materials and methods: the solution 123I‐BMIPP for injections with the following characteristics was exposed to research: volumetric activity not less than 18 MBk/ml, period of validity 48 hours from the moment of preparation. Dynamics distribution of 123I‐BMIPP was investigated on white rats‐male with mass of 250‐300, to which through a femoral vein was injected 123I‐BMIPP in a dose of 2,5 mBk/kg, then they were killed by groups (of 5) on different terms of research. The radiometry of internal organs was made in 5, 15, 30, 60, 120, 180, 360 minutes after 123I‐BMIPP injection. Distribution of 123I‐ BMIPP in heart was realised on unbreedy rabbits ‐ male with mass of 3,1‐3,5 kg. Results: after intravenous introduction in 1 ml of a blood of rats the contents 123I‐BMIPP on the 5 minutes did not exceed 1,2 %. Since the first minutes after an injection of a preparation the high accumulation of 123I‐BMIPP in a myocardium and liver was marked. The maximal accumulation of a preparation in the heart was observed on the 5 minutes of experiment 5,7 % and to 30 minutes was 5,1 %. In a liver on the 5 minutes the high contents of a preparation ‐ 7,9 % from the entered dose was also marked. The index of myocardium/liver on the 5 minute was 1:1,3. On the 5 minutes of research there were 2,3 % 123I‐BMIPP in lungs from the entered dose remained almost constant during an hour. The index myocardium/lungs on the 5 minutes was 2,5:1. Maximum of accumulation of radiopharmaceutical in kidneys and thin intestine was defined on the 30 minutes, thick intestine on the 360 minutes from the beginning of research. Visually the quality of the heart’s picture of rabbits at a scintigraphy with 123I‐BMIPP was quite acceptable since the 10 mines of observation. Thus optimum time for record of scintigrams was 30 minutes of research. Conclusion: biological behaviour of 123I‐BMIPP is characterized by powerful accumulation radiopharmaceutical in heart (on the data of experiment on rats). The qualitative scintigramm of the rabbit heart was received.
P492 Can a Kit for preparing Platelet Rich Plasma be used to obtain Blood Platelets prior to Radiolabelling with Indium-111 oxine? S. M. Rubow1, M. Tarental2, C. Kammies2, C. Lackay2; 1Stellenbosch University, Tygerberg, SOUTH AFRICA, 2Tygerberg Hospital, Tygerberg, SOUTH AFRICA. Introduction: Harvesting sufficient platelets for radiolabelled platelet studies in thrombocytopenic patients is challenging. Labelling yield increases with the number of platelets per millilitre available. A commercial kit for the preparation of autologous platelet rich plasma (PRP) is used in surgery, dentistry and dermatology. PRP is obtained by adding 8.5 ml blood to a kit test tube, followed by short centrifugation. The aim of this project was to establish the suitability of this kit as alternative method for platelet harvesting prior to radiolabelling. Methods: In a prospective ethics approved comparative laboratory study, blood samples were obtained from 12 healthy volunteers. Each sample was subdivided to provide 4 ml for a full blood count, duplicate 8.5 ml for Regen tubes and 25 ml for our conventional platelet labelling method (repeated centrifugation and resuspension of remaining cells with Plasmalyte B). The volume of PRP harvested for each method was noted and differential cell counts obtained. The yield of platelets per ml of blood initially taken was calculated and white blood cell (WBC) and red blood cell (RBC) contamination expressed as cells per platelet. Paired t‐tests were used to compare results for the different methods. Scores between 1 (not easy, slow) and 3 (very easy, fast) were assigned to each method for the ease of separating PRP from sediment, time required and convenience. In a limited number of samples, harvested platelets were labelled with 111In‐oxine and labelling yield was determined. Results: Kit tubes were very easy to use and harvesting was completed in 15 minutes, compared to at least 1.5 hours for our conventional harvesting (total score 9 vs 3). However, the platelet yield with the kit was significantly lower (81±47x106 versus 6 196±35x10 platelets per ml blood; p<0.005). The ratio WBC to platelets was significantly lower for the kit (0.0003±0.0002) than for the conventional method (0.0013±0.0012) (p=0.02). The ratio of RBC to platelets could not always be calculated as red cell counts in PRP were below the limit of detection in several samples. There was no significant difference for these factors between glass and plastic kit tubes. Labelling efficiency was much lower with the kit method (33±23%) than using our conventional method (69±30%). Discussion: PRP kit tubes are convenient for easy and quick platelet harvesting, with less white and red cell contamination than with our conventional method. The labelling efficiency is however much lower and may rule out practical use of this method.
Poster Presentation
P488
S406
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P493 Cell Pharmacokinetic Radiopharmaceuticals
Method
Evaluating
G. Cao, X. Zhou, Z. Chen, C. Lu, H. Yu, R. Zhang; Jiangsu Institute of Nuclear Medicine, Wuxi, CHINA. Objective: To establish cell pharmacokinetic method with deducing some mathematical formulae for studying radiopharmaceuticals at cell‐level. Methods: The process of radiopharmaceuticals transferring into cell can be mainly concluded as passive diffusion, active transport and endocytosis/exocytosis. Using fundamental theory of pharmacokinetics and chemical kinetics, the process can be described with some formulae and the cell pharmacokinetic method can be established. Results: (1) Passive diffusion. It followed Fick’s diffusing law dM/dt = ‐ DAdC/dX, where dt is time, dM transferred quantities of radiopharmaceuticals within dt, D diffusion coefficient of radiopharmaceuticals, A surface area and dC/dX concentration gradient. (2) Active transport. dM/dt = kPC, where k is rate constant, P concentration of transfer carrier and C concentration of radiopharmaceuticals out of cell. When C>>P, C could be considered a constant and the formula could be rewritten as dM/dt = k1(k1 = kPC, and k1 is constant)with the kinetic order 0. (3) Endocytosis/exocytosis. dM/dt = ‐ kRC, where R is concentration of transcytotic vesicle. When C>>R, C could be considered a constant and the formula could be rewritten as dM/dt = ‐ k2 (k2 = kRC, and k2 is constant) with the kinetic order 0. Conclusions: It is more convenient and simple to study pharmacokinetics of radiopharmaceuticals with cell than that with the organism. The process of radiopharmaceuticals transferring into cell is mainly combined with the three or less steps according to different drugs. When the coefficient corresponding to a step in the general pharmacokinetic equation is very small or zero, it shows that the step isn’t occurent during the process. Therefore, the method can describe drug‐cell interaction mechanism. The data required for calculation can be obtained from experiment with counting radioactivity, such as radiopharmaceuticals concentration out of cell, counts of cell membrane, counts of cell plasm, and so on. Acknowledgement: This study is supported by the Jiangsu Natural Science Foundation (BK2008111)
P494 Membrane Pertraction of Lu(III) with DEHPA as a Carrier and 177 Lu-labeled the Possibilities of Its Application for Purifying Compounds K. Kumric, T. Trtic-Petrovic; Vinca Institute of Nuclear Sciences, Belgrade, SERBIA. Aim: Supported liquid membrane (SLM) extraction, also named pertraction, offers the possibility for cleaning the labeled compound from the unbound radionuclide, after the completed labeling procedure. The aim of the present study was to investigate the pertraction of Lu(III) from an aqueous phase by applying miniaturised single hollow fibre membrane device and to find optimal conditions for efficient removal of unbound 177Lu(III) from 177Lu‐labeled compound. Materials and methods: Pertraction of Lu(III) has been performed in a miniaturised single hollow fibre membrane device operated in a batch mode. The membrane was impregnated with the organic phase (2‐40 % (v/v) DEHPA in dihexyl ether) and then the lumen of the fibre was filled with the acceptor solution (2 mol dm‐3 HCl). The ends of fibre were bent and wrapped with a peace of Al‐ foil, in order to prevent the leakage of the acceptor solution. The membrane was then placed in the donor solution (2 mg dm‐3 Lu(III) in the 0.2 mol dm‐3 sodium acetate at pH = 2.5 ‐ 5.0). In regular time intervals, the membrane was taken out from the donor phase and the concentration of Lu(III) in both phases, donor and acceptor, was determined by voltammetry. Results: The influence of pH and volume of the donor phase, the DEHPA concentration in the organic membrane phase and the time of extraction on the lutetium extraction and stripping behaviour have been investigated. The optimal conditions for the removal of unbound 177Lu(III) from 177Lu‐ labeled compound was proposed based on the experimental results. The maximum removal 3 efficiency of Lu(III) amounted to more than 99% was attained when the donor volume was 2 cm , the donor pH was from 3.5 to 5.0 and the DEHPA concentration of 15%. This indicates that the extraction in a single hollow fibre is suitable for work with small volume samples, like are usually the volumes of labeled compounds. Also, pertraction in a single hollow fiber in a batch mode has two additional advantages over the continuous membrane extraction: it is easy to handle, which is very important in order to avoid radioactive contamination, and the volume of labeled compound solution remains unchanged. Conclusion: Based on the obtained results one can conclude that SLM extraction of Lu(III) in a single hollow fiber presents a simple and fast method, which can be applied after labeling procedure for highly efficient removal of free radionuclide, 177 Lu (III), from the 177Lu‐labeled compound.
P495 Are the Carboplatine doses, using Cockcroft-Gault, MDRD-4 and Wright equations to estimate de glomerular filtration rate, accurate? I. Romero-Zayas1, M. Roca-Engronyat1, M. Perayre-Badia2, M. Rey-Salido2, P. Notta1, D. Ramal-Leiva1, R. Puchal1, J. Martín-Comín1; 1Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, SPAIN, 2Institut Català d'Oncologia, L'Hospitalet de Llobregat, SPAIN. Aim: To compare the doses of Carboplatin (CPt) calculated with the Calvert formula when Cockcroft‐Gault, MDRD‐4 and Wright equations have been used to estimate the glomerular filtration rate (GFR). Material and methods: Data were collected retrospectively on 291 patients (172 men and 119 women), all of them with a neoplasic process. Measurements of GFR were 51 performed by the administration of 100 μCi of Cr‐EDTA according to the recommended method (Nucl Med Comm 2004; 25: 759‐767). The considered area under the plasma concentration‐time curve (AUC) was 5 mg.min/ml to use it in the Calvert formula. Creatinine clearance (Ccr) was estimated using plasma creatinine measurement and appropriates demographics parameters in the Cockcroft‐Gault, MDRD‐4 and Wright formulas. The doses were obtained replacing these values in the Calvert formula. [ D= AUC x (GFR + 25)] Results: The table shows for each formula the following data: Doses of CPt, Pearson correlation coefficient (R), p value, percentage of error (Bias), absolute percentage error (Precision); (*) percentage of patients that would have received
more or equal than 20% of the reference dose, (**) percentage of patients that would have received less or equal than 20% of the reference dose n= 291
Calvert ‐GFR: 51Cr‐ EDTA
Calvert Cockcroft‐ Gault
Calvert‐ MDRD‐ Calvert‐ 4 Wright
Doses CPt (mean ± SD)
516 ± 143
544 ± 182
534 ± 166
575 ± 177
R
‐
0.802
0.645
0.776
p value
‐
< 0.001
< 0.048
<0.001
Bias (mean ± SD)
‐
6 ± 20
5 ± 24
12 ± 21
Precision (mean ± SD)
‐
15 ± 14
18 ± 17
18 ± 17
≥ 20% dose*
‐
21%
21%
33%
≤ 20% dose **
‐
6%
10%
4%
Conclusions: The doses obtained with all the three formulae have a positive bias that means overestimation of doses in reference to the Calvert formula with 51Cr‐EDTA measurements. The most accurate is the Cockroft‐Gault formula. There would be a high percentage of patients who received more or less than the 20% of the reference doses in all the formulae.
P496 Valid method about a cleaning procedure in a Radiochemistry Laboratory for Pet Radiopharmaceuticals Preparations S. Ledda1, S. Aste2, P. Sanna1, O. Summo1, S. Pitzianti2, R. Marzeddu2, A. Loi2, G. Melis1; 1Azienda Ospedaliera Brotzu, Cagliari, ITALY, 2Alliance Medical, Cagliari, ITALY. AIM The aim of this study was to verify the validity of our cleaning procedures in Radiopharmacy Laboratory area and working zone where we usually prepare Pet Radiopharmaceuticals. MATERIALS AND METHODS The cleaning product used are: 1) sodium dichloroisocyanurate, containing active chlorine by 33%, which diluted in water, release hypochlorous acid, 2) alchil‐ dimetil‐benziammonio cloruro 10g for 100gr of product, 3) benzalconio cloruro 0,25 g; alcool etilico 95° 66,29 g. for 100gr of product. The special aseptic technique has correctly apply every day by personnel properly educated with additional training specific that follows exactly a specific procedure before entering in this area. Equipment used are reserved exclusively for Radiopharmaceuticals area. The analysis method consisted in monitoring fertility of the culture media in the presence of the final examined product, as provided by the Italian Farmacopean XI Ed. and the European Pharmacopoeia Current Ed.V. To perform the validation test of sterility was used the following micro‐organism type: aerobic bacteria like Staphylococcus aureus, Pseudomonas aeruginosa, Bacillus atrophaeus; anaerobic bacteria like Clostridium sporogenes and fungi like Candida albicans , Aspergillus niger. The analysis method to performe quantitative detection of pyrogens presence (bacterial endotoxin) of the final product consisted in use of Limulus Amebocyte Lysate (LAL) test. With the dedicated spectrophototometer has done a kinetic colorimetric assay in which the early onset of color can be detected and measured. According to European Pharmacopoeia Current Ed.V. the maximum recommended dose of bacterial endotoxins is less than 175/V IU/ml, V being the maximum recommended dose in millilitres. RESULTS We have perform sterility and apyrogenic test in every batch of 150 synthesis in 2007 year, 248 synthesis in 2008 year and 94 in 2009 year. In all batches (100%) of our Radiopharmaceuticals production has been found no contamination micro‐organism in our condition of the test. In all batches (100%) of our Radiopharmaceuticals production has been found no contamination bacterial endotoxin. CONCLUSION Our cleaning procedure is a valid method to obtain a satisfactory result about no presence of contaminating micro‐organism and a detection level of bacterial endotoxin less than maximum recommended dose in Pharmacopoeia.
P497 Does the Radioactivity and Physico-chemical Reaction Conditions Help in Self-sterilization of Radiopharmaceuticals? A Preliminary Study M. Minotti1, E. Coradeschi1, S. C. Todde1, S. Debbia1, R. Moresco1, D. Gatti1, R. Vannulli1, S. Stucchi1, S. Carletti2, M. Clementi2, L. Gianolli1; 1CNRIBFM, University of Milano-Bicocca, Scientific Institute H San Raffaele, Milano, ITALY, 2Laboraf, Scientific Institute H San Raffaele, Milano, ITALY. Aim: The aim of this paper was the evaluation of the effect of radioactivity and radiosynthesis physico‐chemical conditions on the bacteriological growth in [18F]FDG solutions. Materials and methods: The experiments were conducted using stock cultures of S. aureus, P. aeruginosa, C. albicans and C. neoformans. For each micro‐organism an isolated colony was inoculated in sterile saline in order to obtain a suspension of 108 UFC/ml. [18F]Fluoride was produced via the 18 O(p,n)18F reaction irradiating a silver target loaded with 1.2 mL enriched [18O]H2O (Siemens RDS Eclipse). 20‐3000 mCi of [18F]fluoride were added to 1 mL aliquots of bacterial suspension containing 108UFC/ml of the above micro‐organism, yielding radiation doses of 5‐200 kGy. Additional test were carried out simulating [18F]FDG nucleophilic substitution and hydrolysis reactions, by adding 1N HCl and CH3CN to sterilized vials containing 1 mL of bacterial suspensions. Finally, the growth sensitivity to temperature, and the simultaneous effect of chemicals and temperature were evaluated. Results and discussion: This study showed a major sensitivity to gamma radiation for gram negative bacteria with respect for gram positive and fungi. A dose of 5‐6 kGy resulted sufficient to have a bactericide effects on samples of S. aureus and P. aeruginosa. C. albicans and C. neoformans were more resistant, showing a bactericide dose of 66 kGy. B. clausii vegetative was inactivated at a dose of 101.56 ± 7.81 kGy. A suspension of B. clausii spores was not inactivated at a dose of 157 kGy. Several studies have been conducted on the Bacillus spore resistance to gamma radiation, chemical agents and temperature. As expected, spores are invariably more resistant to such conditions. The treatment with 1N HCl, CH3CN and temperature (125°C), always inactivated samples containing the vegetative form of the above microbiological species. The most important bactericide effect is
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P498 Pharmacokinetic and biodistribution studies DOTATATE radiopharmaceutical in Swiss mice
of
177
Lu-
J. S. Caldeira Filho1, E. B. Araujo1, K. J. V. López2, S. R. C. J. Santos2; Instituto de Pesquisas Energéticas e Nucleares - IPEN, São Paulo, BRAZIL, 2Faculdade de Ciências Farmacêuticas - Universidade de São Paulo - USP, São Paulo, BRAZIL. 1
Aim Propose a distribution model of radiopharmaceutical 177Lu‐DOTATATE from a pharmacokinetic and biodistribution studies in Swiss mice. Materials and Methods Swiss mice (30 ± 3 g) were used as animal model. The radiopharmaceutical 177Lu‐DOTATATE (1110 MBq) was administered through the tail vein. Blood samples of 4 animals were taken from the orbital plexus with glass capillary after 1, 15, 30, 45, 60, 90, 120, 180 and 210 minutes the radiopharmaceutical had been administered. The measurement of samples’ activity was obtained in a NaI gamma counter. The activity data of the whole blood were used for a pharmacokinetic modeling using the software PK Solutions 2.0. A study on the biodistribution in the organs was also carried out. Five animals were sacrificed after 0.25, 0.5, 1, 2 and 4 hours the radiopharmaceutical (1110 MBq) had been administered through the tail vein. The chosen organs were removed, washed, dried, weighted and their activities were measured in a NaI gamma counter. These data were expressed as percentage of activity in the organ, normalized per gram of tissue. Results The pharmacokinetic analysis of the whole blood showed a tricompartmental distribution with the following parameters: 1) t(1/2)α = 4.9 minutes; 2) t(1/2)β = 10.7 minutes; 3) t(1/2)γ = 58.9 minutes. The results of biodistribution in the organs are presented in Table 1. Conclusion The tricompartmental model is in agreement with it is expected from a receptor specific radiopharmaceutical. This pharmacokinetic modeling, combined with the studies about biodistribution in the organs, showed that a faster elimination occurs in tissues which do not have 177Lu‐DOTATATE receptors, as the muscle. A slower elimination happens in receptor‐ positive organs such as pancreas, lung, adrenal, stomach and kidneys. The high impregnation of the kidneys by the radiopharmaceutical is explained by the water solubility of 177Lu‐DOTATATE, the presence of receptors and the possible reabsorption of peptides somatostatin analogues in the proximal tubule. Table 1 ‐ Biodistribution data of 177Lu‐DOTATATE in % activity/gram Organs
0.25 hs
0.5 hs
1 hs
Muscle
0.55 ± 0.04
0.30 ± 0.10
0.12 ± 0.02
Pancreas
4.55 ± 2.99
6.79 ± 2.65
10.95 ± 1.5
Kidney
11.84 ± 2.51
9.19 ± 1.74
6.63 ± 0.58
P499 Development of a Ge-68/Ga-68 Generator System Using New Organic Polymer Containing N-methylglucamine Groups as Adsorbent for Ge-68 M. Nakayama, E. Hatanaka, M. Haratake; Nagasaki University, Nagasaki, JAPAN. Aim: We have already elucidated that organic polymer containing N‐methylglucamine groups have a high affinity for Ge‐68 and a low affinity for Ga‐68. In this study, new macroporous and hydrophilic polymers containing N‐methylglucamine (MGlu) groups were synthesized as the adsorbent for Ge‐68 in the Ge‐68/Ga‐68 generator. Materials and Methods: Hydrophilic matrix polymers using glycidyl methacrylate (GMA) and ethylene glycol dimethacrylate (EGDMA) were systematically synthesized by the radical suspension copolymerization method. MGlu was introduced on the matrix polymers, and the adsorption characteristics of the obtained polymers (PGMA‐EG‐MGlu) for non‐radioactive Ge were investigated. A better candidate, PGMA‐EG‐MGlu (350 mg), was packed into a mini‐column (5 mm diameter) and Ge‐68 in the solution adjusted at pH 7 was passed through the column. The desorption of Ga‐68 produced on the PGMA‐EG‐MGlu were examined by using citrare solution adjusted neutral pH as eluting agent, and the applicability for the preparation of Ga‐radiopharmaceutical was evaluated by ligand exchange reaction. Results: Ge was adsorbed selectively on the PGMA‐EG‐MGlu based on the complex formation of the N‐methylglucamine group with a germanate anion by dehydration condensation. The adsorption characteristics of PGMA‐EG‐MGlu for non‐radioactive Ge were largely dependent on the physical structure of the matrix polymer. The PGMA‐EG‐MGlu with high specific surface areas rapidly and effectively adsorbed Ge by batch method. Ge‐68 was also effectively adsorbed on the PGMA‐EG‐MGlu packed in a mini‐column. After Ga‐68 was built up in the column by decay of Ge‐68, several chelating ligands were examined as eluting agent. When 0.1 M trisodium citrate solution as a low‐affinity gallium chelating ligand was passed thorough the column, about 85% of the Ga‐68 in the column was recovered in 10 mL of the eluate, in which the Ge‐68 leakage was less than 0.0001% of the Ge‐68 adsorbed on the PGMA‐EG‐MGlu. By mixing of the eluate with a high‐affinity gallium chelating ligand such as DOTATOC, Ga‐68‐labeling was performed in high yield by the ligand exchange reaxtion. Conclusions: The macroporous PGMA‐EG‐MGlu rapidly and effectively adsorbed Ge‐68 and most of Ga‐68 produced by decay of Ge‐68 in the column was eluted by using citrate solution adjusted to neutral pH. Ga‐68‐labeling with high‐affinity gallium chelating ligands were easily performed by the ligand exchange reaction.
P500 Study of the evolution of glomerular filtration rate (GFR) in kidney transplant using 51Cr-EDTA
E. Martinez Montalban, C. De Gracia Gonzalez, L. Martin Curto, B. Martinez de Miguel; Hospital Universitario La Paz, Madrid, SPAIN. INTRODUCTION The study of Glomerular Filtration Rate (GFR) using 51Cr‐EDTA is one of the most popular techniques to determine the kidney function. It is important to know the value of this rate in patients who have undergone a renal transplant in order to detect a possible reject or renal failure. AIM To study the evolution of the GFR using 51Cr‐EDTA in recipients of a kidney transplant MATERIAL AND METHODS A retrospective study has been done in 70 patients (52 male and 18 female) who had been submitted to a kidney transplant when they were between 1 and 20 years old. GFR and GFRN (normalized with body surface) values were calculated according to Chistensen‐Groth method.1.1MBq 51Cr‐EDTA and one blood extraction 120 minutes after the radiopharmaceutical administration was performed for patients under 16 years and 2.22MBq 51Cr‐EDTA and one blood extraction 240 minutes after administration for over 18 years. Patients between 16‐18 years were treated as minors or adults depending on their weight. Patients were divided in four groups: group I: males, group II: females, group III: patients between 1‐10 years old (33 patients), group IV: between 11‐20 years (37 patients). GFR and GFRN values before the transplant and 1, 2, 3, 4, 5 to 10 years after it were studied. RESULTS The mean values of GFR and GFRN and standard deviation are shown in this table. 120ml/min was considered as GFR normal value for men and 110mL/min for women
GROUP I
GFR
Previous
14±9.8 22±12.0 12±5.1 23±10.3 12±9.4 23±11.0 15±12.3 23±18.0
1 year post‐tx
47±21.8 67±22.2 34±13.8 55±16.0 41±25.2 71±21.3 50±14.3 60±21.8
2 years post‐tx
44±15.0 59±20.0 32±16.7 52±21.4 39±22.1 63±22.6 47±13.8 55±14.6
3 years post‐tx
53±25.5 69±30.1 43±20.1 54±23.7 41±27.5 63±36.6 53±28.6 63±40.8
4 years post‐tx
50±19.7 62±22.8 41±13.8 54±15.7 41±23.7 58±25.6 54±20.9 61±23.0
GFRN
GROUP II
GROUP III
GROUP IV
GFR
GFR
GFR
GFRN
GFRN
GFRN
5‐10 years post‐tx 46±23.6 56±34.0 35±15.3 56±34.0 45±15.2 53±33.0 46±12.9 50±13.2 CONCLUSION A significant increase of GRF and GFRN takes place after kidney transplant and remains static between the studied years. However there are differences among patients as standard deviation values shown. No differences were found between males and females, neither between the studied ages.
P501 Experimental Animal Studies in Development and Evaluation of Radiopharmaceuticals E. Janevik-Ivanovska1, I. Djorgoski2, K. Mladenovska3, B. Crcareva1, M. Petrovska4, I. Ulcar5, M. Zdravesvka - Kocoska1; 1University “Ss Cyril and Methodius”, Faculty of Medicine, Institute of Pathophysiology and Nuclear Medicine, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF, 2University “Ss Cyril and Methodius”, Institute of Biology, Faculty of Natural and Mathematics Science,, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF, 3University “Ss Cyril and Methodius”, Institute of Pharmaceutical Technology, Faculty of Pharmacy, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF, 4University “Ss Cyril and Methodius”, Faculty of Medicine, Institute of Microbiology and Parasitology, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF, 5 University “Ss Cyril and Methodius”, Faculty of Veterinary Medicine, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF. Experimental animal studies design is a very important component for development of new generation of radiolabeled molecules and technologies (SPECT/PET). Our aim is to present several experimental designed animal models, established procedures and protocols, as an essential part in development of new radiopharmaceuticals and quality control for the existing radiopharmaceuticals. The common animals used in experimental studies are rats and mice. The rats were used for: ‐ Stasis‐induced thrombus in the femoral vein after injection of thromboplastin to demonstrate Deep Venous Thrombosis using radiolabeled Tirofiban ‐ GPIIb/IIIa inhibitor; ‐ Dialysis related amyloidosis induced by multiple application of beta2‐microglobulin. The deposit in the osteoaricular tissues was detected using Tc‐99m‐labeled MDP, hIgG and specific beta2 microglobulin; ‐ Collagen‐induced arthritis as a model of inflammatory arthritis to evaluate Tc‐99m‐labeled hIgG; ‐ Bacterial abscesses by the injection of Staphylococcus aureus to evaluate Tc‐99m‐labeled hIgG; ‐ Chemical induced Colon injury and inflammation (Croh_ disease) using TNSB to test orally administrated gelatin microspheres containing drug, were used for quality control of radiopharmaceuticals (Tc‐99m MDP, Tc‐99m hIgG, Tc‐99m dextran, Tc‐99m colloids); ‐ Liver Transplantation model to imaging of Allograft Rejection using radiolabeled Annexin V; ‐ The clinical utility of Tc‐99m HIDA scintigraphy following liver surgery. Mice animal model was used for: ‐ per os administration of iodine labeled BSA loaded microspheres to show the strong adjuvant effect by inducing IgA secretion at the genito‐urinary mucosa; ‐ athymic nude mice tumor bearning to demonstrate specifity of pretargeting technique referred to the Affinity Enhancement System (AES) uses bispecific antibodies and radiolabeled bivalent haptens; Conclusion: Employing experimental animal models it is one of the main way to introduce and test new radiopharmaceutical. Usually this approach can never replicate the human disease or the multifarious and complex physical and psychological manifestations of the human conditions. Detection of flaws in the developing or final experimental design is often achieved by several levels of review that are applicable to animal experimentation. The experimental design process should be exercised routinely to ensure the generation of valid, reproducible, and publishable data.
P502 Animal model of skeletal infection and visualized using Tc-99m labeled human IgG
inflammation
B. Crcareva1, I. Djorgoski2, M. Petrovska3, M. Zdravesvka - Kocoska1, E. Janevik-Ivanovska1; 1University “Ss Cyril and Methodius”, Institute of Pathophysiology and Nuclear Medicine, Faculty of Medicine, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF, 2University “Ss
Poster Presentation
related to the formation of free radicals that damage the membrane protein of bacteria and fungi. B. clausii spores resulted inactivated only by temperature (125°, 5 min). The heat killing effect on spores is likely due to oxidative damage caused by free radicals formation upon heat treatment itself. Conclusions: These preliminary results confirmed that the radiation damage is not sufficient to consider a typical F‐18 labelled radiopharmaceutical solution as self‐sterilizing. However, physico‐chemical conditions may play a significant role to inactivate some species of bacteria and fungi, including spores.
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Cyril and Methodius”, Institute of Biology, Faculty of Natural and Mathematics Science, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF, 3University “Ss Cyril and Methodius”, Institute of Microbiology and Parasitology, Faculty of Medicine, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF. The long‐term use of well‐established radiopharmaceuticals for visualization of infection and inflammation was a motive to initiate an experimental study in which we wanted to take an advantage of the well‐known radiopharmaceutical 99mTc hIgG, previously not used at our Institute. Materials and methods: We have established experimental model of infection and inflammation using 60 rats from the Wister group in which attenuated bacteria of the group Staphylococcus aureus was injected in one group and collagen with Freund's adjuvant was injected in the other experimental group of rats. After the inflammatory changes have occurred and demonstrated infectious a scintigraphic evaluation with 99mTc hIgG was performed. We have made a blood examination as a part of our protocol (WBC, CRP and RF). 99mTc hIgG was home‐ made freeze‐dried developed kit. Labeling efficiency and stability were accomplished by ITLC and HPLC chromatography using suitable developing systems. The visualization with the specific uptake in the site of the inflammation and infection and biodistribution studies were observed in a normal and experimental animal model using gamma camera 4 and 24 h after administration. Results: The labeling efficiency of Tc‐99m hIgG was more than 98% , stable 4 hours after labeling. Activity accumulated in different organs / tissues was expressed as a percent of injected dose (%ID), and accumulation of the tracer in the tissue with infection / inflammation was expressed as a target to non‐target ratio (T/NT). The ratio T/NT was 1.29+/‐0.17 after 4 hours of administration of Tc‐99m hIgG and 1.23+/‐0.24 after 24 hours in rats with the inflammation. The imaging in infected rats was performed after 4 hours with the T/NT ratio 1.26+/‐0.17, 1.26+/‐0.11 after 24 hours and 1.59+/‐0.26 after 72 hours of administration. We got high values for white blood elements in the both of groups of rats, rats with infection and inflammation in comparison with the normal group. The number of lymphocytes and neutrophyles was increased in the both of groups, but slightly higher in the group of infected rats. The high values of CRP were determinate in the group of rats with infection and RF in the group of rats with inflammation. Our results, demonstrated that Tc‐99m hIgG can contribute in the management of musculoskeletal infection and inflammation and can be recommending in the routine clinical practice. The same models were already used for investigation of several new compounds, potential imaging radiopharmaceuticals.
P56 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Physics/instrumentation:
new
scintillators,
photodetectors and radiation detectors
Aim: Aim of the study was to evaluate the importance of automatic body contouring for detection of myocardial wall perfusion defects in cardiac SPECT studies by comparing the performance of 4 different gamma cameras: two 2‐head cameras with automatic body‐ contouring and two 3‐head cameras with body contouring based on manual input. Materials and Methods: The following 4 gamma cameras were compared: two double‐head gamma cameras both equipped with automatic body contouring, the G&E Millennium‐VG (ML‐VG) and the Siemens Symbia‐S ( SYM‐S ); and two triple‐head‐gamma cameras automatic body alignment based on an operator defined orbit, the Philips Irix and Philips Prism‐3000 (P3000). Cardiac SPECT studies were performed on a chest phantom (Chest‐Capintec), with an insert simulating the myocardial chambers. The simulated myocardial wall of the left chamber was filled with 99mTc water solution with an artificial wall‐defects. SPECT imaging was performed on a 360° orbit, 3°/step, and 5 mm pixel size. The following conditions were simulated on the phantom and scanned with all gamma cameras in the same conditions: one 1 cm wall‐defects located respectively on the anterior, posterior, lateral and septal wall. Short axis images were reconstructed using FBP with ramp filter. For each study, the contrast was measured on the short axis slice with the visible defect. The table shows lesion‐contrast values for each gamma camera and for each lesion Contrast
anterior
lateral
septal
posterior
SYM‐S ML‐VG
34 31 29 25
45 45 37 36
48 46 42 41
38 36 36 32
IRIX P3000
Results: Lesion‐ contrast values were calculated on the lesion containing short axis slice for each lesion and for each gamma camera under identical conditions. Both double‐head gamma cameras equipped with automatic body contouring, the ML‐VG and the SYM‐S, show better lesion‐contrast values than the triple‐head‐gamma cameras, Irix and P3000, for cold lesions located in all regions except for the posterior wall. Especially for the P3000, contrast values are lower in all cardiac regions compared to SYM‐S and ML‐VG, showing lowest capability to detect hypoperfused cardiac regions particularly if located in the anterior wall. Conclusions: The automatic body contouring device appears to increase the value of double‐head vs triple‐head gamma cameras in achieving higher contrast values for phantom simulated myocardial cold defects which, in spite of a longer acquisition time, could increase diagnostic accuracy for ischemic heart disease in the clinical setting.
P505 NEMA NU1-2001 performance tests of Philips Brightview SPECT cameras A. Seret; University of Liège, Liège, BELGIUM.
P503 Evaluation of a Ce-doped Gd2SiO5 detector for blood radioactivity measurement J. Kim, K. Kim, J. Kim, S. Woo, J. Park, G. Cheon, C. Choi, S. Lim; Korea Institute of Radiological and Medical Sciences, Seoul, REPUBLIC OF KOREA. Objectives: Measurement of radiotracer concentration in arterial blood is required to get input function for kinetic analysis and performance for proper detector is demanded. The aim of this study was to evaluate design and performance of GSO(Ce) based blood sampling detection system using four PMT modules. Methods: Four GSO(Ce) crystals optically coupled to four individual PMTs(15mm diameter) were used for increasing sensitivity of detector. The each size of GSO(Ce) crystals is 17mm x 17mm x 20 mm with front‐end polished and it is doped of 1.0 mol % of cerium. Unstable PMT gain induced by operating time, radiation exposure was adjusted using variable gain amplifiers. The ranges of pulse height for various radio‐nuclides were discriminated using QSCA for high sensitive counting. The sensitivity for F‐18 was measured with various activity concentrations. Results: Energy spectrum of a Ce‐doped GSO detector module measured with Na‐22, Cs‐137, F‐18 showed the energy resolutions of 40% @511 keV, 32% @662 keV, and 26% @511keV respectively. Evaluation of sensitivity was performed using different activity concentration of F‐18 solutions (0.005, 0.01, 0.02, 0.08 μCi/cc). The shift of the gamma ray peak energy was observed as a function of source to detector distance and activity rate of the F‐18 source. The pulse height position was degraded about ~4.8% by changing activity concentration about factor 2. The measured detection sensitivity was ~26.4% when F‐18 solutions positioned ~10mm from detector center. Conclusion: The results indicate that GSO(Ce) with four PMT modules have enough sensitivity to be used in the measurement of radiotracer concentration.
Introduction The Brightview is the new dual‐head SPECT and SPECT‐CT camera of Philips with two large field of view digital Anger detectors for gamma‐rays and with a flat panel detector for X‐rays. Materials and methods All primary and some secondary NEMA NU1‐2001 performance tests were conducted on two recently installed Brightview SPECT systems, mainly with Tc‐99m and the LEHR collimators. The intrinsic uniformity for four other isotopes (Ga‐67, I‐123, I‐131 and In‐111) and the extrinsic uniformity with the LEHR, MEGP and HEGP collimators were also measured on one system. The NEMA procedures for acquiring and processing the data were carefully followed except for the energy window width that was set at 20% as recommended by the manufacturer. Only mean value ± s.d. obtained in the UFOV for both systems or both heads are reported. Results For Tc‐99m, the following values were obtained for intrinsic tests: energy FWHM = 8.90±0.18 %, spatial FWHM = 3.08±0.02 mm, absolute (differential) linearity = 0.33±0.08 (0.07±0.02) mm, integral (differential) uniformity = 2.21±0.20 (1.56±0.12) %. The integral (differential) intrinsic uniformity was 3.18±0.01 (1.76±0.21) % for Ga‐67, 2.62±0.16 (1.65±0.03) % for I‐123, 3.93±0.49 (2.64±0.31) % for I‐131, 3.81±0.27 (2.18±0.06) % for In‐111. With Tc‐99m and LEHR, the sensitivity was equal to 72.75±1.20 cp/MBq/s and the FWHM values (after Astonish processing) for system resolution without scatter were as follows. Planar: 7.15±0.10 (4.96±0.09) mm; whole body: 6.95±0.11 (4.82±0.07) mm perpendicular and 7.60±0.01 (5.28±0.01) mm parallel to the bed motion; SPECT: 9.72±0.06 (3.77±0.02) mm central, 9.76±0.08 (3.57±0.11) mm radial, 7.71±0.31 (3.35±0.03) mm tangential and 10.17±0.15 (4.50±0.03) mm axial. With Tc‐99m, the extrinsic integral (differential) uniformity was: 3.45±0.37 (2.00±0.47) % for LEHR, 3.45±0.94 (1.81±0.21) % for MEGP and 3.32±0.92 (1.91±0.09) % for HEGP. The system alignment data could not be processed according to NEMA due to a file writing problem when performing 360° rotation per head. However, the COR test recommended by Philips was performed for both head configurations (180° and 90°) and was found satisfactory. A six‐months follow‐up of the intrinsic uniformity and of the COR test will also be given as well as the NEMA tests for one, and possibly two, SPECT‐CT Brightview camera that will be installed in the next few weeks. Conclusions The measured parameters were almost identical for the two tested systems and they all were within the manufacturer specifications.
P57 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
P506
Physics/instrumentation:
An investigation of the utility of attenuation correction of myocardial perfusion images in patients of normal body mass index
emission
tomography
instrumentation (PET)
P504 Comparison of four different gamma-cameras for detection of phantom simulated ischaemic heart disease: value of automatic body-contouring. F. Voltini1, E. Orunesu2, G. Marotta3, M. Schiavini3, F. Zito3, C. Canzi3, P. Gerundini3; 1Fondazione IRCCS Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, Milan, ITALY, 2Fondazione IRCCS Istituto Nazionale Tumori, MILAN, ITALY, 3Ospedale Maggiore Policlinico Mangiagalli e Regina Elena, MILAN, ITALY.
C. M. Tonge, P. Arumugam, J. M. James, S. Muthu, M. Shawgi, R. S. Lawson, R. A. Shields, M. C. Prescott; Manchester Royal Infirmary, Manchester, UNITED KINGDOM. Attenuation correction has been shown to be a useful tool in the diagnostic evaluation of myocardial perfusion studies, but requires additional imaging time. It is known that attenuation artefacts are more frequent in obese patients and in our department patients with normal body mass index (BMI) are preferentially selected for imaging on a camera without attenuation correction facility. However it has been suspected that attenuation artefacts occur in a significant proportion of normal BMI patients. The aim of this study was to determine the % of patients of normal BMI showing attenuation artefacts. Method All patients with normal BMI referred to our department for myocardial perfusion imaging were invited to take part in this ongoing study. To date 43 patients (16 males, 27 females) have accepted the invitation. All were imaged at stress and rest on a GE Millennium VG with Hawkeye using the imaging parameters standard for our
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% of patients showing improvement in perfusion between NAC and AC images
Observer 1
Observer 2
All patients (43)
53.5%
67.4%
Males only (16)
81.3%
93.8%
Females only (27)
37.0%
55.6%
Changes were most frequent in the inferior and inferolateral regions in both males and females although changes were also seen in the septal and anterior regions in some patients. Conclusions Attenuation artefacts are seen in a significant proportion of normal BMI patients, but are less frequently seen in females than males. Consideration should be given to using attenuation correction for all patients regardless of BMI value.
P507 Performance of iterative reconstruction in cerebral perfusion SPECT with x-ray CT based attenuation correction T. Fujishita1, R. Fujioka2, H. Kurihara3, N. Yamaki2, S. Koura1, R. Kodama1, T. Ideguchi1, M. Ochi1; 1Nagasaki kita Hospital, Nagasaki, JAPAN, 2Nihon Mediphysics, Tokyo, JAPAN, 3GE Helthcare, Tokyo, JAPAN. Aim We evaluated the number of iterations in ordered subset expectation maximization(OS‐EM) algorithm to apply x‐ray CT based attenuation correction(CT/AC) in cerebral perfusion SPECT. The scatter weight was estimated to use dual energy window scattered correction. Efficacy of “FMI Brain Sagging” software, which corrects mis‐registration of emission data and CT/AC, was validated. The contrast obtained from OS‐EM and CT/AC was compared with that from conventional filtered back projection(FBP) and Chang method. Materials Infinia Hawkeye 4 GE Healthcare Xeleris Processing GE Healthcare phantom IB‐10 Kyoto Kagaku Co. Ltd. phantom CF Kyoto Kagaku Co. Ltd. Methods Cold spot phantom IB‐10 and cylindric phantom CF were filled with 123I‐IMP or 99mTc‐HMPAO, and SPECT and CT images were acquired with Hawkeye4. Scatter weight was estimated by profile curve and CV value using phantom CF. The number of iterations 2,3,4,5,6,8,10 and 20 were studied and the optimal number of iteration with subset 10 was evaluated by profile curve and contrast value using cold spot phantom. Efficacy of FMI was validated with 123I‐IMP in 20 patients.. Results The optimal number of iteration was 8 in 99mTc‐ HMPAO and 6 in 123I‐IMP study, respectively. The scatter weight was 0.9 in 99mTc‐HMPAO and 0.8 in 123I‐IMP study, respectively. Contrast value after OS‐EM algorithm was equal to that of FBP method. FMI improved table pallet sagging shift from 8.9mm±1.2mm to 1.9mm±1.4mm. Conclusion OS‐EM with CT/AC showed equivalent contrast compared to FBP and Chang method in cerebral perfusion SPECT. OS‐EM algorithm with optimal subsets and iterations using CT/AC may provide better images rather than use the conventional method. Improvement of CT/AC may contribute accurate diagnosis in cerebral blood flow SPECT.
P508 The Effect of Crystal Size on Position Detection Accuracy in PET Block Detectors: A Monte Carlo Study S. Lashkari1, S. Sarkar1, M. Ay1, A. Rahmim2; 1Tehran University, Tehran, IRAN, ISLAMIC REPUBLIC OF, 2Johns Hopkins University, Baltimore, MD, UNITED STATES. Aim: In recent years, PET scanner manufacturers have tried to optimize the spatial resolution and position detection accuracy (PDA) of PET scanners by decreasing the crystal size in the block geometry. In this study we utilized the MCNP4C Monte Carlo code to quantitatively evaluate the influence of crystal size on PDA. Materials & methods: The MCNP4C Monte Carlo code was used for detailed transport of 511keV photons originated as pencil beam from a point source toward the central crystal of a block detector consisting of a 13 mm× 13mm crystal array with different pixel dimension with the same crystal depth for LSO and LYSO. A total number of 50000 photons with energy of 511 keV transported from a point source toward the central crystal in each array. The code was validated through comparison with simulated data published by Shao et al. The history of each photon including the coordination, type of interaction, deposited energy and direction cosines for any interaction were registered in a separate matrix. In order to determine the effect of crystal pixel size on PDA, different crystal pixel size (from 1mm to 8mm) were used for calculation of PDA. Results: The results show that with increase in the crystal pixel size until 4 mm, the PDA will increase rapidly, the PDA in LSO crystal is 59.98% for 1 mm and 77.26% for 4 mm, but after 4 mm the PDA increase slowly and reach to almost a constant value, 77.86% for 5 mm and 79.31% for 8 mm. It should be noted that decreasing the PDA when decreasing the crystal pixel area is due to the fact the contribution of inter crystal scattering (ICS) in PDA increases with decreasing the pixel area. Conclusion: This paper includes investigating the effects pixel size (area) of PDA in PET block detector at 511keV photon irradiation, as is pertinent for PET studies. This information can be very useful for accurate measurement and modeling of ICS effect into reconstruction algorithms to produce images which have higher resolution, about which our group are investigating actively. The obtained results also suggest that the MCNP4C code is a useful appliance for investigation of photons interaction in PET block detectors to model the ICS behavior in details for the purpose of resolution recovery in modern PET image reconstruction algorithms.
P58 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Physics/instrumentation:
integrated
multi-modality
systems, PET/CT, SPECT/CT and others
P509 PET/CT GE STE16 tomograph performance at different 18F doses and 3-D acquisition times O. Nibale1, P. Chiaramida2, A. Massaro1, L. Rampin1, M. Marzola1, E. Banti1, G. Grassetto1, D. Rubello1; 1Hospital Rovigo, Rovigo, ITALY, 2GE Healthcare, Roma, ITALY. Phantom study. NEMA 2001 IQ phantom was used to evaluate lesion detectability at different 18F doses and 3‐D acquisition times. Six spheres were used (17,13,10,8,5,3 mm) to simulate lesions. Phantom tank was filled with a solution of 18F with a concentration of 1.85 MBq/Kg in order to simulate an injected dose (ID) of 3.7 MBq/Kg (0,1 mCi) 1 hr after injection. Spheres were filled with a radioactivity concentration ratio of 4:1 compared to BKG. A series of 3D PET scans (5‐ min each) was acquired in list‐mode (VIP) until the radioactivity decayed to a level similar to a clinical WB acquisition. A second series of scans was acquired after a time enough long to have 1.11 MBq/Kg inside the tank, in order to simulate an ID of 2.22 MBq/Kg (0,06mCi). Acquisitions were done both putting the spheres in the centre of the FOV and on the overlap, in order to evaluate how the eventual decreased image quality may influence the detectability of the lesion. Patient study. 2 groups of pts (20 pts/group) were studied: one with an ID of 3.7 MBq/Kg, the other of 2.22 MBq/Kg of 18F‐FDG. 3D VIP acquisition mode was used. Data reconstruction. The data acquired in VIP mode were used to obtain acquisitions at 3, 2.5 and 2 min/bed. The unlisted data were processed using the onboard system algorithm VUEPOINT HD, composed of a fully 3D‐ OSEM algorithm with all corrections (randoms, scatter, attenuation, geometry) included in the iterative process. Parameters were: subsets 28; iterations 2; image matrix 256x256 and 128x128 pixels; post filter 3.7 and 4.5 mm; FOV 70 cm. Data analysis. Phantom images were evaluated by two physicians. The quantitative evaluation was done drawing ROIs on lesion and on BKG and evaluating contrast values. The lesions’ ROIs were drawn using CT images in order to avoid partial volume problems. The parameters evaluated for the quantitative analysis were the recovery coefficient and lesion variation. Results. On both dose concentrations all the simulated lesions were able to be seen. The contrast values for the more little lesion (1.0 cm diameter) were 24% at 1.85 MBq/Kg and 21% at 1.11 MBq/kg. This little gap was more and more less with the biggest lesions. These finding were confirmed in patients' study. Conclusion. Our data show that a low 2.22 MBq/Kg 18F injected dose is adequate to obtain good quality images using a PET/CT GE STE16 tomograph.
P510 Iodine contrast enhanced CT-scan fluorodeoxyglucose Positron Emission technical and practical considerations
during 18FTomography:
C. Houzard1, D. Maintas2, F. Giammarile1; 1Centre Hospitalier Lyon Sud, EA 3738, Pierre Benite, FRANCE, 2Institute of Radioisotopic Studies, Athens, Medical Center, Athens, GREECE. Aim With technical advances in PET‐CT cameras, iodine contrast enhanced CT‐scan during 18F‐ fluorodeoxyglucose Positron Emission Tomography (18FDG PET‐CT) in clinical current practice remains an opened question. We report our experience, the conditions we use this method and the advantages for the patient. Materials and methods We have first studied the influence of high density on CT attenuation corrected PET (CTAC) images on 3 PET‐CT cameras with a Jaszczak modified phantom (containing 3 pairs of vials with water, alcohol and KI solutions, with equal activities of 18‐FDG in one vial of each pair). After reconstruction, scaling and segmentation, attenuation correction with procedures proposed by the constructors, we measured the activities of the 6 vials and of the background using the ROIs method on CTAC and NAC images. Then, a prospective study with our camera (Gemini Philips) has evaluated the feasibility of contrast enhanced CT‐scan for diagnosis purpose, performed during 18FDG PET‐CT study in 25 lymphoma staging. 2 CT scans were acquired: lCT (usual low dose CT before PET) and dCT (CT after PET, with classical parameters and iodinated contrast). For each patient, CTAC PET images were visually compared. Density in Hounsfield units (HU) and maximum Standardized Uptake Value (SUVmax) were measured on different organs and specific lymphoma localizations (294 measurements). Finally, a retrospective study was done to evaluate the clinical advantage of this method. 50 lymphoma staging were separately analyzed by a physicist and a radiologist on CTAC PET, CT and fusion images. Results Phantom study showed that attenuation correction by CT for high atomic number may produce artifact depending on the camera (false activity measured in vial containing KI solution on the CTAC images). Our camera (Gemini Philips) was not affected by high atomic number neither elevated density. In the in vivo prospective study, visual analysis was similar for the 2 modalities, without discordant interpretation for the pathologic sites. SUVmax means and standard deviation of each organ for lCTAC and dCTAC were comparable. The equation of the fitted multiple linear regression model was: dCT=0.0748191 + 1.17024*lCT (98.71%; p<0.01). In the in vivo retrospective study, enhanced CT scan showed less indeterminated data (N = 8/76) thus improving diagnosis accuracy. Conclusion With our camera, the use of iodine contrast enhanced CT during 18FDG PET‐CT studies is possible. We now currently use this method in current clinical practice and great benefit is obtained on diagnostic, logistic (“one stop shot”) and radioprotection purposes.
P511 Integrated PET/MRI (iPET/MRI) for small animals: Performance characteristics and initial experiences E. Shimosegawa1, S. Yamamoto2, M. Imaizumi1, Y. Kanai1, M. Tatsumi1, M. Aoki3, E. Sugiyama3, J. Hatazawa1; 1Osaka University Graduate School of Medicine, Suita, JAPAN, 2Kobe City College of Technology, Kobe, JAPAN, 3 Hitachi Metals. Ltd., NEOMAX Company, Tokyo, JAPAN.
Poster Presentation
department and low resolution CT. Realignment was performed using proprietary software to correct any registration errors and trans‐axial slices reconstructed using OSEM with and without attenuation correction. Two sets of bulls‐eye images were created for evaluation by two experienced observers (attenuation corrected (AC) and non‐corrected (NAC)). These were evaluated for the presence of resolving defects between the NAC and AC images without knowledge of gender or clinical history. The observers were also asked to record whether the change in appearance affected the diagnostic outcome. The effect of scatter correction was also evaluated. Results Improvement in perfusion was apparent in a significant proportion of normal BMI patients with males showing more areas of improvement than females.
S410 Objectives: We developed a fully integrated (i) PET/MRI system for small animal imaging. The iPET/MRI consists of DOI block detectors made of LGSO, optical fibers (~80cm), PSPMTs for PET, RF‐coil (φ7.6cm), and 0.3T Nd‐Fe‐B permanent magnet for MRI. Axial FOV was 21 mm for PET and 80 mm for MRI. The purpose of this study was to demonstrate initial imaging experiences in rats and mice. Methods: All animals were anesthetized by MRI‐compatible inhalation device with 1.5 % isoflurane and room air. Approximately 74 MBq of PET tracers (18FDG, Na18F, 11C‐methionine) were injected to tail vein. For vascular and hepatobiliary contrast enhancement, 0.009 mmol of Gd‐DTPA and Gd‐EOB‐DTPA was utilized for MRI. Simultaneous PET (list mode) and MR (fast low angle shot T1‐weighted sequence, TR/TE=50/5 msec) imaging was performed at appropriate time points. Results: Simultaneously obtained PET‐MRI images demonstrated organ specific accumulation of PET tracers; Na18F to bone, 18FDG to harderian gland, brain, brown fat, myocardium, and urinary tracts, 11C‐methionine to salivary gland, liver and pancreas. FLASH MRI with EOB showed high signal intensity in the liver associated with increased 11C‐methionine uptake. MR angiography depicted major intracranial, cervical, and thoracic vessels with PET images. Conclusions: The present iPET/MRI can be used for in vivo small animal imaging. Research Support: Program for Promotion of Fundamental Studies in Health Sciences of the National Institute of Biomedical Innovations, Japan (No. 06‐35).
P512 PET/CT image improvement expected from respiratory motion correction: a phantom study S. Bouazza, J. George, B. Krug, A. Pirson, H. Meurisse, T. Vander Borght; Mont-Godinne UCL University Hospital, Yvoir, BELGIUM. In PET/CT studies, respiratory motion induces not only motion artifacts and spatial blurring but also incorrect quantification of the radioactive uptake. Material and methods: A Jaszczak phantom (D210mm filled with air, water or 15 or 40% background activity) with 6 spherical targets (D7.8,9.85,12.4,15.6,19.7 et 24.8mm) filled with the same FDG activity (range 2‐13kBq/ml similar to that of liver metastases) was scanned with Philips Gemini TF PET/CT at rest and in motion, with and without gating. To simulate respiratory motion, the phantom was driven sinusoidally in the superior‐inferior direction with amplitudes of 2cm at 18BPM. The 3D and 4D PET scans (10bins) were corrected with corresponding attenuation maps created from CT data. The partial volume effect and signal loss in the 3D and 4D PET images were measured (max value in a 30mm VOI) and expressed as a percentage of the true activity (recovery coefficient: RC). Results and discussion: RC were similar whatever the statistics and the scatter medium, so that the results were expressed as mean±SD. On images at rest, partial volume effect was observed only for spheres <15.6mm with RC of 52±2% and 24±4% for the 12.4 and 7.8mm spheres, respectively. On images in motion, the quantification was further decreased by ~20% for the 24.8mm, ~30% for the 19.7mm, and ~50% for the smaller spheres, resulting in absolute RC of 75±2% for the greater sphere and 11±1% for the smaller one. Gated acquisitions improved quantification over non‐gated acquisitions by providing similar values of images at rest. Similar improvement of quantification accuracy was also obtained using 15% and 40% background activities. However with the latter background activity only moving spheres >19.7 mm were visualized, whereas gating acquisition allows detection of smaller 15.6mm sphere. Conclusion: Signal loss was found to depend on both the partial volume effect and motion. Using 0, 15 or 40% background activities, 4D PET successfully restored results to those observed when the phantom was static.
P513 Performance Evaluation, Acceptance Testing and Quality Assurance for DiscoveryTM 600 GE PET/CT Scanner M. Mormile1, L. D'Ambrosio2, P. Chiaramida3, V. Cerciello1, M. Aurilio2, S. Lastoria2; 1Medical Physics, Istituto Nazionale Tumori, Fondazione "G. Pascale", Napoli, ITALY, 2Nuclear Medicine, Istituto Nazionale Tumori, Fondazione "G. Pascale", Napoli, ITALY, 3GE Healthcare, Milano, ITALY. Aims: We investigate characteristic parameters of the General Electric DiscoveryTM 600 PET/CT scanner. Quality assurance of PET/CT scanners must be performed to maintain and confirm proper scanner performance. The following acceptance tests were executed: 3D‐Normalization Well Counter Correction (WCC), Coincidence Timing Correction and Quantitative Accuracy of the Image Data (SUV). We used the NEMA NU‐2001 protocol and its recommended phantoms to evaluate: Spatial Resolution, Sensitivity, Image Quality, Attenuation Accuracy & Scatter Correction, Scatter Fraction, Count Losses and Randoms. Materials and methods: The quality control and calibration of a PET/CT scanner includes detector and electronic characterizations such as adjustment of PMT gain, definition of crystal and energy maps and coincidence timing calibration. For the WCC normalization we used a water filled phantom with 18.2 MBq of 18FDG. We correlated the measured numerical values in each image pixel to a specific activity in physical units (activity/volume). Spatial Resolution was estimated with three capillary tubes filled with a of 4,78 mCi/cc 18F solution. The sensitivity test was performed using a “sensitivity phantom” with 10MBq of 18F, placed within the FOV parallel to the scanner z‐axis. The Image Quality (IQ) Phantom was used to asses image quality, the attenuation accuracy and scatter correction. Only four of the six inner spheres were filled with an activity concentration 4 times higher than background. The Scatter Fraction, Count Loss and Randoms were measured with a phantom containing a line source filled with 1,2 GBq of 18F to do an acquisition over a period of 14 hours. Results: The WCC test showed good agreement between measured (2,4) and calculated (2,16 ÷ 2,69) SUV values. The measured resolution had a value of about 5 mm and 6 mm FWHM in transaxial and axial scan at 1cm. The sensitivity calculated as the average value of both radial localizations was 9.13 cps/kBq. The Scatter fraction at low activity was about 35%. The NECR peak was evaluated as 75 kcps. The Correction Accuracy had a maximum error below peak NECR of about 1.9%. For the IQ the measured contrast was always higher than the value specified by the manufacturer and the measured background always lower as requested. Conclusions: The performance of the DiscoveryTM 600 PET/CT scanner evaluated using the NEMA‐2001 satisfies the manufacturer’s specifications and the users’ requirements.
P514 Effective dose rate measurements of PET/CT patients at “Evangelismos” General Hospital and evaluation of radiation
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 protection instructions. A. P. Samartzis1, N. Bertsekas1, G. Fountos2, I. Datseris3, C. Alevizaki1; “Evangelismos” General Hospital, Medical Physics Department, Athens, GREECE, 2Technological Education Institution of Athens (TEI), Department of Medical Instruments Technology, Athens, GREECE, 3. “Evangelismos” General Hospital, Nuclear Medicine Department, Athens, GREECE. 1
AIM: The use of 18F‐FDG for clinical PET studies may increase radiation exposure because of the 511 keV gamma ray energy. Therefore, 18F‐FDG imaging necessitates stricter radiation protection practices. The aim of this study was to assess staff and outpatients relatives potential exposure and evaluate the radiation protection efficiency of our instructions to the patients. MATERIAL‐ METHODS: Sixty patients were randomly selected (out of 512 totally scanned over 3 months) for effective dose rate measurements during their stay in our PET facility for whole body PET/CT scans. Our sample consisted of 34 male (56.7%) and 26 female (43.3%) patients with ages ranging from 15 to 79 years. The injected 18F‐FDG activity ranged from 340 to 450 MBq according to EANM guidelines. Measurements were taken with a hand ‐held survey meter (Innovision 451P), at 1m distance from the patient’s chest. A total of four measurements were taken, D0 immediately after the injection of the radiopharmaceutical, D1 at the end of the one ‐ hour uptake period, Dbv immediately after bladder voiding and Df just prior to the release of the patient. Based on these measurements the percent urinary excretion and the retention of the 18 F‐FDG at discharge‐time were also calculated. RESULTS: Twenty one patients had negative and 39 had pathological findings in their whole body scan. Patient’s effective dose rates were: D0 = (51.95 +/‐ 3.73) uSv/hr, D1 = (29.33 +/‐ 4.49) uSv/hr, Dbv = (26.20 +/‐ 4.21) uSv/hr and Df = (20.92 +/‐ 2.44) uSv/hr. Mean urinary excretion was (9.97 +/‐ 5.40) % and retention (67.23 +/‐ 9.79) %. Retention had a negative correlation with BMI (p=0.05) and correlated with corrected dose prior to release (c=0.85 p=0.000). The Df dose rate measurements of patients with pathological scans were lower than those who had negative results (p=0.035, Mann Whitney test). CONCLUSION: Our results are comparable with those previous published. By our measurements the dose received by staff, family members and public should be well below regulatory limits. Improved efficiency in patient handling is essential for reducing dose to staff involved in patient contact. Simple instructions to the patients, as to avoid close contact with children and pregnant woman for a couple of hours after the examination, are considered adequate for radiation protection purposes. 1
P515 PET-CT transmission imaging with 6 and 64-slice-CT scanners: evaluation of patient radiation exposure during whole-body scans F. Zito1, L. Zappa1, C. Canzi1, L. Leonardi2, G. Re1, G. Tosi2, M. Schiavini1, F. Voltini1, A. Chiti2, P. Gerundini1; 1Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, ITALY, 2Humanitas, Milan, ITALY. Aim: To study for two BIOGRAPH PET‐CT scanners how increased number of CT detector elements can affect irradiation dose component in routine whole‐body transmission images. Materials and Methods: The dose for some organs (eyes, thyroid, lungs, breast, stomach, kidneys, uterus, testes) was assessed by using the Alderson Rando anthropomorphic phantom (Alderson Research Laboratories Inc.). Sixty five triplets of calibrated thermo luminescent dosimeters (GR‐200 Harshaw) were distributed inside the phantom. After preparation the phantom was irradiated (total length of 1025 mm) with an Emotion 6 and a Sensation 64 (6 and 64 slice CT),part of two different BIOGRAPH PET‐CT (Siemens) scanners installed in two nuclear medicine departments in Milan. Irradiations were performed by using routine CT departmental protocols having same 5 mm thick reconstructed slices but different acquisition parameters (Emotion 6: ‐50 mAs and 110 kVp for topograms, ‐95 reference mAs, 130 kVp, 0.6 sec/rotation, collimation 6x3mm, feed/rotation 27 mm for CT scans; Sensation 64: ‐35 mAs and 120 kVp for topograms, ‐90 reference mAs, 120 kVp, 0.5 sec/rotation, collimation 24x1.2 mm, pitch 0.8 for CT scans). The automatic tube‐current control‐system, CARE dose 4D, was active for both protocols. Phantom exposure, including topogram and CT scan, was repeated 3 times for each scanner. Specific scanner dose indexes: ‐effective tube current (mAs) supplied on average and per slice, ‐ CTDIvol (mGy) and ‐DLP (mGy.cm) were considered. Results: As expected, CARE dose 4D system for both scanners allowed to supply lower tube current to thinner body regions as neck and higher to thicker structures as shoulders and pelvis regions. For Emotion 6 and Sensation 64, respectively, the following results per scan were obtained: average current 38 mAs and 46 mAs (range 16 ‐ 55 mAs and 18 ‐ 68 mAs), 4.11 mGy and 3.16 mGy as CTDIvol , 441 mGy.cm and 328 mGy.cm as DLP. Except for thyroid where dose values were comparable (5 mGy), all other considered organs received on average 20% higher dose with Emotion 6 (range 3.0 ‐ 9.0 mGy) than with Sensation 64 (range 2.0 ‐ 5.5 mGy). Conclusion: For the specific whole‐body PET‐CT transmission protocols considered in this study, the use of larger number of detector elements for a CT scan resulted in an average dose reduction of 20%.
P516 To what extent does the presence of a hip resurfacing implant influence the accuracy of CT attenuation corrected SPECT bone images? H. Amarasekera, R. Penny, M. Costa, D. Griffin, N. Williams; University Hospital Coventry & Warwickshire, Coventry, UNITED KINGDOM. Aim Resurfacing arthroplasty of the hip involves the preservation of the femoral neck and head. Subsequent imaging of the bone, following the development of suspected loosening, infection or avascular necrosis, is limited due to the presence of the metal prosthesis. Dynamic, late and SPECT nuclear medicine bone imaging are well established methods of obtaining diagnostic information with respect to conventional total hip replacements. Hybrid imaging (SPECT/CT), in general, has the benefit of providing localisation of pathology and, with attenuation correction, improved contrast and diagnostic sensitivity. SPECT/CT bone imaging of hips following resurfacing arthroplasty will, potentially, improve its diagnostic capabilities; this study assesses the impact the resurfacing prosthesis has on the attenuation correction technique. Method Phantom acquisitions were performed using three sizes of resurfacing implants (Corin Cormet
S411
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Cup Size PS Free Air (%) PS with Pin Only (%) PS with Pin + soft tissue (%)
Without AC With AC Without AC
With AC
4
100
97
114
42
107
8
100
98
111
40
102
10
100
91
105
39
109
(AC Attenuation Correction) Conclusion The results consider the quantitative evaluation of a point source located close to the pin of different sized prostheses. Without attenuation correction the pin of the prosthetic implant has little impact on the detected counts but simulated surrounding soft tissue results in a significant reduction. The presence of the pin causes an overestimation of the attenuation corrected counts but, overall, in the presence of simulated soft tissue, the counts differ by no more that 10% of those acquired in free air. In conclusion, the size and structure of the prosthetic pins used in this study do not affect the attenuation correction algorithm to an extent that could prohibit the use of this technique.
P59 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Physics/instrumentation: image reconstruction, data simulation and modelling.
P517 Implementation of a Cascade-Coincidence Simulation Module for SimSET and PET Imaging With the Isotopes Y-86 and I-124 P. A. A. Santos, P. Almeida; Instituto de Biofísica e Engenharia Biomédica, Lisboa, PORTUGAL. This work aimed at adding a module to the SimSET monte carlo simulation package to allow for the modeling of the the effects of including gamma(γ) photons emited in cascade with the positrons during the decay of non‐pure positron emiting PET isotopes. The decay schemes of I‐ 124 and Y‐86 were implemented, as these decay by positron emission and electronic capture. The presence of these cascade gamma photons render PET images quantitatively inaccurate, diminishing their usefulness for diagnostic and therapeutic purposes. The Photon History Generator(PHG) module of the SimSET package was altered to allow for the simulation of the γ‐ photons that are emitted in cascade with the positron, during the transition of the decay daughter nucleus to ground state. The added module determines which two photons would be detected in coincidence, from the set of positron annihilation photons (511keV) and γ‐photons emitted. These pairs of photons were then propagated through the SimSET collimator and detector modules and were passed on for binning. The binning module was altered to allow the separate binning of the coincidences between two 511keV photons (511‐511) and coincidences that include at least one γ‐photon (Cascade Coincidences) into different sinograms, for both true and scattered events. The γ‐photons that are emitted during decay by electronic capture, were considered to contribute only to the random coincidences, and hence were simulated by propagating single photons through the same cylindrical detector used for the positron emission simulation. The simulated detected single photons (511keV and γ‐photons) were then randomly shuffled, paired and binned into the random coincidences sinogram. For an initial study the NEMA line source, centered and off‐center, in air and in water, was simulated using generic PET scanner characteristics, and the decay scheme of I‐124 and Y‐86. Similar simulations were obtained with F‐18 for comparison purposes. The relative abundances of the 511keV and γ‐ photons obtained in the PHG module photon history files, for the I‐124 and Y‐86 simulations, coincided with the values of the respective decay scheme. The cascade coincidences in the simulated images show a relatively uniform spatial distribution in the center of the images, and an increase of detected radioactivity at the edges of the field of view, that are consistent with the experimental results published for PET images obtained with the considered isotopes. The work in progress includes the validation of the number of cascade‐coincidences included in the images for quantitative accuracy of the simulations.
P518 Performance of a Cascade-Coincidence Simulation Module for SimSET in Predicting the Effects of Cascade Gamma Photons on the Scatter Fraction and Recovery Factors of PET Images with I-124 P. A. A. Santos, P. Almeida; Instituto de Biofísica e Engenharia Biomédica, Lisboa, PORTUGAL. Monte Carlo simulation of PET images obtained with I‐124 can be used to gain insight on the effects of the inclusion of gamma(γ) photons into the images. I‐124 decays by both positron emission and electronic capture, emitting several γ‐photons in cascade that can be detected in coincidence by the PET scanners, originating cascade‐coincidences. A module has been developed for the SimSET (Simulation System for Emission Tomography) package, to simulate cascade‐coincidences and the decay scheme of I‐124 has been implemented. The aim of this work was to assess how this module performs in predicting the effects of cascade‐coincidences on the scatter fraction (SF) and radioactivity recovery factors (RF) of PET images obtained with I‐ 124, with a simplified simulated model of a clinical PET scanner. Since the SimSET package does not yet allow the simulation of block detectors, a simplified model of the scanner detector was used in which the detector's rings were simulated as a continuous ring of detector material. The images were reconstructed from the detected energy information. For this work we have simulated PET images, in 2D and 3D mode, for the isotopes F‐18 and I‐124 for later comparison.
Images of a stainless steel radioactive line source in a water‐filled cylindric phantom (20cm of diameter and 19cm length) were simulated to mimic the acquisition conditions necessary to determine the scatter fraction according to the NEMA NU 2‐1994 protocol. Images of a cylindric phantom (20cm diameter and 15.7cm length) containing 5 line sources of 1cm diameter, in air and water, were used to calculate the radioactivity recovery factors. The RF were calculated using the reconstructed images of the true coincidences, and of the true+scattered simulated sinograms. The results obtained with the simulated images of I‐124 were compared to the ones obtained with F‐18, to determine how the presence of the cascade‐coincidences would impact the SF and RF, as predicted by the cascade‐coincidence simulation module. The SF values obtained for the simulated I‐124 images were significantly higher than the ones obtained for F‐ 18, due to the large number of scattered gamma‐photons included in the images as scattered cascade‐coincidences. The accuracy of the RF was significantly decreased by the presence of cascade‐coincidences in the I‐124 images, due both to true cascade‐coincidences and scattered cascade‐coincidences.
P519 Investigation into the Effect of Reconstruction Parameters and Resolution Recovery on Reproducibility of Gated Myocardial Perfusion SPECT Quantitative Results R. C. Fernandez, S. J. Allen, T. O. Nunan, G. Gnanasegaran, R. Williams; Guy's & St Thomas' NHS Foundation Trust, London, UNITED KINGDOM. Aim Depth dependant resolution recovery (RR) promises improvement in image contrast and therefore gated myocardial perfusion SPECT (GSPECT) is a seemingly ideal application. This study aimed to investigate the effect of varying reconstruction parameters (reconstruction method: analytic/iterative, image zoom, application of RR) on quantitative results obtained from a new version of QGS (Cedars‐Sinai) processing software at this centre. Previous versions of QGS have been evaluated locally, however refinements in the edge detection algorithm of the new software may alter quantitative results and so a secondary aim was to investigate reproducibility of the new QGS software. Method For QGS evaluation, 40 consecutive GSPECT patient studies (2‐ day rest/stress protocol, 800MBq 99mTc‐tetrofosmin administered for each) imaged using a GE Optima gamma camera were retrospectively analysed. The randomly selected patients presented with varying degrees of pathology. Left ventricular ejection fraction (EF), end‐diastolic volume (EDV) and end‐systolic volume (ESV) were calculated using 3 different versions of QGS on 2 different processing workstations: Genie (GE Medical Systems) QGS‐v1, Hermes (Nuclear Diagnostics), QGS‐v3 and v4 To investigate effect of reconstruction parameters, retrospective analysis was performed on a second group of 40 GSPECT patient studies (similar protocol and selection criteria as above) but acquired using the Siemens C‐cam gamma camera. Both un‐ zoomed and zoomed (x2) data were reconstructed with various analytic and iterative parameters, and +/‐ application of the proprietary ‘Flash 3D’ RR algorithm. Results One‐way ANOVA showed no statistically significant difference in all of EF/EDV/ESV with different QGS version/processing platform (EF: F[2,78]=1.63, p=0.20). Consequently, QGS v4 was used for all subsequent analysis. Two‐way ANOVA showed both reconstruction method and image zoom had a statistically significant effect on all of EF/EDV/ESV (EF: analytic/iterative: F[1.76,68.55]=17.69, p<0.005, ηP2=0.31, zoom: F[1,39]=62.96, p<0.005, ηP2=0.62). Mean EF varied by up to 6% when different reconstruction methods were employed. There was no statistically significant difference in all of EF/EDV/ESV as a consequence of applying RR, compared to iterative methods without RR applied (95% CI for mean EF difference= ‐1.65 to 3.53%). Conclusion This study shows thorough evaluation of new software/reconstruction process before clinical application is essential. Different versions of QGS gave no significant difference in quantitative results when reconstruction process was constant. However, varying reconstruction parameters can have both statistically and clinically significant effect on reproducibility of quantitative results. Despite improvement in image quality afforded by RR, changes were not reflected in quantitative results compared to iterative methods without application of RR.
P520 Validation of the Inveon small animal PET system model using GATE N. Dartial1, T. Carlier1, M. Fusellier2, J. Desfontis2, D. Visvikis3, M. Bardiès1, C. Hindorf2; 1INSERM U892, Nantes, FRANCE, 2National Veterinary School, Nantes, FRANCE, 3INSERM U650, Brest, FRANCE. Objectives: The aim of this study was to establish a model of the Siemens Inveon microPET system using GATE (Geant4 Application for Tomographic Emission). The long term objective is to use Monte‐Carlo modelling to optimise PET quantitative imaging within the context of long‐lived positron emitter imaging (124I and 64Cu). Methods: The Inveon model for GATE was developed according to the manufacturers geometry and system component specifications. In addition, a model of the electronic processing chain was implemented. Simulation results were compared to measured data. The system model was optimized based on singles and coincidences rates assessed over a wide range of activity up to 200 MBq. Experimental and simulated data were obtained using mouse and rat sized PMMA phantoms containing a line source of 18F as described by the NEMA NU4‐2008 performance protocol for small animal positron emission tomographs. To account for event losses during electronic processes, a dead time model was applied to the singles and coincidences processing chains. True, random and scatter coincidence rates were also compared to measured data. Finally, simulated and experimental spatial resolution, scatter fraction, sensitivity and Noise Equivalent Count Rate (NECR) were calculated using the NEMA NU4‐2008 protocol. Results: Count rates for simulated singles, prompt and true coincidences were within 5% of measured data. For mouse and rat phantoms, the simulated and experimental NECR curves differed by 10% for activities less than 30 MBq. The difference between simulated and measured absolute sensitivity was 3% at the centre of field of view, for a 350‐650 keV energy window and a 2.8 ns timing window. Additional calculation for spatial resolution over the field of view and image quality are ongoing. Conclusion: Preliminary results demonstrate an accurate modelling of the Inveon PET system, using GATE with appropriate electronics process parameters.
Poster Presentation
cup sizes 4, 8 and 10). SPECT/CT images were acquired of the following three configurations: a point source (PS) of Tc99m in free air and the PS adjacent to the pin of the prosthesis both with and without surrounding soft tissue equivalent attenuating media. All images were reconstructed using iterative reconstruction with a Butterworth filter, cutoff 0.35 cycles/pixel and power 15. The counts within the image volume (point source) were deduced from the reconstructed transaxial slices and normalised to the free air acquisition. Results Mean calculated point source counts as a percentage of those detect in free air
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P521 Quantitative Evaluation of Respiratory motion in Small Animal PET Imaging S. Branco1, S. Jan2; 1Universidade de Lisboa, Faculdade de Ciências, Instituto de Biofísica e Engenharia Biomédica, Lisboa, PORTUGAL, 2 CEA/DSV/I2BM, Service Hospitalier Frédéric Joliot, Orsay, FRANCE. Aim: Respiratory motion is one source of degradation in PET images. Respirator movements introduce image blurring and lead to reduced contrast and reduced quantitative accuracy in terms of recovered activity concentration and functional volume location and size. This work is focus on the study of the impact of respiratory motion and respective degradation on lesion detection. Material & Methods: Our research studied the combined effects of lesion size, lesion‐ to‐background activity concentration ratio and respiratory motion on signal recovery of spherical lesions in small animal PET images. For these purposes, we used the Geant4 Application for Tomographic Emission (GATE) Monte Carlo platform to model the microPET® FOCUS 220 system and implement the digital 4D Mouse Whole‐Body (MOBY) phantom. We created a physiological “stress breathing” condition in MOBY to reproduce the respiratory mouse motion during a typical PET examination. A spherical lung lesion was implemented and its motion modeled. Over a complete respiratory cycle of 0.37s we retrieved a set of 10 temporal frames (including the lesion movement) generated in addition to a non‐gated data set. Sets of static (non‐gated data) and dynamic (gated data) FDG simulations were performed considering different lesion sizes and different activity uptakes. Image noise and temporal resolution were determined on the 3D and 4D images. Signal‐to‐noise ratio (SNR), contrast‐to‐noise ratio (CNR), contrast recovery (CR) and volume recovery (VR) were also evaluated. Results: Measurements of the full width at the half maximum (FWHM) shows that the blurring effect is lower for static acquisitions. When FDG uptake increases the blurring increases for static acquisitions and decreases in dynamic acquisitions. The SNR is as lower as higher is the activity concentration, and is proportional with the growth of the lesion diameter. The dynamic simulations results in larger overestimations of SNR and CNR due to poor counting statistics and high image noise. This effect is more significant as the lesion diameter increases and activity concentration decreases. Motion reduces the CR, while images from static acquisitions can largely recover the signal lost due to motion. As expected, in dynamic acquisitions the lesion volumes were over‐estimated due to the smearing effect resulting from motion. For static acquisitions we got high VR. Conclusion: The location and detection of lung lesions in mouse imaging can be affected by the respiratory motion. This effect should be taken into account when searching for lesions and quantifying tumor tracer uptake in highly deforming structures such as the lungs.
P522 The Influence of Crystal Pixel Size and Collimator Geometry on the Performance of Pixelated Crystal Gamma Camera Using Monte Carlo Simulation M. Rasouli; Tehran university of medical of science, Tehran, IRAN, ISLAMIC REPUBLIC OF. Background and purpose: Dedicated pixelated gamma cameras have been used over years for high performance breast and small animal imaging. It is already known that, crystal pixel size has effects on inter crystal scattering (ICS). Because of small sizes of used collimators, scattered radiation and septal penetration are high and therefore careful design must be considered. The use of Monte Carlo (MC) simulation techniques is widespread in nuclear medicine. They are particularly useful when experimental measurements are not practical. In this study we have investigated the effects of crystal pixel size and collimator geometry on the performance of pixelated cameras using MC simulation. Material and methods: CsI detector arrays with different pixel sizes and collimator geometries were investigated. The MCNP4C MC code was used for detailed transport of 140 keV photons in pencil beam shape originating from a point source at 50 mm distance from the collimator surface toward the central crystal. The code validated through comparison with some experimental measurements. The simulations were performed to investigate the effects of crystal pixel size and collimator geometry on ICS, position detection accuracy (PDA), detection efficiency (DE), spatial resolution (FWHM), signal to noise ratio (SNR) and contrast. Findings: Results indicate that, by increasing crystal pixel size, ICS is decreased, change of DE is negligible but PDA, FWHM, SNR and contrast are increased. For example, using GP collimator with 1 mm hole diameter and 0.2 mm septal thickness, ICS is decreased from 1.01 % to 0.59 %. DE is about 15.15 %; PDA, FWHM, SNR and contrast are increased from 16.41 %, 2.35 mm, 14.27 and 0.2 to 75.57 %, 3.23 mm, 65.76 and 3.1, respectively. By decreasing collimator hole diameter and increase in collimator thickness, contrast and PDA show improvement but ICS, DE and FWHM are decreased. Conclusion: Using MCNP4C general‐purpose MC code, accurate modelling of ICS effects for different crystal pixel size is possible and the best collimator characteristics beside optimum PDA, DE, SNR, FWHM and contrast are also possible to evaluate with less time consuming procedures and cost. In this study we found out that pixel size is the major factor in decreasing of ICS fraction in pixelated cameras. Also collimator geometry plays an important role in camera performance. However, the optimal crystal pixel size and collimator design for high resolution breast imaging are still open questions which require further research and development efforts.
P523 Comparison of Positioning Algorithms for a PET Detector: A Simulation Study D. Talat, A. Guvenis; Institute of Biomedical Engineering, Bogazici University, Istanbul, TURKEY. Aim: To compare the spatial resolution performance of a continuous crystal PET detector at different thickness levels using artificial neural network (ANN) and maximum likelihood based positioning algorithms. In order to be able to determine the best trade‐off between spatial resolution and sensitivity for the optimal design of a PET detector, it is important to determine the spatial resolution‐thickness relationship and to choose the most suitable algorithm. Materials and Methods: In this study we conducted Monte Carlo simulation studies due to the complex nature of the continuous LSO based positron emission mammography (PEM) system. For our simulations we used the BUILDER, GRIT and DETECT2000 software programs. The detector
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 consisted of a continuous LSO scintillation crystal with an area of 49x49 mm2 which has varying crystal thickness levels between 3 mm and 24 mm. The Hamamatsu H8500 multi‐anode (8x8) flat‐panel PSPMT is assumed to be mounted on the crystal. Monoenergetic 511 keV photons have been sent perpendicular to the crystal surface. For construction of training sets, 100 photons of 511 keV energy are sent to each point of the 24x24 uniform grid in the first quadrant of the crystal with 1 mm intervals. To reduce the influence of Compton scatters, an energy threshold of 350 keV was set. Tests were performed on sets of simulated data on a 5x5 uniform grid with 6 mm for each interval taking 1000 photons at each point with the same energy threshold on the same quadrant. The artificial neural network is chosen to be a multilayer perceptron (MLP), where the maximum likelihood (ML) based approach is chosen to be Gaussian. Results and Discussion: Preliminary results show that the spatial resolution‐thickness relationship has relatively flat regions for both algorithms. These results will be useful in selecting the crystal thickness and the algorithm for the best trade‐off between spatial resolution, sensitivity and computational time.
P524 A versatile Monte Carlo Simulator for non-pure positron emitters with SimSET-GATE workflow H. Lin1, Y. Lin1, C. Lin1, T. Chen2, M. Jan3, K. Chuang1; 1Department of Biomedical Engineering & Environmental Sciences National Tsing-Hua University, Hsinchu, TAIWAN, 2Department of Medical Imaging Technology, Shu-Zen College of Medicine and Management, Kaohsiung, TAIWAN, 3 Physics Division, Institute of Nuclear Energy Research, Taoyuan, TAIWAN. Aim The utilization of non‐pure positron emitting nuclides with complex decay characteristics for animal molecular imaging raises several questions about their ability to perform high quality imaging. Monte Carlo simulation is a powerful tool to accurately quantify the micoPET images with these non‐pure positron emitters. SimSET (Simulation System for Emission Tomography) is an efficient Monte Carlo code, but it’s limited in terms of the versatile detector simulation and the support of non‐pure positron emitters. GATE (Geant4 application for tomographic emission) based on GEANT4 offers the ability and the flexibility to model novel detection systems but are not efficient at voxel‐based phantoms. In order to accurately model the scanner systems and maintain the efficient simulation speed as well, our purpose is to develope an efficient and realistic Monte Carlo simulation for non‐pure positron emitters with SimSET‐GATE workflow. Materials & Methods The current SimSET software didn’t provide the temporal information and the simulation of non‐pure positron emitters. In order to perform the complex decay scheme of non‐pure positron emitter, we modified the SimSET photon history generator (PHG) to support the non‐pure positron emitters. The modified SimSET PHG was inserted into the GATE simulation to evade the relatively slow MCS code based on GEANT4 in simulating photon interactions inside voxelized phantoms. For validation, acquisitions of F‐18, Cu‐64 and I‐124 line sources for different positions in a water phantom were performed, together with the corresponding simulations. Energy spectra, resolution, sensitivity values and images obtained for experimental and simulated data were compared. Results Preliminary results indicate that the modified SimSET PHG version with SimSET‐GATE workflow for these positron emitters are in rather good agreement between experimental and simulated energy spectra. Excellent agreement in spatial resolutions was found between GATE‐only and the new workflow. Further, the simulated spatial resolutions differ by less than 0.2 mm from the measured values, for line sources in water at 0 cm and 1 cm made on microPET R4 scanner. Conclusion Our new model allows fast and accurate modeling of microPET acquisition for the non‐pure positron emitter. In the future study, we will explore the possibility of fully Monte Carlo simulation to correct all the non‐ture coincidences for the non‐pure positron emitter.
P525 Interactive Reconstruction for Freehand SPECT: An Approach to Acquisition Guidance? T. Lasser, A. Duliu, T. Wendler, S. I. Ziegler, N. Navab; Technische Universität München, München, GERMANY. Aims: The quality and fidelity of freehand SPECT reconstructions depend critically on the freehand acquisition itself. Besides employing optimized protocols for different indications to ensure a standard quality of imaging, we are investigating computer‐aided methods to further guide the operator during the acquisition. In this particular work, the feasibility of an approach showing an interactive reconstruction from incomplete data during the acquisition process is investigated. Methods: The readings of a gamma probe and an infrared positioning system are acquired simultaneously. From the synchronized data, a system matrix is built using ad‐hoc models and reconstructed using standard algebraic inversion algorithms (e.g. MLEM, ART) to generate 3D tomographic nuclear images (equivalent to SPECT). To enable near‐real‐time reconstruction a faster inversion method, an incremental SVD‐based approach, is implemented and used here. For evaluation means the images were reconstructed with the conventional methods and the new approach for the same datasets in the same coordinate system. Results: Lymphatic mapping using freehand SPECT (Tc‐99m nanocoll, 48‐56MBq) was performed on 5 patients (age 49‐87) with initial diagnosis of cT1 or cT2 invasive breast cancer and no clinical evidence of nodal involvement. Image reconstruction was done both with the standard MLEM method and the near‐real‐time incremental SVD‐based method. The mean normalized residual for MLEM was 1.85 (dev 1.29) and for SVD 0.53 (dev 0.76). The mean normalized cross correlation between the MLEM and SVD reconstruction however was only 0.14 (dev 0.09). Qualitative visual inspection showed the same nodes to be visible with both methods, though the SVD image contained many artifacts that could be misinterpreted as false positive findings. Conclusions: Using incremental SVD‐based reconstruction enables near‐realtime reconstruction, where the operator can see the image evolve interactively during the acquisition. Image quality, while numerically superior, is not comparable with standard algebraic or statistical techniques, but still allows for interactive acquisition guidance.
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Physics/instrumentation:
quantitative
imaging
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correction methods, evaluation and quality control
P526 Liver Spill-Over Correction method for dynamic PET imaging H. Merisaari1, C. Han2, S. Nesterov2, O. Nevalainen1, J. Knuuti1; Department of Information Technology, University of Turku, Turku, FINLAND, 2Turku PET Centre, Turku University Central Hospital, Turku, FINLAND.
1
Introduction Dynamic heart imaging with PET is an effective non‐invasive method for obtaining information of functioning of the heart. The image precision is affected by so called partial volume effects (PVE). The PVE is mainly affected by scanner resolution. In heart imaging there is also large motion artifacts from heart and respiratory movements. Here we focus on correcting spill‐over effect from liver to heart in dynamic PET imaging. The spill‐over of the radioactivity intensity from the liver affects increase of the activity in heart regions that are closest to liver. Further, the observed blood flow parameter values are lower in the corresponding heart regions due this effect. The spill‐over correction has earlier been addressed with reference CT image data. Since reference data is not always available, a novel method for liver delineation is proposed here in order to handle the spill‐over effect in such situations. Subjects & Methods The liver spill‐over correction has been applied by using a reference image for liver delineation by utilizing additional information from a CT image. The liver is first manually or semi‐automatically delineated from a reference image. Then, the liver segment is convoluted with Point Spread Function (PSF) in order to simulate liver activity spill‐over in the PET image. Finally, the liver activity distribution is removed from all time frames of the original PET image. As a result of this, the produced image has no activity from liver in its voxel intensity values. In our liver delineation method the border of the liver is searched by using differences in neighbouring Time Activity Curves (TACs) of each voxel inside a dynamic PET image. We evaluate various methods for obtaining differences between TACs, including: Area under curve, least squares sum, highest activity peak location, wavelet coefficients. When evaluating the proposed method of the present work, we compare it to manual segmentation performed by an expert and an automatic segmentation method based on CT data. In order to examine differences between performances of different delineation methods, the resulting activity values after spill‐over correction are obtained with 5 patients. The evaluated regions consist of four inferior myocardium segments, where the segments are defined with standard 17‐part segmentation. Results and Conclusion The results for the spill‐over correction show that the activity in regions of heart near the liver is reduced and that the corresponding flow parameter values are increased. Correction without reference data avoids being sensitive to co‐registration errors.
P527 Separation of statistical noise from extrinsic uniformity images of gamma cameras A. Van Lingen; NETHERLANDS.
VUmc
University
Medical
Center,
Amsterdam,
Introduction: Based on Poison statistics the NEMA uniformity is proportional to the coefficient of variation (COV) of the pixel counts and that with perfectly uniform detectors this proportionality factor r equals the 2‐tailed Fisher z‐score for normal distributions. If the detector is not perfect, the uniformity exceeds r*COV. Aim: Quality assurance of gamma camera extrinsic integral uniformity performance based on statistical criteria. Methods and materials: Dynamic images (90 frames per detector, 128 matrix, 3 Mcounts each) were acquired on a dual head gamma camera from an uniform 57Co flood source between both detectors. After acquisition, the images were regrouped to form images with counts ranging from 9 to 90 Mcount. According to the NEMA guidelines the field of view (FOV) was determined by 50% threshold edge detection and a S9‐ smooth was applied. The integral uniformity U was defined as U=(max‐min)/(max+min)*100%, where max and min represent the maximum and minimum pixel counts in the FOV. The uniformity U was determined in both the 64 and 128 matrix of the regrouped images. Images with purely statistical noise based on the mean pixel count as in the regrouped images were generated using a software normal distribution generator. The number of runs was 10.000 to ascertain the confidence limits of the Fisher z‐scores of the statistical variability. Results: For the 128 matrix images the COV decreased from 4.0% to 1% and the measured NEMA uniformity decreased from 5.5% to 3.2% . The statistical variability ranged over this interval of the COV from 4.5% to 1.5%, showing that the true detector uniformity was only for 2.7% rather than the measured 3.2%. At a COV of 0.5%, the measured NEMA uniformity of the 64 matrix images was 2.8% whereas the statistical variability was limited to 0.7%. Conclusion: Using the statistical criteria for normo‐Poison‐like count statistics, the true uniformity performance of a gamma detectors can be determined, separated from the noise statistics.
P528 Automated Evaluation of Standardized Tomographic Quality Assurance Test Phantom Data K. J. Nichols, B. Babchyck, W. Robeson, C. J. Palestro; North Shore Long Island Jewish Health System, Manhasset & New Hyde Park, NY, UNITED STATES. Objective: To maximize SPECT and PET image quality, it is essential to periodically test these systems three dimensionally. This is commonly done using standardized amounts of radioactivity in water and Plexiglas® phantoms, which include a uniform section, and rods and solid spheres of 6 different sizes. Processing these data requires several manual steps, potentially introducing variability in assessing image quality. Since there are definite, published, acquisition guidelines, input data should be sufficiently predictable to enable designing completely automated data processing algorithms. This investigation tested the degree to which automated algorithms succeed in emulating expert observers’ choices in processing and interpreting standardized quality assurance tomograms. Materials and Methods: Phantom data were acquired for 26
simulations on one PET and 4 SPECT systems, using 99mTc (n=20), 18F18 (n=3) or 201Tl (n=3). Algorithm input consisted of attenuation‐corrected transaxial reconstructions. Algorithms applied contrast thresholds to identify optimal sections for spheres, a 1‐cm thick section of rods, and a 1‐ cm thick uniform section. Algorithms also reported the number of spheres and rods exceeding contrast limits. An experienced imaging physicist independently selected optimal sections of spheres, rods and uniform sections. Two imaging experts independently graded algorithm selections versus manual selections for each phantom section using a 5‐point scale: ‐2 = manual much better than algorithms, ‐1 = manual slightly better than algorithms, 0 = equivalent, +1 = algorithms slightly better than manual, +2 = algorithms much better than manual. Readers independently scored the number of rods and spheres seen in phantom data. Results: Mean scores for success of algorithms choosing correct slices were ‐0.04±0.19 for spheres, 0.08±0.48 for rods and ‐0.15±38 for uniform sections, not significantly different from “equivalent” for any of the 3 phantom sections. Readers agreed with one another as to these scores (paired t‐test p=0.43), the number of spheres seen (Χ2 = 51.1, p<0.0001), and the number of rods seen (Χ2 = 35.9, p=0.0003). Algorithms agreed with readers as to the number of spheres detected (reader #1: Χ2 = 29.1, p=0.0006; reader #2: Χ2 = 38.2, p<0.0001), and the number of rods detected (reader #1: Χ2 = 43.5, p=0.0001; reader #2: Χ2 = 68.8, p<0.0001). Conclusion: Automated algorithms identified optimal slices in agreement with imaging experts, and generated accurate reports about the number of spheres and rods detected in standardized phantom data. This suggests that automated processing potentially can replace manual selections, thereby minimizing variability in quality assurance tomogram interpretation.
P529 Optimizing Iterative Reconstruction Technique for SPECT/CT Acquisition of DaTSCAN and IBZM in Diagnosis of Extrapyramidal Diseases M. Bieńkiewicz1, J. Siennicki1, M. Górska-Chrząstek2, A. Gajos3, A. Bogucki3, A. Mochecka-Thoelke4, J. Kuśmierek5, A. Płachcińska1; 1Dept. of Quality Control and Radiological Protection, Central Teaching Hospital, Medical University, Lodz, POLAND, 2Dept. of Nuclear Medicine, Central Teaching Hospital, Medical University, Lodz, POLAND, 3Dept. of Extrapyramidal System Diseases, Medical University, Lodz, POLAND, 4 Dept. of Neurology, Medical University, Lodz, POLAND, 5Dept. of Nuclear Medicine, Central Teaching Hospital, Medical University of Lodz, Lodz, POLAND. Quality of DaTSCAN/IBZM images is crucial for diagnostics of extrapyramidal diseases. SPECT/CT acquisition gives possibility for OSEM reconstruction with CT attenuation correction (AC). We previously demonstrated that quality of OSEM reconstructed DaTSCAN images was superior to that provided by FBP and semi‐quantitative assessments (SQA) had better intra‐operator reproducibility. Aim To establish the optimum number of subsets and iterations of OSEM algorithm (with AC) for SQA of binding potential of striatum with DaTSCAN/ IBZM. Material and method We reanalyzed DaTSCAN and/or IBZM SPECT/CT examinations of 45 consecutive patients with use of different equivalent number of iterations EI (product of the iterations and the subset numbers) varying from 20 to 200 (subs: 8,10,12,20 for 2,4,6,8,10, 20 iter). SPECT/CT with Infinia Hawkeye GE was performed 4h after i.v. administration of 5mCi of 123I‐DaTSCAN or 2h after i.v. administration of 5 mCi of 123I‐IBZM (120/45s, 128x128, zoom 1.5, pixel 2.94mm) in double energy window:159keV±10% (scatter:130keV±10%). Images reoriented to orbito‐meatal plane were reconstructed with iterative OSEM method with scatter correction, AC and postfiltration: Butterworth 0.50/10. Image quality and its usefulness for SQA was assessed by: ‐ striatal binding indices: SBI=S/B where S and B are mean number of cpp in striatum and occipital cortex, calculated for each striatal structure in both hemispheres: caudate ‐CBI; putamen ‐PBI. All indices were calculated as an average for 3 consecutive transversal slices with most intense striatal uptake. ‐ coefficients of variation of pixel counts (as measure of noise) in circular ROIs at caudate‐ CV(T) and occipital cortex (background)‐CV(B). Striatum structures were delineated by fixed templates of putamen and caudate ROIs (manually adjusted by shift and rotation to match respective structure). Background ROI was placed on occipital cortex in approximately same manner on each slice. Results: All images were legible for visual interpretation providing high contrast and clear delineation between striatum structures. SBI improved with increasing number of subsets and/or iterations until EI=100. Highest values obtained for 10iter/10subs were insignificantly higher than respective indices for 4iter/10subs which induce lower noise (CV(T)=4.7%; CV(B)=29.1% (4iter/10subs) vs CV(T)=4.9%; CV(B)=30.3% (10iter/10subs)). Images reconstructed with EI>100 had higher noise (CV(T)> 5%; CV(B)>30%) and lower values of binding indices used for SQA. Striatal binding indices for OSEM (4iter/10subs) in group of 45 patients were: DaTSCAN: CBI:4.73±1.86; PBI:3.88±2.02 IBZM: CBI:2.39±0.33; PBI:2.14±0.31 Conclusion: OSEM algorithm with use of 4iter/10subs for reconstruction of DaTSCAN/IBZM images provided optimal images for visual and SQA of striatal structures without significant increase in noise.
P530 A method to obtain the recovery coefficient for I-124 based on F-18 measurements L. Strigari1, A. Soriani1, D. Castelluccio1, C. Giliberti2, R. Sciuto1, C. Maini1, G. Iaccarino1; 1Regina Elena National Cancer Institute, Rome, ITALY, 2 National Institute for Health and Safety at Work, Rome, ITALY. Aim: To evaluate the recovery coefficient (RC) of F‐18 and I‐124 PET radioisotopes for our scanner in order to carry‐out a correction factor able to obtain the RC of I‐124 based on one of F‐ 18 measurements. Materials and Methods: Measurements were performed using the combined PET/CT (Biograph HiRez16). The NEMA‐2001 body phantom (elliptically shaped torso phantom) with six spheres with volumes ranging from 0.52 to 26.5 ml was filled with radioactive sources. The lesion to background ratio was 8:1, similar to that clinically observed in patients with metastatic differentiated thyroid cancer treated in our Institute. Activity measurements were performed using a radionuclide calibrator Comecer PET DOSE, and gravimetric measurements were performed using an analytical precision balance OHAUS Analytical Plus AP210. Regions of Interest (ROIs) were delineated using the CT images in order to obtain volumes of spheres, using a home‐made tool. The expected activity in each sphere was calculated based on measured concentrations using CT‐based volumes. The measured activity based on PET/CT images was obtained summing the cps in each voxel of the ROIs, based on the usual F‐18 calibration
Poster Presentation
P60 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
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procedures. The RC was calculated by the ratio between measured and expected activity for each radionuclide. The image reconstruction was performed after Fourier re‐binning with AW‐OSEM (using two iteration and eight subsets) and a 4‐mm/6‐mm Gaussian filter (Gf), with/without scatter and with/without CT‐based attenuation correction. Results: The CT‐based volumes of spheres were comparable to nominal ones. The use of I‐124 produces a significant amount of spurious activity due to gamma cascade that is not removed by standard packages of PET systems. For each radionuclide, the various image correction methods resulted in identical RCs for the largest spheres and a higher RC using 4‐mm rather than 6mm Gf. The normalized to maximum RC of I‐124 without either scatter or CT‐based attenuation correction was approximately unity (within 10%), with the exception of smaller volume of spheres. Conclusion: The RC of F‐18 was higher than I‐124, and a correction factor of about 15% can be used to obtain the RC of I‐124 based on one of F‐18 measurements.
performing person. Procedures used to track the performance of SPECT were arranged in the following order: Intrinsic parameters 40 MBq point source ‐ intrinsic flood field uniformity, intrinsic linearity and spatial resolution (visual estimation with 4 quadrant bar phantom), intrinsic count rate performance in air. 4 MBq line source ‐ intrinsic spatial resolution. System parameters 2 GBq LS ‐ system spatial resolution at 10cm a) in air & b) with scatter. 10 MBq in a syringe ‐ system planar sensitivity, precision of measurement (χ2 test). 40 MBq point source ‐ detector shielding, COR. 2 LS in cylindrical phantom ‐ SPECT reconstructed spatial resolution with & without scatter, whole body system spatial resolution without scatter. 550‐750 MBq in a Jaszczak phantom with inserts of cold rods & solid spheres ‐ reconstructed image uniformity, reconstructed SPECT spatial resolution (visual estimation), SPECT contrast. Besides the improved radiation safety of the staff this approach allows to carry out acceptance testing of a SPECT in one day.
P531
P534
A Novel Random Correction Method for I-124 imaging in PET
Fast daily quality control of gamma camera energy response by simultaneous multiwindow acquisition
K. Chuang, S. Chen, H. Lin, C. Lin, M. Jan; National Tsing-Hua University, Hsin-CHu, TAIWAN. Aim There is a growing interest in the use of non‐pure positron emitters (e.g. 124I) in PET for their longer half‐lives and target specific properties. However, these isotopes also emit high energy gamma rays (called associated gamma) that cause additional random coincidences with the annihilation photons. Random coincidence causes a uniform distribution of background on the image and degrades the accuracy of quantitative analysis. The conventional means of correcting random coincidence is by on‐line subtraction using a delayed coincidences channel. Since the random coincidence estimate is statistical, the subtraction increases noise in the data. Furthermore, this approach can not correct for non‐pure isotopes, since the associate gamma and the annihilation photons are emitted simultaneously. Materials & Methods This work examines the feasibility of using beam stoppers (BS) for correcting the non‐true (random + scattered) events in a 3D PET scanning at the same time. The origin of the photons of the non‐ true event is not on the line of response (LOR). Therefore, a BS placed on the LOR passing through the source position will absorb a fraction of the true events but has little effect on the non‐true events. Using dual scans, with and without BS, we can compute the non‐true events at the LOR intersecting with the BS. We can then estimate the non‐true for the whole sinogram from the local measurements using a cubic spline interpolation. A GATE Monte Carlo simulation on a Zubal phantom filled with 124I is conducted to validate the proposed approach. Results and Conclusion Note that the estimate of random coincidence is based purely on the geometric relationship between the BS location and the LOR and this method is not affected by the timing of the random events. Therefore, this BS approach is capable of correcting both scattered and random (correlated and uncorrelated) coincidences in the same time.
V. Fidler1, S. Škalič2, S. Fidler3, K. Škalič2; 1University Technology Park, Ljubljana, SLOVENIA, 2Oncology Institute, Ljubljana, SLOVENIA, 3Faculty of Computer and Information Science, Ljubljana, SLOVENIA. Introduction Examining of gamma camera local energy response helps most efficiently in defining the causes for the non‐uniformities in the flood or point source QC acquisition. Aim Development of fast simultaneous acquisition method for the energy response and uniformity quality control for daily camera inspection. Methods The most common QC of camera uniformity is provided by the standard static acquisition of uniform gamma ray flux to the detector and NEMA or other standard analysis of the scintigram. We have modified the acquisition by the following way: in the same acquisition eight scintigrams are formed from the incoming positional and energy data (X,Y and E): scintigrams in symmetric 15% photopeak window with and without count correction, the serie of scintigrams in 15 % energy window steps below and above the photopeak. By this way the local efficiency of PMTs is tested Results The acquisition into several energy dependent scintigrams using the multithread data sorting takes insignificantly longer time. By this modified acquisition we are able to get in the same time much more inside information about the PMTs efficiency. Additional to the NEMA analysis of scintigram in symmetrical photopeak window without count correction the percentage shifting of local photopeak is analyzed in the directions of increased and decreased PMT efficiency and the percentage changes of the NEMA QC indexes are computed. Conclusions Efficient fast acquisition method for the energy response and uniformity quality control for daily camera inspection was developed that provides a precise information about the status of PMTs and follow up of uniformity correction.
P532 Comparison of Optimized WB PET/CT Breast Protocol to a Dedicated Breast PET scanner
Imaging
M. Ivanovic, B. Yoder, A. Khandani; University of North Carolina, Chapel Hill, NC, UNITED STATES. Aim: The high sensitivity and resolution of state‐of‐the‐art WB‐PET/CT systems may be suitable for breast imaging. This study aimed to optimize image acquisition and reconstruction parameters for breast imaging on a WB‐PET/CT system and compare image quality with a dedicated breast PET scanner. Materials and Method: A Micro Deluxe Phantom (Data Spectrum Inc) fixed to the Deluxe Jaszczak Phantom approximated a torso and breast arrangement. Both phantoms used hot‐spot inserts to allow estimation of resolution within the reconstructed volume. The torso phantom was filled with an activity concentration equivalent to 10mCi of FDG injected into a standard woman 1 hour prior to imaging. The activity in the micro‐phantom ranged from 20μCi to 400μCi in 20mL approximating physiologically appropriate values. Evaluations were performed on the Siemens Biograph TruePoint PET/CT and the Naviscan PEMFlex dedicated breast PET. Acquisition times were chosen to mimic clinically relevant times; 10min for the PEMFlex, and 5‐20 minutes for a single bed position with the WB‐PET/CT. Using WB‐PET/CT the breast phantom was reconstructed using both 3D and TrueX OSEM (4‐8 iterations, 8‐21 subsets) with 0.51mm/pixel. The line source FWHM in air across the FOV was measured for both systems. Results: The WB‐PET/CT FWHM using TrueX reconstruction was 2.4 mm in center of FOV and 2.6mm at 16 cm axial distance. The FWHM using the 3D OSEM was 3.9mm at the center and 5.7mm at 16cm axial distance. Although the TrueX reconstruction showed better performance than 3D‐OSEM for the line source, phantom data did not agree. The 3D OSEM reconstruction (8 iterations, 21 subsets) allowed resolution of the 3.2mm sector in the breast phantom while the TrueX reconstruction appeared to have additional smoothing that prevented resolution of the 3.2mm rods. The smallest sector of the torso phantom (4.8mm) was resolved with 3D‐OSEM and a pixel size of 1.3mm. The FWHM for the PEMFlex was 2.32mm at the center, and 2.80mm near the edge of the FOV. The resolution for the PEMFlex allowed the 2.4mm rods in the micro phantom to be resolved for all tested activity concentrations and did not depend upon the phantom position in FOV. Conclusion: By optimizing the reconstruction parameters for a WB‐PET system, the resolution and sensitivity could approach the performance of a dedicated breast imaging scanner. The dedicated scanner could resolve a smaller rod size than the WB‐PET/CT scanner, but at the expense of smaller FOV and lack of 3D tomographic data.
P533 Improved radiation safety during quality control of SPECT P. I. Trindev; Medical University, Sofia, BULGARIA. Increased clinical role of QC to track stability of performance of SPECT is widely recognized. Although it is desirable to track constancy of the majority of SPECT parameters more often in reality the trend is to test only 2 or 3 of them. The main reason for this attitude of the staff is due to the time consuming procedures on one hand and reluctance to handle high activity radioactive sources on the other hand. The aim of this study was to arrange in expedient sequence the QC procedures in order to minimize the total time used for measurements. In addition a dedicated line source (LS) was developed which allows reducing vastly the time for the relevant measurements. The main feature of this LS was the opportunity to produce high count rate (consistent with NEMA requirements) while providing complete radiation safety for the
P61 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Physics/instrumentation: biomedical models and data analysis
P535 Carimas V2.0: A cardiac PET data analysis solution C. Han, S. Piirola, H. Merisaari, M. Tättäläinen, J. Knuuti; Turku PET Centre, Turku, FINLAND. Introduction: For developing a complete solution for cardiac PET imaging data, an analysis package, named Carimas (CARdiac IMaging Analysis System), was designated in Turku PET centre. It is free usage for academic purpose. Carimas v1.0 was released in June 2008. V1.0 was programmed by IDL language. Considering the further team development of this software and the advantage of .NET, the new version has been programmed by C# in the VisualStudio environment. Furthermore the functions in new version have been extended widely. Method: C# programming language was utilized in this project and VisualStudio2008 was used as a development environment. A few open‐source libraries were employed in the project. Managed VTK(http://www.vtk.org) is used mainly for image visualization, managed ITK(http://www.itk.org) is employed for image segmentation and TPClib (an open source C# library developed in Turku PET centre. http://www.turkupetcentre.net/programs/tpc_csharp.html) is responsible mainly for data input/output and modeling. Several segmentation methods are employed in this project, such as region‐growing, watershed and deformable model. Many general fitting methods and models are supported, such as linear and exponential fitting, Patlak and Logan method, 2‐ compartmental model, 3‐compartmental model. Additionally, a specific modeling module of O‐15 labeled water/N‐13 labeled ammonia/Rb‐82 rubidium for cardiac perfusion study is included. Results and Discussion: This package is a complete solution for cardiac PET imaging data, furthermore it is also applied to general PET data. It supports mostly‐used medical image formats, such as Ecat7, Dicom, Analyze, Interfile and microPET data. Using this package, user can visualize dynamic data in several ways, such as frame by frame, difference image and summary image. A powerful ROI/VOI tool is implemented in this package. ROI/VOI can be defined manually and semi‐automatically. Heart segmentation is similar with in the previous version. Many fitting and modeling methods are implemented. Furthermore, a plugin mechanism is implemented. Using plugin, external developers can easily access the data and perform their own operations on image and on tissue‐active curves. The results generated by plugin programs can be visualized and progressed further in this package. Conclusions: Carimas v2.0 is a complete solution for cardiac PET image data. Furthermore, powerful functions for processing general PET data are implemented. It is free for academic usage.
S415
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Physics/instrumentation: animal imaging systems and intra operative probes
P536 Small PET System Using Position Sensitive CdTe Detector Blocks for Experimental Animal Study Y. Kikuchi, K. Ishii, H. Yamazaki, S. Matsuyama, M. Nakhostin, A. Terakawa; Tohoku University, Sendai city Aobaku, Miyagi, JAPAN. Now, we are advancing a project of development of a new generation PET scanners using semiconductor detectors. The goal of the project is to construct a PET scanner with high spatial resolution and high sensitivity. We think that position sensitive semiconductor detectors based on charge division method are promising for the scanner. In the project, many kinds of detectors were made, and we constructed a PET measurement system in order to evaluate them. As results of evaluations, it was confirmed that some detectors are promising for the PET scanner. We have developed a small PET scanner by improving the system for more detailed evaluations through animal study. The measurement system consists of a gantry for installation of detectors, external analog electronics and a data acquisition system. Although images of very small phantoms could be acquired with the system, it was not possible for small animals in vivo due to lack of utility of the gantry. Therefore, the structure and configuration of detectors was modified to obtain enough FOV. The detectors are a type of two‐dimensional position sensitive CdTe detectors which have been developed in the project, and a position resolution about 1‐2mm in X axis and 2‐4mm in Y axis have been already confirmed. A detector block consists of 16 detectors, and the gantry of the scanner is formed by arranging 6 blocks. Electronics and the data acquisition system which characterizes the measurement were adapted again. The data acquisition system contains two types of ADC modules called the mother modules and the daughter modules, and enables flexible data processing due to the composition. The former is based on digital signal processing and employed for time stamping and energy discrimination. For determination of hit position based on the charge division method, it is required that several signals from a detector are measured coincidently and the daughter is employed for this purpose. With the scanner, reconstructed images were acquired, and resolutions of the images are 1.1 mm FWHM in transaxial and 1.6 mm FWHM in axial.
P537 Intraoperative detection of cancer deposits using Beta- and High-Energy Gamma Probes N. Zarzhevsky, C. Guo, L. Wang, M. Piert; University of Michigan, Ann Arbor, MI, UNITED STATES. Aim: High‐energy gamma and beta probes gained considerable attention due to ability to intra‐ operatively detect cancerous lesions using 18F‐fluoro‐2‐deoxyglucose ([18F]‐FDG) in humans. However, the in‐vivo detection threshold for very small disease has not been investigated, particularly under presence of high background radiation from urinary excretion of radioactivity. It is unknown whether the sensitivity of such probes would allow detection of remaining tumor tissue in resection bed after removal of macroscopic disease. In this study, the performance of a commercial system (Intra Medical Imaging) was investigated in rat tumor model. Methods: Rat gliosarcoma tumors 9L were generated in Fisher 344 rats by injecting 5 x 10*6 tumor cells into lower extremities. Micro‐PET was performed to confirm presence of the tumor after 10‐14 days. Within 2 hours the tumors were surgically exposed and beta and high‐energy gamma probe readings of tumor and background tissues were done in triplicate, with shielding of urinary bladder activity. After excision, 12 minute tumor fragments were replaced into the operation bed and re‐measured. After sacrifice, excised tumors, fragments and muscle tissues were weighted and “true” tumor‐to‐muscle background ratio (TBR) were obtained in scintillation counter for reference. The presence of tumor tissue was verified by histology. The phantom studies were performed to evaluate the spatial resolution and sensitivity of the probes. Results: 42 total tumors were generated (TBR 1.27 ‐ 22.8): 13 primary (weight 1.06‐5.96g); 17 lymph nodal metastases (0.015‐0.69g) and 12 minute tumor fragments (0.001‐0.032g). Under conditions simulating a real surgery with high levels of background radiation, beta probe detected total 90% (38/42) of the lesions (TBR > 1.3): 100% (13/13) primary tumors; 88 % (15/17) lymph nodal metastases and 83% (10/12) tumor fragments. The undetected lesions (4) had low TBRs (< 1.3) and small sizes (0.001‐0.04g). The gamma probe detected total 40% (16/42) of lesions (TBR > 1.3): 77% (10/13) primary tumors, 29% (5/17) lymph nodes and 1 % (1/12) tumor fragment. The mean intra‐operative tumor‐to‐background detection ratio was significantly higher for beta probe as compared to gamma probe (2.2 versus 1.3; p < 0.01). Conclusions: The beta probe identified minute amounts of tumor undetectable with gamma probe. Beta probe is capable of detecting residual tumor in resection bed under challenging conditions of intense background gamma radiation. This could be used in differentiating tumor from scar at the surgical resection margins. Despite heavy shielding, gamma probe detection was clearly limited by the presence of background radioactivity.
P538
18
A dual contrast agent protocol improves F-FDG and PET/CT imaging of mice bearing abdominal tumours.
18
F-FLT
N. Aide1, K. Kinross2, O. Neels2, P. Roselt2, R. J. Hicks3; 1Centre Baclesse, Caen, FRANCE, 2Peter Mac Callum cancer centre, Melbourne, AUSTRALIA, 3 Peter Mac Callum Cancer Centre, Melbourne, FRANCE. BACKGROUND PET scanning of abdominal tumours is challenging, because of the high physiological uptake in the gastrointestinal tract. CT scan is unable to delineate tumours from surrounding tissues on images acquired without contrast media injection, because they have similar densities. Thus, we aimed to develop a dual contrast media protocol to improve tumour detection. MATERIALS AND METHODS We used 13 mice bearing ovarian tumours, either spontaneous or transplanted. eXia160 (Benitio international) was used as an IV contrast agent and mixed with FDG or FLT in order to have only one tail vein injection per PET/CT scan.
Omnipaque 300 (GE healthcare) was used for intraperitoneal (IP) injections. PET/CT scans were acquired on a Siemens HD Biograph equipped with an advanced reconstruction algorithm leading to a 2.2 mm spatial resolution. First, we searched for the optimal concentration and infusion method of IP contrast agent. Nine mice were first injected with eXia, and received an IP injection either immediately thereafter or 60 min post IV injection. The volume and concentration of IP injections ranged from 0.5 mL to 1.5 mL and from 10 to 20 mg iodine /mL, respectively. Secondly, we searched for a potential impact of the use of IP contrast media on quantitation in mice PET imaging. Small tubes were filled with an 18F‐FDG solution (0.75, 0.95 and 1.15 MBq/mL) and placed at the center of a 30 mL syringe in order to mimic tumours surrounded by IP contrast media. A syringe filled with saline was used as a control. Lastly, the impact of a dual contrast media protocol on tumour delineation and quantitation was evaluated in 4 mice. Eight organs and 8 tumours were used for quantitation. PET data were compared to ex vivo counting. RESULTS The optimal sequence we found was to inject a mix of tracer plus IV contrast agent, and then 1 mL of IP contrast agent at a concentration of 20 mg iodine/ mL 10 min before PET/CT acquisition. The high densities induced by the IP injection of contrast agent led to a 4.6 % +/‐ 1.4 % overestimation of radioactivity concentration. Tumour detection was excellent, and correlation between PET/CT quantitative data and ex vivo counting was good (r2= 0.91, slope=0.7). CONCLUSION A dual contrast agent protocol is useful in PET/CT scanning of mice bearing abdominal tumours. The high densities induced by IP injection of contrast agent lead to an acceptable overestimation of PET quantitative data.
P539 Assessment of new semiconductor animal PET performance in the rodent using [F-18]FDG, [C-11]raclopride, [C-11]doxepin and [C-11]donepezil Y. Funaki1, Y. Kikuchi2, K. Nakazawa2, H. Yamazaki1, K. Ishii2; 1Cyclotron and Radioisotope Center, Tohoku University, Sendai, JAPAN, 2Department of Quantum Science and Energy Engineering, Graduate School of Engineering, Tohoku University, Sendai, JAPAN. Positron emission tomography (PET) using small animals such as rodent is a very useful modality not only for the biomedical study but also for the development of new imaging probes in the clinical use of PET. Especially, the high spatial resolution is necessary for obtaining the image of rodent brain such as mice and rats. We have recently developed a very high‐resolution animal PET scanner (Fine‐PET) using CdTe detectors. In this study, we present the new semiconductor animal PET performance in rodent using various imaging probes. Three mice or four rats were injected with various radioactivity of [F‐18]FDG (mice: 7.4, 18.5, 37 MBq, rats: 18.5, 37, 111, 185 MBq) and dynamic brain scan was carried out for 90 min after 60 min of [F‐18]FDG injection. Each rat was injected with [C‐11]raclopride, [C‐11]doxepin or [C‐11]donepezil, respectively and dynamic brain scan was carried out for 90 min. The mouse with small size of tumors (< 3 mm) was injected intravenously with 77.7 MBq of [F‐18F]FDG. After 60 min of [F‐18]FDG injection, PET scanning was carried out for 120 min. All data were acquired using a Fine‐PET in three‐ dimensional mode and reconstructed by the method of FORE + ML‐EM (30 iterations). The accumulation of [F‐18]FDG was observed in the cerebral cortex and the striatum in the mouse that had administered more than 18.5 MBq of [F‐18]FDG. Moreover, non‐accumulation of it in a white matter was recognized. When more than 37 MBq of [F‐18]FDG was administered in the rat, the same image as the mouse was observed. Similarly, specific accumulation was observed using each C‐11 imaging probe in rat brain. The FDG images of tumors of 1.1~2.0 mm size can be clearly recognized. This study demonstrates that the Fine‐PET is very useful in small animal PET that used the rodents. Especially, the images of very small size of tumors using [F‐18]FDG were succeeded to obtain. The Fine‐PET is now being used for mice and rats imaging studies in various research groups.
P540 The halo artefact in small animal SPECT/CT imaging : does it limit quantification and scan procedures? J. De Swart, P. P. M. Kooij, A. E. M. Reijs, E. P. Krenning, M. de Jong; Erasmus MC, Rotterdam, NETHERLANDS. Imaging with a SPECT‐CT animal system, may result in counts that are projected outside the phantom on the resulting scan: the halo artefact. Aim: we investigated in under which conditions and to what extent this artefact may occur. Methods We used the four headed Bioscan NanoSPECT‐CT gamma camera, mounted with four apertures with nine pinholes. The pinhole diameter was 1.4 mm. We scanned a point source and syringes with varying amounts of 99m Na TcO4, (0,16‐80 MBq), varying volumes and diameters of syringes. Scans were made with a varying number of projections (8‐120 over 360 degrees) and reconstruction was performed using 3 different settings in the number of iterations. Of every reconstructed scan the counts inside the phantom were compared with the number of counts in the whole image. The counts were determined by drawing a region of interest around the syringe and one containing the whole image. Results In a 7ml phantom filled with 4 MBq 99mTc or more, scanned with 28 projections, there was no change on the artefact. Below 4 MBq, the artefact slightly decreases, below 1 MBq the artefact increased again. Using the 7ml phantom, under the worst conditions (8 projections, lowest number of iterations), 30% of the total counts were outside the phantom. At 60 projections, we measured 2.4% More projections gave minor improvements. Using the highest number of iterations, at 20 projections we measured 2.7% Using a point source, these numbers were 6.5% in the worst condition, improving to 0.9% at 36 projections. Using the highest number of iterations, at 20 projections this was 1.0% For a 1ml phantom in three different geometrical shapes, results were slightly better when te axial length was shorter with a larger diameter. The results were in between the results of the 7ml phantom and the point source. Conclusion Increased angular sampling and iterations reduced the halo artefact. This artefact was more profound in sources with a larger volume, and in a large volume below 4 MBq the effect changes with the amount of radioactivity. The shape of a phantom has a small influence on the artefact. Since the volumes of most mouse organs are 2ml or less, this artefact will play a minor role. However, in dynamic scanning when one may choose low angular sampling to achieve high time resolution, or in calibrating the system using a phantom with a relative large volume, one should be aware of this artefact.
Poster Presentation
P62 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
S416
P541 Dual isotope imaging in small animal SPECT-CT J. de Swart1, S. C. Berndsen1, M. Melis1, S. Ahlgren2, S. Pool1, E. P. Krenning1, M. de Jong1; 1Erasmus MC, Rotterdam, NETHERLANDS, 2 Uppsala University, Uppsala, SWEDEN. Animal SPECT has been shown to have high potential, e.g. in the development of new drugs or in monitoring of (new) treatment modalities. Due to the small size of rats and mice, the level of scatter is low. Therefore the various gamma energies can be well distinguished, making this imaging modality highly suitable for dual isotope scanning. Comparison of localization of different radiopharmaceuticals in one animal using dual isotope imaging is an interesting option. Aim We investigated different applications of dual isotope imaging in small animal SPECT using 99mTc and 111 In labeled radiopharmaceuticals. Methods The four headed multi‐pinhole NanoSPECT‐CT gamma camera (Bioscan) was used, with the gamma energy window width set to 10%. Both rat and mouse studies were performed. Xenograft imaging was performed to test newly developed radiolabelled Affibody molecules, one with 99mTc, another with 111In. Dynamic renal imaging was performed after simultaneous administration of 99mTc‐MAG3 and 111In‐DTPA to monitor kidney function beyond 90 days after peptide receptor radionuclide therapy (PRRT). Furthermore, 99mTc radiopharmaceuticals were used as a landmark. First, 99mTc‐MAG3 was injected 20 min. before imaging an orthotopic xenografted prostate carcinoma 3 h after administration of an 111In‐ labelled bombesin analogue, to delineate the bladder. Second, 99mTc‐nanocolloid was used to mark liver parenchyma in a rat model of liver metastases of pancreatic tumour, visualized using 111 In‐DTPA‐octreotide. Results Both 99mTc and 111In images were free from any visible cross talk. The pharmacokinetics as well as the tumor uptake of two different types of Affibody molecules could be investigated simultaneously in the same animal. Dynamic renal imaging using 99mTc‐ MAG3 and 111In‐DTPA gave results in excellent agreement with variable kidney condition after PRRT. With regard to 99mTc‐MAG3, the results of dual isotope scanning were similar with results obtained using single isotope scanning.99mTc‐MAG3 was also successfully used to discriminate between bladder and radiolabelled prostate as the In‐111‐labelled bombesin is also excreted via the bladder. Combining 99mTc‐nanocolloid and the In‐111‐labelled somatostatin analogue octreotide offered the opportunity to localise intrahepatically grown tumors. Conclusion It is feasible to perform dual isotope imaging using the NanoSPECT‐CT. There are two main applications: simultaneous imaging of two radiopharmaceuticals in the same animal for functional purposes, and second, the use of one of the radiopharmaceuticals as a landmark to delineate a certain organ. Using a radiopharmaceutical as a landmark has the advantage of high contrast in soft tissue compared to CT, and gives functional information as well.
P542 Practical performance evaluation of a commercial small animal SPECT system with a single-pinhole and a 5-hole collimator M. Inubushi, M. Shidahara, C. Murai, C. Seki, A. Tsuji, M. Koizumi, I. Kanno, T. Saga; National Institute of Radiological Sciences, Chiba, JAPAN. Purpose: From the viewpoint of practical use, we evaluated the basic performance of a commercial high‐resolution small animal SPECT system FX(SPECT/CT) (Gamma Medica‐Ideas, CA) In our system, a single‐pinhole and a 5‐hole collimator, which consists of 1 mm φ apertures, can be mounted on a 12 x 12 cm NaI(Tl) scintillation detector. Methods: For evaluation of spatial resolution, sensitivity and effective FOV, a line source, a point source and a cylindrical phantom (1.6 cm φ) filled with 99mTcO4‐ solution were scanned with various rotation of radius (ROR) from 2.5 cm to 8.0 cm. The sensitivity, ε [cps/MBq], using a point source located at the center of rotation was calculated by the division of measured total counts in the projection and its known activity. For resolution FWHM was calculated by fitting the line source image with Gaussian function. The axial length of cylindrical phantom, which preserve less than 10% bias compared with averaged counts in 1 cm φ circular region of interest (ROI) at the central slice, was regarded as effective FOV. Results: The relationship between sensitivity (y) and ROR (x) was y = 175.9∙x (‐ 1.97) , y = 1641∙x (‐2.04) for single‐pinhole and 5‐hole collimator, respectively. The relationship between resolution (y) and ROR (x) was y = 0.13∙x+0.49, y = 0.19∙x+0.29, respectively. Effective FOV (y) of single‐pinhole collimator (y = 1.2∙x‐1.3) resulted in quite different from that of 5‐hole collimator (y = 0.42∙x‐0.45) due to the amount of overlapping in projection data. Conclusions: We evaluated the basic performance of the pinhole SPECT system, and revealed it did not depend only on detector system but also on ROR and the type of collimator. For its practical use, therefore, physical setting such as ROR and collimator should be carefully optimized for research purposes.
P63 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Physics/instrumentation: miscellaneous
P543 Education and Training of Medical Physicists in Europe and the countries of North America: modulation of a professional framework A. P. Stefanoyiannis1, C. Psichis2, X. Geronikola-Trapali1, S. N. Chatziioannou1, I. Armeniakos1, A. Prentakis1; 12nd Department of Radiology, Nuclear Medicine Division, University General Hospital of Athens “Attikon”, Athens, Greece, Athens, GREECE, 2Department of Medical Physics, Navy Hospital of Athens, Athens, Greece, Athens, GREECE. Aim: Medical Physicists working in a Nuclear Medicine Department are part of a team, responsible for the reliable diagnosis and treatment by means of radioactivity. Their role is multifold and includes estimation of the dose absorbed by patients and personnel, quality control of medical equipment, shielding studies and training of health professionals. The aim of this study was to investigate the present status of Medical Physics Education and Training in Europe, as well as the countries of North America (USA‐Canada). The collection, process and comparison
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 of important information can lead to useful conclusions about the profession world‐wide. Materials & methods: In order to collect information from European countries efficiently, EFOMP prepared and sent a questionnaire to the National Organisations for Medical Physics (NMO) of each member‐country. 23 out of 34 member‐countries responded. The main parts of this questionnaire were 3 in total, concerning Medical Physics Education, the different levels of a Medical Physicist (qualified medical physicist, QMP, and specialised medical physicist, SMP) and the existence of a National Register of Medical Physicists. Subsequent research led to the collection of corresponding data for the countries of North America. Results: Summarised: • In most countries, working as a Medical Physicist requires holding an MSc in Medical Physics and 1‐ 3 years of clinical experience. • The training programme is usually approved by a responsible Ministry or University. • Education and Training takes place in both university and hospital. The total duration of the programme is 4.5‐9 years. • In 61% of all European countries, holding a diploma or license to work as a Medical Physicist is mandatory. In USA and Canada, a certification from the responsible bodies is enough. • Generally, there are National Registers for Medical Physicists, the entrance of a member being voluntary. • Renewal mechanisms in the Registers exist in the majority of the cases, based on a Continuing Professional Development (CPD) system. The cycle duration of education and recertification is 4‐10 years. Conclusion: In conclusion, a common policy is generally followed world‐wide, on topics concerning Education and Training as well as the practice of the Medical Physicist profession, despite the presence of few differences. From the analysis of the questionnaire’ answers, the value of two major components arises: hospital training of Medical Physicist candidates as an important part of a basic cycle of education‐training and CPD, as a means of quality assurance of professional qualifications and skills.
P544 Comparison of the Lunar DPX-L and Prodigy dual-energy Xray absorptiometers for assessing bone mineral density of 3 sites R. Babicheva, K. S. Lee, H. Dixson; Bankstown Hospital, Bankstown, AUSTRALIA. The aim of this study was to compare of the Lunar DPX‐IQ pencil beam with the newer Lunar Prodigy narrow angle fan beam dual‐energy X‐ray absorptiometer (DXA) for measuring bone mineral density (BMD) of femoral neck (FN), lumbar spine (LS) and distal radius (DR). A total of 32 patients (6 males and 26 females) aged 42‐87 years (mean 63), weight 44‐90kg (mean 68kg) and height 150‐175cm (mean 160cm) were scanned on the same day on the Lunar DPX‐IQ and Lunar Prodigy DXA. Correlation and best fit linear regression line in DPX‐IQ (y axis) vs Prodigy (x axis).
Correlation Slope Intercept
FN 0.961
1.061 ‐0.069
LS 0.945
0.939 0.032
DR 0.891
0.602 0.035
There was excellent correlation for both FN and LS but less good correlation for DR. There is a systematic difference at the DR (slope 0.6 rather than 1) and this may be due to differences in the way the distal radius region of interest is drawn by the two machines. In conclusion BMD measurements of FN and LS were directly comparable between the Lunar DPX‐IQ and Lunar Prodigy despite the differences in pencil beam and narrow angle fan beam technology. DR measurements correlated well but multiplication by a factor is needed to allow computerise with data for the older system.
P545 Kinetic Modeling of PET-tracers for Dopamine Receptors in the CNS V. Singh, A. Mishra; University of Lucknow, Lucknow, INDIA. Traditional tracer kinetic models have formal compartmental structures and the rate constants are fitted for using standard techniques .Using one scan, derived parameters such as the distribution volume (DV) (the ratio of ligand concentration between tissue and blood at equilibrium) or binding potential (BP) can be obtained and both are proportional to the Bmax and Ka (affinity constant of the radioligand). These models have generally been applied to ROI analysis .We have tried to utilize these model for Dopamine receptor analysis. There is a range of parametric imaging analysis techniques. Examples of model‐driven approaches include a one‐ tissue compartmental model for the estimation of blood flow and two‐tissue compartment models for glucose metabolism and receptor ligand binding. Another aspect of modeling, is to adjust the PET‐acquisition protocol to better fit the model. Instead of just injecting the radioactive tracer in a single intravenous bolus, the bolus injection may be followed by a continuous infusion of the tracer. Such a bolus‐infusion protocol has the advantage of reaching a steady state earler which is maintained throughout the PET‐acquisition. The steady‐state reached with the bolus infusion protocol has also proved advantageous in studies of tracer displacement, measuring dynamic changes of receptor binding levels. It has been shown that TWO 18F‐labeled compounds is high for all of the compounds at early times after injection, but clearance rate of radioactivity from brain tissues varied substantially. Based on the high selective retention in brain regions that contain a high concentration of the dopamine receptors, the major radioactive component (> 93 %) present in brain 40 min after injection was identified as the respective intact tracers. The binding affinity to the human dopamine receptor was 0.6 and 0.15 nM for two tracers respectively. In vitro auto‐radiography of on rat brain sections produced patterns in accordance with the known distribution of dopamine receptor expression. Thalamic and striatal regions were selectively labeled with a concomitant low labeling of non‐target regions . Compared to [ 11C] labelled currently used in PET, the 18F‐labeled ligands potentially provide better statistics and quantification of dopamine receptor in prolonged study protocols.
P546 Feasibility and utility of rover semi-automated software analysis for quantification of metabolically active volume of 18 spinal bone marrow metastases on F-FDG-PET/CT
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 R. Fernández López1, S. Alapati2, D. Torigian2, F. Hofheinz3, A. Alavi2; HHUU Virgen del Rocío, Seville, SPAIN, 2University of Pennsylvania School of Medicine, Philadelphia, PA, UNITED STATES, 3ABX advanced biochemical compounds GmbH, Radeberg, GERMANY.
1
Metastatic disease is the most common malignancy to involve the spinal bone marrow. At present, there is no widely accepted methodology to estimate the metabolically active volume of tumor in this location. ROVER (Region of interest (ROI) Visualization, Evaluation, and Image Registration) is semi‐automated image analysis software designed for quantitative 3D evaluation of PET datasets (ABX GmbH, Radeberg, Germany). The aim of this study was to assess the feasibility of ROVER to quantify the metabolically active volume of spinal bone marrow metastases from 18F‐FDG‐PET/CT scans, and to compare the metabolically active lesional volume estimates with lesional volumes manually measured from spinal MRI. MATERIALS AND METHODS We conducted a retrospective search for patients with spinal bone marrow metastases who had 18 F‐FDG‐PET/CT and spinal MRI within 45 days of each other without therapy. 16 patients (7 men/9 women, mean age: 64.96±14.71 years‐old (range: 19‐80)) were found (43.75% lung carcinoma, 12.5% breast carcinoma, and 43.75% others). We selected for lesions with complete hypermetabolic uptake of 18F‐FDG. 31 lesions in total were evaluated. Manual measurements of lesional volumes were performed on sagittal T1 or T2‐weighted MR images using dedicated software (Terarecon, USA). ROIs were drawn about outer contours of lesions on each slice to estimate lesional areas and were summed and multiplied by slice thickness to obtain lesional volumes. ROVER software was then used to automatically delineate 3D ROIs for corresponding 18 F‐FDG avid spinal bone marrow metastases, and to automatically estimate metabolically active tumor volumes. PET derived and MRI derived lesional volumes were subsequently compared based on volumetric differences as well as correlation analysis. RESULTS The mean volume of all lesions determined by manual measurement from MRI was 4.35±4.09 cm3 (range: 0.82‐21.28 cm3). Using ROVER, the mean volume of all lesions was 3.63±2.40 cm3 (range: 0.96‐10.69 cm3). The average lesional volumetric difference between ROVER PET/CT and manual MRI measurements was 0.71±2.37 cm3, and the Spearman correlation coefficient between them was 3 0.78 (p<0.0005). The largest discrepant volumes were seen in two large lesions (>9 cm on MRI) as ROVER did not capture the periphery of these lesions. CONCLUSIONS ROVER is a novel easy to use experimental semi‐automated software application that makes it feasible to estimate metabolically active volumes of spinal bone marrow metastases, which are strongly correlated with volumes measured from MRI. We believe that this approach will become part of the standard structural‐functional quantification of metastatic disease burden in the future.
P547 Unsupervised Change Detection for Nuclear Medicine Image Data Using The Three dimensional Dual-Tree Complex Wavelet Transform(3D-DT-CWT) M. J. Carroll; Royal Liverpool University Hospital, Liverpool, UNITED KINGDOM. Objectives : Automatic change detection between image data acquired at different time instances has important applications in nuclear medicine. For example in monitoring the response to chemotherapy using sequential PET‐CT imaging and in assessing the efficacy of multiple targeted radionuclide therapies , for example using Leutitium‐177 Dotatate for neuroendocrine tumours. Methods: The DT‐CWT possesses attractive properties including shift invariance and more directional information compared to conventional discrete wavelet transforms. The change detection technique exploits the inherent multiscale structure of the 3D DT‐CWT to decompose tomographic data sets into 28 directional subbands, oriented approximately uniformly over the surface of a hemisphere (7 bands per quadrant), at each scale. The absolute valued difference of the corresponding DT‐CWT domains at different scales and directions constitutes the change field between the image sets. The differences resulting from the changes between 2 3D data sets at two time instances is analyzed automatically by unsupervised selection of the decision threshold that minimizes the total error probability of change detection . The final binary change maps are produced through merging different sub‐ bands using both inter and intra‐scale information. Results: This change detection technique is illustrated by results from both phantom data with artificially introduced changes and by patient data obtained from sequential PET‐CT studies and from post Leutitium‐177 Dotatate treatment imaging to determine therapy efficacy through tumour tracking. Conclusions: The application of the 3D DT‐CWT to change detection provides a robust approach to change detection through its exploitation of intra‐scale information ionherently provided by this transform.
1.5 (3‐1) μSv.hr‐1 for right and left hand sides respectively. A single exponential decay model was fitted to the data to give calculated dose rates as a function of time. Conclusion: Based on the data obtained it was proposed to discharge patients after a minimum of 24 hours post therapy and extend the restrictions / instructions (from three to four days) set out in the patient instruction sheet given at discharge. This has been agreed with the Radiation Protection Advisor.
P549 Dosimetry for Repeated Phaeochromoblastoma
131
I-mIBG
Therapy
of
C. Happel, I. Selkinski, M. Middendorp, B. Sauter, W. Plastowez, J. Diener, W. T. Kranert, F. Grünwald; Department of nuclear medicine; Hospital of the Johann-Wolfgang Goethe University, Frankfurt / Main, GERMANY. Aim: Since its development in the 1980s 131I labelled meta‐Iodbenzyl‐guanidin (mIBG) is established for diagnostic and therapy of phaeochromoblastoma, ‐cytoma and neuroblastoma as well. Due to its high sensitivity and specivity the substance is used for therapy of inoperable or malignant phaeochromoblastoma particularly. Material and Methods: A 56 year old patient suffering from phaeochromoblastoma was treated iteratively (4 treatments) with a total of 28 GBq 131I‐mIBG within 14 months. Each in‐patient stay lasted 6 ‐ 10 days. During this time several whole‐body scintigraphies were carried out by using a scintillation camera DST XL (GE) (scan speed: 12 cm/min; matrix: 512 x 2048). Whole body activity time curve was executed with daily measurements of the activity remaining in the patient using an individual calibrated gammaprobe (distance: 6 m; dead time <20 %; individual calibration factors: 0.88 cps/MBq ‐ 0.96 cps/MBq). Geometrical means of the twice a day determined ventral and dorsal countrates were used to calculate the activity remaining in the patient (biexponential fit Excel). Tumor size was calculated from CT‐Images. Results: Even after four 131I‐mIBG therapies an enduring uptake of mIBG in the different foci of the phaeochromoblastoma is reported. A tumor size decrease of the known filiae (reference laesion paracaval from 3.3 x 2.7 to 2.6 x 2.5 cm after the third therapy) was determined during the therapies. No new filiae were detected. Calculated effective half life times remained constant during the four therapies (fast phase: mean 0.55 d (0.4 d ‐ 0.7 d); slow phase: mean 2 d (1.8 d ‐ 2.2 d), whereas relative part of the fast phase related to the complete kinetic increased according to the number of therapies (1st therapy 42 %, 2nd 42 %, 3rd 52 %, 4th 62 %) correlating to the decrease of the reference laesion. Body weight adapted accumulated whole body dose amounts 2.5 Sv (MIRD calculated; S‐value whole body 0.276 x 10‐3 mSv MBq‐1 h‐ 1 ) (1st therapy 694 mSv, 2nd 588 mSv, 3rd 595 mSv, 4th 599 mSv). Conclusion: Repeated activities up to 28 GBq within 14 months causing a total whole body dose of 2.5 Sv were tolerated without any relevant complications. In consideration of the good therapeutical response additional therapies of the phaeochromoblastoma are planned.
P550 Dosimetry during radioiodine differentiated thyroid cancer.
therapy
in
metastatic
M. R. Castellani1, C. Chiesa1, F. Botta2, R. Azzeroni2, A. Negri2, D. Mansi1, M. Maccauro1, E. Orunesu1, E. Seregni1, E. Bombardieri1; 1Nuclear Medicine Division, Fondazione IRCCS - Istituto Nazionale Tumori, Milano, ITALY, 2 Post-graduate Health Physics School, Milano, ITALY. Objectives: To evalutate if dosimetry estimation can improve clinical efficacy of radioiodine therapy in metastatic differentiated thyroid cancer. Methods: Eighteen dosimetric studies were performed on 16 patients injected with a median of 9.2, range [5.8‐12] GBq of 131I. Blood and red marrow dosimetry was based on published EANM guidelines. Gammacamera dead time & scatter correction, absolute calibration, conjugate view technique were applied. Target volumes were measured on CT scans. Dosimetry results were used for subsequent clinical decision‐ making. Results: Absence of hematologic toxicity is in agreement with low blood/red marrow doses. Tumor dose could be calculated in 9 of 18 studies for 17 lesions. Only 1 lesion got 290 Gy, more than Maxon’s 80 Gy threshold of efficacy. Four lesions doses were between 80 and 40 Gy, whereas 6 lesion doses were below 10 Gy. In some patients we observed high variability of dose between different lesions (288 ‐ 2 Gy). Conclusions: In our experience, the quantitative evaluation has improved the quality of radionuclide therapy, even considering a factor of 2 of inaccuracy. Post treatment dosimetry changed the subsequent clinical therapeutic strategy in 6/16 patients with insufficient tumor doses, leading to additional surgery or external beam radiotherapy.
Radionuclide therapy/dosimetry: clincial: mIBG and peptides
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Patients receiving Y-DOTATOC / DOTATATE - How long do we keep them as In-patients? G. Jones, I. Hufton, H. Stockdale, M. Carroll, P. Maltby, C. Ramesh, S. Vinjamuri; Royal Liverpool University Hospital, Liverpool, UNITED KINGDOM. Objective: At present patients receiving 90Y‐DOTATOC / DOTATATE for cancers expressing somatostatin receptors are treated as an inpatient procedure being discharged at around 45 hours post treatment (two night stay). We have undertaken a dose rate assessment to determine if this time period can be reduced thereby benefitting the patient and freeing up the single occupancy room sooner for use. Method: Dose rate measurements were taken on thirteen patients (12M:1F). Administered activities ranged between 4860 ‐ 5200 MBq with an average 5060 MBq. Dose rates were recorded at distances of 0.5 and 1.0 m from each patient on right and left hand sides at various times up to 48 hours post therapy. Results: Average measured dose rates at 1 m (and max‐to‐min ranges) immediately after therapy were 7.2 (20‐3) and 8.2 (20‐4) μSv.hr‐1 for right and left hand sides respectively. At 24 hours dose rates were 1.5 (4‐1) and
P551
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Therapy of Neuroendocrine Tumors with Y- DOTA-TATE 1
1
1
V. Obradovic , V. Artiko , S. Novosel , N. Petrovic1, D. Sobic-Saranovic1, S. Pavlovic1, E. Jaksic1, D. Macut2, M. Petakov2, B. Popovic2, S. Damjanovic2; 1 Centre for Nuclear Medicine CCS, Belgrade, SERBIA, 2Clinic for Endocrinology, Diabetes and Metabolic Diseases CCS, Belgrade, SERBIA. Aim: The aim of the study is presentation of the preliminary results of the therapy of neuroendocrine tumors (NETs) with 90Y DOTA‐TATE. Patients and methods: The therapy was applied in 15 patients with various neuroendocrine tumors (5 unknown origin, 6 pancreatic neuroendocrine carcinoma, one pancreatic gastrinoma, one gut carcinoid, one bronchial carcinoid, one lung NET). Five of them received all 4 cycles of the therapy,3 received 3 cycles, another 3 received 2 cycles, while remaining 4 received only one cycle. In all of them, together with other laboratory analyses and imaging methods, scintigraphy with somatostatin analogues was performed (in 6 with 111In Octreoscan and in 9 with 99mTc Tektrotyd) and high tumor uptake (gr III‐IV) was observed. The therapy was performed with 2‐4,5 GBq 90Y DOTA‐TATE /patient/cycle, in the infusion in the physiological liquid (150 ml/15 min).Between the cycles, there was a time delay of 6‐8 weeks. The infusion of amino acids have been applied 30 min before the therapy, and 4h after. After 24h‐96h, "bremsstrahlung" imaging was performed. Results: Analysis of the "bremsstrahlung" images showed uptake of the radiopharmaceutical in the liver, but the most of the activity was observed in the regions of the "hot spots" grade 3 and 4 (planar T/B= 1,70±0.9, SPECT T/B=2.9±0.8) registered with previous 99mTc Tektrotyd and/or 111In Octreoscan images. According to our results, after the therapy, in four patients occured progressive disease (PD ‐ 4 with neuroendocrine pancreatic carcinoma with liver mets. In the
Poster Presentation
P64 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
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majority of patients (n=8), stable disease (SD) was registered (one with bronchial carcinoid and liver mets, one with pancreatic gastrinoma, one with NET of unknown origin and liver lung and bone mets, two with neuroendocrine pancreatic carcinomas with liver mets, one with NET of unknown origin with liver mets, one with lung neuroendocrine carcinoma with liver and bone mets, one with NET of unknown origin with bone and skin metastases), and in three partial remission (PR ‐ coecal carcinoid with liver mets and 2 with NET of unknown origin with liver mets). Up to now, there were no major clinical side effects hepatic function. Transient pancytopenia occurred in two patients, and impairment of kidney function in one. Conclusion: Beneficial effects on clinical symptoms, hormone production and tumor proliferation were found, without major clinical side effects. Thus, treatment with 90Y DOTA‐TATE might be useful for the management of patients with inoperable or disseminated neuroendocrine tumors.
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Treatment with tandem Y-DOTA-TATE and Lu-DOTA-TATE of neuroendocrine tumors refractory to conventional therapy: preliminary results E. Seregni1, M. Maccauro1, A. Coliva1, M. R. Castellani1, E. Bajetta1, G. Procopio1, G. Aliberti1, B. Padovano2, M. Testoni1, A. Negri2, C. Chiesa1, E. Bombardieri1; 1Istituto Nazionale Tumori, Milan, ITALY, 2University of Milan, Milan, ITALY. Aim: neuroendocrine tumours overexpress somatostatin receptors and literature data have demonstrated the efficacy of the peptide receptor radionuclide therapy with somatostatin analogues labelled with high activities of β‐ emitting radioisotopes, such as 90Y and 177Lu. 90Y has a max penetration range in tissues of 12 mm while 177Lu deposits its energy in a maximum range of 2 mm so the former can irradiate also cells not expressing receptors or not reachable from the peptide and the latter would allows concentration of energy inside or in proximity of lesions, particularly in small ones . Stating these considerations, we decide to evaluate an original tandem treatment based on administration of radiolabeled DOTA‐TATE alternating 177Lu and 90Y. Aim of our study was to evaluate the feasibility, the efficacy and the toxicity of this treatment in neuroendocrine tumors expressing somatostatin receptors relapsed or refractory to conventional therapies. Methods: patients were treated with 4 therapeutic cycles alternating 177Lu‐DOTA‐TATE (5.55 GBq) and 90Y‐DOTA‐TATE (2.6 GBq) with a break of 6‐8 weeks. Dosimetric evaluation after administration of 177Lu‐DOTA‐TATE allows to calculate the cumulative absorbed doses in healthy organs. Blood samples were collected at 5 min, 1, 6, 24, 48, 72, 96 h and scintigraphy was performed once a day for 4 days after administration. Toxicity of red marrow, liver and kidneys was evaluated considering haematological parameters and renal toxicity was evaluated comparing basal and end of treatment glomerular filtration rate (GFR). Efficacy related with biochemical and RECIST criteria. Results: up to now 21 pts underwent at least 1 treatment; 3 pts completed all cycles. Treatment was well tolerated with no adverse event registered. Haematological parameters and GFR showed no damage to healthy organs in accordance with the calculated absorbed doses both for 177Lu (kidneys 3.2 ± 1.0 Gy, liver 0.6 ± 0.5 Gy, red marrow 0.2 ± 0.06 Gy and bladder 0.6 ± 0.6 Gy) and 90Y (kidneys 6.3 ± 1.6 Gy, liver 1.2 ± 0.8 Gy, red marrow 0.4 ± 0.06 Gy and bladder 0.8 ± 0.6 Gy ). We had a partial response in 2 pts that were evaluated 3 months after the end of last treatment. Conclusions: until now few patients joined and concluded our study; preliminary results are encouraging and indicate the feasibility of our study. This study was supported by AIRC.
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111
Y-DOTATOC and/or In-pentetreotide in the treatment of somatostatin receptors-expressing tumors (SSTR): personal experience A. Herberg, G. Murè, V. Militano, R. Lo Gullo, R. Paratore, S. Baldari; Nuclear Medicine Unit, Messina, ITALY. BACKGROUND: Peptide Receptor Radionuclide Therapy (PRRT) with radiolabelled somatostatin analogues is an effective tool for treatment in patients with metastasized neuroendocrine tumors 90 (NET) and other SSTR‐positive cancers. Treatment with Y‐DOTATOC resulted in partial and complete remissions in 10‐30% of cases. Few experiences are reported with 111In‐pentetreotide which seems to be less effective and fewer about combined approach using both radiopharmaceuticals. AIM: We refer our experience in the treatment of patients with (SSTR)‐ positive tumours, to evaluate and compare the efficacy of 111In‐pentetreotide and 90Y‐DOTATOC. Materials and Methods : Since 2005 overall 219 treatments has been performed in 62 patients: 22 had GEP (15 pancreas, 7 bowel), 9 liver metastases of unknown origin NET, 13 other NET (9 lung, 3 mediastinum, 1 gallbladder), 3 medullary thyroid cancer, 1 paraganglioma, 1 chemodectoma, 2 SLCL, 1 Merkel’s cells , 1 glioblastoma and 5 SSTR‐positive carcinomas (2 NSCLC, 1 exocrine pancreas, 1 clear cell renal and 1 breast). Furthermore, 4 patients had relapsed/inoperable meningioma. Sixteen of 62 patients presented with a carcinoid syndrome; 38/62 patients had high levels of Cromogranine A. We treated 20 patients with 90Y‐DOTATOC (Group I; 1‐6 cycles, 1.8‐ 14.0 GBq), 20 patients with 111In‐pentetreotide (Group II; 1‐8 cycles, 5.5‐ 56.4 GBq); in 22 patients which had reached high kidney radiation dose after repeated dose 90Y‐ DOTATOC, we continued treatment with 111In‐pentetreotide (Group III; 2‐9 treatments). All patients received renal protection with aminoacid. Patients were retreated every 6‐10 weeks (median 8 weeks). Follow‐up data were valuable for 17 patients in Group I, 15 in group II and 21 in Group III. Results:
Objective Response Stable
Progression
Group I 6/17 (35%)
6/17 (35%) 5/17 (35%)
Group II 4/15 (26%)
7/15 (48%) 4/15 (26%)
Group III 5/21 (24%)
12/21 (57%) 4/21 (19%)
Seven of 53 valuable patients (13%) experienced mild and transient haematological toxicity, 3 patients who received multiple treatments of 90Y‐DOTATOC showed an increase of serum creatinine levels. Conclusions: Our results confirm the data shown in literature regarding the 90 effectiveness of Y‐DOTATOC, although some patients with low life expectancy have contributed to increase the number of cases of progressive disease reported in our study. In our experience 111 In‐Pentetreotide provides a better response rate than data reported in literature. Selection
criteria of patients ( high performance status, longer life expectancy, small size, intense and homogeneous lesional uptake ) could have most likely contributed to determine these results.
P554 Can serum catecholamine at 1 week after I-131 MIBG therapy predict response in malignant pheochromocytoma? T. Higuchi1, N. Oriuchi1, Y. Arisaka1, G. Miyashita2, T. Ishikia2, H. Hanaoka3, H. Otake4, K. Koyama5, K. Endo1; 1Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, Maebashi, JAPAN, 2Department of Stomatology and Maxillofacial Surgery, Gunma University Graduate School of Medicine, Maebashi, JAPAN, 3 Department of Bioimaging Information Analysis, Gunma University Graduate School of Medicine, Maebashi, JAPAN, 4Department of Radiology, Gunma University Hospital, Maebashi, JAPAN, 5Department of Radiology, Gunma Prefectural Cardiovascular Center, Maebashi, JAPAN. [Objectives] In malignant pheochromocytoma, I‐131 MIBG therapy is widely used. However its therapeutic effect is relatively slow comparing with other treatment such as chemotherapy. Early response evaluation of I‐131 MIBG therapy for malignant pheochromocytoma is preferable to make a reasonable and qiuck decision of the additional dose of MIBG or the alternative therapeutic strategy. In our study, catecholamines were measured after MIBG therapy to evaluate the clinical usefulness for the early response prediction. [Materials and Methods]Eight eligible cases were selected from 14 pheochromocytoma patients who underwent I‐131 MIBG in Gunma University Hospital during the period from June 2003 to December 2008. Catecholamines including epinephrine, norepinephrine and dopamine in the serum and urine is measured before MIBG therapy and at 1 week and 3 months after MIBG therapy with a dose of 5.55 to 7.4 GBq. Catecholamine decrease ratios at 1 wk (CDR‐1W) and 3 m (CDR‐3M) were calculated and responder (CDR‐3M<0.8) and non‐responder (CDR‐3M>0.8) were defined. CDR‐1W and CDR‐3M were correlated with the outcome of patients. [Results]CDR‐1W and CDR‐3M showed significant correlation (y=0.4x+0.26, r=0.73, p=0.039). Responders (n=5) showed significantly lower CDR‐3M (0.54+‐0.15) than non‐responders (n=3, CDR‐3M=1.07+‐0.14, p<0.01)). During follow up, all responders were alive, whereas, 2 of the non‐responders were dead and the other showed no clinical response (Final CDR; 1.57) after 3 MIBG therapy at every 6 months. [Conclusion] The present study suggested that catecholamine levels at 1 week after MIBG therapy can be used as a therapeutic response predictor.
P555 Assessment of Somatostatin Receptors Expression in Predicting Results of Peptide Receptor Radionuclide Therapy (PRRT) in Neuroendocrine Tumours (NET) A. Sowa-Staszczak1, M. Trofimiuk1, A. Stefanska1, W. Wierzchowski2, J. Kunikowska3, R. Mikolajczak4, D. Pawlak4, D. Pach1, R. Tomaszewska2, L. Krolicki3, A. Hubalewska-Dydejczyk1; 1Endocrinology Department, Nuclear Medicine Unit, Medical College, Jagiellonian University, Krakow, POLAND, 2 Pathology Department, Medical College, Jagiellonian University, Krakow, POLAND, 3Nuclear Medicine Department, Warsaw Medical University, Warszawa, POLAND, 4Radioisotope Centre POLATOM, Institute of Atomic Energy, Otwock-Swierk, POLAND. PRRT with labeled somatostatin analogues is one of the methods of palliative treatment in disseminated NET. Considering potential side effects of the therapy, it is important to qualify the patients adequately, choosing the ones who will benefit most. The aim of the study was to indicate the value of the immunohistochemical staining for the sstr expression in tumour tissues as the predictive factor in assessment of the PRRT results in patients with disseminated NET. Material and methods: The study included 13 patients with disseminated NET [4 males, 9 females; median age 50 years (43‐72 years)]: 8 with foregut NET including 2 with pancreatic tumours, 2 with midgut NET, 1 with hindgut NET, 2 with medullary thyroid cancer. All patient 90 90 177 were treated with either Y ‐DOTATATE (11 patients) or Y /Lu ‐DOTATATE (2 patients) ‐ median cumulative dose 360 mCi. Median observation time was 23 (3‐44) months. Each patient had been qualified for therapy based on results of SRS with Tc99m‐[EDDA/HYNIC]‐octreotate ‐ the tumour tracer uptake was estimated based on the semi‐quantitative four point scale. Tumour response was assessed according to RECIST criteria. Sstr expression (sstr1‐sstr5) in NET tissue specimens was assessed semi‐quantitatively (0‐3 scale) by immunohistochemical staining (Gramsch, Germany). Results: PRRT resulted in partial response (PR) in 5 (38%), stable disease (SD) in 3 (24%), and progressive disease in 5 (38%) patients. Mean time to progression was 11 (3‐ 18) months. 4 patients died. Expression of sstr1 was found in 5 (38%), sstr2a in 11 (84%), sstr2b in 3 (24%), sstr3 in 3 (24%), sstr4 in 0 and sstr5 in 4 (31%) patients. There was no statistically significant correlation between the PRRT results and the strength of both sstr2a and all sstr expression. Moreover, no correlation between the SRS results and intensity of sstr expression was found. Conclusions: The assessment of sstr expression in NET tissue cannot be used as the tool for predicting the PPRT results. It may result for example from heterogenous distribution and strength of sstr expression within both primary tumour and its metastases. Other measures for predicting tumour response to the therapy should be searched for.
P556 Scintigraphy 131I-mlBG in patient with positive RET germline mutation for medullary thyroid carcinoma P. Vlček, J. Zimak; University Hospital Prague-Motol, Prague, CZECH REPUBLIC. Purpose: The RET proto‐oncogene is involved in neural crest disorders. Activating germline mutations in the RET proto‐oncogene cause the development of familial medullary thyroid carcinoma (FMTC) or medullary thyroid carcinoma (MTC) as a part of multiple endocrine neoplasia type 2 syndrome (MEN2). Methods: This study presents a novel Czech kindred with FMTC phenotype. Two family members (mother and son) were tested for RET germline mutations in exons 10, 11, 13, 14, 15 and 16. In these pacients were performed 123I‐mIBG
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 scintigraphy, too. In son we detected liver metastases disease with positive 123I‐mIBG scintigraphy. Results: Direct fluorescent sequencing of genomic DNA revealed heterozygous mutation in the RET proto‐oncogene in the exon 13 in both tested persons. This family was reclassified thanks to genetic screening from the apparently sporadic MTC to FMTC and the treatment of 131I‐mIBG was used. Conclusion: The therapy 3.7 GBq 131I‐mIBG was performed in son, where germline mutation was detected due to the systematic genetic screening of the RET proto‐oncogene, which is useful for genetic counselling of potential risk of MTC in other family members.
(27.6%) platelet transfusions. The most frequent non haematological toxicity was asthenia. One patient developed severe mucosytis. Two patients have concomitant associated tumours (colon and prostate) and at now non secondary malignancies have been observed. Conclusion: In our experience therapy with 90YIbritumomab/tiuxetan is a safety and effective therapy, specially in patients with follicular non‐Hodgkin's lymphoma that can obtain higher complete response than other types of lymphoma and prolonged median survival time.
Radioimmunotherapy with Y Ibritumomab Tiuxetan in patients with relapsed or refractory B - cell non-Hodgkin lymphoma.
Radionuclide
therapy/dosimetry:
clinical:
radioimmunotherapy
P557 Imaging with Ibritumomab lymphoma
111
18
90
In-Ibritumomab and F-FDG PET/CT in Yradioimmunotherapy of non-Hodgkin´s
I. Banzo, I. Martinez-Rodriguez, R. Quirce, J. Jimenez-Bonilla, A. SainzEsteban, J. Barragan, H. Portilla-Quattrociocchi, P. Medina-Quiroz, J. Carril; H.U. Marques Valdecilla. Servicio de Medicina Nuclear, Santander, SPAIN. Aim: The aim of this study was to evaluate the contribution of 111In‐Ibritumomab and 18F‐FDG PET/CT (FDG) scans in radioimmunotherapy (RIT) with 90Y‐Ibritumomab of non‐Hodgkin´s lymphoma (NHL).. Materials and Methods: This is a retrospective study of 10 patients (6 male, 4 female, age range 53‐76 y.) with NHL who were treated with 90Y‐Ibritumomab for refractory/relapsed NHL (6 patients) or consolidation of first remission (4 patients). NHL patient population consisted of follicular (3), mantle (3), and diffuse large B‐cell (4) subtypes. All patients received two infusions of Rituximab 250 mg/m2 seven days apart. The first Rituximab infusion was followed by an infusion of 111In‐Ibritumomab 185 MBq and a whole‐body scan was carried out at 5 day. The second Rituximab infusion was immediately followed by an intravenous infusion (10 min) of 90Y‐Ibritumomab (11.1 or 14.8 MBq/kg depending on platelet count, max 1,184 MBq). Hematologic toxicity was weekly evaluated after RIT for 8 weeks or until recovery. Also, patients underwent FDG scan (8 MBq/kg, 90 min tracer uptake time, 6 beds/2‐5 min per bed) before and after RIT to assess the metabolic response of tumor. Mean of follow‐up was 7.5 + 4.35 months. Results: Grade 3‐4 neutropenia was observed in 2 of the 10 patients (20%) and grade 3‐4 thrombocytopenia, in 5 of 10 patients (50%). Refractory/relapsed NHL group (6 patients). Five of 6 patients had 111In‐Ibritumomab scan. Both 111In‐Ibritumomab and FDG scans showed similar positive findings in abdominal mass (2) and thigh mass (1). FDG scan showed more extensive disease than 111In‐Ibritumomab scan in abdominal lymph nodes (1) and systemic involvement (1). One patient with cervical lymph nodes had only FDG scan. After RIT, FDG scan showed partial metabolic response in 3 patients, disease progression in 2 patients, and non‐response in 1 patient. Consolidation therapy group (4 patients). 111In‐Ibritumomab scan was acquired in 3 patients: 2 negative and 1 positive results. Before and after RIT, FDG scans were negative in 3 patients, 2 of them had negative 111In‐Ibritumomab scan. Before RIT, the fourth patient had positive 111In‐Ibritumomab and FDG scans in abdominal mass; after RIT, decrease in FDG activity of mass but a new lesion in other location was observed. Conclusion: Disease extension was identified on pretreatment 111In‐Ibritumomab and FDG scans in NHL patients. RIT with 90Y‐ Ibritumomab produced a decrease of FDG activity in lesions responding to therapy. Consolidation of first remission is an effective use of 90Y‐Ibritumomab therapy in NHL patients.
P558 Therapy with 90Y Ibritumomab tiuxetan in Relapsed/Refractory Non-Hodgkin Lymphoma. Analysis of recent outcomes. T. Baringo1, P. Liévano1, P. Navarro1, E. Arroyo1, M. Añaños1, L. De la Cueva1, M. González1, M. Abós1, P. Giraldo2; 1Servicio de Medicina Nuclear. Hospital Universitario Miguel Servet, Zaragoza, SPAIN, 2Servicio de Hematología. Hospital Universitario Miguel Servet, Zaragoza, SPAIN. Introduction: Add‐on treatment of follicular non‐Hodgkin's lymphoma (NHL) with 90YIbritumomab/tiuxetan has become an efficient alternative. The aim of this study is analyze our updated information of patients treated with 90YIbritumomab/tiuxetan in the clinical practice setting and to retrospectively analyze treatment outcome. Subjets and Methods: 58 relapsed/refractory lymphoma patients were included in a clinical protocol conducted by a multidisciplinary team and treated in the same centre According the inclusion criteria: relapsed/refractory CD20+ LNH patients with neutrophils ≥ 1,5 x 109/L, platelets ≥ 100 x 109/L, bone marrow lymphocytes CD20+ ≤ 25%. All patients received 0,3 or 0,4 mCi /kg IV of 90YIbritumomab/tiuxetan and response evaluation was performed 12 weeks after. Period of study: September 2005/March 2009. Endpoints: Objective response rate (ORR), time to relapse (TTR) overall survival (OS) and safety. Other clinical prognostic factors were observed to asses their possible influence upon treatment value. Results: Until March 2009, 58 patients had received treatment with 90YIbritumomab/tiuxetan, but only 48 completed the follow‐up and were considered to analysis; M/F 48.3%/51.7%; mean age 61.88 years (30‐85); ECOG 0‐1 94.8%; 37 NHL follicular (63.8%), 8 NHL mantle cell (13.8%), 9 NHL BDLG (15.5%) and 4 Hodgkin Lymphoma (6.9%). According FLIPI score distribution: (0‐1)60.3%, FLIPI(>1)39.7%. Previous therapy schedules 1‐2(44.8%), >2(55.2%). The median follow‐up time: 16.23 months, median TTP: 34.4 months (95% CI: 29.7;39.0). Mean OS 58.14 months (range: 4‐202), median: 45,5±48.3. Completed response (CR) was different according with lymphoma subtype: 28 (CR) NHL follicular, 8(CR) NHL mantle cell and 6(CR) NHL BDLG. ORR: 56.9%. Complete response 53.4%, partial response 3.4% and relapsed 15.5%, no follow‐up completed 15.5% and 12% death or withdraw. Median TTR was 42 months for NHL follicular vs. 15 months for other NHL subtypes. Safety: thrombocitopenia being the most frequent (27.6%) haematological toxicity median time to G3‐4 fourth week, and neutropenia (22.4%), but the median time to recover normal values was 4.2 and 2.6 weeks respectively. In 6 patients (10.3%) red blood cell transfusion were required and 16
90
C. Olivas, P. Bello, J. L. Vercher, J. L. Loaiza, J. F. Martí, I. Hervás, A. Rivas, C. Ruiz, R. Pérez-Velasco, A. Mateo; Department of Nuclear Medicine University Hospital La Fe, Valencia, SPAIN. Introduction: Ytrium‐90 Ibritumomab Tiuxetan (Zevalin®) is a radioimmunotherapeutic agent approved for the treatment of relapsed or refractory low‐grade, follicular, or CD20_ transformed non‐Hodgkin’s lymphoma (NHL). Aim: To present our clinical experience with Zevalin® in the management of refractory/relapsed NHL. Materials and Methods: From Apr‐05 until Feb‐09, 31 patients were treated with Zevalin®. The group included 17 male and 14 female, with age range of 27‐79 years. 29 of them had Follicular‐NHL and two Mantle Cell Lymphoma. All the patients underwent Zevalin therapy using the standard regimen (15 MBq/Krg or 11 MBq/Kg in patients with a platelet count in the range of 100.000‐150.000 /µl). Haematological toxicity was evaluated with weekly blood count for 12 weeks or until haematological recovery. Results: At medium term ® follow‐up (3 months), Zevalin induced complete response (CR) in 14/31 patients (45%) and partial response (PR) in 9/31 (29%). Early progression disease (DP) was noted in 3/31 (9.7%) patients and 4 died (13%). At one year follow‐up, 9/27 patients (33%) presented CR and PR were observed in 2 (7.4%). There were 8/27 patients (30%) with disease progression and two died.
Evaluation
3 months (N=31) 1 yr. (N=27)
CR
14
9
RP
9
2
DP
3
8
Exitus 4
2
NE
6
1
Evaluation
Grade 3 and 4 hematological toxicity occurred in 12 patients (39%), but was reversible. No other significant toxicities were observed. Conclusion: Our data suggest that clinical practice with Zevalin® radioimmunotherapy is an effective and safe treatment. At present, we are included in several clinical trials to assess the possible inclusion of radioimmunotherapy with Zevalin® in earlier phases of treatment and its utility in aggressive lymphoma.
P560
90
Role of Y-ibritumomab tiuxetan administration to consolidate rescue therapy after chemo- or radio-therapy followed or not by autologous bone marrow transplantation B. Palumbo1, I. Sabalich1, F. Falcinelli2, M. Capponi2, M. Martelli2, R. Palumbo1, H. Sinzinger3; 1Nuclear Medicine Section, University of Perugia, ITALY, 2Haematology Section, University of Perugia, ITALY, 3Nuclear Medicine Department, University of Vienna, AUSTRIA. Aim: Scarce data are available on 90Y‐ibritumomab tiuxetan administration to consolidate rescue therapy after chemo‐ or radio‐therapy followed or not by autologous bone marrow transplantation (ABMT). To contribute to this knowledge, we investigated efficacy of 90Y‐ ibritumomab tiuxetan consolidation therapy in relapsed patients and therapy safety in ABMT recipients. Materials and methods: 90Y‐ibritumomab tiuxetan (0.4 mCi /kg) was iv administered to consolidate rescue in 19 patients (13M, 6F, median age: 58yrs) with follicular lymphoma relapsed after rituximab treatment (n.14) and ABMT (n.5). All patients had previously received rituximab immunochemotherapy and 15 had received at least two lines of chemotherapy. Bone marrow was normal in all subjects, except one with molecular evidence of involvement. Neutrophil counts were > 1500 mmc, platelet counts were > 100.000 mmc. Response to therapy was evaluated as follows: complete response (CR), near complete response (CR), partial response (PR), no response (NR), disease progression (DP). Before radioimmunotherapy 10 patients had 18 nCR, 7 PR and 2 NR. Response was investigated by clinical examination and FDG PET/CT scan performed before and 16 weeks after treatment. Results: At a median follow up of 13.7 months (range 1‐25 months) 18 out of the total 19 patients survived. Three patients did not respond (Pre‐ infusion data: 2 NR. 1 PR). Two of them with rapid DP, had a bulky mass > 5 cm and a stage IVB at the time of diagnosis. One subject died for DP. Four months after 90Y‐ibritumomab tiuxetan administration, 10 out of the 14 evaluable patients had CR (pre‐infusion data: 7 nCR, 3 PR), 1 patient relapsed 24 months after, 2 (Pre‐infusion data: PR in both) presented DP after 5 and 7 months respectively. The 5 subjects treated by 90Y‐ibritumomab tiuxetan after ABMT maintained CR. Considering safety profile, 3 patients developed grade 3 neutropenia, 14 required granulocyte growth factor support, 3 developed grade IV thrombocytopenia (solved by transfusion). All subjects treated had a good haematological reconstitution after 12 weeks. None had severe extra‐haematological toxicity or needed hospitalization. Conclusion: Survival and quality of life were good in the majority of our patients. Subjects refractory to previous treatment did not respond to 90Y‐ibritumomab tiuxetan infusion also. In very high risk patients in nCR or PR before 90Y‐ibritumomab tiuxetan therapy, radioimmunotherapy appeared as effective and safe as 90 consolidation therapy. Furthermore after ABMT, Y‐ibritumomab tiuxetan was safe.
Poster Presentation
P65 ‐ Monday, October 12, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
P559
S420
P561 Short-term efficacy of Zevalin in heavily pre-treated, Rituximab refractory, Follicular and Diffuse Large B Cell lymphoma. F. Cicone1, R. Baldini1, E. Russo2, F. Torelli2, B. Veggia2, A. Tofani1, F. Scopinaro1; 1Department of Nuclear Medicine, “Sapienza” University, Rome, ITALY, 2Department of Haematology, “Sapienza” University, Rome, ITALY. Aim. To retrospectively assess the efficacy of Zevalin (Z) in a population of heavily pre‐treated, Rituximab refractory patients. Materials and Methods. Nineteen consecutive patients (median age=59), who had been routinely addressed to Z at S. Andrea Hospital of Rome up to May 2008 were analysed. Twelve patients (63%) had indolent lymphoma (8 grade 2 + 4 grade 3a FL) and 7 (37%) had aggressive lymphoma (2 grade 3b FL + 5 DLBCL). Median number of previous lines of therapies was 3 (range 1‐11); median number of prior Rituximab‐including treatments was 2 (range 1‐4). Four (21%) patients had a prior ASCT. According to response to their last previous therapy, 12 patients were classified as “responders” [8 Complete Responses (CR) to salvage therapy + 1 Partial Response (PR) + 3 untreated relapses]. Seven patients were “non‐responders” due to a stable/progressive disease. Nine patients, 8 CR + 1 PR (5 grade 2 FL, 1 grade 3b FL, 3 DLBCL), had therefore received Z as consolidation therapy. Median follow‐up was 14,5 months. Age, time from diagnosis, time from the beginning and from the end of last previous therapy, number of previous therapies, histological grade, stage, response to last previous therapy were analysed in univariate and in bi‐variate models: PET/CT was used for staging and follow‐up. The Failure Free Survival (FFS) was determined from the date of Z therapy until the date of any documented adverse event i.e. : partial response, relapse/progression, next treatment or death. Results. In the entire series the median FFS was 5 months; one year FFS was 36% (error: 11%). All patients who experienced a failure underwent further anti‐lymphoma treatment within three/four months from restaging. In patients who had responded to their previous therapy, one year FFS was 57% (0.28‐0.85 95% CI; p<0.001, Log Rank Test). The same parameter was 0% in non responders. All other pre‐therapy characteristics, excluding stage, did not significantly correlate with outcome. In particular, FFS was not significantly different in patients with indolent and aggressive lymphoma (p=0.34). The short‐term prognostic significance of sensitivity to last therapy was independent from all other variables, as shown by multiple bi‐variate analyses. Conclusions. Patients refractory to prior Rituximab‐including therapies show high rates of failure and no long term remissions. Z given as consolidation, even in case of prior numerous relapses, should be taken into account as a valid therapeutic option in patients with both indolent and aggressive lymphoma.
P562 Clinic experience with radioinmunotherapy in non-hodgkin's lymphoma R. Jover-Diaz1, R. Oña2, A. De La Fuente2, J. Tomas2, J. Alfonso1; 1Instituto Tecnologico PET, Madrid, SPAIN, 2Centro Oncologico MD Anderson International Spain, Madrid, SPAIN. Aim: Assessment of efficacy (global and complete response rates) and safety (haematologic and extra‐haematologic toxicity) of Zevalin®‐ 90Y‐Ibritumomab‐Tiuxetan‐ in consodilation regimen or with additional stem cell rescue in treatment of non‐Hodgkin´s Lymphoma (NHL). Patients and Method: Evaluated by clinic criteria (Revised International Workshop Criteria) and molecular imaging with PET/CT (basal and 3 months post‐treatment): “low dose” (80 mA, 120 Kv), 2D mode, acquisition after 45 minutes post‐injection of 0.15 mCi/kg of 18F‐FDG and oral radiological contrast. 14 patients (10 men; mean age: 75 years; range: 36‐88). 50% stage IV of Ann Arbor Classification. 43% ECOG Perfomance status >2. 2.7 previous lines of chemotherapy before Zevalin® treatment. 35.7% Diffuse Large B‐cell NHL. 35.7% Transformated Follicular NHL. Others: Mantle cell Lymphoma and Marginal zone Lymphoma. 5 patients were treated with Zevalin® ® consolidation after 1‐2 lines of induction chemotherapy. 9 patients received Zevalin therapy and an additional stem cell rescue after induction chemotherapy with 2‐5 lines. Follow‐up: 12 months (range: 4‐26) Results: Global Response Rate: 64%. Complete Response Rate: 50%. Consolidation treatment with Zevalin® in 5 of 14 patients: 4 patients alive with complete response, 1 patient ® alive with active lymphoma Zevalin therapy and an additional stem cell rescue in 9 of 14 patients: 2 patients alive with active lymphoma, 3 patients alive with complete response, 4 exitus patients with tumour progression (2 partial response after Zevalin® treatment) 100% of patients showed haematologic toxicity after Zevalin® treatment. Second neoplasies (urotelial carcinoma)in two of all patients of this study. Conclusions: Zevalin® is an adequate option treatment in B‐cell non‐Hodgkin´s Lymphoma. In early treatment (less than 2 cycles of induction chemotherapy), patients obtained higher response rates.
P563 67
Cu complex for Radioimmunotherapy
S. Singh; Banaras Hindu University, Varansi, INDIA. 67
copper based 1‐aminoethyl‐5, 8, 12‐tri (carboxymethyl)‐Cyclam for Radioimmunotherapy : Radiochemistry and preclinical results Sweta Singh, R Mathur, Anand Pandey, B.Singh, A. K. Mishra* Department of Chemistry, Banaras Hindu University, Varanasi‐221005,INDIA Division of Cyclotron and Radiopharmaceutical Sciences,Institute of nuclear medicine and Allied Sciences,Brig. S. K. Mazumdar Road, Delhi‐110054, India. Aim 67Cu was first advocated for use in RIT by DeNardo and DeNardo in 1983 and by Wessels and Rogus in 1984, because of its useful physical and chemical properties. The 62‐h half‐life of 67Cu is similar to the residence time of many MAbs in tumors . To use 67Cu effectively, the macrocyclic chelating agent was designed 67 specifically to bind Cu selectively and tightly, enabling its conjugation to MAb. TE3A‐EA binds 67 Cu in preference to other metals; therefore, the resulting radiophar[[Unsupported Character ‐ Codename ]]maceutical can have a high specific activity. The complex has exceptional structural stability, functional integrity, and product yields. Material and Methods: All used chemicals were purchased from commercial sources, while TE3A‐EA was synthesised by starting from Cyclam in three step reaction.. Analytical 1H and 13C NMR spectra were recorded on a Bruker 400 MHz spectrometer . Mass Unit mass determinations were carried out by using a electro spray ionization mass spectrometry (ESI‐MS) on an SL 1200 system (Agilent) with ion trap detection in the positive and negative ion modes. After incubation at 90°C for 30 min, ITLC and
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 HPLC analyses were carried out to check the radiochemical purity of complex. Biological experiments were performed on male Wistar rats. Results: It was found that the complex formation is dependent on temperature. The optimal temperature range for the Complexation was 70 ‐ 80 °C. The characteristics checked were buffer pH and excess of ligand. The optimal pH interval for rapid complex formation was 5.5 ‐ 6.5 and excess of ligand was necessary. Finally, 1‐ aminoethyl‐5, 8, 12‐tri (carboxymethyl)‐Cyclam can be easily labelled by Cu‐67 with high radiochemical purity. Biodistribution studies in rats confirmed that radiolabelled complexes under study were rapidly cleared from the blood, other organs and tissues. The main elimination pathway of radioactivity was urinary excretion. No specific accumulation of radioactivity in any organ and tissue was detected. Conclusion: It turned out that Complexation and biodistribution results of radiolabelled 1‐aminoethyl‐5, 8, 12‐tri (carboxymethyl)‐Cyclam are comparable to those of known ligand. So it can go for next phase of clinical trials.
P564 Radioimmun therapy with (90)Y-Ibritumomab tiuxetan in patients with non-hodgkin's lymphoma H. Kaya1, O. Ayyildiz2, G. Kaya Altunci1, B. Kizilkan Bellur1, A. Isikdogan3; Dicle University School of Medicine the Department of Nuclear Medicine, Diyarbakir, TURKEY, 2Dicle University School of Medicine Department of Hemathology, Diyarbakir, TURKEY, 3Dicle University Medical Faculty, Medical Oncology of Internal Medicine, Diyarbakir, TURKEY.
1
Introduction: Rituximab is monoclonal antibody which commonly used as a single agent or in combination therapy for NHL. Radio immunotherapy is a new age treatment for NHL. Ibritumomab is used for RIT is a murin anti CD20 antibody. Ibritumomab in 90Y‐ibritumomab tiuxetan form bind to tiuxetan by a MX‐DTPA bind chelating agent’s assistance. It consists of ibritumomab covalently attached to tiuxetan(a chelator). The tiuxetan forms a stable link to the radionuclide, either 90Y for therapeutic doses. 90Y is a pure β emitter and its the mean effective path length in soft tissue invivo is 5mm, or approximately 100 to 200 cell diameters. The aim of our study with RIT targets radiation to cancer cells with relatively minimal risk to unaffected organs. Material‐Method: Between December 2005 and September 2008 9 NHL patients who were refractory and no response to rituximab based chemotherapy (R‐CHOP and R‐DHAP) or relapsed patients after standart combination chemotherapy included to our study. The ibritumomab tiuxetan treatment regimen consisted of pretreatment with rituximab (250 mg/m² intravenously on days 1st and 8th) to deplete peripheral blood B cells, then 90Y‐ibritumomab tiuxetan (0.4 mCi/kg; maximum, 32 mCi) intravenously on day 8th, administered on an outpatient basis. Results: 5 of nine patients were female and 4 were male. Their age average was 50.33 (26‐ 72). Three of our patients had follicular NHL and 6 patients had diffuse large B cell lymphoma.We administered 0.3mCi/kg 90Y‐ibritumomab tiuxetan to 3 patients whose platelet count was between 100.000‐149.000 /µL and 0.4Ci/kg (maximum 32 mCi) to rest of them whose platelet count were high then 150.000 /µL. All of 90Y‐ibritumomab tiuxetan’ s conjugation quality control percentage were high than 95%. There were no advers effects at administration period. After the administration of RIT, 5 patients(%55) had complete remission, 2 patient(%22), had partial remission, 2 patients (%22) who used combination therapy and ressistant to all therapies, died. A patient who has been in remission period of one and half years and after that time relapsed and died because of progressive illness and pulmoner infection. Conclusions: 90Y‐ibritumomab tiuxetan is the first radio immune therapy agent at relapse after rituximab administration or refractory 20CD(+) NHL patients. Finally 90Y‐ibritumomab tiuxetan radio immunotherapy is a useful new treatment modality for patients with B cell NHL who ressistant to standart combination therapies. More studies are required for the optimal role of RIT in the treatment of NHL.
P66 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radionuclide therapy/dosimetry: clinical: thyroid, bone pain palliation + misc
P565 Investigation of liothyronine effects on accumulated dose and exposure of thyroid cancer patients in radioiodine therapy, Isfahan, Iran D. Shahbazi-Gahrouei, M. Moslehi, Z. Shahi, P. Bonyadi; Isfahan Uni. of Medical Sciences, Isfahan, IRAN, ISLAMIC REPUBLIC OF. Background: Patients administered with a therapeutic dose of 131I for thyroid cancer treatment are potential sources of unacceptably high radiation exposure to other individuals, particularly the patient’s immediate family members. The aim of this study is to investigate effects of early liothyronine consumption after radio‐iodine therapy on accumulated dose and exposure rate in patients with thyroid carcinoma. This study was also undertaken to provide specific guidelines as to when 131I treated thyroid cancer patients may be safe to resume close contact with their family members. Methods: Forty patients treated postoperatively by 131I with first iodine therapy history were studied. These patients were divided into two groups of twenty group 1 with liothyronine and group 2 without liothyronine). The administered activity was 100 mCi for all patients. Thermoluminescent dosimeter chips were placed on the neck of the patients to measure thyroid dose. Liothyronine was administered 24 h after iodine therapy. Accumulated dose was measured at 12, 24, 36 and 48 h after iodine therapy. Exposure rate was also measured at 0.5, 1 and 1.5 meters from the patient’s body axis with Geiger‐Muller detectors at discharge time and a week after discharge time. Results: The findings indicated that liothyronine reduces accumulated dose of thyroid and fastens excretion from the body after 48 h in patients. The patient exposure rate was significantly higher in group 2 in both discharge time and a week after discharge time. Conclusion: This study shows that liothyronine consumption decreases the exposure rate of patients at discharge time to values lower than that recommended by relevant organizations.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Prospective evaluation of ALP, bone ALP and PSA serum 153 level after Samarium-EDTMP administration in patients with hormone-refractory prostate cancer and painful bone metastases J. Dolezal, J. Vizda, E. Urbanova, M. Matysova, P. Kafka; Teaching Hospital, Hradec Kralové, CZECH REPUBLIC. Aim: to present alkaline phosphatase (ALP), bone ALP and prostate‐specific antigen (PSA) serum levels changes after 153Samarium‐EDTMP treatment for painful bone metastases in patients with hormone‐refractory prostate cancer. Materials and Methods: Thirty‐nine men (aged 50‐83, median 72 years) with bone disseminated hormone‐refractory prostate cancer and bone pain received 153Samarium‐EDTMP. Mean applied dosage was 40 MBq per kg of patient’s body weight. The ALP, bone ALP and PSA serum levels were obtained before and 1 and 3 months after 153 Samarium‐EDTMP treatment. Changes in ALP, bone ALP and PSA were compared by analysis of variance (Fisher LSD test) after logarithmic data transformation and were expressed as median, minimum and maximum. Results: Significant pain relief was observed in 48% and 41% of patients, mild relief in 31% and 31% and no effect in 21% and 28% of patients one and three months after administration, respectively. The pain palliation was accompanied by an improvement in mobility and a decrease in necessary dosage of analgetics. Table shows ALP, bone ALP and PSA serum levels (median, minimum and maximum) 1 and 3 months after treatment. A decrease of ALP serum level 1 month after 153Sm‐EDTMP treatment was observed (p<0.05). 153Sm‐EDTMP administration had no statistically significant influence on bone ALP 153 serum levels (p>0.05). Sm‐EDTMP administration had no statistically significant influence on PSA serum level (p>0.05) 1 month after administration and a increase was observed 3 months 153 after Sm‐EDTMP administration (p>0.001). Conclusion: only a decrease of ALP serum level was observed 1 month after 153Sm‐EDTMP treatment. 153Sm‐EDTMP administration had no statistically significant influence on bone ALP, ACP a PSA serum levels.
basal
ALP (µkat/l)
7.36 (1.38‐41.7) 6.24 (1.42‐37.41) 6.49 (1.45‐67.23)
1 month
3 months
bone ALP (µkat/l) 2.64 (0.34‐39.72) 2.22 (0.28‐41.03) 2.8 (0.3‐36.8) PSA (µg/l)
44.4 (0.19‐749.8) 44.94 (0.23‐781) 90.6 (0.35‐2088)
P567 The effect of external irradiation on radioiodine excretion in remnants upon I-131 treatment of thyroid cancer patients O. Kozak1, O. Trembach2, O. Butrim3, O. Butrim3; 1Region Oncological Hospital, Kiev, UKRAINE, 2National Cancer Institute, Kiev, UKRAINE, 3 Central Military Clinical Hospital, Kiev, UKRAINE. The use of external irradiation in the treatment of patients with differentiated thyroid cancer is still under consideration. The aim of the study was to compare Tef in thyroid remnants in patients with and without external irradiation prior to radioiodine treatment. Patients and methods. 70 patients with thyroid remnants after resection of thyroid and dissection of lymph nodes were treated by I‐131. Patients were divided in two groups: Group I‐with external irradiation prior to treatment‐ 21 pts and Group II‐ who did not receive external irradiation ‐49 pts. Activities administered ranged from 1000 to 4500 MBq. I‐131 kinetics was followed daily during first 4 days after activity administration on the basis of scintigraphy. Tef in sequential courses of I‐131 treatment has been measured at the same patients. The probability of the full remnant ablation after the first course of radioiodine treatment (p) has been calculated. Results. It was shown that in Group I Tef = 3.87 days in average, in Group II Tef = 2.9 days. p was higher in the Group II as compared with Group I in every activity interval. In Group II Tef was actually the same in sequential courses of I‐131 treatment. At the same time in Group I Tef decreased in every patient. Conclusion. External irradiation resulted in slowing down of I‐131 excretion in thyroid remnants. Radioiodine treatment influences in different way at the previously irradiated and not irradiated cells.
P568 «Double product value» (DPV): A new semiquantitative index with pain response implications of 186Re-HEDP therapies for osseous metastases A. Zafeirakis1, A. Zissimopoulos2, N. Baziotis3, G. S. Limouris4; 1401 Army Hospital of Athens, Athens, GREECE, 2Demokriteion University of Thrace, Alexandroupolis, GREECE, 3St. Savvas Anticancer Hospital of Athens, Athens, GREECE, 4Araiteion University Hospital, Athens, GREECE. AIM: The aim of the present study was to describe a new semi‐quantitative method to predict pain response to 186Re‐HEDP therapy with the combined use of a modified bone scan index, based on the estimation of the size of the largest painful bony lesion, and pre‐therapy pain scoring. MATERIALS‐METHODS: Forty five patients (33 males with prostate cancer, 12 females with breast cancer), received 73 doses of 186Re‐HEDP during a period of pain relapse without extraosseous disease progression. All patients were under stable regimen of analgesics and zoledronic acid, far off other therapeutic manipulations. Degree (Level I; no response, to level IV; excellent response) and duration of pain response were recorded according to validated scoring methods. Imaging studies regarding a modified estimation of Bone scan index, were applied; the value of the largest bony lesion (called mBSI) was taken into account, provided that each one also corresponded to the most prominent site of osseous pain and a new index called «Double Product Value» (DPV), equal to pre‐therapy pain score times mBSI was entered in the response result analyses to investigate any possible correlations with response endpoints. RESULTS: Favourable response occurred after 35 of 47 evaluable therapies of the final database (74.5%; excellent response in 12 patients, 25.5%). Responders and predominately, excellent responders had significantly lower DPV (3.4+/‐2.3 vs 10.2+/‐6.2, P = 0.0029 and 2.0+/‐1.2 vs 6.2+/‐4.9, P = 0.000032, respectively). Patients with pre‐therapy DPV > 4 had lower probability for considerably better (HR 2.29; P = 0.00003), or excellent (HR 7.46; P = 0.0089) pain response versus those with
DPV=4, and also a lower median period of pain relief (respective values 2.1 months, range 0‐7 months and 5.9 months, range 1‐17 months, HR 2.82; P = 0.0001). CONCLUSIONS: This new index, as developed and implemented in the current study, provides a new and highly reproducible tool for assessing pain response after palliative therapies with 186Re‐HEDP. That method, taking into account only the most prominent single bone lesion instead of the BSI, is deprived of the drawbacks of the visual skeletal scoring systems; it is faster and less complex than total bone lesion counting or BSI calculations, yet unaffected by coalescent lesions. Finally, DPV appears as the best independent pre‐therapy variable, that provides a convenient stratification of the patients with metastatic bone disease who will gain the most profits from palliative radionuclide therapies.
P569 Radioiodine low-dose for remnant ablation in differentiated thyroid carcinoma: considerations of a pilot study. L. Burroni1, M. G. Castagna2, C. Cipri2, F. Pacini2, A. G. Vattimo1; 1Dept. of Nuclear Medicine, University of Siena, siena, ITALY, 2Dept. of Endocrinology, University of Siena, siena, ITALY. Total thyroidectomy followed by radioiodine ablation of residual thyroid tissue is considered the treatment of choice for differentiated thyroid carcinoma (DTC) because it facilitates subsequent follow‐up of the patients. The optimal activity required to achieve remnant ablation remains controversial. To assess the rate of successful ablation using low dose of I‐131 (555 MBq) after rhTSH preparation, in patients with DTC. We perform a pilot study on a selected population of 9 patients (6 F and 3 M; mean age: 66.5 years) with T1‐T2 tumors (mean size: 1.78±1.45cm) treated with total thyroidectomy and without evidence of extrathyroidal invasion or distant metastases at time of surgery. One injection of 0.9 mg of rhTSH was administered for two consecutive days; 24 hours after the last injection patients received 1.8 MBq of I‐131 orally and radioiodine neck uptake (RAIU) was calculated after 4 hours. After RAIU measurement patients received a therapeutic fixed dose of I‐131 (555 MBq) orally and whole body scan (WBS) was performed 72 hours later associated to an high resolution image acquired on the neck with a dedicated gamma‐ camera. Successful ablation was assessed 6 months after therapy, using serum Tg determination and diagnostic I‐131 WBS (185 MBq) after rhTSH administration. At neck ultrasound no patients had evidence of important thyroid remnant. Mean 4‐hours uptake value was 2.49±1.34%). The presence of areas of uptake in the thyroid bed was confirmed in the post‐dose WBS in all patients. No extrathyroid or distant metastases were revealed. Stimulated rhTSH serum Tg was detectable in all patients (mean value: 2.92±3.14 ng/ml). Successful ablation, defined as no visible uptake in the diagnostic WBS after rhTSH stimulation (6 months after therapy) was achieved in all patients. Basal and rhTSH‐stimulated serum Tg was undetectable (<1.0 ng/ml) in all of them. The interest in administering the smallest effective dose to achieve remnant ablation in DTC is the advantage of outpatient treatment with economy and convenience, associated to the decreasing risk of total body radiation. In conclusion, 555 MBq of I‐131 appears to be an effective activity for remnant ablation at least in this pilot study aimed ad the rationale basis for a large prospective study. Such a protocol would have the advantage of treating patients as an out patient basis with low social cost and lower radiation exposure.
P570 Ablative dose planning for radiodine therapy of grave's disease: Clinical and autoimmunity outcomes of a prospective study J. F. Nwatsock, F. Dong-a-zok; Yaounde General Hospital, Yaounde, CAMEROON. Background and Objective: Management of Grave’s disease (GD) includes antithyroid drugs (ATD), thyroidectomy and radioiodine. In existing literature, the optimal activity of 131‐ radioiodine, the effectiveness of this therapy and the autoimmune response are controversial. Moreover, the doses calculation requires procedures that are not achievable in all clinical settings. Ablative dose therapy is a more feasible alternative but remains insufficiently evaluated. We report an audit of clinical and autoimmunity outcomes of radioiodine therapy of GD in a resource‐limited setting. The aim of this study was to determine the effectiveness of radioiodine therapy after an ablative activity and to assess the effects of this treatment on TSH‐receptor autoimmunity. Research design and methods: In March 2006, we introduced the systematic use of protocol based on high standard activities of 131‐radioiodine administration, careful hydration and affordable follow‐up for the management of GD in Yaounde. We included prospectively all patients referred for GD radioiodine therapy in Yaounde General Hospital. Clinical and biological data were collected and were independently coded and compared for outcomes including treatment effectiveness as primary endpoint and evolution of TSH‐receptors autoimmunity as secondary endpoint. Results: A total of 82 patients were treated. Their age ranged from 22 to 52 years with a mean of 40±14.1 years and a F‐to‐M ratio of 6/1. The mean duration of GD since the diagnosis was 3±1.1years with 76% of patients having more than 5 years old of recurrent GD (p=0.05) and 3% having a previous thyroid surgery. Concerning the primary endpoint, 91.8% of all patients achieved hypothyroidism and euthyroidism after 3 months of follow‐up versus 98.6% at the end of study. The duration of disease before radioiodine therapy and the presence of TRAb>3Ui/l after 1year of follow‐up were significantly associated (p=0.03) with poor outcome (failure of therapy). Radioiodine therapy was followed by a disappearance of blood TRAb within 1 year following treatment in 78.1% of the patients. However, the overall duration of follow‐up was 2.6 years. Conclusion: The proposed ablative dose planning can be safely used to treat GD with better outcomes than in literature. Key words: Grave’s disease, radioiodine therapy, autoimmunity, TSH receptors
P571 Bone targeted therapy of strontium-89 in combination with chemotherapy for metastatic bone cancer M. Yoshimura, S. Nagase, K. Koizumi, K. Uchida, J. Park, K. Saito, S. Akata, N. Kanesaka, K. Tokuue, D. Kakizaki; Tokyo Medical University, Shiujuku-ku, Tokyo, JAPAN.
Poster Presentation
P566
S422 Aim: It is difficult to schedule the appropriate combined therapy with chemotherapy, external beam radiotherapy and strontium‐89 for the metastatic bone cancer because each treatment has the similar side‐effect, that is, myelosuppression. Sometimes the prior chemotherapy makes it impossible to administer strontium‐89 or the prior strontium‐89 causes the alteration of the following chemotherapy. According to the EANM guideline for treatment of refractory metastatic bone pain, long‐acting myelosuppressive chemotherapy (e.g. nitrosoureas) should be discontinued at least 4 weeks prior to administration of strontium‐89 and withheld for 6 ‐12 wk post therapy to avoid concomitant myelosuppression. On the other hand treatment can be safely combined with local field external beam radiotherapy. So we assessed if the bone targeted therapy of strontium‐89 in combination with the first chemotherapy for metastatic bone cancer could be underwent tolerantly. Materials and methods: Six patients who were diagnosed primary lung cancer or gastric cancer with metastatic bone pain were assessed. All patients received conventional palliative external beam radiation therapy (EBRT) to the most painful site or to the threatened bone fracture previously. About 2 weeks later from EBRT, the first chemotherapy was started during 2‐3 days from the administration of strontium‐89. Types of the chemotherapies are as follows;CBDCA+PTX, CDDP+GEM, CDDP+CPT, DOC, TS‐1. In the first course of the chemotherapy, total dose were reduced to 80% of the standardized dose. Every patient received each chemotherapy 2 or more courses, and was followed for more 12weeks. Toxicity was scored according to the Common Terminology Criteria for Adverse Events (CTCAE) version 3.0. Results: Grade3 or more hematological toxicity was not observed. No following schedule of chemotherapy was prolonged or canceled because of myelosuppression, and the response to the treatment was better than the chemotherapy alone. Conclusion: The bone targeted therapy of strontium‐89 in combination with the first chemotherapy for metastatic lung and gastric cancer was well tolerated. This option improved clinical outcomes in patients with painful metastatic bone tumor much more than commonly used criteria of strontium‐89.
P572 Relation between clinical and laboratory parameters with radiation dose rates from patients receiving iodine-131 therapy for thyroid carcinoma N. Baharfar1, I. Neshandar Asli1, B. Shafiei1, F. Tabei1, H. Javadi2, M. Assadi3; 1Department of Nuclear Medicine, Taleghani Hospital, Shahid Beheshti University of Medical Science, Tehran, IRAN, ISLAMIC REPUBLIC OF, 2Department of nuclear medicine, 5 AZAR Hospital , 5 AZAR street, Gorgan, IRAN, ISLAMIC REPUBLIC OF, 3The Persian Gulf Health Research Center, Bushehr University of Medical Sciences, Bushehr, IRAN, ISLAMIC REPUBLIC OF. Aim: Analyze the external and internal radiation arising from the thyroid cancer patient treated with 131I, with some specific clinical and laboratory parameters. Matherials & Methods: Three days following administration of RAI in 38 patients, a radiation detection survey meter with a calibrated ionization chamber to check the exposure rate in millirem per hour in adjacent two bags (One to be used for clothes during hospitalization and another to be used for bedsheet clothes) and at l meter from bags in three directions and record mean of them. Following variables were measured: Dose rate close to the dress (D0) , dose rate of dress at 1 m (D1), dose rate close to the bedsheet (B0), dose rate of bedsheet at 1 m (B1) , dose rate of patient at 1 m (P1) and also sum of D1 and B1 (S1). In addition, TSH level, thyroglobulin, anti‐thyroglobulin levels, the presence of metastasis and also reason for dosimetry (ablation vs. follow up) were also carried out. Results: The patient population consisted of 36 females and 2 males, ranging in age from 14 to 72 years old (mean 38.92 ± 15.76 years). A significant correlation was found between age and P1, age and S1 as well as administered dose and P1 and also S1 and P1 values. There were no significant differences in the age , D0 , D1, B0, B1, TSH , Tg and anti‐Tg in three different administered dose groups using ANOVA test but post‐hock test just showed significant difference in the P1 between patients who received 3700 MBq and 7400MBq. In addition, no significant relation between administered dose and D0, number of admission and P1, Tg and B1, Tg and B0, Tg and D1, Tg and D0, Tg and P1, age and D1, Tg and B1, D1 .A careful analysis failed to reveal any significant differences among reason for admission (ablation vs. follow up therapy) and metastatic variable with exposure rates of bags and also patient . Conclusion: Our data demonstrated a positive correlation among radiation exposure from patients and clothes with age and treatment dose after 3 days admission in patients who suffering from differentiated thyroid carcinoma treated with radioactive iodine. These results may prepare a document to practitioners and also all individuals coming in contact with older patients to be made aware of the contamination and radiation hazards. Key words : radiation , thyroid carcinoma, thyroglobulin
P573 Sm-153-EDTMP Uptake does not Predict Haematologic and Therapeutic Response H. Sinzinger1, E. Havlik1, E. Trifina1, S. Granegger1, K. Weiss2, B. Palumbo3, R. Palumbo3; 1Medical University Vienna, Vienna, AUSTRIA, 2 Nuclear Medicine, Wiener Neustadt, AUSTRIA, 3University of Perugia, Perugia, ITALY. Sm‐153‐EDTMP became an accepted treatment for bone pain palliation and benefits beyond in patients with bone recurrences. Optimal dose and application schemes are still under debate. Dosimetric approaches to individualize therapeutic dose would be helpful, but did not succeed so far, their prospective value is unknown. Aim of our analysis was to assess whether bone uptake correlates to haematologic (red and white blood cells, platelets, hemoglobin, hematocrit) and therapeutic response. We examined the uptake of 30 mCi (1,1 GBq) Sm‐153‐EDTMP in 226 hormone refractory prostate cancer patients aged 48 ‐ 76 years with multiple bone lesions naïve to chemo‐ or radiotherapy, correlating it to body weight, waist circumference and BMI, the intraindividual variation after repeated (5 x) administration according to the Vienna protocol, number of visible lesions ( 10) therapeutic response (pain response, flare, lesion stabilization, effects on adhesion molecules and PSA) as well as haematological toxicity. During repeated therapy the Sm‐153‐EDTMP uptake within the same patient is rather constant. In contrast, the interindividual findings (29‐83%) are varying considerably. The uptake showed no correlation to the number of lesions, body weight, pain response and other parameters of therapeutic benefit, nor to myelotoxicity. These findings indicate no significant correlation of administered dose to
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 body weight, uptake and therapeutic and/or haematological response. Consequently, the data do not support any value of prospective dosimetry for later Sm‐153‐EDTMP‐therapy.
P574 Earlier Radio- and/or Chemotherapy does not Significantly Change Hematologic and Platelet Function Response up to 5 Treatments H. Sinzinger1, E. Trifina1, S. Granegger1, B. Palumbo2, R. Palumbo2; Medical University Vienna, Vienna, AUSTRIA, 2University of Perugia, Perugia, ITALY. 1
Since Sm‐153‐EDTMP is more and more (repeatedly) used in early metastasized cancer stages, a potentially enhanced haematotoxicity, especially with earlier radio‐ and/or chemotherapy, is a key concern. In particular, as preliminary reports reveal, that a combined treatment may significantly further improve clinical outcome. In a total of 262 patients with multiple bone recurrences, haematological response (peripheral white [WBC]‐ and red blood cells [RBC] and platelet count [PC], radiotherapy [RT] and ADP‐induced platelet aggregation [PA]) to low‐dose (30 mCi) Sm‐153‐EDTMP according to the Vienna protocol in prostate cancer patients without earlier RT was compared to females with breast cancer receiving earlier RT or chemo (CT)‐ and RT, and finally prostate cancer patients receiving RT before Sm‐153‐EDTMP (tables). Blood was drawn before each treatment dose as well as 3 and 6 weeks thereafter. Earlier treatment with either RT and/or CT did not significantly affect both, duration and extent (%‐change) of RBC, WBC and PC as well as platelet function. Despite a temporary drop in peripheral platelet count, platelet functional activity per cell is temporarily increased in all the patient groups. Multiple treatments according to the Vienna protocol up to 5 times did not affect the extent of the changes either. The findings indicate that under careful surveillance Sm‐153‐EDTMP therapy at 30 mCi doses after or during chemo‐ and/or radiotherapy is remarkably safe. Whether this is also applicable for more often therapeutic Sm‐153‐EDTMP applications according to the Vienna protocol or higher single doses still needs to be assessed. 1.
prostate cancer
‐RT
+RT
+RT/CT
N
100
31
28
Age
51‐76
54‐73
52‐69
2.
breast cancer
+RT
+RT/CT
n
56
47
age
44‐69
47‐71
P575 Thyroid echogenity as a prognostic factor of the outcome of radioiodine therapy in patients with Graves’disease I. I. Iakovou, A. Doumas, T. Christoforidis, V. Nikos, K. Badiavas, D. Lo Presti, S. Georga, N. Karatzas; Nuclear Medicine dept. of the Aristotle University, General Hospital “G. Papageorgiou”, Thessaloniki, GREECE. Aim: the study assesses the role of thyroid echogenity as a prognostic factor of the outcome of radioiodine therapy in patients with Graves’disease. Method: 78 patients with Graves’disease (67 women and 11 men) enrolled in our study. All patients received 131I, assigned to the intended target dose of 200 Gy. Ultrasound examination was performed before 131I administration, 2‐3 days after cessation of antithyroid drugs ranking thyroid echogenicity as hypoechoic or not. A 12 months follow up was performed. Results: Thyroid echogenicity of 44 patients (56%) was ranked as hypoechoic (group A). At 12‐month follow‐up 3 (6.8%) of these patients were euthyroid, 1 (2.2%) hyperthyroid and 40 (91%) hypothyroid. In the rest 33 (44%) patients with no hypoechogenicity (group B) there were 7 (21.4%) euthyroid, 5 (15%) hyperthyroid and 21 (63,6%) hypothyroid patients. Conclusions: In patients with a hypoechogenic gland at 12‐month follow‐up there were more hypothyroid and less hyperthyroid or euthyroid results in comparison of these in group B (p<0.05) setting the evidence that in patients with Graves’ disease hypooechogenic glands are associated with slighter radioresistance.
P576 Pain palliative therapy in women with bone metastases from breast cancer and the role of specific plasma markers as prognostic factors. I. I. Iakovou, V. Nikos, T. Christoforidis, K. Badiavas, D. Lo Presti, S. Georga, A. Doumas, N. Karatzas; 3rd Nuclear Medicine dept. of the Aristotle University, General Hospital “G. Papageorgiou”, Thessaloniki, GREECE. Aim: The study evaluates the effect of treatment with Strontium‐89‐chloride (89Sr) and 186Re‐ 1,1‐hydroxyethylidene diphosphonate (186Re‐HEDP) on pain symptoms, quality of life and bone marrow function in women with painful bone metastases from breast cancer and investigates the role of specific plasma markers as prognostic factors. Method: In total 42 women with breast cancer enrolled in this prospective non‐randomized study. 24 patients were treated with 186Re‐ HEDP and 18 patients with 89Sr. All patients were interviewed using standardized sets of questions before and after therapy weekly for 3 months. Pain palliation was evaluated on the basis of the Wisconsin pain test improvement and response was graded as complete, partial, minimal or absent. Blood counts were taken weekly for 6 weeks and after 3 months. Haematological toxicity and side effects were reported according to WHO guidelines. Correlation between serum interleukin‐2 (IL‐2) and tumour necrosis factor‐a (TNF‐a) levels and the response to therapy was also studied. Results: Treatment efficacy was complete in 47.6% of patients, partial in 33.3% and negative in 19% of patients. The global response rate was 83% for 89Sr and 80% for 186Re‐HEDP, respectively. There were eight patients with a thrombocytopenia grade I, two patients with grade II and one with grade III. Platelet and white blood cell counts returned to baseline levels within 6‐12 weeks after therapy. Patients who respond to palliative therapy had
S423
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P577 Is serum beta-hCG testing useful for the exclusion of pregnancy, prior to radioiodine (I-131) treatment for benign thyroid disease? A single centre experience S. K. Gupta, G. Lewis, M. Saul, S. Viswanathan, L. Allen; Department of Nuclear Medicine & PET, John Hunter Hosptial, Newcastle, NSW, AUSTRALIA. Introduction: Pregnancy is an absolute contraindication to radioiodine therapy. The methods of exclusion of pregnancy include careful menstrual history, a written declaration, urinary beta hCG, serum beta hCG testing or a combination of these. In a busy department, reliance on menstrual history alone may be associated with errors. A urinary beta hCG also has been reported to be associated with failure to detect pregnancy leading to inadvertent radioiodine administration. We aimed to assess possible failure rates to detect pregnancies if declaration alone, as a method of exclusion of pregnancy is used. Methods: John Hunter Hospital is a large tertiary hospital and a large number of nuclear medicine studies and therapies are performed every year in its Department of Nuclear Medicine. Serum beta hCG testing is routinely performed less than 48 hours before treatment of fertile female patients, irrespective of patient declaration. Pregnancy is excluded when the serum hCG concentration is less than 2 IU/L. 1641 radioiodine treatments for goitre and hyperthyroidism were given to 1188 patients between 2003 and 2007 (inclusive). We audited the cancellations of radioiodine treatments performed during this period. Pregnancy test results for these patients were scrutinized, and final outcomes of positive pregnancy tests were identified. Results: A cohort of 472 females less than 55 years age underwent 663 treatments. A positive serum β‐hCG test led to the cancellation of scheduled treatment for four patients. Two patients were later found to be non pregnant and the serum beta hCG returned to normal. There was no incident of inadvertent radioiodine treatment during pregnancy. Conclusion: Reliance on patient declarations alone could have led to inadvertent administration of radioiodine to two pregnant women. Therefore, we recommend exclusion of pregnancy by serum beta hCG in every woman of child bearing age prior to radioiodine treatment.
P578 Kinetics of I ¹³¹ in patients with hyperthyroidism combined with chronic kidney disease or end stage kidney disease on renal replacement therapy. E. Filipowicz, M. T. Plazinska, S. Niemczyk, M. Kobylecka, Z. Shebani, K. Giers, L. Krolicki, J. Matuszkiewicz_Rowinska; Warsaw Medical University, Warsaw, POLAND. I ¹³¹ therapy is an effective method of treatment of hyperthyroidism. The problem is to establish the effective and safe therapeutic dose of radioisotope I ¹³¹ in pts with hyperthyroidism combined with renal failure due to impaired iodine excretion, prolonged effective half‐life of I¹³¹ and iodine removal during dialysis sessions in RRT pts. The aims of this study was to estimate the kinetics of I ¹³¹ in pts with hyperthyroidism and CKD or ESRD on RRT ( HD and PD). The kinetics of I ¹³¹in CKD were calculated only in pts with thyroid cancer. Subjects and methods: The survey included 9 pts with CKD (III‐V stage) , aged 25‐83y( mean 64Y) and 10 pts with ESRD, aged 53‐80y ( mean 64y) and hyperthyroidism. In 7pts Graves‐Basedow disease and in 14 Plammer disease (nodal goiter) was found. In all pts the thyroid gland scintigraphy with diagnostic dose of 4 MBq isotope I¹³¹ was performed and a 9 day evaluation of radioactivity was made. Then the effective time was calculated. The effective time (ET) of half‐life radioactive decay of I¹³¹ induced by excretion and physical decay together were determined. T½ x T excr Formula ET= ‐‐‐‐‐‐‐‐‐‐‐ T½ + T excr In subjects with hyperthyroidism and normal range of GFR the I ¹³¹ ET results were 5‐6 days. In the examined group in 21 pts ET was considerably increased. In RRT pts an average of 55,4 and in CKD pts 16,8 . For statistical analysis nonparametric U‐test (Mann ‐ Whitney test) were applied Tab. 1 Patients on renal replacement therapy gender Thyroid disease GFR ml/min Residual diuresis Type of RRT I¹³¹ dose ET1/2 I¹³¹
Sultan Mehmet Hospital, Radiology Department, İstanbul, TURKEY, 4 Okmeydanı Hospital, Orthopedics Department, İstanbul, TURKEY, 5 Okmeydanı Hospital, Department of Pediatrics, İstanbul, TURKEY. Aim The objective of our study was to determine the role of Magnetic Resonance (MR) imaging and X‐ray studies in assessing the treatment response after radiosynovectomy in patients with hemophilic arthropathy (HA). Materials Eleven patients who suffered from hemophilic arthropathy with a mean age of 11,7 (range between 7‐15) were included in this study. Patients who fulfilled the following prerequisites were included for Y‐90 synovectomy application: (1) more than four hemorrhagic episodes in six months (2) at least a Stage II hemophilic arthropathy according to the classification of Arnold and Hilgartner (3) persistent synovitis. Ten knee joints of ten patients were administered 148‐185 MBq Yttrium 90 silicate (Yt‐90) intraarticularly and one patient was treated with intraarticular 74 MBq Rhenium 186 (Rh‐186) injection into his ankle. We evaluated the X‐Ray graphies and MRI of the joints of the patients before and 6 months after the treatment. Radiographs of each joint were coded according to the Petterson scale with a possible scale of 0‐13 points. MR images were evaluated according to Denver MR Hemophilic Joint Scale. Follow‐up evaluation of the patients was also made with the use of clinical and radiological classification of the Orthopaedic Advisory Committee of the World Federation of Haemophilia (WFH) considering pain, bleeding, clinical features and radiographic changes. Results In six patients a decrease in the frequency of bleeding episodes was observed together with a fall in the WFH scores while there was no change in the MR and X ray scores. In two patients there was an increase in bleeding frequency and WFH scores but X ray and MR scores didn’t show any change. In two patients there wasn’t any change in bleeding frequency, WFH, MR and X ray scores. In one patient there was an increase in WFH, MR and X ray scores associated with an increase in bleeding frequency. The aim of radiosynovectomy is to prevent joint destruction by eliminating frequent joint bleeding before the onset of arthropathy. In this study group there wasn’t a significant correlation between the changes in the bleeding frequency and scores of MR and X ray. Although the number of cases in this study are not sufficient to get statistically significant results, in our opinion, MR and radiographic evaluation are not good indicators of response to radiosynovectomy at least at the sixth month following the application.
P580 Management of thyroid carcinoma in patients with younger age M. Gabriel, D. Waitz, D. Putzer, A. Kroiss, D. Kendler, I. Schnegg-Rehwald, R. Prommegger, I. J. Virgolini; Medical University of Innsbruck, Innsbruck, AUSTRIA. Introduction: During the last year more than 130 radioiodine therapies were applied to patients with thyroid carcinoma at our therapy ward (University Clinic of Innsbruck, Austria). This retrospective analysis shows our experiences in the management of thyroid carcinoma patients with an age younger than 30 years seen within the last 12 months. Patient Material: Eleven patients (10 female and 1 male; range, 15‐27 years; mean age, 23 years) were included. Ten patients suffered from papillary thyroid carcinoma and one patient from follicular carcinoma. In nine cases cervical lymph node metastases were observed and one 26‐year old female patient showed radioiodine positive lung metastases. Intra‐thyroidal spread was observed in 7 and Stage pT3 in 6 patients. Thyroglobulin was elevated in 10 patients. None of the patients showed elevated Tg‐antibodies. All patients received at least one therapy with radioiodine. In 5 patients two radio‐iodine therapies were applied, in one female patient 4 therapies and in an other even 5 therapies with a cumulative dose of 25,4 GBq. This patient was also treated twice by surgery because of a lymph‐node metastases and local tumor recurrence. Results: According to this analysis young‐aged patients frequently show advanced stages at initial diagnosis and lymph‐ node metastases can be found in a high percentage (9/ 11). Three of these patients underwent re‐operation because of an 18F‐FDG‐positive cervical finding due to metastatic spread. In one female patient, as mentioned above, the second surgical intervention was also guided by 18F‐ FDG‐PET because of tumor recurrence. One patient underwent the second surgery because of radioiodine positive lymph‐node metastases in the neck. Post‐therapy scanning revealed lung metastases in a 26‐year old female patient. Surgical interventions and radionuclide therapies were well tolerated and no short‐term toxicity was observed. Conclusions: Because thyroid carcinomas can be frequently observed in advanced stages with higher risk of recurrence, initial tumor management is of high relevance in patients with younger age. In particular, thyroidectomy should also include lymph‐node dissection prior to radioiodine ablation. In case of suspicion for tumor recurrence during follow‐up a more comprehensive re‐evaluation is required using also 18F‐FDG PET to early detect unknown tumor lesions.
F
Plammer
11,6
1000
HD
4MBq
14
F
Plammer
0
0
HD
4MBq
24
F
Plammer
5.24
800
HD
4MBq
25
P581
M
Graves‐Basedow 11
1000
PD
4MBq
26
M
Plammer
2.1
400
HD
4MBq
20
Radiation doses to family members of patients treated with 131I
F
Plammer
0.98
300
HD
4MBq
29
F
Plammer
0.3
50
HD
4MBq
33
M
Plammer
0.2
100
HD
4
315
F
Plammer
7.85
1500
HD
4
53
M y
Graves‐Basedow 5.3
1200
HD
4
15
Tab. 2 patients with CKD Conclusions: 1. I ¹³¹effective decay time in patients with CRF is highly extended. 2. For an effective and safe treatment of hyperthyroidism in pts with CKD or RRT therapeutic radioisotope dose must be significantly reduced and calculated individually .
P579 The Efficacy of Magnetic Resonance Imaging and X-Ray in the Evaluation of Response to Radiosynovectomy in Patients with Hemophilic Arthropathy F. Özülker1, T. Özülker1, E. Eray Özgönenel2, E. Derin3, M. Altun4, F. Pekün5; 1Okmeydanı Hospital, Nuclear Medicine, İstanbul, TURKEY, 2 Avrupa Şafak Hastanesi, Nuclear Medicine, İstanbul, TURKEY, 3Fatih
M. Zdraveska-Kocovska, O. Vaskova, S. Kuzmanovska, V. Majstorov, E. Janevik-Ivanovska, S. Miceva Ristevska; Institute of pathophysiology and Nuclear Medicine, Medical Faculty, Skopje, MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF. AIM: Patients who receive therapeutic amounts of 131I are a potentially significant source of radiation to their family members, members of the public and others. The aim of this study was to assess the level of radioactivity received by relatives of patients treated with radioiodine (131I) for hyperthyroidism and thyroid cancer. METHOD: 15 relatives of hyperthyroid and 15 relatives of thyroid cancer patients were monitored for seven days for radiation after discharging the patients. Thyroid cancer patients were hospitalized for three days and then discharged at aproximatly 400 MBq to 800 MBq residual activity of 131I, and hyperthyroid patients were treated on outpatient basis. The administered activity was given in average of 436 MBq (min 185 MBq and max 1100 MBq) for hyperthyroid patients and an average 3946 MBq (min 3700, max 5550 MBq,) 131I for thyroid cancer patients. The thermoluminiscence dosimeters were used for measuring total personal dose equivalent to family members of the patients. They wore the TLD’s for seven days. The Radiation doses were read with a reader model Thermo 6600 Plus DX TRAD with TLD card model Harshaw 0110 (LiF). The results were compared to the dose constraints of 1 mSv for children, 3 mSv for adults and 15 mSv for elderly as imposed by ICRP. RESULTS: In this study we have observed only two children aged (12 and 8) and the personal dose equivalent they get it was 0,15 mSv and 0,27 mSv respectively. The children were in relation with hyperthyroid
Poster Presentation
higher IL‐2 and lower TNF‐a concentrations than non‐responders. Conclusion: Both radiopharmaceuticals were effective in pain palliation, without induction of severe side effects or significant differences in therapeutic efficacy or toxicity. IL‐2 and TNF‐a are plasma markers proved to be useful indicators of patient response to palliative treatment.
S424 patients. For adult group the observed median personal dose equivalent was 0,66 mSv (min 0,03 mSv, max 1,25 mSv) for hyperthyroid patients and 0,18 mSv (min 0,01 mSv, max 0,43 mSv) for thyroid cancer patients. From the observed results we found that all groups were well below the dose limits. CONCLUSION: The radiation dose to family members of hyperthyroid and thyroid cancer patients are well below the recommended dose limits by the ICRP . The measured doses to family members of hyperthyroid patients were slightly higher compared to doses of family members of thyroid cancer patients, but still enough low compared with a concept of dose constraints. We can conclude that at our institution radioiodine therapy has been performed on quite good safe way, either for hyperthyroid and thyroid cancer patients.
P582 Iodine-131 treatment of hyperthyroidism: our experience. A. Campenni'1, R. M. Ruggeri2, E. Amato1, S. Castorina1, M. Raniolo1, A. Ruggeri1, F. Trimarchi2, S. Benvenga2, S. Baldari1; 1Dep of Radiological Science, Unit of Nuclear Medicine, Università di Messina, Messina, ITALY, 2 Unit of Endocrinology, Università di Messina, Messina, ITALY. Radio‐iodine treatment (RIT) is a well‐established method for treatment of hyperthyroidism due to Graves' disease (GD) or toxic adenoma (TA) and toxic multinodular goiter (TMG). To evaluate the long‐term effects of RIT on thyroid function, we have retrospectively reviewed the records of 463 patients [132 men and 331 women, age 69 +10 yr] who had received 131I for GD (n = 33), single NTG (toxic adenoma TA, n = 254) or multiple NTG (MNTG, n= 176) at our institution during a 15‐year period (1993‐2007). The dose had been calculated taking into account: i) number and volume of the “hot” thyroid nodule(s) in TA and TMG or the sonography‐measured volume of the whole thyroid in GD; ii) the radioiodine thyroid uptake (RTU), measured at 6, 24 and 48 hours, assuming a standard 5‐day half time of 131I within the thyroid. The RTU mean value was 58% (range 16‐98), and the administered dose range was 185‐1100 MBq (mean 548 MBq). About 50% of patients received anti‐thyroid drugs, that were withdrawn 2‐3 weeks before. No side effects were observed within 4 weeks after RIT. 263 patients [69 men and 164 women, F:M 2.4:1; age 68.5 + 10 yr; GD, n=11; TA, n=167, MNTG n=85; mean RTU 57%, range 17‐93; administered dose range 158‐1110, mean 555 MBq] were followed‐up for 2‐144 months (mean 18 months). 17 patients needed two (n=15) or three (n=2) RIT. A 131I thyroid scan was performed 3 months after RIT in 134/263 patients (51%, all TA or TMG). In 122/134 patients (91%) thyroid scan demonstrated total (n=68) or partial (n=54) ablation of the hot nodule(s). 224/263 patients (85%) were euthyroid (successfully treated) within 3 months after RIT (mean 2 months). Among these 224 patients, 58 (26%) developed hypothyroidism 11.5 months (range 6‐72) after RIT. The cumulative incidence of hypothyroidism at 1, 2, 5 and 10 years was 17.4%, 23%, 24.5% and 26%, respectively. Overall, hypothyroidism was 2.5 folds more frequent in GD (6/11) than in either TA (34/167) and MNTG (18/85)(χ2=7.072, P<0.05). In contrast, the rate of persistent hyperthyroidism did not differ significantly. Persistent hyperthyroidism was demonstrated in 39/263 patients (15%): GD=1/11; TA=20/167; MNTG=18/85 (χ2=3.20, P>0.05). None of the patients followed‐up at least 5 years developed bladder or stomach cancer. Considering permanent hypothyroidims as a successful outcome, RIT was successful in 224/263 patients (85%), confirming that RIT is effective and safe for the treatment of hyperthyroidism.
P583 Factors predicting hypothyroidism after radioiodine therapy of toxic nodular goitre hyperthyroidism S. Isgoren, G. Daglioz Gorur, H. Demir, M. A. Oc, C. Haksal, F. Berk; Kocaeli University, Kocaeli, TURKEY. Toxic nodular goitre (TNG) is a common form of hyperthyroidism especially in iodine deficiency areas. Radioiodine (RAI) is an effective form of therapy in this disorder. Nevertheless hypothyroidism after RAI therapy for TNG is not so rare. AIM: The aim of this study was to evaluate the factors affecting the occurrence of hypothyroidism after fixed dose RAI therapy for TNG. METHODS: A total of 167 patients (mean age: 55±12 years; 112 female) who were treated with 15 mCi single fixed dose RAI for TNG (including 87 with toxic adenoma and 80 with toxic multinoduler goitre) and who had a complete follow‐up after 9‐24 months (mean: 12.93±4.12 months) were included in this study. Thyroid sonography, thyroid scintigraphy and radioiodine uptake test were performed in all patients within 2 weeks prior to therapy. Factors possibly affecting post‐RAI hypothyroidism including age, gender, body mass index (BMI), pretreatment dose of anti‐thyroid drugs, 4th and 24th hour RAI uptake level, 4th/24th hour uptake ratio, diagnosis (toxic adenoma or toxic multinoduler goitre), size of the dominant hyperactive nodule, hyperthyroidism severity (subclinical or clinical) and existence of suppressed extranodular thyroid parenchyma on thyroid scan were analyzed. RESULTS: During follow‐up, 29 patients (17,4 %) became hypothyroid. However, 27 patients (16,2 %) remained hyperthyroid and 111 patients (66,4 %) became euthyroid. When analyzing possible factors affecting post‐therapy hypothyroidism, there was no significant difference with age (p=0,48), gender (p=0,81), BMI (p=0,76), pretreatment dose of anti‐thyroid drugs (p=0,89), 4th and 24th hour RAI uptake level (p=0,46 and p=0,39 respectively), 4th/24th hour uptake ratio (p=0,71), diagnosis (p=0,65), size of the dominant hyperactive nodule (p=0,14) and hyperthyroidism severity (p=0,55) between patients with and without hypothyroidism. Nevertheless, occurrence of hypothyroidism was significantly high in patients with absence of suppressed extranodular thyroid parenchyma on thyroid scan (p<0,01). CONCLUSION: In this study, we found hypothyroidism rate 17,4 % following a fixed 15 mCi RAI therapy for TNG. However, hypothyroidism rate is higher in patients with absence of suppressed extranodular thyroid parenchyma on initial thyroid scan. Thus, these patients must be closely monitored for the development of this disorder.
P584 The Side-Effects Observed During the First Three Months Following I-131 Therapy for the Differentiated Thyroid Carcinoma G. Çapa Kaya, M. Koç, Ö. Özdoğan; Dokuz Eylul University School of Medicine Dept. of Nuclear Medicine, Izmir, TURKEY. Aim: The side‐effects due to the administration of I‐131 can be classified as the short‐term (during the hospital stay), the intermediate‐term (following discharge, until 3 months) and the
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 late‐onset (observed after the first 3 months) side‐effects. In our institute we started with radioiodine ablation and metastases therapy last year following the completion of the therapy rooms. We aimed to document the observed side‐effects during the first 3 months following I‐ 131 therapy. Materials & Methods: A total of 69 patients (49 women, 20 men) with the mean age of 45 ± 13 (min: 19, max: 77) years were included in the study. A questionnaire was prepared to record the side‐effects. Nausea, vomiting, pain and tenderness in the neck, abdominal distension, taste and smell disorders, dry mouth and the eye symptoms like dryness, pain, redness and watering of eyes were evaluated. The questionnaire for the side‐effect was filled for every patient (69 patients) during the hospital stay and for 51 patients at third month. Results: An ablative dose of 100mCi was given in 45 patients. The rest of the patients were treated with 150mCi (11 patients), 175mCi (5 patients), 200mCi (3 patients), 75mCi (3 patients), 40mCi (1 patient). A cumulative dose of 350mCi was given in the last patient. The short‐term side‐effects were pain in the neck (36%), dry mouth (32%), nausea (28%), aphagia (20%), taste disorder (19%), cough in the morning (10%), eye disorders (9%), smell disorders (4 %) and vomiting (4 %). The intermediate term side‐effects were dry mouth (22%), eye disorders (20%), pain in the neck (18%), aphagia (6%), cough in the morning (6%), nausea (4%) and taste disorder (2%). There was not any correlation between the doses of I‐131 and the side‐effects. The side‐effects were declared to be more frequent with the doses greater than 200mCi in the literature. In our study group all the patients were given 200mCi or lower doses, and the cumulative dose was higher than 200mCi only in one patient. Conclusions: Dry mouth and pain in the neck were the predominating side‐effects both during short‐term and intermediate‐term. The incidence of eye disorders was increased during first 3 months. Nausea, aphagia and taste disorders were all decreased during this period. The awareness of short and intermediate term side‐effects will increase the success in patient education. It will also help physicians to compose more effective patient information leaflets.
P585 Samarium-153-EDTMP for Treatment Metastasis in Patients with Superscan
of
Painful
Bone
I. Slim, I. Yeddes, S. Krimi, I. El Bez, B. Letaief, A. Mhiri, F. Ben Slimene; Nuclear Medicine Department, Salah Azaiez institute, Tunis, TUNISIA. Introduction: Bone metastasis are a major complication of several different cancers and can lead to severe pain. Bone‐seeking radiopharmaceuticals are one of the available therapeutic tools for palliation of bone pain. It may be preferable in the case of diffuse metastatic bone involvement. Aim: the aim of our study was to assess the effectiveness of Samarium‐153‐ EDTMP for palliation of metastatics bone pain in patients with superscan appearance on bone scintigraphy. Patients and Methods: between January 2004 and December 2008, we treated 67 patients with Samarium‐153‐ EDTMP (1mCi/kg) for painful bone metastasis. In 11 from them (10 male, 1 female), a metastatic superscan appearance was faound in bone scintigraphy with various cancers (7 prostate, 2 bladder, 1 breast, 1 nasopharynx). All of this 11 patients had blood cell count within certain limits (leukocyte > 2.5 x 109/L and thrombocyte >100 x 109/L). Seventy two percent of them were taking opioid analgesics (8/11). After Radionuclide therapy, patients were followed‐up by assessment of pain palliation and hematologic tests every 2 weeks until 2 monthes. Results: pain palliation was achieved in 55% of patients (6/11), without change of the opioid analgesics consumption. In the 6 responding patients, the mean VAS (visual analogue scale) value decreased from 6.5 (±1.51) to 3 (±1.1; p<0.05) and the mean Karnofsky value increased from 53% to 69% (p<0.05). The pain relief was complete in only one patient. hematologic toxicity was observed in 63% of patients (7/11). Grade 2 or less toxicity was observed in 72%. Grade 3 anemia was noted in tow patients. Thrombopenia and leukopenia were reversible in all patients except one with rapid progression of disease. Conclusion: Samarium‐ 153‐ EDTMP treatment is safety in painful bone metastasis in patients with superscan. However, it seems to be less effective than in patients with focal bone metastasis. Nevertheless, in responder subjects, a significant improvement in quality of life was achieved.
P586 Effect of radioiodine therapy in patient with non-toxic goiter with low RAIU in the enlarged nodule: a case report S. S. Abdelrazek1, F. Rogowski1, P. Szumowski1, M. Frackiel2, M. Szelachowska2; 1Medical University of Bialystok,Department of Nuclear Medicine, Bialystok, POLAND, 2Medical University of Bialystok,Department of Endocrinology, Diabetology and Internal Medicine, Bialystok, POLAND. A young woman aged 23 years old, with a very large left‐sided, non‐toxic goiter with low radioiodine uptake was treated in our Department with the purpose of volume reduction of the goiter. Full history and clinical examination was done. FT4, FT3 and TSH serum levels were measured and was within normal range, high resolution ultrasonography (HRUSG) show very large glands (60ml), with two nodules in both lobes, the nodule in the left lobe was more prominent. Malignancy was ruled out by ultrasound‐guided fine‐needle aspiration biopsy (FNAB). Thyroid radioiodine scintigraphy showed homogenous and diffuse uptake in the right lobe, with very low uptake in the left lobe, radioiodine uptake (RAIU) after 24 and 48hr was 29% and 27%. The effective half‐life measured by the use of RAIU after 24 and 48hr was about 7 days. We referee the patient to surgical department, but the patient refused surgical operation. We explained to the patient the out come and the failure rate of volume reduction of nodule with low radioiodine uptake and the high risk of hypothyroidism after the first dose of radioiodine therapy; the patient agreed to be treated with radioiodine. The activity dose was calculated by Marinelli’s formula and the patient received 280 MBq of I‐131. The absorbed dose was about 240Gy. Follow up control was done every 4 weeks. After 6 months of radioiodine therapy, thyroid scintigraphy with RAIU after 24 and 48hr showed homogenous and diffuse uptake in the left lobe and very low uptake and decrease in the size of right lobe. Thyroid USG also show a decrease in the volume of right lobe. RAIU after 24 and 48hr was 36% and 35% respectively. The patient received a second dose of radioiodine 600 MBq, the absorbed dose was about 300Gy. Follow up control was done every 4 weeks. Thyroid USG and thyroid scan were done after 12 months of radioiodine therapy to assess thyroid volume. The patients received l‐thyroxin replacement therapy for hypothyroidism. Thyroid volume decreased about 53%. Radioiodine is non‐invasive, safe and cost effective method of therapy for reduction of goitre even in patient with low radioiodine uptake in the enlarged nodule and should not be restricted to elderly, or to patients with high operative risk, but should be used as first choice in every patient with non‐toxic nodular
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P587 The evaluation of radioiodine therapy out come after five years in patient with subclinical hyperthyroidism M. Frackiel1, S. S. Abdelrazek2, F. Rogowski2, A. Zonenberg1, M. Szelachowska1, A. Parfienczyk2, M. Karolczuk-Zarachowicz1, A. Shehumi1, S. Szczepanska2; 1Medical University of Bialystok, Department of Endocrinology, Diabetology and Internal Medicine, Bialystok, POLAND, 2 Medical University of Bialystok, Dept. of Nuc. Med., Bialystok, POLAND. The aim of our study was to evaluate the short term (5years) effect of radioiodine (I131) therapy on the achievement of euthyroidism, prevention of adverse effects on the cardiovascular and skeletal systems and prevention evolvement to overt hyperthyroidism. Material and Methods: We treated 140 patients, aged 30‐70 years; (86%) of the studied groups were female and (14%) male; 50 patient with multinodular goitre (MNG), and 90 patient with autonomous nodule (ATN). Qualification of these patients was based on clinical features, normal levels of serum fT3 and fT4, low levels of serum TSH and characteristic appearance on thyroid scans and ultrasound. Some of the patients were treated with antithyroid drugs for 6 to 12 months before I131 therapy (25 patient). Malignant changes were excluded in all nodules by fine needle aspiration biopsy. All the patients had serum TSH levels less than 0.1 mU/l and effective T‐half measured by the use of T24 and T48 was more than 3 days at the time of treatment. The activity dose was calculated by the use of Marinelli’s formula and ranged between 200‐600 MBq. The absorbed dose (Gy) for MNG ranged between 150 and 260, and for ATN: 200‐300 and was proportional to thyroid volume. Follow up control was done every 6 weeks in the first year. Then every 6 months for the four years. Repeated radioiodine therapy was given after 6 months of the first dose if indicated. Results: In general the success of treatment after one year was: 99% of patient with ATN and 92% of patient with MNG achieved euthyroidism. 1% of patient with ATN and 7% of patient with MNG develop hypothyroidism. 1% of the patients had persistent or relapse of hyperthyroidism and received second dose of radioiodine therapy. After 3 years of radioiodine therapy 2% of patient with ATN and 8% of patient with MNG develop hypothyroidism. After 5 years of radioiodine therapy 2% of patient with ATN and 9% of patient with MNG develop hypothyroidism. In all of the patients the symptoms and signs of subclinical hyperthyroidism disappeared (palpitation, tachycardia, atrial fibrillation, exercise tolerance improved, the blood pressure normalised and the quality of life improved). Conclusions: The achievement of euthyroidism and the remission of the symptoms and signs of subclinical hyperthyroidism, were due to good diagnosis, well preparation of the patients; accurate measurement of administered activity, effective half‐life, and well‐organised follow up.
P588 Menstruation after Radioiodine Therapy in Patients with Thyroid Cancer. K. Hwang, Y. Lee, M. Lee, W. Choe; Gachon Medical School, Gil Hospital, Incheon, REPUBLIC OF KOREA. Objectives: We investigated the influence of radioiodine (RAI) therapy on subsequent menstruation in the female patients with thyroid cancer. Methods: The retrospective study was conducted in 23 young female patients with thyroid cancer aged younger than 40 years who had received therapeutic doses of I‐131 (3.7 to 5.55 GBq) by reviewing the medical records and interviews. Detailed menstrual histories after RAI therapy were taken and analyzed. Results: Only two patients experienced significant menstrual abnormalities after RAI therapy, which were normalized within 3 and 6 months, respectively. The remaining patients had no change in menstruation after radiation exposure. Conclusions: Usual therapeutic radioiodine dose for postoperative thyroid ablation seldom cause significant menstrual abnormality, but only transient mild menstrual change in minority. Further studies are warranted.
P589 153
Sm-EDTMP As Consolidation Therapy In Multiple Bone Metastatic Hormone-Dependant Prostate Cancer Patients: Implementing A Reliable Dosimetric Model F. J. Pena Pardo, F. J. García Cases, A. Crespo-Jara, M. Redal, M. Sureda, A. Brugarolas; USP Hospital San Jaime, Torrevieja, SPAIN. Introduction: Metabolic radiotherapy of metastatic bone has a recognised efficiency in pain alleviation; nonetheless, it is often underused and applied in very late phases. Currently available data suggest the convenience of earlier use, larger doses and combination with other treatments. In May 2008 we started a clinical trial to assess 153Sm‐EDTMP (Quadramet®) utility as consolidation therapy in multiple bone metastatic hormone‐dependant prostate cancer patients. In this setting, the rationale of dosimetry seems clear to reach better results. Aim: To set a feasible and reliable scintigraphic imaging‐based dosimetric model, with a view to sharpening the dosage of further treatments (e.g. successive doses of 153Sm‐EDTMP). Material & methods: For the dosimetric studies we included the patients from the clinical trial as well as those (hormone‐ resistant) referred for pain alleviation. We were based on the model by W Brenner et al for quantification of diphosphonate uptake based on conventional bone scanning. Whole‐body scans were obtained at 0min and 3, 6‐8 and 24h after injection of standard dose (37 MBq/kg) of 153Sm‐ EDTMP repeating acquisition conditions systematically: the scanning speed was the sole variation (40 cm/min for the initial study, due to its higher count rate, and 10 cm/min for the rest). Total counts/pixel were calculated from regions of interest (ROI) in bladder, adductor muscles of both thighs (soft tissue activity) and a region outside the body contour and close to head and shoulders (to measure Bremsstrahlung from beta component) in anterior and posterior views; ROI around the most significant metastatic lesions and matched healthy bone were also drawn to get tumour‐to‐normal bone uptake ratios. In addition, we take and measure (in dose calibrator and well counter) blood and 24h urine collection samples to check the results. Results: 8 patients with a median age of 71.5 years (range: 53‐89) were studied. Measured median (range) bone uptake, urinary excretion and soft tissue activity at 24h were 51.2% (34.2‐76.7), 40.65% (16.3‐ 57.5) and 8.2% (5.4‐18.8), respectively. Measured 3h and 24h blood activities were 2.2% (0.7‐4.0)
and 0.1% (0‐0.1). These results are concordant with previously reported data. The median tumour‐to‐normal bone ratio was 3.95 (1.6‐7.6). Conclusions: The observed interindividual variability can affect the therapeutic effectiveness and the toxicity of the treatment. This is especially important when repeated or high doses (as in consolidation setting) are going to be used; so, making dosimetry should be mandatory. The chosen dosimetric model is practical and reliable, although it requires a methodical performance.
P590 Differentiated Thyroid Carcinoma in Children and Young Adults: A Large Clinical Experience G. Ucmak Vural, B. E. Akkas, N. Ercakmak, S. Aslan, C. Sasani; Ankara Oncology Research and Training Hospital, Ankara, TURKEY. Aim: The goal of the study was to evaluate response to radioiodine (RAI) therapy in children and young adults with differentiated thyroid carcinoma (DTC). Patients and Methods: Seventy children and young adults (age:8‐21 years, 55 female, 15 male, < 10 years: 6 %, 100 % male, 11‐ 17 years: 57 %, 80% female, 20% male, 18‐21 years: 23 %, 88 % female, 12 % male) with DTC were treated with RAI between 1988 and 2008. All patients had previously undergone bilateral total thyroidectomy and if necessary, lymph node dissection. RAI treatment was given to all patients, except two with papillary microcarcinomas. Results: Tumor types was consisted of 43 (61%) pure papillary carcinomas, 14 (20 %) papillary carcinomas with follicular variant, 6 (9 %) follicular carcinomas, 3 (4 %) hürthle cell carcinomas, 4 (5%) microcarcinomas. Overall, the average tumor size was 2.3 centimeters. Capsular and/or vascular invasion was present in 33 % of patients. Lymph‐node involvement in the neck was found in 35 % of patients at initial diagnosis. Lung metastases were observed in 14 patients (20 % ) and 83 % of lung metastases were micronodular. In 11 of these patients lymph‐node involvement was present. Total RAI dose range was 60 to 1100 mCi, given in 1 to 5 times, repeating not earlier than 10 months. Medical and nonmedical precautions such as steroids, analgesic, anti‐acid and lemon drops were taken in all patients to minimize the radiation related side effects during treatment. All patients had post‐ therapy scan. We lost contact with five patients on follow up, but in 65 patients, follow‐up range was 1 to 19 years (mean: 6 years). Thirty‐nine (60 % ) patients were disease‐free, 17 (26 %) patients had low stimulated serum thyroglobulin levels (1‐5 ng/ml) and negative RAI scan and had good response to therapy, 6 (9 %) patients with lung metastasis had persistent‐stable disease, 3 (5 %) patients showed locoregional recurrence. Late side effects of RAI treatment and death were not observed in any of the patients. Conclusion: Adjuvant RAI therapy and regular follow‐up significantly decrease locoregional recurrence and improve quality of life and may increase overall survival in children and young adults patients with DTC.
P591 Radioiodine-131 and hyperthyroidism H. Guerrouj, S. Issami, N. Ben Rais; Avicenna Hospital, Rabat, MOROCCO. The aim of this study is to provide an epidemiological approach of different etiologies of hyperthyroidism in Morocco and to show the place of iodine‐131 treatment of this pathology. We analysed retrospectively the results obtained during 7 years iodine‐131 treatment of 213 thyrotoxicosis cases. Graves’s disease is the most common etiology, followed by toxic adenoma, and toxic multinodular goitre. The association with other diseases especially diabetes is sometimes found. Iodine‐131 has frequently been proposed after the failure of antithyroid drugs. 23 patients were initially threaded by iodine‐131 while 9 patients had received iodine‐131 after failure of medical treatment and recurrence after surgical treatment. The therapeutic efficacy of a one dose of radio iodine assessed after 6 months was 80% in Graves’s disease, 48% in toxic adenoma and 33% in toxic multinodular goitre. No acute complications were observed. Taking into account our socio‐economic context, we conclude that the radio iodine is the most cost effective in the treatment of hyperthyroidism in our country.
P592 Evalution of differentiated thyroid carcinoma in patients younger than 21 years submitted to thyroidectomy and radioiodine therapy B. A. L. Abreu1, D. A. R. Gonçalves2, B. P. Falcão2, N. M. Freitas2, G. P. Morais de3, J. B. Abreu1; 1Centro Bionuclear de Diagnostico, Teresina, BRAZIL, 2Faculdade de Medicina - Universidade Estadual do Piauí, Teresina, BRAZIL, 3Hospital São Marcos, Teresina, BRAZIL. Introduction: The differentiated thyroid cancer (DTC) is rare in childhood and adolescence, accounting for 0.5% to 3% of malignancies in this age group. About 10% of all DCT occur in patients younger than 21 years with predominance in females. In pediatric and adolescent group is biologically independent, takes a more aggressive and has greater risk of recurrence than in adulthood. Surgery is the treatment of choice for tumors of thyroid and treatment of primary DCT in children and adults includes a combination of surgery, administration of radioactive iodine (131I), and thyroid hormone therapy, applied in varying levels of intensity. Aim: To perform an evaluation of anatomo‐pathological data of DCT in patients younger than 21 years underwent surgery for thyroidectomy and Radioiodine therapy in clinical reference in the city of Teresina, Brazil, between 1996 and 2006. Materials & Methods: We conducted a retrospective study in which information was collected in medical records. The study was approved by the Ethics Committee in Research of UESPI. Results: We analyzed 14 patients, while 78.5% (11 patients) were female. The average age at diagnosis was 17,6 years. The DCT‐ follicular variant of papillary carcinoma was found in 50% of cases, the DCT‐classic variant of papillary carcinoma in 36% , the DCT‐cells high variant of papillary carcinoma and the follicular carcinoma at 7% of cases. Metastasis was present in 42.8% of cases. In patients with metastasis, the lymph nodes were affected in all, while the lungs by 33% . Blood invasion was presence in 64.3% , while the capsule invasion in 92.8% of cases. was detected in 75% of patients (data for this item were found in 12 patients). Evaluation of surgical margins was described on the pathology report in 9 patients, and of these 55.5% showed compromised. Right lobe was the most affected, accounting for 78,5% of cases. Conclusion: Presence of blood invasion, invasion of capsule, extrathyroid extension and involvement of surgical margins were present in most cases, as in the literature. A significant number of young patients with DCT present with metastasis and will require radioiodine therapy.
Poster Presentation
goitre (>40ml) especially in patients with special professions (singer, teacher) or patients wish a non‐invasive treatment modality.
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P67 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radionuclide collection
therapy/dosimetry: methods
/
dosimetry:
dosimetric
data
models
/
pharmacokinetics
P593 Use of the Bremsstrahlung for the estimation of the accumulation of 90Y- citrate in the knee joint after Radiosynovectomy M. Kempińska1, P. Lass1, J. B. Ćwikła2; 1Medical University of Gdansk, Department of Nuclear Medicine, POLAND, 2MSWiA Hospital, Department of Nuclear Medicine, POLAND. Radiosynovectomy is mainly used in chronic joint inflammation in cases resistant to conventional therapy. The Bremsstrahlung phenomenon has been used for the purpose of the visualization of the joint radioisotope distribution. Aim of the research: An aim of the investigation was estimation of the activity changes and the distribution of Yttrium ‐ 90 citrate colloid in the area of the knee joint cavity in the function of the time. Material and methods: Examination has been performed on twelve patients. Scintigraphy was done with dual head gammacamera. Area of cumulation of the radiopharmaceutical in the knee joint was divided in 4 subregions. Ten minute spot study of the knee joint after injection was done 1, 24 and 96 hours in every patient. Whole body study after injection was performed 1, 24 and 96 hours in 4 patients in the purpose of the assessment of the extra ‐ articular location of tracer. Results: Quantitative analysis had show that the experimental half‐life (58 h ± 8 h) in the whole area of the joint is similar to the physical half ‐ life. Qualitative analysis had show an absence of the radiopharmaceutical flow outside the joint cavity. Analysis of the radiopharmaceutical activity in all segments indicate the phenomenon of biological transport. The analysis of 4 segments of the joint showed the significant displacement of the activity from: the upper lateral synovia compartment (the place of the injection) towards the medial lower synovia compartment (n=7); the upper lateral synovia compartment (the place of the injection) towards the lower lateral synovia compartment (n=8); the upper lateral synovia compartment (the place of the injection) towards the medial femur synovia compartment (n = 2). The analysis of the whole body scintigraphy pictures proved, that no more than 10% of the original the radiopharmaceutic activity injected to the joint escaped outside joint cavity. Conclusion: In the examination described migration of the maximum activity of an Yttrium ‐ 90 colloid within the knee joint has been shown. The clinical meaning of this fact demands further investigation.
P594 Determination of Calibration Curves for Radionuclides Used in SPECT Scans and Calculation of Absorbed Dose in Radioiodine Ablation A. Miranti1, J. Heikkonen2, M. Tenhunen2, D. Arginelli3, C. Peroni1, S. Ridone3, L. L. Vigna1; 1University of Turin, Department of Experimental Physics, Turin, ITALY, 2Helsinki University Central Hospital, Department of Oncology, Helsinki, FINLAND, 3ENEA-Italian National Agency for New Technologies, Energy and the Environment, Re-search Centre of Saluggia, Department of Biotechnologies, Agro-Industry and Health Protection, Radiation Protection Institute, Saluggia (VC), ITALY. Patient‐specific dose calculation requires the knowledge of the tissue mass where the radionuclide is distributed. SPECT measurements of a radioactive substance are affected by a considerable inaccuracy, because gamma camera reconstructs small volumes with sizes larger than the real ones. For this purpose we determined calibration curves which relate measured volumes to real ones. SPECT scans were acquired and reconstructed with different algorithms with and without scatter correction for comparison. Methods: Four different radionuclides (Tc‐ 99m, Sn‐117m, In‐111 and I‐131) were measured with a Symbia T2TM gamma camera by Siemens at Helsinki University Central Hospital. Syringes filled with known volumes (1‐10 cm3) and specific activities (9‐77 MBq/cm3) were located in polystyrene phantom. The LEHR collimator was used for Tc‐99m and Sn‐117, MELP collimator for In‐111 and HE collimator for I‐131. SPECT scans were made with continuous method and counts were acquired using a 128x128 matrix size. SPECT data was displayed as transversal, coronal and sagittal slices. Real volumes were calculated both using an automatic threshold method and measuring the dimensions in sagittal, coronal and transversal slices. Projection have been reconstructed using FBP, OSEM and Flash‐3DTM algorithm with and without scatter corrected slices. Calibration curves for SPECT studies with I‐ 131 have been evaluated for the measurement of the remnant mass and for calculation of radiation dose with Maxon’s method in two radioiodine treatments. Results: Correction curves are almost linear for volumes larger than 15 cm3. For small volumes an exponential or power function yield best fitting results for isotopes and collimators used in this study. The Flash 3DTM algorithm with scatter corrected images yield better results than the corresponding uncorrected images. Calculated radiation doses in thyroid remnant tissue were 460 Gy (patient A) and 860 Gy (patient B) with radioiodine activities of 3.7 GBq and 1.1 GBq. Conclusions: Measurements on two patients have been performed using the VOI‐analysis and General Tomo with Scatter Correction method. For both patients, the obtained results with the two methods are in agreement. Dose evaluation for the patient A is also in agreement with the results from other studies in literature, while for the patient B it is higher, probably because the remnant mass was smaller. Remnant thyroid mass can be evaluated with SPECT scans and using correction curves but larger number of patients should be included in the study before this issue can be settled.
P595 Evaluation of dosimetry in patient-based 86Y-SMT-487 data for several radionuclides using Olinda/EXM software
F. X. Hanin, S. Walrand, S. Pauwels, F. Jamar; St Luc Hospital, Brussels, BELGIUM. Background: The intrinsic physical properties of radionuclide are essential to efficiency of internal radionuclide therapy. Internal emitters dosimetry is challenging due to several limitations (assessment of biodistribution, washouts, different affinity for receptors from diagnostic to therapeutic compound, lack of tumor phantom model). S‐factors found in libraries and Residence Times (RTs) obtained from external imaging are needed to calculate absorbed doses. 86Y can be used as surrogate to 90Y which is not appropriate for quantitative imaging. The aim of this study was to assess the effect on dosimetry of varying the radionuclide by re‐using our data obtained with 86Y‐SMT‐487 to calculate dosimetry for other beta and alpha emitters. Methods: In 10 patients RTs were recomputed from 86Y‐SMT‐487 data to fit with each radionuclide’s period. The data were input in Olinda/EXM to get dosimetry for kidneys, tumors, and red marrow, for each radionuclide. The dose to red marrow was assessed as target‐only organ (i.e. with RT=0) and then compared to data obtained by introducing a fixed RT for red marrow (mean observed in 6 patients from another study). Results: For a fixed target dose of 23 Sv to kidneys, the mean±SD doses to tumors (n=34), expressed as a ratio to 90Y were 1.4±0.3, 0.7±0.1, 0.7±0.1, 1.0±0.1, 1.1±0.1, 0.9±0.1, 1.3±0.3, 0.8±0.2, 0.8±0.2 for 177Lu, 111In, 66Ga, 67Cu, 186Re, 188Re, 131I, 212Bi, and 213Bi, respectively. Doses to the red marrow varied between 0.9±0.6 and 3.8±1.1 Sv when no specific red marrow uptake was considered. When including a mean red marrow RT, the dose to the Red Marrow was increased by a factor 1 to 5, with the highest effect for 212Bi, 131I and 66Ga. Simulation of a radionuclide cocktail showed that 177Lu delivered higher doses to tumors than 90Y. Conclusion: The pure physical differences between isotopes are shown and discussed, enhancing the need to incorporate heterogeneity in a model of tumor dosimetry assessment.
P596 Is the radiosensitivity of the Graves' disease thyroid 131 functional tissue units related to the I uptake? Preliminary Results F. Orsini1, A. C. Traino2, M. Grosso1, F. Guidoccio1, G. Mariani1, Y. Chait3; Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, ITALY, 2Medical Physics Section, Health Physics Unit, UniversityHospital of Pisa, Pisa, ITALY, 3Mechanical & Industrial Engineering Department, University of Massachusetts, Amherst, MA, UNITED STATES.
1
In this work we analyzed data on thyroidal radioiodine kinetics and thyroidal mass in a group of patients in whom a prior treatment with 131I had not cured Grave' disease. Methods: We re‐ evaluated 29 Graves' disease patients (11 men, 18 women) who had persistent hyperthyroidism within 12 months after 131I therapy. Data available for each patient included: U0 = baseline maximum thyroid uptake (i.e., baseline uptake before the first 131I treatment); m0 = baseline thyroid mass (i.e., thyroid mass before the first 131I treatment); Uf = final maximum thyroid uptake (i.e., maximum uptake before the second 131I treatment); mf = final thyroid mass (i.e., thyroid mass before the second 131I treatment). According to prior results obtained by our group during long‐term follow‐up of patients treated with 131I therapy, for each patient the measured maximum thyroid uptake (U) and mass (m) can be fitted into the following equation (1): Uf / U0 = φ (mf / m0) From Eq. (1), the unknown coefficient φ which correlates 131I‐induced reduction of thyroidal mass to 131I uptake, can be calculated as: φ = m0 Uf / mf U0 Results: Statistical analysis of the φ values obtained in the whole group showed a mean ± DS equal to 1.84 ± 0.86 (range 0.76 ‐ 4.72). These results question the generally accepted hypothesis of a homogeneous 131I uptake in the Graves' disease thyroid. In fact, most of φ values are > 1, thus indicating that reduction in mass is almost invariably greater than reduction in thyroidal uptake. Whereas, homogeneous uptake would result into φ values around 1. Conclusion: Our results allow to put forward the hypothesis of a non‐homogeneous uptake of the Graves' disease thyroid, considering the rearranging factor φ as a function of the thyroid mass reduction (mf/m0) due to 131I therapy. Moreover, the measured values of φ can be explained by relating the different radiosensitivity of the thyroid functional tissue units (i.e., the follicles) to the capability of these units to concentrate iodine.
P597 Pharmacokinetics And Dosimetry For Therapy Based On Bremsstrahlung Imaging
Y90-DOTATATE
L. D'Ambrosio, L. Aloj, M. Aurilio, M. Mormile, C. Caraco', A. Tommaselli, S. Lastoria; Nuclear Medicine, Istituto Nazionale Tumori, Fondazione "G. Pascale", Napoli, ITALY. Objectives: Bremsstrahlung imaging may be an alternative technique to study the biodistribution of radiopharmaceuticals labelled with Y90. The aim of this study was: 1) to obtain dosimetric information on uptake, half‐life and mean absorbed organ and tumor doses from the Bremsstrahlung imaging in patients undergoing Y90‐DOTATATE therapy and 2) to compare qualitative and quantitative data from Y90 images and Ga68‐DOTATATE uptake by PET. We have expanded the data analyis presented at EANM 2008 (D’Ambrosio et al.). Methods: 43 treatments with Y90‐DOTATATE in 22 patients were analyzed. Patients received 1‐4 cycles with a mean injected activity of 3.77 GBq (range 2‐5.8 GBq) per cycle. Whole‐Body (WB) images were acquired using a 50‐300 KeV window and medium energy collimators over the course of 4 days from administration of the dose. The Fraction of Injected Activity (FIA) in organs and lesions for each time point were determined by normalizing to an image taken immediately after injection was considered 100% IA. Time activity curves were fit to a mono‐ or bi‐exponential model and doses estimated according to the MIRD formalism with OLINDA‐EXM. CT was used to assess organ/tumor volumes. Results: Maximal activity was reached within 30 minutes after injection in normal organs followed by a very rapid decrease (50% of max within the first 3 h). Estimated doses to normal organs and tumor lesions per cycle based on Y90 images were: Kidneys 2.4±1.1 (range 0.6 ‐5) mGy/MBq; Spleen 2.2±1.2 (range 0.64‐5.3) mGy/MBq; Liver 0.6±0.36 (range 0.21‐ 1.73) mGy/MBq; WB 0.23±0.29 (range 0.05‐1.83) mGy/MBq; tumor lesions 0.6‐214 mGy/MBq, mean 8.8. The FIAs estimated on the first Y90 image (~30 min post‐injection) and the Ga68 PET image showed a good correlation in most organs and tumors, indicating that PET image data may be used to define initial FIA and Y90 images used to determine the time course of distribution. Considerable differences were seen only in kidneys (P=0.068) and spleen (P=0.028) based on a paired t‐test. In patients undergoing multiple treatments there was high reproducibility in the
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P598 A preliminary biokinetic model for the radiopharmaceutical 153 [ Sm]Sm-EDTMP in order to improve dosimetry evaluations S. Ridone1, D. Arginelli1, E. Inglese2, A. Lucca2, R. Matheoud3, A. Miranti4, M. Montalto1, C. Peroni4, M. Rudoni2, C. Secco3, S. Vallegiani2, L. Vigna4; 1 ENEA-Italian National Agency for New Technologies, Energy and the Environment - Radiation Protection Institute, Saluggia, ITALY, 2Hospital “Maggiore della Carità” of Novara - Department of Nuclear Medicine, Novara, ITALY, 3Hospital “Maggiore della Carità” of Novara - Department of Medical Physics, Novara, ITALY, 4University of Turin - Department of Experimental Physics, Turin, ITALY. Aim. The radiopharmaceutical [153Sm]Sm‐EDTMP is used in palliation cares of painful bone metastases originated from different primary tumours (mainly prostate and breast cancer). Since administration occurs according to patient’ s weight (37 MBq/kg), with no evaluation on patient‐ specific characteristics or previsional dosimetry to target (bone) and critical organs (red marrow), the administered activity and, consequently, the dose to these tissues can be over‐ or underestimated, decreasing treatment effectiveness or increasing side effects. Our aim is to study the biokinetics of the radiopharmaceutical in order to find a suitable dosimetric model, considering the in‐vivo stability of the compound to investigate the amount of injected compound able to reach the target. Materials and methods. After studying the radiopharmaceutical in‐vitro stability in physiological solution (NaCl 0,9%, pH=7) and in human blood, maintained at 37 °C, using instant thin layer chromatography (ITLC) with H2O:CH3OH:NH4OH (4:2:0,2) on a glass fibre support, we analysed treated patients blood and urine samples, collected within the 24 hours after the injection. The activity was measured by beta spectrometry by liquid scintillation counting. To evaluate blood clearance and excretion, the same biological samples were measured by gamma spectrometry with a NaI detector. Results. The in‐vivo stability was considered high, especially during the distribution phase from the blood to the target, so that, in a preliminary approach, we can neglect the contribution of free samarium in analysing biokinetic data. From the plasmatic clearance and the urinary excretion, we elaborated a system of differential equations to find a preliminary biokinetic model for the radiopharmaceutical. According to this model, we identified a central compartment (blood), a transit compartment (soft tissues) and two storage compartments, related to the target (bone tissue) and to the excretion (urinary bladder). We calculated the main pharmacokinetic parameters, as the rate constants, noticing a relevant biological variability in the biodistribution of the radiopharmaceutical. Conclusions. Differences in blood clearance, urine excretion and bone uptake (with consequent different doses to target and to red marrow) suggest the importance of a personalised therapy with the radiopharmaceutical [153Sm]Sm‐EDTMP, showing that the administration only based on the patient’ s weight is not sufficient to optimize the treatment. Our preliminary model can be applied for dosimetry evaluations, by using a work sheet, and it represents a practical tool for physicians and physicists involved in the routine activity of a Nuclear Medicine unit. We hope to improve this model increasing the number of the examined cases.
P599 Pulmonary I-131 Radioiodine Clearance in Patients with Differentiated Thyroid Carcinoma. I. Selkinski, C. Happel, M. Middendorp, W. Plastowez, B. Sauter, T. Kranert, F. Grünwald; Nuclear Medicine, Frankfurt am Main, GERMANY. Aim: Radioiodine therapy (RIT) is the standard treatment in most cases of differentiated thyreoid carcinoma (DTC) subsequent to surgery. RIT is usedfor ablation of remnant thyroid tissue and for elimination of tumour relapse. The pharmacokinetic of the administered I‐131 and its excretion is important for dosimetry and for control of possible contamination pathways. Aim of the study was to evaluate the elimination of radioactivity via bronchial secretion. Materials and Methods: A 67‐year old male patient with tracheostoma, treated for DTC, received a RIT (intravenous application of 3.229 MBq under hypothyreosis). Radioiodine distribution levels were controlled at 75 min, 5 h, 12 h, 24 h and 48 h after radioiodine administration in blood and bronchial secretion and correlated with whole body measurements performed with an individual calibrated gamma probe each 12 hours. Results: Daily whole body dosimetrical measurements showed an effective half life time (ehlt) of 0.8 d (ehlt calculated with Excel Solver). Time activity curve in blood (ehlt 0.02 d (early rapid phase); 0.78 d (late slow phase) and bronchial secretion (ehlt 0.08 d; 0.67 d respectively) showed a biexponential devolution. Correlation between I‐131 activity in blood (34.6 kBq/ml, 30.6 kBq/ml, 26.6 kBq/ml, 13.2 kBq/ml and 5.5 kBq/ml respectively) and in bronchial secretion (26.7 kBq/ml, 10.7 kBq/ml, 4.4 kBq/ml, 2.0 kBq/ml and 1.1 kBq/ml, respectively) was overlaid. Conclusion: I‐131 radioiodine distribution via bronchial secretion correlates with the I‐131 level in blood. Biexponetial ehlt indicates a contamination risk depending on the amount of administered I‐131 activity in the fast distribution phase and on the amount of bronchial secretion. Acute pulmonary inflammation as well as chronic inflammatory conditions like asthma or COPD promote hypersecretion. In the second phase the contamination risk significantly decreases because of low radioactive concentration in bronchail secretion.
P600 Uptake Kinetic Studies of 99mTcO-4 and 188ReO-4 on CRL1472 and MNNG-HOS Cell Lines L. Metello1, L. Cunha1, L. Lourenço1, A. Abrantes2, M. Laranjo1, C. Gonçalves3, A. Sarmento-Ribeiro2, I. C. Dormehl4, M. F. Botelho2; 1Nuclear Medicine Department (ESTSP IPP), Porto, PORTUGAL, 2 Biophysics/Biomathematics Institute, CIMAGO, IBILI – Faculty of Medicine, 3 University of Coimbra, Coimbra, PORTUGAL, Biochemistry Institute,
CIMAGO, Faculty of Medicine, University of Coimbra, Coimbra, PORTUGAL, 4 AEC Institute for Life Sciences, University of Pretoria, Pretoria, SOUTH AFRICA. Introduction: It is actually well known and widely accepted the crucial importance of Nuclear Medicine techniques and methodologies for the study and characterization of new chemical entities. In our consortium of departments we are working to develop a new agent for Metabolic Therapy. For that reason, it is essential to understand the metabolic pathways of distinct cell populations and two cell lines (CRL‐1472 and MNNG‐HOS, respectively human bladder cancer and human osteosarcoma cell lines, from ATCC) were studied using two distinct radioactive tracers: Na99mTcO4 (99mTc) and Na188ReO4 (188Re). This presentation relates with preliminary results already obtained regarding uptake profiles of those cells concerning the above mentioned radioactive products. Material and Methods: Cells were developed under standard culture conditions (37ºC temperature, 95% air and 5% CO2 atmosphere). Experiments took place during the log phase of cell growth, being incubated with 3.7 MBq of 99mTc (or 188Re, considering the specific case). At 5, 15, 30, 45, 60, 90, 120, 150, 180, 210 and 240 minutes, samples were collected, doubly centrifuged and both, cell pellet and supernatant, separated and quantified in a gamma well counter. Each measurement was done in double or triple, and the experiment was repeated, in order to provide an adequate statistic. Uptake quantification is expressed as a percentage of the activity added to the culture medium and calculated by the ratio between the activity found in the pellet and the total activity (pellet + supernatant). In each of the experiments, a final viability study was performed using the Trypan Blue assay. Results: Results obtained demonstrated that the uptake curves over the time of both cell lines are very consistent for both agents, with the same level (less then 2%) of uptake values. Nevertheless, the resulting kinetic curves have completely distinct profiles, with the uptake values showing an increase over the time for 99mTc for both cell lines, and, oppositely, decreasing uptake values for 188Re for both cell lines. Conclusion: The different behaviour in uptake kinetics of the two agents used can be an interesting characteristic to be further explored, namely in terms of therapeutic approach.
P601 Semiautomatic low resolution/low dose CT (GE Hawkey) based segmentation targeting quantification of radionuclide organ uptake in SPECT - possible but with pitfalls T. Magnander, J. Himmelman; Sahlgrenska University Hospital, Goteborg, SWEDEN. Background The radionuclide uptake and distribution in patients undergoing peptide receptor radionuclide therapy with radiolabelled somatostatin analogues are currently evaluated in planar posterior/anterior gamma camera scans. Emission‐transmission acquisitions with single‐photon emission computed tomography (SPECT) and computed tomography (CT) with SPECT‐Hawkeye systems can be of value to quantify activity uptake and distribution for dosimetry. 3D image quantification has obvious advantages versus planar 2D when overlapping uptake exists. The low resolution in Hawkeye CT images is a challenge in the segmentation process. The aim of this work was to develop a method and a tool to segment the renal volume, thus providing a base for dosimetric evaluation of organs at risk in patients undergoing radionuclide therapy. Methods and Results A complementary SPECT/CT (GE Millenium VG Hawkeye) acquisition was added to the protocol to make 3D processing possible. A semi‐automatic method was developed to segment the renal volume in reconstructed transmission images. The operator defines one or more points within the VOI to be segmented. The image processing is utilizing the open source software tools of the Insight Segmentation and Registration toolkit (ITK). The images were filtered before segmentation. Segmentation algorithms evaluated are connected threshold, confidence connected, neighborhood connected, isolated connected and the fastmarching method. The segmented volume was outlined in the reconstructed emission (SPECT) images. In some cases the segmentation algorithm was unsuccessful due to artifacts caused by the patient's arms occuring in the image. Conclusion Hawkey CT transmission image based semiautomatic segmentation of the renal volume is possible and after fusion of SPECT and Hawkeye images the radionuclide uptake in the organs can be investigated. Special care has to be taken when positioning the patient, arms in image frames of interest can cause artifacts which must be avoided to make the segmentation process successful.
P602 Increasing intrahepatic tumour uptake octreotide by loco regional administration.
of
111
In-DTPA-
S. E. Pool, B. Kam, W. Breeman, G. Koning, C. Van Eijck, E. Krenning, M. De Jong; ErasmusMC, Rotterdam, NETHERLANDS. Aim For patients with liver metastases of gastroenteropancreatic neuroendocrine tumors (GEPNETs) the median overall survival is 2 to 4 years. Classical therapeutic options as surgery and chemotherapy are limited. Peptide Receptor Radionuclide Therapy (PRRT) with [177Lu‐DOTA‐ Tyr3]‐octreotate showed in > 500 patients a survival benefit of 40 to 72 months from time of diagnosis with minor side effects. To further improve PRRT with [177Lu‐DOTA‐Tyr3]‐octeotate in patients with neuroendocrine liver metastases the aim of this study is to explore the effect of loco regional administration of 111In‐DTPA‐octreotide (OctreoScan) via the hepatic artery on the intrahepatic tumour uptake in an animal model and in a patient study. Materials and Methods Preclinical experiments in rats: Biodistribution studies were performed in rats with intrahepatic somatostatin receptor subtype 2 (sst2) positive CA20948 tumour after systemic or locoregional administration of 111In‐DTPA‐octreotide (4 MBq/0.5 μg). For loco regional administration, the gastroduodenal artery was canulated. Clinical study: Ten patients with liver neuroendocrine liver metastases scheduled for PRRT with [177Lu‐DOTA‐Tyr3]‐octeotate will participate in this pilot 111 study. All patients will be scanned twice with In‐DTPA‐octreotide after systemic or locoregional administration with an interval of 2 weeks … weeks prior to PRRT. Locoregional administration is applied via a catheter placed in the hepatic artery. Planar and SPECT images of the liver and kidneys are made at 1, 4, 24, 48 and 72 hours after injection. Blood samples are taken at various time points and the urine is collected for 48 hours... Results In preclinical experiments we saw 2* higher uptake of 111In‐DTPA‐octreotide in a liver metastases tumour model after administration via the hepatic artery. Preliminairy patient data showed a more than 3* higher uptake of 111In‐ DTPA‐octreotide in liver metastases after loco regional administration compared to the normal systemic administration. The route of administration did not change kidney uptake, nor blood and urine excretion. Conclusion Preclinal and preliminairy clinical data indicate that loco regional
Poster Presentation
measurement of doses to organs at risk from cycle to cycle, indicating that dosimetry values measured in the first treatment cycle may be utilized to predict future absorbed doses and aid in treatment planning. Conclusions: Use of Bremmstrahlung imaging in combination with Ga68‐ DOTATATE PET provides useful information that may be utilized to optimize Y90‐DOTATATE treatment procedures.
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administration of 111In‐DTPA‐octreotide via the hepatic artery is a promising method to increase 111 In‐DTPA‐octreotide uptake in neuroendocrine, sst2‐positive liver metastases.
64‐slice CT system
Coronary CT angiography
15
Circulation 2009; 119(7):1056‐65
P603
X‐Ray Angiography
Coronary angiography (diagnostic)
7
Radiology 2008; 248:254‐ 263
Individualized Dosimetry Methods and Monte Carlo Simulation in Sm 153 - EDTMP Palliative Treatment
P605
N. Lagopati, G. Papanikolos, M. Sotiropoulos, C. Panayides, J. Vamvakas, G. S. Limouris, M. E. Lyra; University of Athens, Athens, GREECE.
Radiation protection of patients and medical personnel during radiosynovectomy of knee joint with Yttrium - 90 citrate
Aim: Bone pain is a common symptom of metastatic disease in cancer. Samarium 153 ‐ EDTMP (ethylenediamine tetramethylene phosphonate) is a bone‐seeking radiopharmaceutical used for the palliation of pain from bone metastases. The more favourable physical characteristics of Samarium, with a half life of 46.27 h, beta emissions of 0.64, 0.71 and 0.81 MeV and a 0.103 MeV gamma emission, permit optimum internal radiotherapy with prospective estimation of radiation dose to metastases and bone marrow in each patient. Our aim is to compare individualized palliative treatment absorbed doses, by planar images data, single photon emission computed tomography (SPECT) data and Monte Carlo N ‐ Particle Code (Extending version ‐ MCNPX). Monte Carlo methods make it possible to model scenarios in the virtual world and are especially valuable in the improvement of the setup and the assessment of in vivo measurements. Materials and Methods: Planar (anterior and posterior planar images) and SPECT data by Elscint Apex 4 SPX tomographic gamma camera ‐revised by GE Healthcare‐ were obtained for twelve patients with skeletal metastases in series from 1 hour up to 6 days post injection and were used for an estimation of the dose in the lesions of interest, according the MIRD schema. Patient specific results (residential times, lesions volumes in voxels, absorbed dose calculations) were obtained. In order to justify the individualized schema, Monte Carlo MCNPX code is used for the calculation of the detector efficiency, given a specific in vivo measurement scenario and it is employed to simulate the distribution of the Samarium in the area/volume of importance and calculate absorbed doses in the metastatic lesions as well as in critical organs Results: We have calculated Dose Indices (X) indicating the ratio between the absorbed doses in metastatic lesions’ areas/volumes and those absorbed by the critical organs, by planar, tomographic and Monte Carlo methods: where Dlesion.area: absorbed dose in the metastatic lesion area/volume and Dcritical.organ: absorbed dose in the critical organ (red marrow, kidneys, bladder). Conclusion: The results of the simulations have been processed and compared with the data obtained from the patient specific measurements. There is a good agreement between virtual and real data: the overall error is of 6% for SPECT and 9% for planar data calculations comparing to Monte Carlo MCNPX code. The results therefore validate the method applied for creating the voxel model and the whole Monte Carlo simulation presented here.
M. Kempińska, P. Lass; Medical University of Gdansk, Department of Nuclear Medicine, POLAND.
P606
P68 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radionuclide quantitative
therapy/dosimetry: analysis
and
dosimetry:
treatment
planning
/
dosimetry for clinical trials
P604 Lowering absorbed dose for patients performing ECG-gated SPECT is possible: Guidelines analysis and procedure optimisation M. De Marco, M. Iantomasi, S. Maggi; A.O. Ospedali Riuniti - Ancona, Ancona, ITALY. Reduction of radiation exposure for patients performing electrocardiogram‐gated SPECT (G‐ SPECT) will be a key factor for a more liberal use when compared with other imaging modalities like (ECG)‐gated 64‐slice computed tomography or coronary angiography. This study was designed in collaboration with nuclear cardiologists with the AIM of ensuring that radiation doses absorbed by the patient are ALARA. Materials and Methods: The currently EANM protocol for a gated 2‐day stress/rest study suggests an administration of 99mTc‐radioisotope ranging from 600 to 900MBq/day. In this study, we enrolled 80 patients: ‐ with a know history of ischemic cardiomyopathy without abilities of revascularisation, ‐ who already underwent a G‐SPECT years before. In the first step, we reduced the amount of administered activity to 500MBq/day; patients underwent a 2‐day G‐SPECT study as usually and the results were evaluated separately by different cardiologists. Based on the previous results, we performed a retrospectively analysis on all those patients, whose clinical condition has remained unchanged since the last control. Quantitative analysis of myocardial perfusion has been obtained comparing the currently performed stress‐study, with the rest‐study that patient did in the past. Results: In all the patients nuclear cardiologists found no differences in the uptake score values after administration of 500MBq 99mTc‐tetrofosmin instead of 600MBq. Moreover, in 65 patients, they stated that it might be possible to perform only the stress study. These results become of great relevance in the continuous process of minimizing the radiation dose absorbed by patients. Representative values of effective doses reported in the literature for various procedures are presented in the next table. The absorbed dose coefficients related 2‐day G‐SPECT, are adopted from ICRP publication no.80. Conclusions: We report our initial experience with a revised protocol of the current EANM Guidelines for myocardial perfusion imaging. In all patients included in the study (test diagnostic sensitivity of 100%), a reduction of administered 99mTc‐ radioisotope to 500MBq/study is possible. That means lowering of about 20% (from 8mSv to 6,5mSv) the patient absorbed dose. This value is similar in magnitude to that received from a Coronary X‐Ray‐angiography (7.0mSv) and is less than half the value received from a 64‐slice CT (15mSv). Moreover, in 80% of the enrolled patients, nuclear cardiologists stated that it might be possible to perform only the stress study, reducing the total absorbed dose to 3mSv. Table 1. Comparison of Absorbed doses in assessing coronary artery disease Imaging Modality
Study
ECG Gated‐SPECT 2‐day G‐SPECT
Radioisotope synovectomy is based on an Yttrium ‐ 90 citrate injection into the knee joint cavity. The performance of procedure needs participation of a nuclear medicine specialist as well as an orthopedist or a rheumatologist and a technologist, who prepares radiopharmaceuticals. The ionization doses for patients and personnel are depending not only on the injected activity, but also on the method and process of injection and the radioactivity measurement procedure used. Aims of the research: ‐ evaluation of the degree of radiation exposure of patients and medical personnel during performance of the therapy with 90Y, ‐ establishing of the role of the radiological supervision of the medical personnel performing this therapy. Material and methods: For the purpose of the quantification of the exposure to ionizing radiation thermoluminescence dosimeters type: PI‐01, DI‐02 and DS‐04 (Laboratory of Individual and Environmental Dosimetry of the Institute of Nuclear Physics in Krakow, Poland) were used. In this way personal dose equivalent at 0,07 mm and 10 mm depth in the body (30 persons) and medical personnel (14 persons) and kinetic energy released per unit air mass was calculated. Static studies (10 minutes) of patient’s knee joint were performed. Imaging studies were done using a single or dual head gammacamera. Final image processing was based on drawing a ROI (Region of Interest) in a form of a circle covering the joint and performing statistical calculations (mostly regarding an amount of counts within a region) depending on a patient clinical data. Whole body study after injection was performed in 4 patients in the purpose of the assessment of the extra ‐ articular location of the tracer. Results and Conclusions: The results of the presented above comparative experiments performed on patients demonstrated, that measurements obtained with dosimeters can be replaced by the results the scintigraphy (cheaper and more available in the Departments of Nuclear Medicine). Average number of radiosynovectomy procedures performed monthly in Polish Nuclear Medicine Departments is four. Individual dosimetry of the medical personnel proved that so small number of conducted procedures is completely safe for medical staff. Patients after radiosynovectomy of the knee joint with Yttrium ‐ 90 citrate and persons from their environment are safe, if rules of radiation protection are fulfilled.
Effective dose (mSv)
Reference
8 (600 MBq) 6.5 (500 MBq)
ICRP 80 ‐ EANM Dosage card
Evaluation of voxel-based dosimetry for targeted radionuclide therapies in phantom studies B. Schweizer1, A. Schaefer2, P. Donsch2, S. Kremp2, E. Gouverneur2, G. Farmakis2, A. Grgic, MD2, M. Bal3, C. M. Kirsch2, D. Hellwig2; 1Philips Technologie GmbH Forschungslaboratorien, Aachen, GERMANY, 2Saarland University Medical Center, Homburg, GERMANY, 3Philips Healthcare, Eindhoven, NETHERLANDS. Aim: With an increasing number of targeted radionuclide therapies, detailed patient dosimetry is of growing importance. Aim of this study is to validate the calculated dose values of the image‐ based, voxelized dosimetry software STRATOS in a phantom study using the therapeutic radioisotope Iodine‐131. STRATOS is developed by Philips and part of the research version of the radiotherapy planning system Pinnacle3 and the IMALYTICS workstation. Materials & Methods: A cylindrical phantom with a total volume of 1280 ml, including 9 cylindrical inserts with a volume of 60 ml each, was filled with gel mixed with I‐131 sodium iodide in activities between 0 and 57 MBq. SPECT images were acquired 29, 172, 244, 340 and 539 h afterwards and reconstructed including correction for scatter and attenuation. A calibration factor was determined from a cylinder phantom homogeneously filled with I‐131. The SPECT and MR datasets of the phantom were imported into STRATOS. All SPECT images were registered to the MR volume. The inserts were delineated on the MR images. Voxel‐wise residence time maps were calculated by integrating the time‐activity‐curves and using a mono‐exponential tail‐fitting. The residence time maps with a voxelsize of 4.42 mm were convolved with precalculated kernels (dose‐convolution method). Region‐based dose statistics determined by STRATOS were compared to theoretical dose values based on the known activity concentrations. Correction of the partial volume effect (PVE) was performed by iterative deblurring with 30 iterations of “Blind Deconvolution” in MATLAB. Results: In STRATOS, we looked at the 3D dose maps fused with the MR images. Without PVE correction, these inspections showed that the calculated dose distributions were blurred beyond the boundaries of the inserts and highlighted the necessity to use PVE correction. The maximum dose value in each insert was in agreement with the theoretical value with a percentage error of less than 13.3%. The average dose values in the inserts were approximately 38% smaller than the theoretical value, primarily due to the blur in the SPECT images. Blind deconvolution corrected for the observed blur and reduced the percentage error to less than 9% in average dose. Conclusion: The dose values found by serial SPECT imaging and the dosimetry software STRATOS showed good agreement with the values calculated from known I‐131 concentrations. PVE correction is important in order to obtain quantitatively correct dose values. The blind deconvolution of the dose maps was identified as a promising technique for PVE correction.
P607 Assessment of the exposure to radiation by [F18]BAY 949172, a new PET tracer for detection of cerebral β-amyloid plaques B. Sattler1, H. Barthel1, A. Seese1, M. Patt1, A. Starke1, B. Rohde2, G. Holl2, C. Reininger2, B. Eggers3, U. Hegerl4, H. Gertz4, O. Sabri1; 1University Hospital Leipzig, Dept. of Nuclear Medicine, Leipzig, GERMANY, 2BayerSchering Pharma AG, Berlin, GERMANY, 3Arzneimittelforschung Leipzig
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 4
University Hospital
Leipzig,
Dept.
of
Aim: [F‐18]BAY 94‐9172 is a new and promising PET tracer for detection of β‐amyloid plaques in the brain. To assess the putative radiation risk resulting from the application of the tracer and, thereby, ensure appropriate clinical application, the biodistribution, resulting organ doses (OD) and the effective dose (ED) were determined in a proof of mechanism and a phase 1 clinical trial. Methods: Up to present, whole body dosimetry of [F‐18]BAY 94‐9172 has been performed in 20 healthy volunteers (age: 63.8 ± 5.4; 11 female, 9 male). All subjects were imaged up to 7h after intravenous (i.v.) injection of 300 MBq ± 20% [F‐18]BAY 94‐9172 using a SIEMENS ECAT HR+ PET scanner (3D mode, 8 or 9 bed positions per frame, 1min/bed position, correction for measured attenuation, iterative reconstruction). Furthermore, for up to 12h post injection all urine voided was collected and the activity concentration determined. All relevant organs were defined by volumes of interest (VOIs), and were displayed as time‐activity‐data. Exponential curves were fitted to this data using the EXM module of OLINDA. ODs and the ED were calculated using the adult male model for all subjects. Results: The gallbladder received the highest OD (108.0 ± 40.9µSv/MBq), followed by the urinary bladder (53.0 ± 17.0µSv/MBq), liver (35.9 ± 5.0µSv/MBq) and the intestine (upper large intestine: 32.6 ± 10.4 µSv/MBq; lower large intestine: 31.4 ± 11.3 µSv/MBq; small intestine: 27.9± 12.3µSv/MBq). The highest contributions to the ED were derived from the lower large intestine (3.77 ± 1.36µSv/MBq), ovaries (3.03 ± 0.41µSv/MBq), urinary bladder (2.65 ± 0.85µSv/MBq) and the liver (1.80 ± 0.25µSv/MBq). According to these data, the ED by i.v. application of [F18]BAY 94‐9172 results in an ED of 17.9 ± 2.6µSv/MBq. Conclusions: The ED as a measure of the overall individual radiation risk upon i.v. application of 300 MBq [F‐ 18]BAY 94‐9172 is 5.4 ± 0.8 mSv. This is well within the range of that resulting from the application of other [F18]‐labeled compounds. This favorable dosimetry data encourage the further development of [F‐18]BAY 94‐9172 as a clinical tool for PET brain imaging. References: The trial was sponsored by the Bayer‐Schering Pharma AG
P608 Biological half-life in
177
Lu-Octreotate radionuclide treatment
1
M. Sandström , U. Garske2, H. Lundqvist3; 1Medical Physics Academical Hospital Uppsala, Uppsala, SWEDEN, 2Nuclear Medicine Academical Hospital Uppsala, Uppsala, SWEDEN, 3Department of Oncology, Radiology and Clinical Immunology, Uppsala University, Uppsala, SWEDEN. Aims To determine the biological half‐lives in tumour tissue and organs at risk in patients receiving radionuclide therapy with 177Lu‐Octreotate. This information is then used to estimate, with the same absorbed dose to the main risk organ, how the absorbed dose to tumours varies for different radionuclides. Patients 100 patients (54 female and 46 male) undergoing radionuclide therapy with 177Lu‐Octreotate were included in this study. Methods The radionuclide (177Lu) concentration was in each patient measured with SPECT at three occasions spaced over a week. The biological half‐life was determined for the kidneys, liver, spleen and tumour tissues. In the study the maximal absorbed dose of the kidneys, the main dose‐limiting organ, was kept below 23Gy. With the same kidney dose and using the measured biological half‐ lives the absorbed dose to the tumour was calculated using alternative therapy radionuclides (90Y and 114mIn) with varying physical half‐lives. Results The biological half‐life of the radioactivity in organs at risk and tumour tissue are listed in table 1. Compared to 177Lu (160h) the radionuclide 90 Y (64h) gave more than 20% lower absorbed dose to the tumour while 114mIn (1152h) increased the absorbed dose with about 50%. Conclusion The biological half‐life in the tumour tissue was in most cases longer than in the kidney. This was also true for other organs like the liver and the spleen. In the octreotate therapy a radionuclide with a longer half‐life is favourable in the aspect of absorbed dose. Table 1 The measured biological half‐life in hours of varies organs and tumour tissue. Organ
Minimum
Median
Maximum
Kidney Dx
41
79
170
Kidney Sin
48
79
151
Tumour
43
256
>2000
P609 Dosimetric evaluation of Neuroblastoma patients submitted to 131I-MIBG M. T. Rézio, T. C. Ferreira, L. Salgado; IPOLFG, EPE, Lisboa, PORTUGAL. Aim: To evaluate the whole body dose (WBD) and the doses to the lesions (DTL) of patients (pts) with neuroblastoma submitted to therapy with 131I‐MIBG. It was assumed that WBD should not exceed 4 Gy. Two pts had more than one lesion. Method: 2.1 Therapeutic protocol Therapy was administered in accordance with the following scheme: Day 0: 1st administration of 131I‐MIBG (200 mCi) + whole body dosimetry Day 0 to Day 6: administration of Topotecan + tumour dosimetry (SPECT) Day 14: 2nd administration of 131I‐MIBG (200 mCi) + whole body dosimetry Day 14 to Day 20: administration of Topotecan + tumour dosimetry (SPECT) 2.2 Determination of WBD The WBD was measured as effective dose rate at 2 m distance from the patient. The measurements were done with a detector G‐M at the following time points: (i) Immediately after the administration of 131I‐MIBG, pre‐miction and post‐ miction; (ii) With 2 h intervals, post‐ miction (excluding nights and rest of the patient) At each cicle of therapy 3 studies of SPECT for evaluation of tumour dosimetry were performed: on the first and second day after 131I‐MIBG administration and on the last day, before discharge. 2.3 Determination of the lesion dose The activity of each lesion was calculated based on the number of counts in that lesion, obtained by SPECT images. The images were calibrated with a Jaszczack phantom (Diameter 20 x 20 cm) filled with water containing a sphere of 4 cm in diameter, with an activity of approximately 7mCi of 131I, which simulates the lesion. 3. Results We studied 4 patients: three of them did 2 treatments each and one did 4 treatments. We evaluated whole body and lesions doses (tumour and metastasis). The results were: Patient 1 (2 treatments): WBD ‐ 3,5 Gy ; DTL ‐ 56 Gy, Patient 2 (2 treatments): WBD ‐ 4,0 Gy, DTL ‐ 15 Gy Patient 3 (4 treatments): WBD ‐ 3,9 Gy, DTL ‐ 46 Gy; Metastasis Dose ‐ 42 Gy Patient 4 (2 treatments): WBD ‐ 3,6 Gy, DTL ‐ 84 Gy; Metastasis 1 Dose ‐ 33 Gy, Metastasis 2 dose ‐ 12 Gy 4. Conclusions In all pts treated WBD was less than 4 Gy. Primary tumour dose showed an inverse correlation with whole body dose.
P610 Evaluation of Absorbed Doses to Autonomous Tyroid Nodules (ATN) During 131-I Treatment: Comparison between Traditional Approach and Geant4 Monte Carlo E. Amato, D. Lizio, R. M. Ruggeri, M. Raniolo, A. Campennì, S. Baldari; Università di Messina, Messina, ITALY. Aim: Dosimetry during therapy of nodular toxic goiter is usually carried on by using a traditional formulation based on the estimation of nodule mass, maximum uptake fraction and effective half‐life. We developed a Monte Carlo simulation in Geant4 environment of nodule volumes made from soft tissue defined by MIRD Commission uptaking 131I, in order to compare the absorbed dose estimates resulting from the traditional approach and our calculation. Materials and method: We developed a Monte Carlo code in Geant4 environment to simulate the interaction of beta and gamma radiations emitted by 131I into ellipsoidal volumes of soft tissue characterized by different ellipticities and homogeneously uptaking the radionuclide. Such volumes are surrounded a simplified antropomorphic phantom. We compared the outcomes from different parametrisations of electromagnetic processes: the standard model from Geant4, the low‐energy EM Livermore data and the Penelope models, with both auto‐determined and fixed cuts for ionization, bremsstrahlung X‐ray emission and electromagnetic processes. We enrolled 10 patients affected by ATN; considering nodule volumes in the range 1‐50 cm3. The patients underwent ultrasonographic study, in order to determine the number of nodules and their volumes, and radioiodine thyroid uptake (RTU) measurements between 3 and 168 hours after radioiodine tracer dose administration. The maximum radioiodine uptake was between 35% and 68% (mean 57%) and the administered activity (range 111‐613 Mbq, mean 296 MBq) was calculated from the prescribed dose using the traditional formula, and the absorbed doses calculated by our Monte Carlo are compared with the prescribed ones Results and conclusion The results show that the mean energy deposited in target volumes decreases as the volume decrease. From the clinical experience presented here, our results indicate that the radioiodine activity calculated using the different approaches do not differ significantly for medium‐large volumes. For volumes below about 20 cm3, the average deposited energy calculated by Monte Carlo is lower than the average value considered in the traditional formula, and for nodule volumes as small as 1 cm3 the relative difference reaches 8%. In order to improve the accuracy in dosimetry of small volume thyroid nodules, we suggest to use the modified formula introduced in our work for the calculation of the activity to be administered.
P611 Development of Image-Based Patient-Specific Dosimetry Technique for Internal Radiotherapy (IRT) for Neuroendocrine Tumours: A Preliminary Report B. Birkenfeld1, M. H. Listewnik1, P. Zorga1, H. Piwowarska-Bilska1, J. Grimes2, S. Shcherbinin2, A. Celler2; 1Pomeranian Medical University, Szczecin, POLAND, 2University of British Columbia, Vancouver, BC, CANADA. Aim: The goal of radionuclide therapy is to deliver a dose that will affect tumour cells causing their death or apoptosis. So far, determination of the doses in peptide receptor radionuclide therapy remains a challenging task due to difficulties in quantitation of radiotracer distribution in heterogeneous tissues, determination of effective half‐life (Teff) and limited accuracy of dose calculation methods. Our aim is to design and validate a patient‐specific, quantitative method for accurate calculation of doses for IRT. The method uses biodistribution information from imaging (ex. Tc‐99m) to predict doses to be delivered by a therapeutic agent (such as Y‐90). Materials & Methods: Two patients with multifocal neuroendocrine metastases seen on Tc99m‐Tektrotyd examination underwent a series of scans following a special imaging protocol which included: for patient A two WB planar scintigraphy scans (WBPSS) at 1 and 5 hours and SPECT/CT at 5.5 hours, and for patient B three WBPSS at 2, 4 and 24 hours and SPECT/CT at 3 hours. Tomographic images were reconstructed with our qSPECT algorithm [PMB2008] (OSEM, CT‐based attenuation and scatter corrections and resolution recovery) and co‐registered with WBPSS data. Activity in each tumour (3 for patient A and 4 for patient B) was determined for each series of WBPSS using conjugate views and converted into absolute activity through normalization with SPECT. The cumulative activities (area under the time‐activity curve (TAC)) for all tumours were determined from these data and used in OLINDA [JNM2005] dose calculation. Results & Conclusion: Quantitative measurement of activity and accurate determination of the TAC are essential for dosimetry calculation (DC). Our results indicate that two WBPSS performed for patient A did not provide sufficient temporal information for Teff determination. Thus, in DC the Teff was assumed to be equal to the physical half‐life of the radioisotope. However, the analysis of patient B data (with the third WBPSS performed at 24 hours) showed the biological half‐life of the radiotracer to be equal to 5h. This produced large discrepancies for dose calculations done with and without taking the 24h WBPSS into account. Although, for Tc‐99m the effect was small (about 10‐15%), the doses calculated for Y‐90 (T1/2=64h) with and without this additional information differed by a factor of 3‐4, clearly demonstrating the importance of the extended biodistribution measurements. Table 1. The difference in calculated dose for patient B with and without 24h WBPSS taken into account
Tc‐99m Dose (Gy)
Y‐90 Dose (Gy)
Tumour Mass (g) With 24h WB Without 24h WB With 24h WB Without 24h WB 1
8.7
0.014
0.016
2.1
8.0
2
84
0.021
0.025
2.9
11.0
3
5.1
0.024
0.026
4.4
13.0
4
4.6
0.018
0.020
3.6
10.3
P612 Deterministic algorithms for the calculation of tumor and organ doses in Targeted Radionuclide Therapy (TRT) and their implementation with voxel models
Poster Presentation
GmbH, Leipzig, GERMANY, Psychiatry, Leipzig, GERMANY.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
D. Reiner1, M. Blaickner1, F. Rattay2; 1Austrian Research Centers GmbH – ARC, Department Health & Environment, Molecular Medicine Unit, Seibersdorf, AUSTRIA, 2Vienna University of Technology, Vienna, AUSTRIA. Radiopharmaceuticals administered in Targeted Radionuclide Therapy (TRT) rely to a great extent on Beta Minus nuclides but also on a few emitters of monoenergetic electrons. Recent advances like combined PET/CT devices, the consequential coregistration of both data, the concept of using Beta‐Couples for diagnosis and therapy respectively as well as the development of voxel models offer a promising potential for developing TRT dose calculation systems similar to those available for external beam treatment planning. This project aims to report on a deterministic algorithm for the calculation of tumor and organ doses in Targeted Radionuclide Therapy (TRT) and the implementation with voxel models. MATERIALS & METHODS: Basically there are two different approaches for calculation methods: stochastic and deterministic methods. A deterministic method to calculate the three‐dimensional, heterogeneous absorbed dose distribution in a tumour and the adjacent tissue is the convolution of the cumulated activity distribution with the point‐source kernel; both are represented by large three dimensional matrices. To reduce the computation time required for these calculations, an implementation of convolution using three‐dimensional Fast Fourier Transform (3D FFT) has been realised. This approach was implemented with a voxel phantom of an organ containing a malign tumor. The tumor shape is assumed to be spherical with different diameters: 0.5cm, 1cm and 1,5cm. Convolution has been performed for three nuclides representing short, middle and long CSDA‐ range: P33, P32 and Y90. Three different distribution cases have been modelled: homogenous, linear and hull distribution of cumulated activity within the spherical tumor. The results have been compared with a Monte Carlo Simulation using the MCNP5 code. RESULTS & DISCUSSION: The comparison of the convolution algorithm compared with the Monte Carlo Simulations showed a very good accordance. While in case of the long and middle range nuclides a percentage difference between MCNP and convolution results of 4‐10 % at hot regions is noticeable, differences at cold regions decline to beneath 0,0001 %. In the case of the short range nuclide P33 the voxel value differences don´t exceed 2 % even in hot regions and decline to zero very fast.
P613 Absence of dose-toxicity correlations in 90Y glass microspheres liver radio-embolization for hepatocellular carcinoma on the bases of planar dosimetry C. Chiesa1, A. Negri2, M. Maccauro1, R. Romito3, C. Morosi4, R. Azzeroni2, A. D. Padilla3, C. Sposito3, E. Civelli4, R. Lanocita4, E. Seregni1, T. Camerini5, C. Spreafico4, E. Bombardieri1, V. Mazzaferro3; 1Nuclear Medicine Division, Foundation IRCCS Istituto Nazionale Tumori, Milan, ITALY, 2Post graduate Health Physics School, University of Milan, Milan, ITALY, 3General Surgery, Foundation IRCCS Istituto Nazionale Tumori, Milan, ITALY, 4 Radiology, Foundation IRCCS Istituto Nazionale Tumori, Milan, ITALY, 5 Scientific Direction, Foundation IRCCS Istituto Nazionale Tumori, Milan, ITALY. Aim: We investigated retrospectively the possible correlations between absorbed dose to liver and the toxicity in intermediate/advanced HepatoCellular Carcinoma (HCC). Methods: 61 patients were evaluated for 90‐Y radio‐embolization. Planar conjugate view was used for individualized dosimetry. On the bases of simple phantom SPET, 3D dosimetry without CT based attenuation correction was too inaccurate. Planned mean dose D to the target lobe was 120 Gy. The activity A to be injected was fixed according to the target lobe mass M, measured on CT scan. Intra arterial injection of 99m‐Tc MAA was assumed to reproduce the distribution of 90‐Y glass microspheres (Theraspheres®, MDS Nordion). Correlation between target lobe absorbed dose (or BED) with toxicity parameters (Child, total bilirubin) was investigated. In order to test the hypothesis of radiobiological behaviour as parallel organ, a second correlation analysis was performed on the basis of the recalculated mean dose to the whole liver (M = whole liver mass). 2 patients were treated with 120 Gy to the remnant left lobe after surgical resection of the right one. Results: 9 patients were excluded because of the presence of shunts or excessive tumor burden. Mean liver lobe dose was 106 [33, 165] Gy, while BED was 271 [50, 577] Gy. Lung dose was 0.7 [0.0, 15.4] Gy. Tumor dose was 496 [161, 2070] Gy. Weak correlation was found only in a patient subgroup according to pre‐therapy cirrhotic status. Marked radio induced liver function impairment (2 units or more of child score increase within 6 months) was found in 7/10 (70%) of patients with initial liver function compromised by cirrhosis (child > A5), while in only 17% of patients with good initial liver function (child = A5). A unique weak correlation between dose and bilirubin increase (R2=0.5) was found for patients with initial child > A5 if mean dose to the whole liver was considered. The 2 patient treated with 120 Gy to the remnant left lobe showed extreme child increase. Conclusions: The radiobiological behaviour of liver as parallel organ together with the absence of whatever correlation for the large majority of patients demand a more refined dosimetric approach for improving future protocols, with different dose planning depending on the initial liver status and maybe according to the whole liver mean dose. Non uniform dose distribution within the parenchyma should be introduced on attenuation corrected SPET‐CT images to investigate the missing correlation between dose and observed liver toxicity.
Organs S values
Source
Adrenals Adrenals
Adrenals
Adrenals
Target
Adrenals Spleen
Pancreas
Liver
S Factors mGy/(MBq.s) 2.36E‐03 1.33E‐06
1.71E‐06
1.00E‐06
Cellular S values
Source
Cell
Cell Surface Cell Surface
Target
Cell
Nucleus
Cell
S Factors (Gy/(Bq.s)
2.33E‐03 7.77E‐04
1.29E‐03
P69 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Radionuclide therapy/dosimetry: biological and longterm effects / animal and in-vitro studies.
P615 Inducing Apoptosis Effect on Biodistribution Characteristics in 188 Xenografts of Re-AGPNA
for
Dose
Calculation
in
Targeted
A. M. Govignon1, M. Bardiès1, J. Barbet1, L. Ferrer2, C. Hindorf3; 1Inserm U892, Nantes, FRANCE, 2Centre René Gauducheau, Nantes, FRANCE, 3 National Veterinary School, Nantes, FRANCE. Aim: A range of techniques is used for dose calculation in targeted radiotherapy. Most are limited to operating of a specific scale. Monte‐Carlo simulation can be used over a wide range of scale but the calculation time is very long. The present work describes a fast tool, valid for most scales of interest in radionuclide therapy. This tool is based on the concept of dose point kernel convolution. Materials and methods: A dose point kernel is defined in a homogeneous medium for each source of interest. This is used to calculate a voxel dose kernel which is applied to a quantitative distribution of activity derived from SPECT, PET and autoradiography imaging. 3‐
Patu8988 Cell and Nude Mice Bearing
B. Zhang, Y. Wu; The First Affiliated Hospital of Soochow University, Suzhou, CHINA. Antigene peptide nucleic acid (AGPNA) hybridization probes targeted k‐ras 12 point mutation oncogene can depress the k‐ras gene expression and be labeled with 188Re. Objective To investigate the inducing apoptosis effect on Patu8988 cell and biodistribution characteristics, determine the dosimetry in nude mice bearing xenografts of 188Re‐AGPNA. Methods (1) At 3d to 5d after treatment with Patu8988 cell in culture flask with 925KBq 188ReO4‐ or 188Re‐AGPNA, the cell’s apoptosis was detected everyday by flow cytometry. (2) 28 nude mice model bearing human pancreatic carcinoma cell Patu8988 xenografts were established. At 15min, 1, 4, 24, 72, 120 and 148h after intratumor injection with 188Re‐AGPNA, the mice were killed and organs of interest were excised, weighted and counted on a gamma counter. The organ uptake was calculated as a percentage of the injected dose per gram of wet tissue (%ID/g) and the ratios of tumor to normal tissue (T/NT) were calculated. (3) Scintigraphy imaging was performed for each nude mice at 15min after intratumor injection with radiopharmaceuticals, in which serial planar scintigraphy imaging were performed for 6 nude mice at 15min, 1, 4, 24, 72, 120 and 148h after intratumor injection with 188Re‐AGPNA. (4) According the mean %ID/g of organs in different time point, the absorbed dose of organs were calculated. Results (1)At 3d to 5d after treated with 188 ReO4‐ and 188Re‐AGPNA, float cell ratio were (5.68±0.82)%, (8.14±0.12)%, (11.87±0.17)% and (5.99±3.59)%, (25.66±8.51)%, (29.59±4.92)%, respectively. Float cell’s apoptosis ratios of 188ReO4‐ 188 and Re‐AGPNA group were (3.88±2.10)%, (8.75±3.11)%, (16.87±5.85)%, and (5.28±1.12)%, 188 (26.30±7.45)%, (27.90±10.38)%, respectively. (2) Re‐AGPNA was major distributed in tumors and the largest uptake of tumors was (53.23 ± 16.64)% at 15min after injection. The uptake of tumor were (35.96 ± 7.80)% and (15.46 ± 4.93)% at 24h and 148h after injection, respectively. (3) Tumor in nude mice could be seen clearly in scintigraphy images until 148h after intratumoral injection with 188Re‐AGPNA. (4) The absorbed dose of tumor was 15569mGy/MBq. Conclusion 188 Re‐AGPNA was major distributed in tumors after intratumor injection in nude mice bearing 188 human pancreatic cancer xenografts, and we propose that Re‐AGPNA may be a potential tumor transarterial radionuclide therapeutic agent used in clinic.
P616
P614 Multi Scale Tool Radiotherapy
dimensional areas representing the distribution of activity and the voxel dose kernel are convoluted using a Fast Fourier Transformed filter implemented in ITK. Results are visualized with VTK based image viewer. For purpose of validation both the cell and organ scale were considered. A cell model has been implemented based on MIRD specifications (1). Calculated cellular S values were compared to the reference cellular S values (1). Radius of the cell and cell nucleus are respectively 3 μm and 2 μm. Organ scale S values were calculated from a voxelized anthropomorphic phantom (2) and compared to published reference values (3). The spectrum of I‐131 was used in each case. Results: Calculated and reference S values agreed to within 13% at the cellular scale, and 8% at the organ scale within the abdomen. Outside of the abdominal region, relative errors of 25% to 50% were observed. Table 1 shows a selection of S values calculated at the cellular and organ scale. Further comparisons with additional sources, for the existing phantoms and for a voxelized mouse phantom are ongoing. Conclusion: A multi‐scale convolution based dose calculation tool has been implemented. The tool works reasonably well at the cellular scale but, at the organ scale, the violated assumption of homogeneity inherent in the convolution method can introduce significant errors. (1) Goddu et al, MIRD cellular S values, Society of Nuclear Medicine, 1997. (2) Snyder et al, Estimates of specific absorbed fractions for photon sources uniformly distributed in various organs of a heterogeneous phantom, Society of Nuclear Medicine, MIRD Pamphlet NO.5, 1978. (3) Snyder et al, "S," Absorbed dose per unit cumulated activity for selected radionuclides and organs, Society of Nuclear Medicine, MIRD Pamphlet No.11, 1975. Table.1 Feuil1
Proliferation Inhibition Effect of Carcinoma Cell
188
Re-IGF-1A on Pancreatic
Y. He, Y. Wu, B. Zhang; The First Affiliated Hospital of Soochow University, Suzhou, CHINA. The insulin‐like growth factor‐1 receptor (IGF‐1R) is a cellular receptor found to be overexpressed in many tumor cell lines from different anatomical sites. It can be used as molecular targets by which radiolabeled insulin‐like growth factor 1 analogue (IGF‐1A) can localize cancers for peptide receptor radiation therapy. Objective To investigate cell combination and proliferation inhibition effect of 188Re‐IGF‐1A to Patu8988 human pancreatic carcinoma cell. Methods 1. Direct labeling method was adopted to label IGF‐1A with 188Re, and the combinative efficiency of 188Re‐IGF‐1A with Patu8988 cell was determined. 2. Patu8988 cell were seeded onto 96‐well plate and divided into blank control group, IGF‐1A group (1, 5, 10, 20μg), 188ReO4‐ group (0.37, 1.85, 3.70, 7.40MBq) and 188Re‐IGF‐1A group (0.37, 0.74, 1.85MBq). 3. The proliferation inhibition effect of 188Re‐IGF‐
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P617 3`-(2-iodovinyl)uridine: A New Ribonucleoside Radiotracer for Tumor Visualization A. Morgenroth, B. D. Zlatopolskiy, E. A. Urusova, C. Dinger, T. Kull, C. Lepping, S. N. Reske; Nuclear Medicine Clinic, University Ulm, Ulm, GERMANY. Aim: Uridine cytidine kinase 2 (UCK2), an enzyme normally expressed in human placenta and testis and highly overexpressed in many neoplasias of blood and solid tissues, catalyzes monophosphorylation of pyrimidine ribonucleosides with efficiency 15‐20‐fold higher than ubiquitously expressed isozyme UCK1. In this study we report synthesis of 3'‐(2‐iodovinyl)uridine (IV‐14) and its preclinical evaluation as a new radiotracer derived from an UCK2‐selective antitumor agent 3'‐(ethynyl)uridine (EUrd). Methods: Radioiodinated 3'‐(E)‐(2‐iodovinyl)uridine (IV‐14) was prepared from the respective stannyl precursor. I‐131‐IV‐14 was studied in cell uptake assays and tested for serum stability as well as for stability to thymidine phosphorylase, liver and mucosa specific murine uridine phosphorylases. UCK1 and UCK2 expression level in different tumor cell lines was determined by Western blot. Cellular distribution of I‐131‐IV‐14 was determined in HL60 cells. Biodistribution studies and γ‐camera scintigraphy were carried out in HL60 xenograft severe combined immunodeficiency mouse model. Results: I‐131‐IV‐14 demonstrated excellent serum stability. It was stable to human thymidine phosphorylase as well as to liver and mucosa specific murine uridine phosphorylases. A cell uptake of I‐131‐IV‐14 in Mia‐PaCa‐2, CX‐1, HL60, Capan‐1 and Panc‐1 cells was 4.27±0.214, 3.66±0.13, 2.69±0.065, 2.24±0.18 and 3.26±0.18 %ID, respectively, after 24 h incubation. The uptake and retention of IV‐ 14 was regulated by two factors: by UCK2 expression level and by intracellular transport mediated, partially via hENT1 nucleoside transporters. A biodistribution study of I‐131‐IV‐14 in HL60 SCID mouse model showed selective retention of the radioactivity in tumor tissue at 4 h p.i.: rel. acc. radioactivity/g: tumor (1), spleen (0.4), colon (0.22), bones (0.18), small intestine (0.14), others < 0.1. Scintigraphy with I‐123‐IV‐14 (4 h p.i.) indicated good tumor visualization. In addition high accumulation of radioiodide in gastrointestinal tract content was observed, presumably due to metabolic degradation of IV‐14. Conclusion: IV‐14 is a UCK2 specific marker, allowing for in vivo addressing of tumor with high RNA‐synthesis independent on proliferation rate.
P618 Cellular effects of 140 keV ionizing radiation 1
2
2
3
4
R. Oliveira , A. M. Abrantes , J. Rio , C. Goncalves , M. Pinto , A. B. Sarmento-Ribeiro3, I. M. Carreira4, M. F. Botelho2; Biophysics/Biomathematics Institute, IBILI - Faculty of Medicine; Cytogenetic Unity, Biology Institute - Faculty of Medicine, Coimbra, PORTUGAL, 2Biophysics/Biomathematics Institute, IBILI - Faculty of Medicine, Coimbra, PORTUGAL, 3Biochemistry Institute, Faculty of Medicine, Coimbra, PORTUGAL, 4Cytogenetic Unity, Biology Institute Faculty of Medicine, Coimbra, PORTUGAL. 1
Aim: Since the second half of the 20th century, after the discovery of X rays, the effects of ionizing radiation on living cells have been subject of intense research. Cells, when exposed to ionizing radiation fields, undergo physical alterations as ionization and excitation of atoms, chemical alterations like rupture of connections between atoms, formation of free radicals and organic alterations that are responsible by cellular function alterations and consequent biological damages. The aim of this work is to study ionizing radiation cell effects over the time in two different human cells, amniocytes and lymphoblasts. Material and Methods: Cellular irradiation was performed using a human lymphoblast cell line (ATCC ‐ RPMI7666) and human amniocytes obtained from primary cell cultures. All cells were exposed to ionizing radiation from an external source of 140 keV energy peak. After irradiation, with an exposure dose of 4 Gy, we study radiation effects, 4 hours after irradiation for both cell lines, 96h for amniocytes and 120h for lymphoblast. The radiation effects were evaluated through chromosomal analysis and flow cytometry methodology with different fluorocromes. To study cell viability we used Annexin V/Propidium Iodide, DCFH2‐DA to evaluate reactive oxygen species production, mercury orange for anti‐oxidative defenses (GSH), and JC‐1 for mitochondrial membrane potential. Results: Through flow cytometry we observed a time dependent decrease on cell viability. For both cell lines at 96h and 120h after irradiation a higher percentage of cell death by apoptosis/necrosis is shown. However, our results also show an higher percentage of cell death in lymphoblasts. Additionally to cell viability changes, reactive oxygen species increase with time after irradiation. Oppositely, anti‐oxidant defenses increase only in the first 4 hours after irradiation decreasing after. Mitochondrial membrane potential was also altered demonstrating a time dependent increase of monomers/aggregates ratio, which is associated with a membrane potential decrease. Related to chromossomic analysis it was impossible because the amniocytes culture does not show metaphases having cell cycle arrested at G1. Conclusion: Ionizing radiation induces identical effects in amniocytes comparing with lymphoblasts, although amniocytes are less sensitive to ionizing radiation used. These observed effects are more evident immediately
after irradiation. Our cytogenetic results suggest that a more accurate cell cycle analysis is mandatory.
P619 New modality of curietherapy submicronic particles
with
holmium
oxyde
J. Taleb1, B. Mutelet1, L. Maciocco2, D. Kryza3, S. Humbert4, O. Tillement5, F. Simonelli, E. Hiltbrand4, C. Louis6, M. F. Janier3, S. Roux5, K. Abbas2, P. Perriat7, C. Billotey3; 1Université Claude Bernard Lyon1, Villeurbanne, FRANCE, 2Advanced Accelerator Applications, Saint Genis Pouilly, FRANCE, 3Université Claude Bernard Lyon1, Hospices Civils de Lyon, LYON, FRANCE, 4CERMA, Archamps, FRANCE, 5Université Claude Bernard Lyon1, CNRS, Villeurbanne, FRANCE, 6NanoH, Saint-Quentin Fallavier, FRANCE, 7INSA, Villeurbanne, FRANCE. Introduction : Arguments of radioactive particles using such as curie therapy agent is to obtain a more homogeneous and intense radio effect and consequently improve anti‐tumoral effect and decrease ratio of relapse. The aim of this study is to demonstrate that sub‐micronic holmium oxide particles (NanoH™) could be activated without alteration of particle structure, could be directly injected in a tumour, with a high intra‐tumour permanence, without overall adverse effect, and with anti‐tumour effect. Materials and Methods: The tumour model is double xenograft of murine breast cells (1372 MAT B III cell lineage) in Fischer rats. 106 cells were injected under isoflurane anaesthesia by sub‐cutaneous route at both thigh of 13 rats. 300nm sized particles containing about 90% of holmium oxide were synthesized, dessicated and then activated in neutron reactor. 166Ho particles were suspended in a solution of PVA and 10% ethanol to obtain a solution with a specific activity of 56.5 MBq/100µl and mass particle concentration of 7.7 %. Each 8‐10 mm diameter tumour of 10 rats were injected at 7 days post‐ tumour graft with an activity of 15 to 200 MBq, either with a hypodermic syringe either a high kinetic injection system (CERMA™) in 7 rats (14 tumours). Volume of tumours were daily calculated in all rats. Animals were sacrificed at 14 days post xenograft. Results : In witness rat population, mean of tumour volume at 7, 11, and 14 days is respectively : 0.012 cm3(SD = 0.038), 1.5 cm3(SD = 0.98), 4.84 cm3(SD = 2.97) and 8.8 cm3(SD = 4) with mean ratio of a increased volume between d7 and D11 = 46%.. One rat was death at D10 due to anaesthesia problem. In treated rat mean of tumour volume at 7, 11, 14 and 16 days is respectively : 0.95 cm3(SD = 0.43), 0.98 cm3(SD = 0.51) and 1.3 cm3(SD = 0.37) with mean ratio of a increased volume between d7 and D11 = 9.9%.. In 9/12 tumours, growth of tumour after injection of holmium particles at D11 is inhibited (mean of increasing volume tumour ratio= ‐9%, ‐43% to + 27%). In 3/12 tumours, growth of tumour was observed (mean of increasing volume tumour ratio= 71 %, 41% to + 113%), maybe related to a bad injection (without the tumour). Conclusion : Curietherapy with submicronic holmium oxyde particles are promising new agent for curietherapy by direct intra‐ tumor injection, with perspectives of additional treatment in glioblastoma.
P620 Biodistribution of Re-188 MN-16 Lipiodol and Re-188 MN-16ET Lipiodol in Rats with Hepatic Tumors after Intra-arterial Injection via the Hepatic Artery W. Lin1, T. Luo2, Y. Lin3; 1Taichung Veterans General Hospital, Taichung, TAIWAN, 2Isotope Application Division Institute of Nuclear Energy Research, Taoyuan, TAIWAN, 3Chunghsing University, Taichung, TAIWAN. Aim: Re‐188 lipiodol has many advantages for liver cancer treatment. However, according to the literature, the reported labelling methods were too complicated. In addition, the yield rates for the Re‐188 lipiodol were low due to the limitation of labelling methods. In this study, we developed two kinds of Re‐188 labelled lipiodol derivatives. Biodistribution examination was performed to determine the best lipiodol derivative and its potential for the treatment of liver cancer was evaluated.. Materials&Methods: Two kinds of Re‐188 labelled lipiodol including Re‐ 188 MN‐16 lipiodol and Re‐188 MN‐16ET lipiodol were developed. Thirty male rats bearing hepatic tumor were divided into two groups (fifteen rats in each group using one kind of Re‐188 compound). The rats were sacrificed at 1 hr, 24 hrs and 48 hrs after injection of 0.1 mCi of Re‐188 Lipiodol derivatives via the hepatic artery. Samples of various organs were obtained to calculate the tissue concentration.. Results: Our data showed that both Re‐188 MN‐16/Lipiodol and Re‐ 188 MN‐16ET/Lipiodol were essentially accumulated in liver tumors and in normal liver tissue following intrahepatic arterial injection. The concentration of radioactivity in other tissues such as kidney, spleen, testis, intestine, muscle, bone, urine and whole blood was quite low. Nevertheless, the group with Re‐188 MN‐16ET/Lipiodol injection showed a higher uptake and longer retention of radiotracer in the tumor. The tumor to liver uptake ratio (T/N ratio) is 1.63, 1.38 and 1.17 at 1, 24 and 48 hours, respectively, for Re‐188 MN‐16/Lipiodol and 1.66, 2.57, 3.27 at 1, 24, and 48 hours, respectively, for Re‐188 MN‐16ET/Lipiodol. Conclusion: We consider both Re‐188 MN‐16/lipiodol and Re‐188 MN‐16ET/lipiodol can be a candidate for the therapy of liver tumor. However, Re‐188 MN‐16ET/Lipiodol has better therapeutic potential for the treatment of liver tumor.
P621 The histopathologic comparison of the protective effects of LCarnitine and amifostine against high-dose radioiodine therapy -induced lacrimal gland damage in the guinea pig G. Durmus-Altun1, A. Ozdil-Muratli2, N. Torun1, A. Ergulen1, F. Ustun2, S. Altaner1; 1Trakya University, Edirne, TURKEY, 2Onsekiz Mart University, Canakkale, TURKEY. Background and Purpose: High‐dose radioiodine therapy with I‐131 (HD‐RIT) has been a well‐ established procedure since the 1940s in the management of differentiated thyroid carcinoma. The three most important side effects involving the eye area are inflammation of the lacrimal gland, obstruction of the lacrimal duct, and conjunctivitis. Radioiodine is known to accumulate within the lacrimal gland and, in sufficient concentration, may deliver enough radiation exposure to result in local inflammation and subsequent reduced production of tears. Reduction of side
Poster Presentation
1A group and 188ReO4‐ group on cell growth was detected every day by MTT test from 1d to 7d after administration. The proliferation inhibition effect of IGF‐1A group was detected every day from 1d to 6d, and inhibition rates were calculated. 4. At 3d after treatment with 188ReO4‐ and 188 Re‐IGF‐1A (1.85, 3.70, 7.40 MBq), the cell’s apoptosis was detected by flow cytometry. Results 1. The total combinative efficiency of 188Re‐IGF‐1A with Patu8988 cell was (24.13±2.03)%, and the special combinative efficiency was 12.68%. 2. Inhibition rates of Patu8988 cell with 188Re‐IGF‐1A group (0.37, 0.74, 1.85MBq) were (64.48±4.18)%,(66.89±1.39)% and (89.71±1.27)% after 3d, and the inhibition rates was higher when the radioactive dose higher. After 6d, inhibition rate of Patu8988 cell with 188Re‐IGF‐1A group (1.85MBq) was (93.20±1.93)%. 3. Inhibition rates of Patu8988 cell with 188Re‐IGF‐1A group were always higher than 188ReO4‐ group and IGF‐1A group. The difference was significant (P<0.05). 4. At 3d after treated with 188ReO4‐ and 188Re‐IGF‐1A, float cell ratio were (16.58±3.57)%, (24.58±6.50)%, (34.12±7.39)% and (16.56±0.95)%, (33.39±5.93)%, (43.76±1.38)%, respectively. Float cell’s apoptosis ratio of Patu8988 cell with ‐ 188 ReO4 and 188Re‐IGF‐1A group were (9.27±1.80)%, (16.00±1.15)%, (15.47±0.65)% and (12.70±2.27)%, (17.80±1.51)%, (23.23±1.22)%, respectively. Conclusion Proliferation of human pancreatic carcinoma cell Patu8988 can be inhibited and apoptosis can be promoted with 188Re‐ IGF‐1A.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
effects of HD‐RIT, i.e. lacrimal gland impairment is important. Several radioprotective agents exist to decrease radiation injury to normal tissues, and radioprotective activity of L‐carnitine (LC) and amifostine (AMI) on different organs has been shown in several studies. To our knowledge, there are no studies in which the role of radioprotector in HD‐RIT‐induced lacrimal gland damage. The aim of the present study is to estimate the radioprotective efficacy of LC and AMI in HD‐RIT ‐ induced lacrimal gland damage. The evaluation of lacrimal gland damage with and without LC as well as AMI pretreatment was the primary study objective, with a secondary objective in which the comparative efficacy of LC and AMI were examined. Method: Thirty adult male guinea pigs (mean weight: 754±85 g) were randomly divided into six groups: 1: AMI+ HD‐RIT (AMI+RIT) (n=5), 2: L‐Carnitine+ HD‐RIT (LC+RIT) (n=5), 3: L‐Carnitine alone (LC) (n=5), 4: control (CONT) (n=5), 5: Amifostine alone (AMI) (n=5), 6: HD‐RIT alone (RIT) (n=5). HD‐RIT was applied with a single dose of 666 GBq I‐131 by ip. The lacrimal gland was examined by light microscopy and a histopathologic scoring system was used to assess the degree of tissue damage. A histopathological classification into four grades was established based on the degree of glandular atrophy, fibrosis and lymphocytic infiltration. Results: The mean histopathologic score of study groups were 1.6±0.8 in CONT, 4.6±0.9 in RIT, 3.7±1.5 in AMI, 5±3.2 AMI+RIT, 1.2±0.5 in LC and 5.0±2.6 LC+RIT. Tissue specimens in RIT, AMI+RIT and LC+RIT were characterized by diffuse swelling of the serous acini and various degrees of acinar atrophy accompanied by destruction of the structure of the glandular lobule. Acinar morphology of AMI+RIT and LC+RID groups was well protected than RIT group. Additionally, secretuar capacity of lacrimal gland was more protected in LC+RIT than AMI+RIT. Conclusion: We concluded that both LC and amifostine have comparable and significant protective effects against HD‐RIT‐induced lacrimal gland damage.
P622 Experimental high dose radioactive I-131 ablation model in guinea pig N. Torun, A. Ergulen, B. Dirlik, G. Durmus-Altun; Trakya University, Edirne, TURKEY. BACKGROUND: The treatment with high dose radiatioactive I‐131 ablation is the oldest and the most common treatment model in area of nuclear medicine. However, to observe the hystopathological and functional changing in tissues and to form experimental models to test radioprotectivity against I‐131 in extratyroideal tissues and to confirme this model is necessary.The purpose of this study is to make a treatment model with high dose radioactive I‐ 131 ablation,to get the calculation of internal dosymetry in guinea pig, which is used to make a treatment model with high dose radioactive I‐131 ablation , and to confirme the efficiency of this model. MATERIAL AND METHODS: Tissue radioactivity levels were measured in a guinea pig model for the 24, 48, 72‐h postinjection period. At first ; as a standart dose 37 mBq I‐131 by ip is given to a guinea pig (Gender: male, BW:819 g); and after 24,48,72 hours whole body images were obtained in prone position using high energy high resolution colimator in 128*128 matrix 600 sc. The regions of interests (ROIs) were drawn over whole body, salivary and tyroid gland, stomach and vesica urinaria. At the second step, 666 mBq I‐131was injected 2 adult guinea pigs by ip, which had taken views with the same image protocol. MIRD method was used on the basis of cumulated activity calculated. Third step of study, high dose treated 5 guinea pig were followed up to 4 week. Basal and after four week of treatment, tyroid funtions (fT3, fT4, TSH) were evaluated. All animal underwent Tc 99m pertecnetat thyroid scan for examination of thyroid ablation. RESULTS: Table 1. and Table 2. show the absorbed dose of each organ according to high and low dose regime . The measurement of T3 (2.79±0.25 vs. 0.270±.01) and T4 (1.8±30.14 vs 0.25±0.003) before and 4 weeks after the high dose the treatment was shown as significantly different (p:0.001, p:0.001). Tyroid tissue was observed in none of subject. CONCLUSIONS: It is reasoned that the model of high dose radiatioactive iyode ablation in human is able to be modeled in guinead pigs using 666 MBq I‐131 and the dose distributions are same , althouh partial differences have been considered. Table 1. Absorbed Doses of Low Dose I‐131 (mGy/MBq) Organs
1.day
2.day 3.day
Thyroid
385
690 770
Stomach
3,5
1,4
0,75
Salivary gland
2,1
0,4
0,5
Table 2. Absorbed Doses of High Dose I‐131 (mGy/MBq) Organs
3.day
Thyroid
777
Stomach
2,7
Salivary gland
0,45
P623 Radiobiological Effects of Low Doses of Gamma Radiation in Four Types of Cell Lines L. Metello1, L. Cunha1, L. Lourenço1, M. Laranjo1, A. Abrantes2, A. Sarmento-Ribeiro2, I. C. Dormehl3, M. Lima4, M. F. Botelho2; 1Nuclear Medicine Department, ESTSP IPP, Porto, PORTUGAL, 2 Biophysics/Biomathematics Institute, CIMAGO, IBILI – Faculty of Medicine, 3 University of Coimbra, Coimbra, PORTUGAL, AEC Institute for Life Sciences, University of Pretoria, Pretoria, SOUTH AFRICA, 4Cytometry Laboratory, Hematology Department, Hospital Geral de Santo António, Centro Hospitalar do Porto, Porto, PORTUGAL. Introduction It is consensually considered of utmost importance to study and understand the effects of low dose radiations in biological structures, mostly unknown in the current state‐of‐ the‐art of radiobiology, for pathologic as well as for non‐pathological tissue samples. This work comes in this direction and it aims to study the effect of several radiation exposure doses in various cell lines. This presentation relates with preliminary results obtained using Na99mTcO4 (99mTc) as radioactive agent to induce low dose exposures. Material and Methods It has been decided to use four distinct types of cell lines, CRL‐1472 and MNNG‐HOS ‐ respectively human bladder cancer and human osteosarcoma cell lines ‐ from ATCC, and SH‐SY5Y, neuroblasts from
neural tissue from SIGMA‐ALDRICH, and non‐pathological fibroblasts are being introduced in the study in this moment. Cells were developed under standard culture conditions (37ºC temperature, 95% air and 5% CO2 atmosphere). Experiments took place during the log phase of cell growth, each time with one sample of cells from each group being divided in four distinct sub‐groups (constituting one of them the control group) following, in parallel, the same assay. All of them were incubated with distinct amounts (and/or within distinct conditions) of 99mTc, in order to induce radiation exposures of 0.25, 0.5, 1.0, 1.5, 2.0, 2.5, 3.0, 3.5 and 4.0 Gray (Gy). The cell cultures were then incubated at the same initial conditions and, at different time points, samples were collected and the radiobiological effects (namely those related with the apoptotic process) were studied using multiple techniques, using optical methods and techniques (epifluorescence microscopy, for instance) as well as flow cytometry. Results This work is currently in progress, having started in the beginning of this year and it is expected to last for two years more. Late summer the preliminary results till then obtained will be presented on tables, describing both the findings for each one of the cell types, as well as comparison charts between them. An attempt of biological explanation of the findings so presented will be advanced at the same moment. Conclusions It is believed ‐ from the data we are already getting ‐ that the results so obtained will allow us to have a consistent starting point to be developed on the remaining phases of this study, namely concerning radiobiological effects of low gamma radiation doses in living cells.
P624 Interstitial microbrachytherapy in veterinary patients using small holmium-166 microspheres for radioablation of intrahepatic tumors and other malignancies W. Bult1, M. A. D. Vente1, B. A. Zonnenberg1, J. Kirpensteijn2, B. P. Meij2, C. G. Van der Bovenkamp2, K. Peremans3, S. Vermeire3, E. Vandermeulen3, E. Dekkers1, G. C. Krijger4, R. de Roos1, A. D. Van Het Schip1, J. F. W. Nijsen1; 1University Medical Center Utrecht, Utrecht, NETHERLANDS, 2 University of Utrecht, Faculty of Veterinary Medicine, Utrecht, NETHERLANDS, 3University of Gent, Faculty of Veterinary Medicine, Gent, BELGIUM, 4Department of Radiation, Radionuclides and Reactors, Faculty of Applied Sciences, Delft University of Technology, Delft, NETHERLANDS. Aim: the aim of this paper is to provide an overview of the experimental treatments of veterinary patients suffering from inoperable solid cancers by intratumoral injections with holmium‐166 acetylacetonate microspheres and holmium‐166 acetylacetonate poly (L‐lactic acid) microspheres (Holmium‐166‐AcAc‐MS and Holmium‐166‐PLLA‐MS). Materials & methods: patient characteristics: four cats (2x hepatocellular carcinoma, 1x cholangiocarcinoma, 1x melanoma), and one dog (non‐functional pituitary gland adenoma). Holmium‐166‐AcAc‐MS (mean diameter: 8 μm; Ho‐content: 45% w/w) or Holmium‐166‐PLLA‐MS (mean diameter 30 μm; Ho‐content: 17% w/w), suspended in water for injection containing 2% Pluronic® F‐68 and 10% ethanol abs., were injected into the tumors under ultrasound guidance. The dosages that were used varied between 400‐1000 MBq (200 mg). P.i. gamma scintigraphy (planar and/or SPECT) was performed to assess the distribution of the injected Holmium‐166‐MS. Follow‐up consisted of regular physical examinations, ultrasonography, and the evaluation of biochemical and hematological parameters. Results: gamma scintigraphy revealed that the Holmium‐166‐MS had been deposited into the tumors. The clinical conditions of two of the three cats with inoperable liver malignancies rapidly improved and remained stable for five and six months, respectively. The third cat with liver cancer did not improve but developed comorbidity (meningitis and renal failure), most probably not treatment‐related. The neurological signs of the dog with the pituitary gland adenoma that had been manifest pretreatment, almost completely resolved within 48 hours. The values of the relevant biochemical and hematological parameters either remained stable or normalized. Conclusions: in relatively small veterinary intratumoral injections with Holmium‐166‐AcAc‐MS or Holmium‐166‐PLLA‐MS appear a safe and straight‐forward method for the ablation unresectable malignancies of a variety of location and origin. However, further research under controlled conditions, i.e. laboratory animal studies, is warranted before this treatment will be routinely available in veterinary and human patients. For intra‐arterial radioembolization by a catheter of radioactive Holmium‐166‐PLLA‐MS for treatment of liver malignancies research is completed and will result in the start of a phase‐1 patient study in the near future.
P625 Treatment of metastasised neuroendocrine tumours with the radiolabeled somatostatin analogues Lu-177 or Y-90-DOTATATE: Long term toxicity and survival in 543 patients R. P. Baum1, V. Prasad1, M. Hommann2, C. Zachert1, D. Hoersch3; 1Dept. of Nuclear Medicine and Centre for PET/CT, Zentralklinik Bad Berka, Bad Berka, GERMANY, 2Dept. of General and Visceral Surgery, Zentralklinik Bad Berka, Bad Berka, GERMANY, 3Dept. of Internal Medicine, Gastroenterology, Endocrinology and Oncology, Zentralklinik Bad Berka, Bad Berka, GERMANY. Aim: Although differentiated neuroendocrine tumours (NET) are relatively slowly growing, median overall survival (OS) in patients with gastroenteropancreatic NET (GEP NET) with liver metastases is only 2 to 4 years. In metastatic disease, cytoreductive therapeutic options are limited. A relatively new treatment is peptide receptor radionuclide therapy (PRRT) with the radiolabeled somatostatin analogues 177Lu or 90Y DOTA‐TATE. Here we report on the toxicity and survival in 543 patients undergoing PRRT in our neuroendocrine tumour centre. Patients and Methods: Patients were treated with 1.5 to 5 GBq of Y‐90 and 4.5 to 8.0 GBq of Lu‐177 DOTA‐ TATE per cycle, usually for 3‐5 cycles at an interval of 12‐16 weeks. Survival study was done in 415 out of 543 patients (until September 1, 2008) with metastasised NET including GEP NET. Nephrotoxicity was analysed in 543 patients (including serial DTPA and MAG3 studies) and detailed hematotoxicity was evaluated in 150 patients. Results: Serious adverse events that were likely attributable to the treatment (along with pre‐existing risk factors like chemotherapy, diabetes, hypertension) were: nephrotoxicity (requiring dialysis) in 2/543 patients (<1%), and myelodysplastic syndrome in 5/543 patients (< 1%). The detailed analysis in 150 patients showed grade 1‐2 erythrocytopenia as the most common hematotoxicity followed by (short term) leuko‐
S433
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 and thrombocytopenia. Overall survival is summarized in table‐1. Compared with reported PRRT results of using Lu‐177 DOTA‐TATE only (46 months; Kwekkebom et al. JCO 2008), there was a median overall survival of 50 months from start of treatment and 185 months vs. 128 months from the time of first diagnosis in GEP NET. Conclusion: Treatment with 177Lu‐ or 90Y DOTA‐TATE has relatively few adverse effects. Compared with historical controls (not treated by PRRT), there is a benefit in OS from the time of diagnosis of several years. Lung and high grade NET and carcinoma of unknown primary (CUP) are associated with worst prognosis. Table‐1 Mean Median
From first diagnosis
190
214
From First PRRT
51
59
From last PRRT (minimum duration of 3 months follow‐up after last PRRT) 35
‐‐
From the time of first diagnosis in months for LUNG NET
111
118
From the time of first diagnosis in months for GEP NET
217
185
From the time of first diagnosis in months for CUP NET
146
136
From the time of first diagnosis in months for OTHER NET
232
‐‐
From the time of first PRRT for LUNG NET
48
43
From the time of first PRRT for GEP NET
59
50
From the time of first PRRT for CUP NET
50
From the time of first PRRT for OTHER NET
69
57
Low‐Intermediate grade Ki67 < 20%
43
49
High grade Ki67 > 20%
40
38
Efficacy, safety and tolerability of repetitive doses of samarium-153 lexidronam (153Sm- EDTMP) in patients affected with bone methastasis from solid tumors M. Catalano, M. L. De Rimini, S. Piccolo, G. Borrelli, M. Bifulco, B. Magliulo, G. Mazzarella, P. Muto; Nuclear Medicine AORN Monaldi, Naples, ITALY.
P626 Evaluation the iodine-125 seeds distribution in the target organ using SPECT/CT H. Shi, Y. Gu, Z. Yan; Zhongshan Hospital, Fudan University, Shanghai, CHINA. Aims: To evaluate the implanted iodine‐125 seeds distribution in the target organ and its radiation range using SPECT/CT.Materials and Methods: Three patients suffered from prostate cancer were performed iodine‐125 seeds implanted guided by ultrasound. Fourteen patients with portal vein or upper vena cava tumor thrombus were accepted stent and iodine‐125 seeds implanted by interventional guided by DSA. Those patients underwent whole body scan and the target organ SPECT/CT imaging after iodine‐125 seeds implanted 24h later using Philips precedence SPECT/CT system with 16 slice CT. The energy peak was centered at 30 keV with a 50% window using low energy, high‐resolution parallel collimator. The scan speed was 20 cm/min for whole body scan. A step and shoot protocol of 20 s/3°for a total of 60 views per camera head was used. Three experienced nuclear medicine physician reviewed those imaging individually to evaluate the seeds distribution and its radiation range.Results: The whole body scans only showed if there were radioactive seeds in the body or not. SPECT/CT fusion imaging could show the seeds position accurately and also tell the radiation range roughly. The imaging showed almost all seeds distributed in the target organ and its radiation range mainly kept in it. One seed was found in left spermatophore in one case. And a seeds chain was found in right ventricle which was implanted in the superior vena cava. Conclusion: Based on whole body scan, SPECT/CT fusion imaging provide helpful information about seeds distribution and its radioactive range. It could be useful to evaluate the therapy response and predict the probably radiation side effect.
P627 And
M. Aurilio, L. D'Ambrosio, F. De Martinis, E. Squame, L. Aloj, S. Lastoria; Istituto Nazionale Tumori, Fondazione "G. Pascale", Napoli, ITALY. Aim: Therapy with 90Y labeled DOTATATE, ZEVALIN and SIR‐spheres is performed routinely at our institution. Four staff members are rotated in the preparation and administration of these compounds in order to distribute extremity doses. We report on our findings on routine measurement of finger doses recorded in the past 10 months. Methods: The local skin dose was measured by use of TLD dosimeters placed at the fingertips under a latex glove by each staff member. Every procedure involved carrying out the labeling procedure (DOTATATE and ZEVALIN), purification (DOTATATE), quality control (DOTATATE and ZEVALIN), and preparation and administration of patient doses (DOTATATE, ZEVALIN and SIR‐spheres). All labeling operations are performed behind plexiglass shielding (2 cm) with manual procedures. Plexiglass vial holders, syringe shields and metal tongs with plexiglass shielding are utilized. Dose measurements were initially obtained on all fingers of both hands. After determining that the index fingers received the highest doses, dosimeters on each index finger were utilized for further assessment. Data were obtained for 20 treatments with 90Y‐DOTATATE, 17 with 90Y‐ Zevalin® and 4 for 90Y‐SIR‐spheres® between May 2008 and March 2009. Activities manipulated ranged from 2 to 12 GBq per procedure.Results: All operators are right handed and the left hand receives a higher dose than the right in most procedures. The mean radiation doses (mSv/MBq) and the dose range that the operators received are presented in the table: Finger doses (mSv/MBq) 90Y‐DOTATATE Operator 1 Operator 2 Operator 3
L INDEX: mean (range) R INDEX: mean (range) 1.19 (0.56‐3) 1.41 (032‐4.36) 2.08 (0.67‐4.84) 1.21 (0.23‐1.61) 1.48 (1.16‐1.89 1.45 (0.87‐2.03)
90Y‐SIR‐Spheres L INDEX: mean (range) R INDEX: mean (range) Operator 1 0.79 (0.29‐2.7) 1.14 (0.06‐2.14)
P628
Radionuclide therapy/dosimetry: miscellaneous
R INDEX: mean (range) 0.43 (0.25‐0.60) 3.27 (0.55‐6.93) 18.3 (0.90‐32.5) 3.90 (0.21‐12.3)
Conclusion. For the current patient load of our department our rotation scheme allows for each operator to stay within the allowed yearly limit for extremity doses (500 mSv). Although the procedures are standardized a wide range of exposure is obtained by different staff performing the same procedure as expertise and operation speeds play a critical role in determining overall doses.
P70 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Finger Doses Of Staff Involved In Preparation Administration Of Y-90 Labelled Radiopharmaceuticals
L INDEX: mean (range) 0.45 (0.32‐0.58) 4.95 (4.10‐5.80) 21.1 (3.25‐33.7) 4.14 (0.68‐7.14)
AIM: Efficacy, safety and tolerability of repetitive doses of samarium‐153 lexidronam (153Sm‐ EDTMP) in patients affected with bone methastasis from solid tumors were evaluated. METHODS: Patients (pts) affected with multiple skeletal methasasis positive at bone scintigraphy were enrolled. A total number of 66 doses of 153 Samarium lexidronam were employed in a total number of 26 pts. 17 pts received 2 doses, 4 pts received 3 doses, 2 pts received 4 doses, 1 pt received 5 doses and 1 pt received 8 doses. The standard dose of 37MBq/Kg was administred every tree months if white blood cells and platelets range permit it, independently from pain symtom. All pts underwent 2 years follow up. RESULTS: All pts had bone pain relief , decreased antidolorific drugs assumption, a better life quality without pain experience between each dose. There were no episodes of severe medullar toxicity, but only mildly decrease of white blood cells and platelets count after each administration, with spontaneous regression to normal value. No desease progression was observed at bone scintigraphy performed every six months after multidose therapy beginning. Serum prostate specific antigen levels were variable because they were stable in some pts but increased in others one in wich therapeutic effect on bone pain was obtained too. CONCLUSION: Bone methastasis from solid tumors can be successfully treated with repetitive doses of 153Sm‐EDTMP without increased toxicity and the result of a better performance status along the treatment period was obtained. Until now (2 years follow‐up) all patients enrolled in this study are still alive.
P629 Treatment of Unoperable and Chemorefractory Liver Metastasis of Colorectal Cancer by Yttrium-90 Resin Microspheres: Experience at Ankara University Medical Faculty I. L. Öz, A. Peker, Ö. Küçük, U. Sanlıdilek, S. Bilgiç; Ankara University, Ankara, TURKEY. Purpose: to evaluate efficacy of radioembolization with yttrium‐90 (Y‐90) resin microspheres for the treatment of unoperable and chemorefractory liver metastasis of Colorectal cancer. Materials/Methods: 18 patients with liver metastasis of colorectal cancer were treated by yttrium‐90 resin microspheres. All patients have been treated with chemoteraphy, before Y‐90 resin microspheres treatment. All patients were evaluated by PET/CT and carcinoembryonic antigen level before and after 1,5 and 6 months of treatment Results: all procedures were safe without any complications like pulmonary toxicities or duodenal ulcers. Median follow‐up was 10 months. The over all median dose delivered was 1.6 Gbq in the lobe. 18 patients were followed by PET/CT and carcinoembryonic antigen level. In 16 patient, reduced activity at PET/CT, a decrease in carcinoembryonic antigen level were observed. Conclusion: Y90 radioembolization seems to be safe and effective therapeutic option for the treatment of unoperable and chemorefractory liver metastasis of colorectal cancer. The best imaging follow‐up method for tumor response to treatment is PET/CT.
P71 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: pediatrics
P630 Evaluation of renal paranchymal disease with Tc 99m DMSA scintigraphy in siblings of children with known vesicoureteral reflux in 6 families. E. Ceylan Gunay1, A. Erdogan1, A. Delibas2; 1Mersin University Faculty of Medicine Department of Nuclear Medicine, Mersin, TURKEY, 2Mersin University Faculty of Medicine Department of Pediatric Nephrology, Mersin, TURKEY. Purpose/Introduction: The prevalence of vesicoureteral reflux (VUR) among siblings of patients with reflux is higher than normal population. Since reflux carries an increased risk of pyelonephritis and long‐term renal impairment we aimed to screen the siblings of children with VUR. Subjects and methods: In this study we evaluated 13 children (9 girls, 4 boys )in 6 families with ultrasonography, voiding cystourethrography (VCU), and Tc‐99m DMSA renal scintigraphy. Results: Three siblings in one family and two siblings in each of the 5 families were investigated ( age range: 3 months‐ 14 years ‐median age: 9 years). There was intermarriage in parents of children in 5 of the 6 families. Six children had recurrent urinary tract infection,and one child had enuresis. Two of the children had additional stone disease. Six of the children who were screened
Poster Presentation
Survival
90Y‐ZEVALIN Operator 1 Operator 2 Operator 3 Operator 4
S434 siblings were symptom free. Five children had grade 4‐5 VUR in VCU (bilateral in one child , unilateral in others ). All of the patients with VUR had paranchymal scars and functional loss in DMSA scintigraphy. One of the patients had grade 4 reflux to the right kidney with duplicate collecting system in which DMSA scintigraphy showed nonfunctional upper system. The screening of siblings revealed grade 2 VUR in one of the patients. Renal agenesis in 2 patients and nonfunctional unilateral kidney in one of the patients were incidentaly detected. Two children had normal DMSA scan and VUR did not detected in VCU. Discussion‐Conclusion: Tc‐99m DMSA scintigraphy was quite useful for detecting not only renal scarring, but also nonfunctional kidney or agenesis which were detected incidentaly. Even the number of the patients were insufficient, DMSA scintigraphy had significant contribution to the clinical evaluation of the siblings of patients with VUR especially in a region having high ratio of intermarriage as in ours.
P631 Individual clinical and demographic parameters exerted a variable imapct on the incidence of abnormalities on nuclear medicine bone scintigraphy in suspected or confirmed non accidental injury in children. D. Ma; Geelong Hospital (Nuclear Medicine Department), Geelong, AUSTRALIA. Aim: To identify those clinical and demographic features that influence the incidence of abnormalities on bone scintigraphy in the setting of non accidental injury in children. Method: This is a retrospective observational study of all suspected or confirmed cases of non accidental injury in which bone scintigraphy was performed for the purpose of excluding skeletal injuries from 1999 to July 2007. The reports and images of the bone scan and other imaging examinations as well as the medical history of each patient were systemically reviewed and a comprehensive database was constructed. The following parameters were noted: 1 Age, 2 Sex, 3 Australian Postcode, 4 Findings on bone scintigraphy, 5 Findings on XR and other imaging studies, 6 Site & distribution of bruising, haematomas and burns, 7 Clinical suspicion of head injury. Results: A total of 28 children (12 females, 16 males) underwent whole body bone scintigraphy for suspected or confirmed non accidental injury. The mean age was 16 months. These children came from 10 localities with almost half the cohort coming from two. There were 26 and 28 abnormalities on the bone scan and plain X‐ray examinations respectively in this cohort. Contrary to observations from a number of published studies, XR detected more abnormalities in the long bones than bone scintigraphy, while a similar number of abnormalities in the axial skeleton were detected with either modality. There was a mean of 0.92 bone scan abnormalities per patient (“mean”). Female patients accounted for more than 60% of all the bone scan abnormalities in this cohort, with a mean of 1.33 abnormalities per patient in this group. Those patients under 12 months of age accounted for 65% and 93 % (means 1.1 and 1.6) respectively of all the bone scan and XR abnormalities. Patients from one locality accounted for 42% of all the bone scan abnormalities (mean 1.7). Bruising and a clinical suspicion of head injury were not associated with a disproportionate number of scan or XR abnormalities. Conclusion: In this cohort of Australian children with confirmed or suspected non accidental injury, XR is more sensitive than bone scintigraphy in the detection of long bone injuries. The female sex, age under 12 months as well as certain localities of abode are associated with a higher incidence of abnormalities on bone scintigraphy, while skin bruising and a clinical suspicion of head injury are not.
P632 Initial Renal Cortical Scintigraphy in Children with Acute Pyelonephritis E. Jaksic1, L. Bojic1, R. Bogdanovic2, S. Beatovic1, M. Blagic1, V. Artiko1, D. Sobic-Saranovic1, S. Pavlovic1, V. Obradovic1; 1Institute of Nuclear Medicine Clinical Center of Serbia, Belgrade, SERBIA, 2Institute of Mother and Child Health Care of Serbia, Belgrade, SERBIA. Aim: Assessment of first febrile urinary tract infection (UTI) in children has been the subject of debate for many years. Diagnosis of acute pyelonephritis (APN) is usually based on clinical and biological data. Clinical usefulness of early Tc‐99m DMSA scintigraphy remains controversial, although it may influence the type and duration of the treatment. The aim of this study was to assess the role of initial cortical scintigraphy in detection of early renal parenchymal damage in children highly suspected on APN and to compare scintigraphic findings with selected clinical/laboratory parameters and ultrasonography. Material and Methods: A prospective study was conducted in 34 infants and young children (18 boys, 16 girls), aged 1.5 to 36 months (mean 9.8 ± 8.7 months), hospitalized with a first episode of clinically suspected APN between December 2007 to November 2008. Within the first 5 days after admission Tc‐99m DMSA renal scintigraphy, ultrasonography (US), erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), white blood cell count (WBC) and urine analyses were performed on all patients. The criteria indicative of early parenchymal damage on the acute renal cortical scan were divided into three types of abnormalities of increasing severity. Results: The DMSA scintigraphy showed changes consistent with APN in 27/34 (79.4%) patients, mean age of 10.9 month, 44% males and 56% females. Out of 9 febrile children with negative urine culture and supportive evidence of UTI, scintigraphy showed parenchymal involvement in 8 children (23.5% in the whole group, 29.6% in scintigraphically documented APN). There were not any statistically significant correlations between the frequency or size of initial scintigraphic abnormalities and age, sex, body temperature, CRP levels, or ESR. A CRP level of >54 mg/L and a WBC of > 13,300/mm3 had sensitivities of 57.7% and 96.2% and specificities of 85.7% and 57.1%, respectively. US showed changes consistent with APN in 7/34 (20.6%) in the whole group and in 7/27 (25.9%) patients with positive cortical scan (p<0.05). Conclusion: In the absence of specific symptomatology in infants and young children, initial DMSA renal scintigraphy is a sensitive method for early diagnosis of APN, useful in detection of the severity of kidney injury even in patients with negative urine culture. Clinical, biological and ultrasound parameters do not identify children with renal damage. Normal DMSA study, excluding parenchymal involvement and late sequelae, could minimize the use of scintigraphy in the follow up and reduce the redundancy of cystography.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P633 Dacrioscintigraphy in the nasolacrimal duct obstruction
diagnosis
of
congenital
C. Lizarraga, F. Cañete, J. Clavel, A. Martinez, M. Gonzalez, M. Anton, J. Verdu, M. Riera, M. Martinez, E. Mengual, O. Caballero; Hospital Universitario San Juan, Alicante, SPAIN. INTRODUCTION. Congenital nasolacrimal duct obstruction appears in 5‐6% of newborns and can rise up to 20% in premature children. The dacrioscintigraphy (DS) is a physiological dynamic exam that can be used to study the lacrimal duct system in patients with epiphora. AIM. To compare results between Jones Tests and DS in children with suspicion of congenital nasolacrimal duct obstruction. MATERIAL AND METHODS. We studied the nasolacrimal duct systems of 30 patients with congenital nasolacrimal duct obstruction suspicion (mean age 26±17 months, range 5‐72) The DS results were compared with signs of epiphora and Jones Test. DS was performed with 100 µCi of technetium‐99m dissolved in a 20 µl of isotonic saline drop. At the beginning of the test, a drop of this solution was instilled in the lateral canthi of each eye using micropipettes. After that, we started the study in a gamma camera equipped with pin‐hole collimator with sequential images every minute with the following phases: Phase 1 Basal study: 10 sequential images after the instillation of the tracer. Phase 2 Water Overload: instillation of 20 µl saline drop and a new series of 10 images. Phase 3 Forced Maneouvers: in order to increase pressure in nasolacrimal duct. RESULTS. Fifteen of the 60 lacrimonasal duct system studied, were considered permeable by the Jones test and 14 of them were also permeable with the DS. Twenty five of the 45 lacrimonasal duct systems diagnosed of congenital nasolacrimal duct obstruction by the Jones test, showed the same results with DS, and 20 demostrated permeability (kappa =0,34, p=0,01) CONCLUSION. Our results suggest that DS is able to differenciate functional non‐obstructive epiphora from congenital nasolacrimal duct obstruction in those cases that Jones Test shows obstructive systems. This can help planning the treatment avoiding unnecessary procedures in some children.
P634 Diuretic Renal Renography in Children with Antenatally Detected Hydronephrosis B. Ajdinovic, L. Jaukovic, M. Dopudja, S. Dugonjic; Institute of Nuclear Medicine MMA, Belgrade, SERBIA. Purpose: Technetium‐99m DTPA diuretic renography is used in postnatal evaluation of children with antenatally detected hydronephrosis. The aim of this study to determine the incidence and pattern of abnormal renal scintigraphy findings in postnatal investigation of children with antenatal hydronephrosis. Patients and methods: Thirty four infants (27 boys and seven girls, mean age 6.7 months) who presented with antenatal hydronephrosis and mild to moderate hydronephrosis on ultrasound in newborn period underwent DTPA diuretic renal scintigraphy (F+15). Micturating cystoureterography was performed in twelve children revealing vesicoureteral reflux (VUR) in three of them. Antenatal hydronephrosis was secondary to pelviureteric junction obstruction in 14, megaureter in 8, VUR in 3, multicystic kidney and duplex system in 7 and posterior urethral valves in two cases. Results: Antero posterior pelvic diameter evaluated on postnatal ultrasound ranged from 6 to 32 mm. DTPA diuretic renography was used to evaluate the renal drainage and split renal function. Good or almost good drainage was shown in 11 /34, partial drainage in 9/34 and poor or no drainage in14 patients. Split renal function (SRF) within the normal range was observed in 15 patients, reduction in renal function (SRF less than 40%) was found in 14, and poor kidney function (SPF less than 10%) in 5 infants with kidney malformations and high VUR of grade IV associated in two of them. Conclusion: DTPA findings revealed significant slowing in drainage in 14/34 patients. Renal scintigraphy was useful in determination of underlying cause of antenatally detected hydronephrosis.
P635 Assessment of bone and somatostatin receptor scintigraphy in paediatric patients with Langerhans Cell Histiocytosis. I. Hervás, P. Bello, J. L. Vercher, J. L. Loaiza, R. Pérez-Velasco, A. Rivas, C. Ruiz, J. F. Martí, C. Olivas, J. L. Pérez-Pastor, A. Mateo; Department of Nuclear Medicine. University Hospital La Fe., Valencia, SPAIN. Aim: Langerhans cell histiocytosis (LCH) is a granulomatous disease which can involve multiples sites of the body. Diagnostic imaging is of utmost importance in the management of these patients. Since now radiographic skeletal survey and bone scintigraphy (BS) have been used to assess bone involvement (both with low specificity). Magnetic Resonance Imaging (MRI) and Computerized Tomography (CT) have been used to assess visceral involvement but with the limitation that can not give information about the functional status. Recently somatostatin receptor scintigraphy (SSRS) has been proposed to detect active lesions and for monitoring the response to treatment, due to the somatostatin analogue octreotide binds to the cell membrane of activated lymphocytes expressing somatostatin receptors. The aim of this study is to assess bone and somatostatin receptor scintigraphy in the detection of bone involvement in LCH in children. Matherials and methods: Thirty children (17 boys, 13 girls; mean age 6 +/‐ 4 y; age range 3m‐17y) with histologic confirmation (28) or suspicion (2) of LCH, were included. Patients were studied and followed up using clinical examination, laboratory tests and different imaging modalities including X‐rays, CT, MRI, BS and SSRS. A total of 40 SSRS and 27 BS were performed. Results: In 68% of the cases the clinical symptoms and the results obtained in the different imaging modalities (X‐rays, CT, MRI, BS and SSRS) were concordant. SSRS detected two lesions not visualized by other imaging techniques. BS could visualize one unknown and unsuspected lesion. BS presented 71,5% true positives (TP), 18% true negatives (TN), 7% false negatives (FN) and 3,5% False positives (FP). SSRS presented 39% TP, 34% TN and 27% FN. The Bayesian analysis shows for BS: sensitivity (S) 91%, specificity (E) 83%, positive predictive value (PPV) 95% and negative predictive value (NPV) 71%. For SSRS: S=59%, E=100%, PPV=100% and NPV=56%. Conclusion: Bone scintigraphy and Somatostatin receptor scintigraphy may be useful for the identification of active osseous lesions in Langerhans cell histiocytosis. Both techniques were able to show new lesions unsuspected clinically. Somatostatin receptor scintigraphy has lower sensitivity than BS in the detection of bone involvement in LCH in children. For that reason we recommend the use of both techniques in the follow‐up of children with LCH.
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DMSA study performed during febrile urinary tract infection: a predictor of patient outcome? X. Geronikola-Trapali1, I. Armeniakos1, P. Karabina1, A. Stefanoyiannis1, V. Lyra1, S. Bakalis1, P. Zotou1, A. Prentakis1, S. Fessatou2; 1University General Hospital “Attikon”, Nuclear Medicine Department, Chaidari, GREECE, 2 University General Hospital “Attikon”, 3d Pediatric Department, Chaidari, GREECE. DMSA study is an established method for the assessment of renal sequeale after acute pyelonephritis related to febrile urinary tract infection (UTI) .However, the prognostic value of this study during the acute phase of the UTI for the evaluation of the patient’s outcome has not yet been well established. Aim : To evaluate the contribution of DMSA study during the febrile UTI for the prediction of the patient’s outcome. Materials and methods: Our study involved 67 children (3 boys and 64 girls ‐ age range : 2m ‐ 5y ) .DMSA study was curried out during the acute phase of the UTI (first 4 days ).Planar and pinhole scintigraphy acquisition was performed. All patients had positive suprabubic urine culture (94,5% E.Coli, 4%Proteas mirabilis, 1,5 % Klebsiela )and received antiobiotic therapy.Direct voiding cystography was performed after the acute phase for the detection of vesicoureteric reflux (VUR).Nineteen children (28,3%)with abnormal DMSA study ,VUR or recurrent UTI had a DMSA control scan (6‐8 months after UTI). Results : DMSA study was normal during the acute phase of the UTI in 48 patients (62,5%).We did not effectuate DMSA follow up study in 30 of these patients because of a good clinical outcome (no VUR, no UTI recurrence).The rest 18 had normal DMSA follow up study. Nineteen (28,3%) who presented cortical lesions (focal or indinstinct margins) during febrile UTI underwent DMSA control study. Fifteen of them presented normal control DMSA study. The rest four (6% of all patients) presented cortical lesions,1 associated with high grade VUR. Nineteen patients were followed up by control DMSA study and no significant correlation between initial and follow up study was observed. Conclusions: According to these data we conclude that DMSA study performed during the acute (febrile) UTI may not be a useful tool for the prediction of the patient outcome .Control DMSA study and cystography appears to be more useful for the detection and selection of patients at risk for future chronic cortical lesions development.
P637 Bone scintigraphy contribution in therapeutic management of child lameness : a monocentric retrospective analysis T. Eugene1, C. Bodet-Milin1, A. Hamel2, A. Oudoux1, L. Geffroy2, F. KraeberBodere1, J. Rogez2, C. Ansquer1; 1Nuclear Medecine Department, Hotel Dieu, Nantes, FRANCE, 2Pediatric Surgery Department, Hotel Dieu, Nantes, FRANCE. Objectives : Bone scintigraphy (BS) is routinely practiced in the child lameness assessment. We retrospectively assessed the tests conducted in our institution over a period of 1 year to evaluate its performance in therapeutic management. Materials and Methods : Of the 153 BS conducted in this indication, 30 were excluded from the analysis because of a lack of follow‐up data and 32 due to pathological history of the painful joint. Ninety one children, median age 7.9 years ( 2 months to 15 years), underwent a whole body BS 3 h after injection of 99mTc‐HDP. BS was interpreted according to the clinical context as follows : 0 = normal, 1 = positive but suggesting a common pathology which does not require specific treatment, 2 = pathological . The final diagnosis was based on the clinical, bacteriological, histo‐pathological or conventional imaging data, and when necessary the following data. The results of type 0 and 1 were grouped for the statistic analysis . Results : Final diagnoses were: 18 osteoarticular infections (OI), 8 benign tumors (BT) (including 3 aneurysmal bone cysts, 3 non ossifying fibromas, 1cortical defect and 1 exostosis), 1 hip osteochondritis (HOC), 4 calcaneal epiphysitis (CE), 2 bone contusions, 1 osteosarcoma, 1 leukemia, 12 hip synovitis (HS), and 44 indeterminate benign diseases. BS was considered as type 2 in 26 cases (29% of patients) including 23 true‐positive cases : 15 / 18 OI, 1 / 1 HOC, 1 / 1 osteosarcoma, 1 / 1 leukemia, 2 / 2 bone contusions and 3 / 8 BT. The result of the BS type was 0 or 1 in 65 cases (71%) including 62 true‐negative results. In particular, it was type 1 in 20 cases (22%): 4 / 8 BT, 1 / 18 OI, 11 / 12 HS and 4 / 44 indeterminate benign pathologies. False‐negative results were 3 OI : 1 bacteriologically proven, 1 chronic osteomyelitis and 1 clinically suspected. The sensitivity, specificity, positive and negative predictive values for the detection of lesions requiring a specific or modified treatment were: Se = 88.5% ; Sp = 95.0% ; PPV = 88.5% ; NPV = 95.0%. Conclusion : This study confirms the good performance of BS in the assessment of child lameness , especially, to exclude lesions requiring no specific or modified treatment
P638 The relationship between the degree of gastroesophageal reflux and the gastric emptying time in children S. Hizli1, I. Peksoy2, O. Ozdemir1, P. Arıcan2; 1Ankara Keciören Training and Research Hospital, Ankara, TURKEY, 2Ankara Numune Training and Research Hospital, Ankara, TURKEY. Purpose: The aim of our study was to evaluate both the relationship between gastric emptying half time (GEHT) and gastroesophageal reflux (GER) and connection amongst GEHT with GER severity in children. Methods and Materials: Two hundred six patients (pts) between 6 months and 16 years of age (84 boys, 122 girls) with clinical suspicion of GER disease were included in the study. Patients were divided into 4 groups according to the age range: group A, 0‐2 years (30 pts), group B 3‐5 years (46 pts), group C 6‐10 years (76 pts) and group D 11‐16 years (53 pts). Each group was divided into 2 subgroups according to the scintigraphic study as GER positive and negative. Cow’s milk with Tc‐99m DTPA as radiotracer was used. GEHT was calculated by computer program. The detection of activity in the esophagus at any time during scintigraphy was considered an indicator of GER episodes. Reflux episodes were graded as Grade 1 if activity was detected on one to 3 episodes, Grade 2 if activity was detected 3 to 5 episodes and Grade 3 if activity was detected on more than 5 episodes. All subjects were evaluated statistically both generally and each group regarding GER existence, severity and GEHT. Results: One hundred twenty‐four of the 206 pts (60%) had GER findings on scintigraphy. The comparison of GEHT between positive and negative GER scintigraphy groups was statistically significant (p<0.001).
Similarly meaningful value for each age group was found from A to D respectively 0.013, 0.004 0.012 and 0.002. Without Group C mild statistical correlation was found the all age groups between reflux severity and prolonged GEHT. Conclusions: Our results show that patients with existence GER had delayed gastric emptying and prolonged gastric emptying to be a pathogenetic factor in gastroesophageal reflux in children.
P639 Clinical Contribution of F18-FDG PET/CT in the Pediatric Oncologic Patients F. Aydin, G. H. Kaplan, V. Hazar, A. Yildiz, A. Boz, F. Gungor; University of Akdeniz, Antalya, TURKEY. Aim The aim of this retrospective study was to evaluate the clinical contribution of F18‐FDG PET/CT in the pediatric oncologic patients. Material and Methods The study was conducted between April 2008 and March 2009 and comprised 28 pediatric oncologic patients (16 boys, 12 girls; mean age 10.4±5.6), included Ewing sarcoma (n=8), Hodgkin’s lymphoma (n=7), Burkitt’s lymphoma (n=4), neuroblastoma (n=3), non‐Hodgkin’s lymphoma (n=2), rhabdomyosarcoma (n=2), testicular germ cell tumor (n=1), and hepatoblastoma (n=1). Thirty‐three FDG PET/CT exams (for initial staging, re‐staging, monitoring therapy response, and detecting primary focus in 14, 7, 11, and 1 exams, respectively) were performed. Initial diagnosis was confirmed by histopathology while the gold standard at follow‐up was established by clinical follow‐up, additional imaging modalities and/or biopsy. Results Six of the 21 patients (29%) that were performed F18‐FDG PET/CT studies for initial staging and re‐staging have been found alteration in staging with PET/CT . Seven of the 11 patients that were done PET/CT studies for monitoring therapy response have been showed complete response with PET/CT and it has been determined primary focus with PET/CT in one patient who had primary unknown origin and this patient has been found Ewing sarcoma with biopsy. Conclusion F18‐FDG PET/CT is a useful imaging tool in the initial diagnosis, for monitoring the response to therapy and for detecting disease recurrence in pediatric oncologic patients.
P640 Quantitative Scintigraphy For Sacroiliitis Revisited: Can We Use The Same Sacroiliac Index Values For Pediatric Patients As Well? M. F. Bozkurt, B. Temelli, P. Kiratli; Hacettepe University Faculty of Medicine Department of Nuclear Medicine, Ankara, TURKEY. Objective: The clinical diagnosis of sacroiliitis can be difficult to confirm, especially in early stages of the disease. Overlaps between scintigraphic sacroiliac index (SIx) values of healthy and pathologic sites in adult population have been reported, but there is no sufficient data for pediatric patients. This study is aimed to assess standard SIx in different age groups of pediatric patients using 2 different quantitative methods. Materials & Methods: Seventy‐nine normal reported pediatric bone scans (30 female, mean age:11y, range:3‐20y) referred for various reasons in a period of 25 month were retrospectively reviewed. Static anterior‐posterior pelvic images were used. In the 1st method, a rectangular ROI over the two sacroiliac joints and the sacrum ‐for background‐ and in the 2nd method L5 vertebra was used instead of sacrum. SIx was calculated as the ratio between the counts from the right and left sacroiliac joints divided by sacrum in the 1stmethod and by L5 vertebra in the 2nd. The right and left SIx from sacrum counts (Rs and Ls) were compared with those calculated from L5 counts (Rv and Lv) in relation to gender and age groups, as group 1 (<5y), group 2 (6‐10y), group 3 (11‐15) and group 4 (16‐20y). Results: Gender‐based comparison yielded significantly higher SIx for females compared to males with the 1st method (Rs:1,33±0.26 vs 1,50±0,32 p=0,01and Ls:1,33±0,28 vs 1,49±0,33 p=0,02) while no significant difference existed in the 2nd method. Significant increased SIx with both methods was found with aging (p=0,00). Significantly lower SIx was found with the 2nd method between close age groups as Group1‐2 or Group 2‐3 (p=0,04), while no such difference was present with the 1st method (p=0,94). For each patient in any group, method‐based comparison resulted a significantly variable SIx (p=0,00). Conclusion: In normal pediatric bone scans, SI tends to increase with aging. Quantitative methods using sacrum as background yield significantly higher SIx for females, while methods using L5 yield variable SIx results compared to the previous method, especially among close age groups. Since different methods give diverse SIx, individualized cut‐off value for each age group per any method is practically warranted. .
P641 Effect of Pyeloplasty in Infants with Ureteropelvic Junction Obstruction: Ultrasonographic and Scintigraphic Evaluation F. Aydin, F. Gungor, A. Gur Guven, S. Akman, M. Melikoglu, G. Karaguzel, S. Yucel, E. Guntekin, E. Alimoglu, A. Kabaalioglu; University of Akdeniz, Antalya, TURKEY. Objective Ureteropelvic junction obstruction (UPJO) develops in utero and renal parenchymal loss could not be re‐gained even after proper interventions were made in the postnatal life. Patients 14 children who underwent pyeloplasty because of UPJO were retrospectively evaluated. Pyeloplasty indication was undertaken by our multidisciplinary Pediatric Urology Team (Departments of Nuclear Medicine, Radiology, Pediatric Surgery, Pediatric Urology, and Pediatric Nephrology) following our institutional algorithm. Ultrasonographic and scintigraphic findings obtained before and after pyeloplasty were compared. Results Mean age at the time of operation was 8 months (1‐21). Ten infants had left, 4 had right side UPJO. Mean follow‐up time was 51.3 ± 37.2 months. Mean grading of hydronephrosis (HN) (according to Society of Fetal Urology criteria) reduced from 3.7 ± 0.7 to 2.6 ± 1.2 (14 patients had grade IV HN preoperatively resolved: 6 patients grade IV, three grade III, five grade II postoperatively), additionally anterior‐ posterior diameters of renal pelvises were reduced from 38.6mm to 23mm. Mean pre‐and postoperative differential renal functions of ipsilateral sides were 33.51% and 43.96 % respectively. On postoperative controls 14 patients featured partial or complete (9) diuretic response, while it was limited to one infant preoperatively. Conclusions We showed that multidiciplinary and algorithmic approach contributes to successful ultrasonographic and scintigraphic outcome in children with ureteropelvic junction obstruction who underwent pyeloplasty.
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P642 Treatment response assessment and prognostic value of Gallium-67 scintigraphy in pediatric non-Hodgkin’s lymphoma G. Meristoudis, I. Ilias, V. Giannakopoulos, C. Batsakis, A. Paschou, C. Roussis, J. Christakopoulou; Sotiria Hospital, Athens, GREECE. Introduction: Pediatric Non‐Hodgkin’s lymphoma (NHL) represents one of the most rapidly growing malignancies and it exhibits clinically a tumoral behaviour that is quite different from that of Hodgkin lymphoma and NHL seen in adults. Aim: The aim of this study was to assess the prognostic value of gallium‐67 (67Ga) scintigraphy, based on changes in 67Ga uptake observed after treatment, in pediatric patients with non‐Hodgkin’s lymphoma, and to compare the overall survival between the patients whose gallium studies after treatment were negative and those whose studies remained positive. Patients and methods: The results of 52 consecutive paediatric patients with NHL, (median age of 10 years, range 2 to 16 years), who underwent 67Ga scans 48‐72 h after injection of 37‐111 MBq of 67Ga citrate, were retrospectively reviewed. Follow‐up ranged from 13 to 102 months (median 40 months). The diagnostic effectiveness of this imaging technique has been analysed by comparing the scintigraphic changes at the 1st scintigraphic follow‐up examination after induction therapy with the clinical outcome. The duration of overall survival (OS) and disease‐free survival (DFS) was calculated using Kaplan‐ Meier cumulative survival plotting. Patients were divided according to the changes observed on post‐therapy 67Ga scintigrams into 2 groups: those showing a complete response (CR) at diagnostic imaging and those showing signs of partial response (PR) or progression. In these 2 groups OS and DFS were compared and univariate analysis with the log‐rank test was performed; p values less than 0.05 were considered statistically significant. Results: On the basis of 67Ga scans 34 patients (65.4%) were considered as having a CR, while PR or progression was found with 67Ga scintigraphy in 16 patients (34.6%).67Ga scan was concordant with clinical outcome in 97%. As for the evolution of NHL during clinical follow‐up, among patients who did not achieve a CR on 67Ga scintigraphy the relapse rate was 55.55% (10/18), while it was only 11.76% (4/34) among those with a negative result on 1st 67Ga scintigraphy. DFS and OS were statistically different in these 2 groups of patients: both disease free survival and overall survival were higher in the group with CR according to gallium scan results (p=0.0001 and 0.0004, respectively). Conclusion: Our data demonstrate that evaluation of the 67Ga uptake is very useful as a prognostic parameter; changes in 67Ga uptake after therapy indicate a favourable prognosis, whereas children still positive on post‐treatment 67Ga scintigrams should be given more aggressive treatment. 1
P643 99m-TcDMSA scan: Is it clinically relevant in negative routine urine test? M. A. Shimpi, B. A. Krishna; P.D.National Hinduja Hosp & MRC, Mumbai, INDIA. Aim: The routine urine examination is false negative in 15‐18% of suspected urinary tract infection in pediatric patients. Hence, the aim of the study was to assess the clinical relevance of DMSA renal scan in patients with suspected urinary tract infection, whose urine examination was negative. Materials and Method: This is a retrospective study of 210 patients who underwent DMSA scan, of which 122 were girls (58%) and 88 were boys (42%), aged from 11 months to 11 years. The symptomatology included abdominal pain, burning micturition, refusal to feed, vomiting or only fever. Of the 210 patients who underwent DMSA renal scan, 21 patients (10%) with the clinical suspicion of urinary tract infection had negative urine examination. This group was the subject of analysis in our study. These patients also had micturating cystourethrography and /or ultrasonography evaluation. The scan was performed at 1 and 4 hours after intravenous injection of 3 mCi DMSA. Images were acquired in anterior, posterior, right posterior oblique and left posterior oblique views. Result: Of the total 21 patients in our study, 11 patients (52.5%) showed abnormal DMSA scan. MCU was done in 16 patients, of which 11 patients were positive for VUR (68%). In this group of 11 patients, DMSA scan was positive in 7 patients (43.7 %) and negative in 4 patients (25%) %). In the remaining 5/16 patients in whom MCU was negative, DMSA scan was positive in 2 patients (12.5%) and negative in 3 patients (18.7 %). Conclusion: From our study, we conclude that DMSA scan was useful in 52.5% patients with negative urine examination. Hence, we propose that DMSA scan should be performed even if urine examinations DOES NOT show evidence of infection.
P644 Tc-99m labeled HMPAO white blood cell scintigraphy in pediatric patients F. Aydin, F. Gungor, A. Boz, M. Erkilic, B. Karayalcin, A. Yildiz; University of Akdeniz, Antalya, TURKEY.
A. Sellem, W. Elajmi, N. Elkadri, H. Hammami; Nuclear Medicine Departement, Military Hospital, Montfleury, TUNISIA. BACKGROUND: Tc99m DMSA (dimercaptosuccinic acid) scintigraphy has a high sensitivity for the detection of cortical kidney damage. AIM: To evaluate the Tc99m DMSA renal scintigraphy in children with a first episode of acute pyelonephritis and its association with clinical findings and laboratory parameters. PATIENTS AND METHODS: We studied 40 children (age range 5 months, 13,75 years), 95% female hospitalized with the clinical diagnosis of acute pyelonephritis (first episode) with a positive urine culture. renal scintigraphy was performed within eight days of diagnosis. DMSA scan was considered the gold standard for the detection of cortical lesions. Its results were related to the presence of fever, C‐reactive protein (CRP) and white blood count (WBC). RESULTS: Thirteen patients (32,5%) had an abnormal DMSA scan. There were no differences between sex, age and laboratory parameters in children with normal or abnormal DMSA scans, except for CRP (p=0,033). CONCLUSIONS: Given the low specificity of clinical findings and available laboratory tests to define the site of urinary infection in children, we recommend DMSA renal scan as the test of choice to confirm the diagnosis of acute pyelonephritis in these patients.
P646 The role of indirect micturating cystouretrography in the detection and follow up of children with vesicoureteral reflux M. Dopudja1, B. Ajdinovic1, L. Jaukovic1, S. Dugonjic1, Z. Krstic2; 1Institute of Nuclear Medicine, Military Medical Academy, Belgrade, SERBIA, 2University Pediatric Clinic, Belgrade, SERBIA. BACKGROUND/AIM: Micturating cystouretrography (MCUG) is the referent test for detection of vesicoureteral reflux (VUR). The indirect micturating cystouretrography (IMCUG) offers the possibility of detecting vesicoureteral reflux without a bladder catheterization, and allows micturation to be studied under physiological conditions. The aim of this study was to determine the sensitivity of IMCUG in detecting VUR documented on MCUG and determine the sensitivity of IMCUG in detecting VUR in group of high grade of VUR documented on MCUG. PATIENTS AND METHODS: We analyzed 62 patients, 40 patients with VUR, detected by referent test (30 girls and 10 boys, mean age 5.75) and 22 patients (14 girls and 8 boys, mean age 6.3) with no VUR on MCUG. RESULTS: Abnormal findings, determine by IMCUG in group with VUR, were in 22 patients, and thus giving sensitivity of 55% (22/40), and in group with no VUR on MCUG, 18 patients had normal finding and thus giving specificity of 82% (18/22). Out of 40 patients, 18 of them had VUR high grade (III, IV and V) and 22 had low grade VUR (I and II). Abnormal findings of IMCUG was shown in 15 of 18 patients with high grade of VUR and thus giving the sensitivity of 83%, and 15 of 22 patients with low grade of VUR had normal findings and specificity of 68%. Accucracy of IMCUG in detecting VUR was 64,5% in all group of patients and 75% in patients with high grade VUR. CONCLUSION: IMCUG was of limited value in diagnosis and grading of reflux. Due to lower radiation doze delivered, method can be recommended in the follow up of children with reflux of significant clinical importance (high grade of VUR).
P647 Evaluation and Comparison of Initial and Follow-up DMSA scan After Urinary Tract Infection G. Koca, A. Baskin, S. Ozyurt, K. Demirel, M. Korkmaz; Ministry of Health, Ankara Training and Research Hospital, Department of Nuclear Medicine, Ankara, TURKEY. Evaluation and Comparison of Initial and Follow‐up DMSA scan After Urinary Tract Infection Aim: Tc‐99m DMSA scan is a non‐invasive and practical method which is regularly used in determining renal scar after reoccurring urinary tract infections. The purpose of this study was to evaluate kidneys with DMSA scan after urinary tract infections (UTI) and compare follow‐up scans. Material and method: Between March 2003 to March 2009 seventy female and 30 male total 100 patients, mean age: 9.34 ± 11.1 years who had at least one follow‐up DMSA scan, were included to our study. Mean time period between the follow‐up scan after initial DMSA scan was 8.63 ± 5.43 and mean time period between 1st and 2nd follow‐up scan was 8.68 ± 5.48 months. Contribution to total function of kidneys were defined quantitatively and each kidney were visually evaluated for scar formation. Results: Contribution of the left and right kidney to the total function for initial DMSA scan after UTI, 1st follow‐up and 2nd follow‐up DMSA scan kidney results respectively; 49.38 ± 14.77, 50.62 ± 14.1; 50.5 ± 15.91, 49.5 ± 15.94; 48.0 ± 21.9, 52.0 ± 22.08. Kidneys were grouped as normal (N), at least one hypoactive region (H), decreased DMSA uptake (DU), scar (S) and atrophy (A) for each kidney. There was strong positive correlation between DMSA scan results (p>0.001). Conclusion: When there is evidence for scar formation in initial DMSA scan, follow‐up scan is highly recommended as it may alter treatment.
N H DU S A st
Aim:The aim of this retrospective study was to evaluate the value of Tc‐99m labeled hexamethylpropylene amine oxime (HMPAO) white blood cell (WBC) scintigraphy in pediatric patient population. Material and Methods:The study was conducted between January 2006 and December 2008 and included 13 patients (5 boys, 8 girls; mean age 6.88±6.18). Those patients had suspicion of bone infection (n=7), fever of unknown origin (n=3), and suspicion of acute appendicitis (n=3) were evaluated retrospectively. Tc‐99m HMPAO labeled WBC scintigraphy imaging was performed to all patients. Diagnosis was done according to operation and pathological results, or clinical follow‐up. Results: Tc‐99m HMPAO labeled WBC scintigraphy has been found to be true positive in 4 cases, true negative in 8 cases, and false negative in one patient who had fewer unknown origin. The false negative case has been found encephalitis with MRI. Conclusion:Our results showed that WBC scintigraphy might be reliable used for diagnosis of suspected bone infection and acute appendicitis, fever of unknown, and acute appendicitis on pediatric patient population.
P645 99m
Tc-DMSA scintigraphy pyelonephritis: correlation laboratory tests.
in children with clinical
with acute findings and
1 DMSA Follow‐up DMSA
Left 54 33 6 5 2 Right 64 25 5 5 1 Left 60 25 7 7 2 Right 67 20 6 6 1
P648 Decreased tracer uptake in the inner kidney on 99mTc-DMSA scintigraphy: correlation with hydronephrosis and vesicoureteral reflux S. Tsiouris, T. Exarchopoulos, E. Siomou, A. Papadopoulos, A. Georgiou, E. Gkika, M. Pavlou, D. Dristiliaris, E. Koletsi, A. Fotopoulos; University General Hospital of Ioannina, Ioannina, GREECE. Background: Static renal scintigraphy by 99mTc‐DMSA has emerged as the imaging modality of choice for the detection of acute pyelonephritis and permanent cortical renal lesion (scarring). 99m However, a usual finding on Tc‐DMSA scanning is that of diminished tracer uptake in the inner border of kidney. Aim: To investigate possible correlation of the latter finding with the existence
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P72 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical
Science:
nephrology,
urology
and
hypertension
P649 Comparison between Tc-99m p-Aminohippuric acid and Tc99m MAG3 renography E. Jaksic1, S. Beatovic1, V. Artiko1, D. Sobic Saranovic1, S. Pavlovic1, D. Djokic2, D. Jankovic2, V. Obradovic1; 1Institute of Nuclear Medicine Clinical Center of Serbia, Belgrade, SERBIA, 2Vinca Institute of Nuclear Sciences, Belgrade, SERBIA. Aim: In vitro and animal studies of Tc‐99m p‐aminohippuric acid (Tc‐99m PAH) showed a potential for developing this new radiopharmaceutical. Tc‐99m PAH is prepared from a lyophilized kit and labeled with Tc‐99m in presence of DTPA. Our preliminary studies in humans have indicated that it is rapidly secreted by the kidneys with tubular secretion and provides renal images of satisfactory quality with no extrarenal background. The aim of this study was to compare renography and clearance studies with Tc‐99m PAH and Tc‐99m MAG3. Materials & Methods: After bolus injection of Tc‐99m PAH (111 MBq) renal dynamic scintigraphy was performed in 10 healthy subjects (potential kidney donors) and 5 patients with suspected obstructive nephropathy. Clearance measurements were performed with ten plasma samples withdrawn between 2 and 120 min post‐injection. The study was repeated with Tc‐99m MAG3 several days later for comparison. Time/activity curves, functional ratios, clearance values and excretion patterns were analyzed. Results: The mean values of time to peak activity and the time from peak to 50% activity in healthy subjects for Tc‐99m PAH (3.6 ± 0.9 and 6.9 ± 2.7 min, respectively) and Tc‐99m MAG3 (3.5 ± 0.8 and 6.8 ± 2.1 min, respectively) did not show significant difference. The mean value of Tc‐99m PAH clearance (186.9 ± 12.2 ml/min) was significantly lower in comparison with MAG3 clearance (303.9 ± 19.5). There was no significant difference in renograms and semi‐quantitative indices between Tc‐99m PAH and Tc‐99m MAG3 studies in patients with suspected obstructive nephropathy. Clearance values of two tracers were concordant to those obtained in healthy persons. Conclusion: Our results confirmed good uptake and drainage of Tc‐99m PAH in healthy persons as well as in patients with renal disorders, indicating its usefulness for routine renography. Tc‐99m PAH clearance, however, could not be used for the estimation of renal plasma flow.
P650 A new technique for the quantitation of the absolute renal uptake of technetium-99m DMSA (ARU) in adults M. Gorenberg1, L. Radan2; 1Bnai Zion Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, ISRAEL, 2Bnai Zion Medical Center, Haifa, ISRAEL. AIM: The aim of this study was to evaluate a simplified new technique for determining the absolute renal uptake (ARU) of 99mTc‐DMSA , using the validated QDMSA SPECT measurements as the gold standard for comparison. MATERIALS &METHODS: One hundred and six consecutive patients, mean age 53.57± 16.83 years old, range 19‐89 were retrospectively reviewed in this study. There were 62 males (58.5%) and 44 females (41.5%). Patients were chosen iregardless their underlying kidney pathology. The studies were performed 4 to 6 hours after intravenous injection of 4 mCi of the radiopharmaceutical. The exact dose delivered was determined by measuring the syringe in a dose calibrator before and after injection. Absolute uptake of the radiopharmaceutical by the kidneys was measured using previously described methods QDMSA SPECT (1). Studies were performed using a rotating gamma camera and an all‐purpose, low‐ energy collimator (SP‐6; Elscint, Haifa, Israel). For QDMSA SPECT data acquisition lasted 20 minutes. Kidney volumes and radioactivity‐concentration measurements were calculated on the reconstruction data using the threshold method (1). For ARU measurements a planar posterior view of the kidneys was acquired for one minute, at the end of the QDMSA SPECT study. RESULTS: The ARU measurements were highly correlated to those obtained using the validated QDMSA SPECT method, as determined by linear regression analysis (Pearson's r=0.866, p<<0.001), r squared = 0.749, regression equation: QDMSA‐SPECT=1.143+1.069ARU CONCLUSION: ARU estimation in adults using the newly proposed method was found to be very similar with the validated QDMSA SPECT method. 1. Iosilvsky G, Israel O, Frenkel A, et al. A practical SPECT technique for quantitation of drug delivery to human tumors and organ absorbed radiation dose. Semin Nucl Med 1989;19:33‐46.
P651 Quantitative parameters of dynamic scintigraphy of renal transplants P. Sirucek, O. Kraft, D. Novakova, R. Drozdkova, L. Uhlarova; Dept. of Nuclear Medicine, University Hospital, Ostrava-Poruba, CZECH REPUBLIC. Aim Statistical processing of dynamic scintigraphy of renal graft in the past two years, determination of quantitative parameters in patients with physiological nephrograms and patients with diagnosis of acute tubular necrosis (ATN). Materials & methods From March 2007 to March 2009 we investigated 99 patients with 112 dynamic scintigraphies of renal transplants (52 men and 47 women, average age 54 years, age range 22‐79 years). 93 pts had a cadaver graft (3 pts paediatric kidneys), 6 pts grafts from living donors. Results There were processed results of patients with normal nephrograms and with diagnosis of ATN. In 30 physiological nephrograms (23 patients) there was the average plasmatic creatinine value 172 umol/l, average value of ERPF (effective renal plasma flow) 5.2 ml/s/1.73 m2 (range 2.4 ‐8.4), average value of Hilson´s index 116, the average transit time of whole kidney 368 sec., and the average transit time of renal parenchyma 335 sec. The bladder filled from 4.7 minutes on average (range 3‐8 minutes). Diagnosis of ATN was determined in 45 dynamic scintigraphies in 34 patients. All these patients had cadaver transplants. One patient had combination of ATN with dilating uropathy and one patient combination of ATN with urinoma. The mean plasmatic creatinine value was higher ‐ 546 umol/l, ERPF reduced to an average value of 2.92 ml/s/1.73 m2 (range 0.48 ‐6.73), the whole kidney transit time prolonged ‐ an average of 876 sec., the average transit time of the renal parenchyma 710 sec. The bladder filled with a delay ‐ on average from 6.4 minutes (range 2‐26 minutes). The bladder in five patients did not fill during the 30‐minute study. Other diagnosis ‐ acute rejection, we determined by 11 examinations in 4 patients, chronic rejection in 27 dynamic scintigraphies (20 patients), dilating uropathy by 7 examinations (6 patients), and urinoma in 3 patients. Conclusion Only low part of renal grafts were from living donors with longer prognosis of functionality. Patients with ATN ‐ the most common pathology in cadaver grafts ‐ had significantly higher average of plasmatic creatinine level (in patients with normal nephrograms 172 umol/l on average, in pts with ATN 546 umol/l), reduced ERPF and extended whole kidney and parenchymal transit times. In patients with ATN the bladder filled with a delay or did not fill at all. Dynamic scintigraphy of graft is a useful complementary method, which is able to distinguish normal findings from the most often pathology ATN.
P652 Clinical Study of the Contradiction of Abnormal GFR and Visual Normal Nephrogram (single kidney) in 99mTc-DTPA Dynamic Renal Imaging Y. Pan, G. Huang, Prof., J. Liu, X. Sun; Department of Nuclear Medicine, Shanghai Renji Hospital, Shanghai, CHINA. Purpose: To explore why glomerular filtration rate (GFR) is abnormal with visual normal nephrogram (single kidney) in daily 99mTc‐DTPA dynamic renal imaging and how to avoid this phenomenon. Methods: The number of cases selected from patients whose value of GFR was higher than 55 ml/min/1.73m2 or lower than 40 ml/min/1.73m2 with visual normal nephrogram (single kidney) was 40 respectively in 99mTc‐DTPA dynamic renal imaging from March, 2008 to March, 2009, and their gender, age, height, weight and injection counts were recorded. Each 40 cases were divided into two groups according to right or left kidney. When the value of GFR was calculated in Gates’ methods, the maximum of abdominal aortic mean counts, the time of maximum aortic mean counts and objective renal counts (2 seconds after the time of maximum aortic mean counts) were obtained using region of interest (ROI) extraction methods from the original collecting images. Finally, the reason for the contradiction of abnormal GFR and visual normal nephrogram was concluded through comparing surface areas, injection counts, the maximum of abdominal aortic mean counts and objective renal counts of higher GFR group(GFR≥55 ml/min/1.73m2) and lower GFR group(GFR≤40 ml/min/1.73m2) in single kidney. Results: There was no significant difference of surface areas (t‐test: P>0.05), injection counts (t‐ test: P value of right kidney is 0.3302>0.05; P value of left kidney is 0.0615>0.05) as well as the maximum of abdominal aortic mean counts (t‐test: P value of right kidney is 0.9358>0.05; P value of left kidney is 0.1802>0.05) among higher and lower GFR groups. But the mean objective renal counts (2 seconds after the time of maximum aortic mean counts) of right renal higher and lower GFR groups were 906.2 and 464.8 respectively (t‐test: P value of right kidney <0.0001), and those of left renal two GFR groups were 1186.5 and 546.1 respectively (t‐test: P value of left kidney <0.0001), which is dramatically different in any single kidney. Conclusion: The abnormality of renal perfusion is the dominant reason for value difference of higher and lower GFR groups with visual normal nephrogram.
P653 Hyperfiltration (HF) in patients with spinal cord injury (SCI) and neuropathic bladder (NB). Preliminary results A. Leondi1, C. A. Rapidi2, E. Arhontaki1, D. Tamanidi1, E. Kandylakis2, T. Karianos1, M. Fragkaki2, A. Tsakmakli1, V. Sarandi1, C. Kardara1, J. Koutsikos1, K. Petropoulou2; 1Alexandra University Hospital, Athens, GREECE, 2National Rehabilitation Center “EIAA”, Athens, GREECE. Introduction: NB is characterized by detrusor (D) and sphincteric (S) mechanism dysfunction (overactivity‐OA or underactivity‐UA) that may result in obstructive uropathy, vesicoureteral refluxes and recurrent urinary tract infection. The early detection of nephrourological complications is crucial in order to prevent kidney impairment in pts with SCI and NB. Reduced GFR is indicative of renal damage. OUR STUDY AIMED to detect increased GFR (HF) frequency in pts with SCI and NB Materials and Methods: We studied 147 pts (102 M, 45 F, mean age 38.9 y.o.) without known glomerular injury or diabetes, classified according to American Spinal Injury Association (ASIA) impairment scale (A‐E). NB types (D and S OA or UA) were defined by urodynamic studies according to International Continence Society (ICS) terminology. GFR measurement by 3.7 MBq of 51Cr‐EDTA inj, 3 blood samples at 2, 3 and 4 hrs p.i. was performed. Volume of distribution was obtained by extrapolation of the clearance curve to 0 time. GFR was scaled to a body surface area of 1.73 m2 Results: 87 pts (59%) had normal GFR measurements.
Poster Presentation
of hydronephrosis (HN) or vesicoureteral reflux (VUR). Patients and Methods: We enrolled children aged 2 years or less with first episode of urinary tract infection (UTI), who underwent urinary tract imaging exams over one year (2008). Sixty two (62) children [124 renal units (RUs)] were included in the study (32 girls, 30 boys, aged 1.1±0.4 years (mean ± SD)]. All children received urinary tract sonography (SN), voiding cystourethrogram (VCUG), and voiding urosonography (VUS) within 1‐2 months from UTI episode and 99mTc‐DMSA scintigraphy 6 months later. We performed correlation analysis by Kendall's T‐b test, with significance level set at 0.05. Results: On VCUG 17 RUs were found with low grade (I‐II) VUR, 13 with moderate grade (III), and 9 with high grade (IV‐V). VUS revealed low‐grade VUR in 28 RUs, moderate in 15, and high‐grade in 9. Mild HN (antero‐posterior diameter of pelvis <10mm) was detected in 11 RUs on SN. Diminished 99mTc‐DMSA uptake in the inner border of the kidney was noted in 17 RUs; no RUs were detected with renal scarring. Statistical analysis revealed no significant correlation between decreased tracer uptake in the inner kidney border either with HN [r=0.030 (or 3.0%), P=0,750], or with VUR [r=0.038 (or 3.8%), P=0.671 for VUR]. Conclusion: Decreased tracer uptake in the inner border of kidneys on 99mTc‐DMSA scintigraphy seems to be a non‐specific finding, not related to the existence of VUR or HN.
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Among the remaining 60 abnormal studies, HF was detected in 26 pts. ASIA classification and types of NB are shown in the table.
ASIA
A B C D E D & S OA D OA & S UA D UA& S OA D & S UA
ICS
TOTAL PTS
95 16 12 17 7 111
PTS WITH HYPERFILTRATION 18 1 1 6 0 12
10
10
16
4
2
8
ASIA D was more frequent in pts with HF (46.2% vs 81.8%, P<0.0005). S UA was also more frequent either with D UA (30.8% vs 6.6%, P<0.0005) or with D OA (15.4% vs 5%, P=0.055) Conclusions: HF is not rare (18%) in pts with SCI and NB. The mechanism of this situation remains to be clarified and correlated with the neurological level of SCI
P654 Comparison of accuracy and precision of three methods of GFR determination M. J. Surma; Medical University of Lodz, Lodz, POLAND. There are few procedures for GFR determination: multisample, requiring up to 12 blood samples, and simplified: two or single sample method. Two single sample procedures, elaborated independently by Tauxe and by Constable are more common in use. These both were modified in our Department ‐ modification lay in widening the time period range from 100 to 130 min post injection, in which the blood sample should be withdrawn. The aim of study: To analyze the accuracy and precision of two simplified one blood sample methods and to compare their characteristics with analogous multisample procedure. Methods. To estimate accuracy and precision the repeated determinations of GFR were performed using the simulated results of 99mTc‐DTPA plasma concentration (ClPl), based on typical, theoretically true course of blood clearing process and true activity injected to the patient (Ap). This assumption allowed to calculate the true plasma concentrations at typical moments of blood sampling. To these obtained values the stochastic numbers, from Gaussian random generator, were added. Obtained sums gave the simulated results of plasma concentrations. Similarly, the activity injected to patient was calculated by adding the stochastic error value to the assumed true Ap. For each assumed values of clearing process and Ap the GFR determination was repeated 5000 times. Each obtained GFR allowed to compute average value and standard deviation of results. The study was performed for GFR from 6ml/min to 180ml/min. Results. When the GFR was determined using multisample procedure the maximum difference between true GFR and average determined GFR was less than 5ml/min for whole range of studied GFR. Such value of systematic error may be assessed as negligible, and the multisample method as accurate. Analogous difference obtained for both simplified procedures were greater and they reached 10ml/min. These differences suggest, that the accuracy of simplified methods is not satisfactory. Precision of each studied method depends on absolute GFR value. Precision of multisample method varies from 20% at GFR≤12ml/min to 2% at GFR>90ml/min. Precisions of both simplified methods are comparable and vary from 60% at GFR<15ml/min to 10% at 100ml/min and to 6% at GFR>150ml/min for each sampling. Conclusion. Accuracy and precision of multisample GFR determination are fully satisfactory and should be proposed for follow up examinations. Accuracy and precision of single sample methods are not similarly satisfactory, and they should be recommended for screening examinations.
P655 99mTc-DTPA dynamic renal function of horse shoe kidneys
scintigraphy
in
evaluating
K. K. Kamaleshwaran, C. N. B. Harisankar, H. V. Sunil, A. Bhattacharya, B. Singh, B. R. Mittal; Postgraduate Institute of Medical Education & Research, Chandigarh, INDIA. Postgraduate institute of medical education and research, Department of Nuclear medicine, Chandigarh, India Horse shoe kidney (HSK) is the most common anomaly with an incidence of 1 in 400 and is as twice common in males. In 90% of cases fusion involves lower poles. There is high incidence of hydronephrosis as compared to normal kidneys (64% and 7% respectively). Diuretic renography with 99mTc‐diethylene triamine‐pentaaceticacid (DTPA) has proved to be a reliable non invasive test for diagnosis of upper urinary tract obstruction. Objectives: To evaluate the use of renal dynamic scintigraphy using 99mTc ‐DTPA in determining the function of HSK. Materials and methods: Retrospective analysis of medical records of renal scintigraphy performed with 99mTc‐ DTPA during the last 4 years was done. Out of 3530 cases, 25(0.7%) patients were found to have HSK. There were 20(80%) males and 5(20%) females with age between 2 months to 45 years. Scintigraphy in 13 cases, referred because of small size kidney on sonography, diagnosed this anomaly for the first time. Remaining 12 cases were referred to evaluate function of HSK. Scintigraphy was done as per predefined protocol using 99mTc ‐DTPA with measurement of T½, relative function (RF) of each moiety and glomerular filtration rate (GFR). Each patient also underwent 99mTc‐dimercaptosuccinic acid renal cortical scan to confirm the diagnosis. Results: In all patients both the renal moieties were connected at the lower poles. Small size left moiety was seen in 9 patients whereas 5 showed small right moiety. Remaining 11(44%) patients had preserved equal size. Six of the cases with small moiety revealed hydronephrosis with obstructed drainage and 4 showed slow drainage. All the 10 moieties showed increased T½ and suppressed GFR and relative function of 15‐20%. Remaining 4 patients with small moiety showed good drainage with RF of 20‐25%. Of the 11 cases with preserved size, 4(36%) showed hydronephrosis with obstructed drainage with RF of 35‐40% and 7(64%) were normal with both moieties having RF of 50‐55%. Of the total 25 cases reduced function and excretion was noted in 14 (56%) and 11 (44%) showed preserved function and drainage. No patient had bilateral hydronephrosis. Conclusion: Our study suggests that 99mTc‐DTPA renal scintigraphy plays an important role in evaluation of renal function in patients with HSK. This may be helpful in long term follow up to monitor the development of complications as early as possible.
P656 Does initial MAG-3 renal scintigraphy after cadaveric renal transplantation predict middle- and long-term functional outcome of graft kidneys?
S. Sakamoto, M. Takeda, Y. Onishi, K. Sugimura; Kobe University Graduate School of Medicine, Kobe, JAPAN. Introduction: Renal scintigraphy has a role in evaluating perfusion of transplanted kidneys. Cadaveric graft function is sometimes associated with longer total ischemic time than living‐ related graft function, because donated kidneys are often shipped from distant places. In the development of the immunosuppressant therapy, there is less severe rejection. It is, however, uncertain whether initial Tc‐99m MAG‐3 scintigraphy could be a simple predictor of middle‐ and long‐term functional outcome of the graft. We retrospectively surveyed MAG‐3 scintigraphy, fuctional outcome of the graft and other factors related with donated kidneys. Subjects & methods: Since 1996, we have performed 26 cadaveric renal transplantations (CRT). This study enrolled 15 patients received CRT after April 2005, when scintigraphic camera was newly installed. Three patients were excluded, because MAG3 renography was not performed in the early post‐operative days. We investigated MAG‐3 renal scintigraphy performed for the 12 recipients (8 men and 4 women, aged from 8 to 52‐year old) on zero to four (mean: 3) post‐ operative days. The renogram curve can be divided into a first phase (up to the first‐pass peak) and a second phase (the curve after the initial peak). The second phase of the curve visually classified as gradually ascending (group GA) and flat (group FL). Mean age of the donors was 50.1 ± 13.3 year old, ranged from 35 to 75‐year old. Total and warm renal ischemic time (TIT and WIT), age of the donors, first day postoperative free from dialysis (DFD) and best serum creatinine level after transplantation (b‐sCr) were compared between the two groups. Results: Graft kidneys were visualized in all initial scans, and urinary bladders were scarcely visualized in all of the recipients within 20 minutes after intravenous injection. 7 studies (58%) showed GA curves and 5 (42%) showed FL curves. All the recipients have been successfully free from dialysis during long‐ term clinical follow‐up period. No statistical correlation was observed between age of the donors and b‐sCr. There was no significant difference in the TIT, WIT, age of the donors between the two groups. Neither DFD nor b‐sCr was significantly different between group GA and FL. Conclusion: The renogram curve of the initial MAG3 scintigraphy may neither be a good predictor of the middle‐ and long‐term functional outcome of the grafts nor be that of early recovery after CRT.
P657 Estimation of Glomerular Filtration Rate as a predictor of renal impairment in Systemic Sclerosis, A comparative study between the classic Gates method using Tc99m DTPA and the Cockgroft and Gault formula. A. M. A. A. Abd El-Ghany1, H. S. M. Z. Zaied2, R. H. A. A. Abd El-Latif3; NEMROK, Faculty of Medicine , Cairo University, Cairo, EGYPT, 2 Rhematolog Department, Faculty of Medicine , Cairo University, Cairo, EGYPT, 3Rheumatology Department, Faculty of Medicine , Cairo University, Cairo, EGYPT.
1
Introduction Systemic sclerosis (SSc) is a clinically heterogeneous, systemic disorder which affects the connective tissue of the skin, internal organs and the walls of blood vessels. Prognosis of SSc largely depends on involvement of internal organs. Affection of the kidney has the worst prognosis and highest mortality of all internal organs involved. Objectives: To test the accuracy of two of the available formulae for calculation of glomerular filtration rate which are the Cockgroft and Gault formula and the modification of diet in renal disease equation (MDRD) formula to that of the measured GFR as regards detection of renal involvement in patients with systemic sclerosis. Patients and methods: The current study included 31 scleroderma patients (27 females, 4 males). Patients were recruited from the Rheumatology and Rehabilitation Department, Faculty of medicine, Cairo University. Age and sex matched healthy controls were included. Estimation of disease severity was done using disease severity index (Medsger, et al., 1999).GFR was estimated using the Gates method by dynamic Tc99m DTPA dynamic renal study for 6 minutes which was re‐involved in the above mentioned formula. Results: The current study included 31 scleroderma patients including 27 females (87.1%) and 4 males (12.9%), their ages ranged from 19‐68 years mean of 43.25±11.28 years. They included 12 patients with diffuse systemic sclerosis (38.7%), 16 cases of limited systemic sclerosis (61.3%), and 3 cases with overlap syndrome (9.7%). Their disease duration ranged from 1‐17 years with a mean of 6.6 ± 4.8ys. Analysis of the data regarding measured GFR according to reference ranges revealed that the measured GFR was normal (>80ml/min) in 17 patients (54.8%), GFR ranged from 65‐75ml/min with an alarming function loss in 7 patients (22.6%), GFR 50‐65ml/min showing moderate renal impairment in 4patient(12.9%), severe impairment with measured GFR <50ml/min in 3 patient (9.7%).Comparing results of the calculated GFR using the formulae impaired renal function was reported in only 5 patients (35%) out of the 14 patient who had impaired renal function by the Tc‐99m DTPA Gates method taking the creatinin clearance test as a reference for renal impairment in our cases. Conclusion: Comparing results of the calculated GFR using the formulae showed that the formulae used failed to detect early renal involvement and early decline in GFR in patients with systemic sclerosis. Hence the simple GFR estimation by the routinely used method is more accurate, reproducible, and applicable method for detection of renal impairment in SSc patients.
P658 Results and limits of Diuretic Renography H. Aschawa, R. Aaouini, H. Kandil, M. Kebbou; CHU Ibn Rochd, Casablanca, MOROCCO. Diuretic renography as a noninvasive method is commonly indicated in children and also in adults for evaluating urinary tract obstruction by quantification of differential renal function (DRF) and drainage. Drainage impairment may occur in several renal diseases, mostly congenital. Methodology and results have been extensively studied. The aim of this retrospective study was to report results and limits of this investigation in our experience. One hundred seventeen consecutive patients (36 F and 81 M), aged between 1 month and 72 years (82 children), were studied between January 2006 and January 2009. Indications of investigation were: 1. Drainage and renal function assessment in patients with hydronephrosis (67 cases) and ureterohydronephrosis (25 cases), 2. Outcome after surgery for urinary tract obstruction (15 cases), 3. Lithiasis (5 cases), 4. Preoperative evaluation of a kidney donor (1 case). Indication was not specified in 4 cases. Oral hydration and F+20 protocol were used in 113 patients and F0 in 4 patients. Early and delayed static images after micturition and sitting position were acquired after dynamic acquisition. Qualitative and quantitative parameters were included for
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P659 The usefulness of renograms in the prediction of graft rejection after renal transplantation S. Yanagisawa, M. Momose, M. Higuchi, M. Kadoya; Shinshu University School of Medicine, Matsumoto, JAPAN. Introduction: The most severe complication of renal transplantation is the graft rejection. It is preceded by renal dysfunction. Blood and urine analyses are easy for the evaluation of renal dysfunction, but not specific for the decision of graft rejection. To predict the graft rejection after renal transplantation using diagnostic imaging is very important in determining the necessity of the renal biopsy and appropriate therapy.Renal scintigraphy with technetium‐99m diethylene‐ triamin‐pentaacetic acid (Tc‐99m DTPA) is non‐invasive method in the assessment of the transplanted kidney. In this study, we evaluated the relationship between the first renal scintigraphy findings with Tc‐99m DTPA and graft rejection in patients with the renal transplantation. Materials and Methods:This study included 10 patients (6 men and 4 women aged 23 to 59, median age, 42.6 years old), who had the renal transplantion and renal scintigraphy with Tc‐99m DTPA (256 to 370MBq) from January 2003 to December 2008. The first renal scintigraphy was performed 7 to 34 days after the renal transplantation. First, we classified renograms based on renal scintigraphy into 5 types: type A (normal type), type B (peak and slow descending type), type C (peak and plateau type), type D (rising type), and type E (flattened type). Second, we compared the types of these renograms with pathological findings obtained by biopsy. The renal biopsy was performed approximately 3 months after the renal transplantation to assess transplanted kidney. In patients with the signs of renal dysfunction early after renal transplantation, the renal biopsy was performed within 3 months. Results: Four renograms were classified into type A, other three into type B, remaining three into type C, and none into type D or type E, respectively. None of the patients in the type A showed graft rejection. One of three patients in the type B was diagnosed as graft rejection. All three patients in the type C were diagnosed as graft rejection. Conclusion: This study demonstrates that renograms of the renal scintigraphy with Tc‐99m DTPA about a month following renal transplantation may allow us to predict graft rejection.
P660 Sampe blood volume required for radionuclide glomerular filtration rate (GFR) measurement in adults G. Arsos1, I. Tsehelidis1, G. Sakagiannis1, F. Dogramatzi2, Z. Athanasiadou2, E. Psaroyli1, C. Karakatsanis1; 1Dept of Nuclear Medicine, Hippokration Hospital, Thessaloniki, GREECE, 2Dept of Biochemistry, Hippokration Hospital, Thessaloniki, GREECE. Background ‐ Aim. Timed multiple blood sampling is necessary for GFR measurement with 51Cr‐ EDTA elimination techniques. According to current guidelines (British Society of Nuclear Medicine 2005), 2‐10 samples (if full elimination curve [FEC] is to be obtained) of 10 ml each are ideally suggested for adults. Five additional ml of blood per sample are also discarded before each sampling. Thus, total blood volume required varies from 30 (2 samples) to 150 ml (FEC). The actual plasma volume needed for duplicate counting is 2 ml per sample. As patients referred for GFR measurement are commonly anemic, the total amount of blood drawn may represent a significant loss. The aim of the present study was to calculate the minimum amount of blood sufficient for duplicate plasma sample counting based on patients hematocrit (Ht). Patients and Methods. In a mixed adult (age 49.6±14.6 years) population (n=339, 152 females, chronic kidney disease 91; candidate kidney donors 19; kidney donors 19; renal transplant recipients 170; liver transplant recipients 40), GFR was measured by the slope‐intercept, two sample technique using 51Cr‐EDTA according to BSNM protocol. Plasma creatinine (PCr) levels were measured by the alkaline picrate kinetic Jaffe method. Ht was measured in duplicate in the first (at 2 hours) blood sample by microcentrifugation. Association between Ht and PCr and GFR values was assessed by linear regression analysis. Sample plasma volume was calculated as 10‐Ht/10 Results. Mean GFR was 50.4±25.8 ml/min/1.73 sqm and PCr 1.6±0.90 mg/dL. Mean Ht was 39.1±5.1%, range 24.8 ‐ 55.3%. Five patients (1.47% of the total), all of them renal transplant recipients, had Ht>50% (mean 53.4±.1.8%). Ht values showed a week negative (r=0.31, p<0.001) and week positive (r= 0.26, p<0.001) correlation with PCr and GFR values respectively. Plasma volume available per 10 ml blood sample was calculated to 6.1±0.5 ml and 4.7±0.2 ml for all patients and those with Ht>50% respectively. Conclusions. Assuming that 2 ml of plasma can be recovered from a volume of 2,5 ml which in turn, in the vast majority of patients, can be obtained from a 5 ml total blood volume, we conclude that a volume of 5 ml per blood sample suffice for convenient GFR determination. This blood saving could be of greater importance in cases of full elimination curve studies.
P661 Radionuclide glomerular filtration rate (GFR) measurement after single vs duplicate plasma sample counting G. Arsos1, I. Tsehelidis1, G. Sakagiannis1, Z. Athanasiadou2, F. Dogramatzi2, A. Svoukas1, E. Psaroyli1, C. Karakatsanis1; 1Dept. of Nuclear Medicine, Hippokration Hospital, Thessaloniki, GREECE, 2Dept. of Biochemistry, Hippokration Hospital, Thessaloniki, GREECE.
Background ‐ Aim. Timed multiple blood sampling is necessary for GFR measurement with 51Cr‐ EDTA elimination techniques. Plasma sample counting in duplicate as suggested by current guidelines (British Society of Nuclear Medicine 2005), results in increasing both blood sampling volume needs and preparation and counting time. As the impact of counting in duplicate on GFR value accuracy has not been so far evaluated, the aim of the present study was to compare GFR values after single vs double plasma samples counting and assess the feasibility of single sample counting for GFR assessment. Patients and Methods. GFR was measured in 26 consecutive patients (age 5‐71 years) using the slope‐intercept, two sample, technique after single 51Cr‐EDTA injection, according to BSNM protocol. Patients were injected with 1.47‐4.48 MBq 51Cr‐EDTA with dose escalation according to body size. Two 1 ml plasma samples per time point (A1, A2 and B1, B2 for 2 and 4 hours post‐injection respectively), were delivered in counting tubes using an accuracy pipette with coefficient of variation (CV) 0.84%. Each sample was counted for 30 min. GFR was calculated using both the A1, A2 and B1, B2 averages (GFRav) as well as all the single sample per time point possible combinations : A1B1, A1B2, A2B1, A2B2 (GFRs). For each patient, all possible GFRav‐GFRs differences (Di), their mean (mDi) and the maximum absolute one [max(absDi)] were calculated. Between‐variable association was assessed by linear regression analysis. Results. Average net counts/30min were 7265.5±4233.7 (range 2300.5‐17383.5) and 4740.8± 3791.8 (range 1263.0‐15290.5) with mean CV of duplicate measurements 0.28% and 0.34% for 2 and four hours samples respectively. GFRav was 63.5±31.2, range 14.5‐137.8 ml/min/1.73 sqm. For all the 26 patients, mDi and max(absDi) were 0.03±0.04, range ‐0.02 ‐ 0.16 ml/min/1.73 sqm and 1.06 ± 0.82, range 0.12‐2.79 ml/min/1.73 sqm respectively. No significant correlation was found between mDi or max(absDi) and GFRav. Conclusions. Given precise volume delivery, GFR can be accurately calculated by counting a single plasma sample per time point across a wide range of renal function, the absolute maximum error being less than 3 ml/min/1.73 sqm. Such a technique may allow for reduced blood volume sampling and preparing and counting time, thus facilitating both routine and multiple sampling, full elimination curve studies.
P662 Comparison of Visuel and Semiquantitative Analysis of Tc99m DMSA Scintigraphy in Pyelonephritis T. Erselcan, F. Yumuk, A. Ozdal, P. Kelkit, P. Duman, Z. Hasbek; Cumhuriyet University School of Medicine, Sivas, TURKEY. The aim of the present study was to assess performance of a previously described quantitative method as compared to visual evaluation of 99mTc‐DMSA renal scintigraphy in patients with pyelonephritis (PN). Methods: A total of 21 children (6.6±3.2 years old (mean±SD)) were examined by 99mTc‐DMSA scintigraphy in acute phase of PN (DMSA‐1) and 12.4±6.8 months later (DMSA‐2). Two levels of interpretation were performed independently: first, a visual analysis to classify the kidneys by considering the evolution between DMSA1 and DMSA2, and second, the semiquantitative analysis of DMSA‐1 and DMSA‐2. DMSA‐1 and DMSA‐2 were performed 4h after intravenous injection of 99mTc‐DMSA by use of a dual‐head gamma‐camera, with LEHR paralel collimator in 128×128 matrix and acquiring a total of 1000 kcounts. In visual method, each kidney was evaluated by 9‐points of visual scoring system. A kidney was considered normal when the score was ≥7. Renal scarring was defined when the score was <7 on DMSA‐1 and on DMSA‐2, thus kidneys were classified into two groups as, normal(N) and defective(DF). Semiquantitative analysis was performed by thresholding (between %20‐80) for a kidney and then calculating ratios of the relative count density (nC%= counts in a given isocount / counts in the 20% isocount) and relative surface area in pixels, (nS%=area in a given isocount / area in the 20% isocount). Result: In visual analysis of DMSA‐1, 13 kidneys took place in the N group (mean score; 7.27±0.46) and 29 kidneys in the DF group (score; 4.63±1.18). In visual analysis of DMSA‐2, 2 kidneys showed improvement. Not all but only samples of nC% and nS% values were given in the table below due to limited permission of abstract (Table1). Among them C70% and S70% ratios were considered the best index to classify the kidneys when DMSA‐1 and DMSA‐2 were considered together from the point of view of the determination of which kidney had developed scarring or improvement. In ROC analysis when C70% and S70% were used for the discrimination of N and DF patients, cutoff values of 0.34 and 0.26 (respectively) were found to be able to differentiate between N and DF groups. The sensitivity of C70% was %55 and specificity was %100 (AUC:0.79, SE;0.082). Conclusion: Evaluated quantitative technique may be helpful but, needs improvement to discriminate scarring kidneys. Table 1. Comparison of semiquantitative parameters Semiquantitative parameters Normal Group Defective Group......P S30% S60% S70%
0.87±0.03 0.51±0.08 0.32±0.06
0.85±0.03..........0.056 0.42±0.09..........0.006 0.24±0.08..........0.001
C30% C60% C70%
0.94±0.02 0.65±0.08 0.45±0.07
0.93±0.02..........0.050 0.56±0.09..........0.004 0.35±0.09..........0.001
P663 Sampling requirements for radionuclide glomerular filtration rate (GFR) measurement in children G. Arsos1, G. Sakagiannis1, I. Tsehelidis1, Z. Athanasiadou2, F. Dogramatzi3, A. Iakovidou1, E. Psaroyli1, C. Karakatsanis1; 1Dept. of Nuclear Medicine, Hippokration Hospital, Thessaloniki, GREECE, 2Dept of Biochemistry, Hippokration Hospital, Thessaloniki, GREECE, 3Dept of Biochemistry, Hippokration Hospital, Thessaloniki, GREECE. Background ‐ Aim. Timed multiple blood sampling is necessary for GFR measurement with 51Cr‐ EDTA elimination techniques. According to current guidelines, 7 ml of blood per sample are required (British Society of Nuclear Medicine 2005) while EANM 2005 guidelines do not determine sampling volume. In both guidelines, 3‐5 additional ml of blood per sample are also suggested to be discarded before sampling. The actual per sample plasma volume needed is 2 ml for duplicate counting (BSNM) or 1 ml for single counting (EANM). As children have normally lower hematocrit (Ht) than adults and patients referred for GFR measurement are commonly anemic, excess sampling volumes may represent a clinically undesired loss. The aim of the present study was to calculate the minimum amount of blood sufficient for single or duplicate plasma sample counting based on patients’ hematocrit (Ht). Patients and Methods. In a mixed
Poster Presentation
interpretation (dynamic display, relative renal function, time to maximum activity (Tmax), clearance half time‐T1/2, and residual renal activity). Interpretation included quality of drainage and impact on renal function. The results were univocal in 36 cases showing drainage impairment and decreasing DRF. There was no functional consequence in 18 cases without a good response after furosemide, decreased split function without abnormality of drainage in 28 cases. The exam was not contributive in 14 cases with unilateral or bilateral renal insufficiency. The exam was normal in the other cases(21). Effectiveness of Tc‐99m‐DTPA dynamic renography in patients care depends not only on methodology (hydration of the patient, quality of the bolus, voiding bladder at the beginning of the examination) but also clinical context including age, importance of urinary tracts dilatation and renal function. The poor predictive value of unique exploration is improved by iteration of investigation to assess potential impact of urinary tract distension and guide decision making.
S440 pediatric and adolescent (age 9.3±4.7, range 2‐18 years) population (n=73, 30 females, chronic kidney disease 18; malignancy on potentially nephrotoxic chemotherapy 52; renal transplant recipients 2; liver transplant recipient 1), GFR was measured by the slope‐intercept, two sample technique using 51Cr‐EDTA according to BSNM protocol. Ht was measured in duplicate in the first (at 2 hours) blood sample by microcentrifugation. Sample plasma volume was calculated as sample blood volume x (1‐Ht / 100). Results. Mean GFR was 93.4±33.5 ml/min/1.73 sqm. Mean Ht was 34.4±4.6%, range 24.0 ‐ 44.3%. Plasma volume available per 7 ml blood sample was calculated to 4.6±0.3 ml. Conclusions. Assuming that 2 ml of plasma can be recovered from a volume of 2.5 ml which in turn, in the vast majority of patients, can be obtained from a 4 ml total blood volume, we conclude that a volume of 4 ml per blood sample suffice for convenient GFR determination. In the case of double sampling ‐ single counting or single 120 min sampling ‐ duplicate counting, sampling volume can be reduced to 2 ml per sample.
P664 Can Aspirin renography be an alternative to Captopril renography? S. Dabiri Oskoie, S. Emami, F. Dabiri; Tabriz university of medical scienses, Tabriz, IRAN, ISLAMIC REPUBLIC OF. Aim: Renal artery stenosis (RAS) is the most common cause of secondary hypertension. Aspirin reduces both renal blood flow and glomerular filtration. The aim of this study was to evaluate the value of Tc99m‐DTPA aspirin renography in patients (pts) suspicious for RAS and compare the results to captopril renography. Materials and Methods: We prospectively compared aspirin renography (20 mg/kg orally 1 hour before injection of radiotracer) and Captopril renography (50 mg orally 1 hour before injection of radiotracer) with Tc99m‐DTPA in 30 consecutive pts suspected of having RAS. Tracer uptake, time‐activity curves, and glomerular filtration rate (GFR) were evaluated seprately for each kidney. All pts underwent renal angiography. Results: Of the the 30 pts enrolled, 14 had unilateral RAS on angiography. Decreased parenchymal uptake and GFR (10± 3 ml/min) with delayed secretion was observed in 12 pts after captopril test. Aspirin renography showed the same findings in 11 pts and could not reveal 3 cases with RAS. The sensitivity, specificity, and accuracy for captopril renography were 85.7%, 100%, and 93.3% and for aspirin renography were 78.5%, 100% and 90% respectively. Conclussion: Our data suggest that aspirin renography may be used as an alternative to captopril renography in particular patients who can not discontinue antihypertensive medications or who have contrandications for ACE inhibitors.
P73 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: gastroenterology
P665 Evaluation of the effect of levocetirizine on salivary gland functions in allergic rhinitis patients by [99mTc] pertechnetate salivary gland scintigraphy B. Seven1, O. Yoruk2, E. Varoglu1, H. Ucuncu2, A. Sahin1, A. K. Ayan1, Y. Sutbeyaz2; 1Ataturk University, Medical Faculty, Department of Nuclear Medicine, Erzurum, TURKEY, 2Ataturk University, Medical Faculty, Department of Otorhinolaryngology, Erzurum, TURKEY. Objective: The purpose of this study was to assess the effect of levocetirizine on salivary gland functions in patients with allergic rhinitis using [99mTc] pertechnetate salivary gland scintigraphy. Methods: The study population consisted of sixty‐seven patients with allergic rhinitis and thirty‐ one healthy controls (14 males and 17 females, mean age 30.1 ± 6.8 years). The patients were divided into two groups: an untreated patient group (thirty‐two patients, 17 males and 15 females, mean age 29.9 ± 6.5 years) and a levocetirizine‐treated (5 mg.day‐1 for 4 weeks) patient group (thirty‐five patients, 16 males and 19 females, mean age 33.5 ± 7.8 years). All of the patients and healthy controls underwent salivary gland scintigraphy. After intravenous administration of 185 MBq (5 mCi) of [99mTc] pertechnetate, dynamic salivary gland scintigraphy was performed for 25 min. On the basis of the time‐activity curves, the following glandular function parameters were calculated for the parotid and submandibular salivary glands: uptake ratio, maximum accumulation, and ejection fraction. Results: All of the functional parameters obtained for the untreated patient group were significantly lower than for the levocetirizine‐ treated patient group and healthy controls (P < 0.05), but there was no significant difference in any functional parameters between the levocetirizine‐treated patient group and healthy controls (P > 0.05). Conclusion: This study demonstrated that levocetirizine did not affect the salivary gland function in patients with allergic rhinitis, and that this condition can easily be evaluated by [99mTc] pertechnetate salivary gland scintigraphy.
P666 Early-onset functional dyspeptia confirmed using scintigraphic gastric emptying in anti-hepatitis C viral therapy E. Kawamura, S. Shiomi, S. Higashiyama, H. Fujii, S. Kobayashi, T. Yasuda, H. Morikawa, M. Enomoto, J. Kawabe, A. Tamori, H. Sakaguchi, N. Kawada; Graduate School of Medicine, Osaka City University, Osaka, JAPAN. Aim: Scintigraphic gastric emptying (SGE) is useful for the quantitative diagnosis of functional dyspeptia (FD). To confirm the side effects of worldwide‐standard pegyrated interferon‐α‐2b plus ribavirin therapy (PEG‐IFN/RBV) for chronic hepatitis C (CH‐C), we carried out SGE before and after PEG‐IFN/RBV initiation. Materials & Methods: Of 24 CH‐C subjects, 10 patients were liver histological grade 1 (F1), 10 were F2, two were F3, and two were F4. SGE using 37 MBq of Tc‐99m diethyltriamine pentaacetic acid‐labeled pancakes and evaluation of digestive symptom score (DSS) were evaluated done before and four weeks after PEG‐IFN/RBV initiation. The region of interest was established for anterior views of the radioactivity of the whole (W), proximal (P), and distal (D) stomach. Half‐time of gastric emptying (T1/2); ratio of T1/2 after PEG‐IFN/RBV initiation
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 divided by the value before initiation (T1/2 ratio); and the DSS ratio were also calculated. The T1/2 ratio and DSS ratio were compared in two groups with or without mosapride citrate (Gasmotin®, 15 mg/day 5‐HT4 receptor agonist). Results: The W‐T1/2 and DSS after PEG‐IFN/RBV initiation were higher than that before initiation: before vs. after; 91 ± 24 min vs. 104 ± 28 min, 2.1 ± 1.9 vs. 3.6 ± 3.8 (p = 0.020, 0.094; respectively). The P‐T1/2 and D‐T1/2 after PEG‐IFN/RBV initiation were both higher than that before: before vs. after; 60 ± 24 min vs. 63 ± 26 min; 102 ± 38 min vs. 122 ± 35 min (p = 0.530, 0.021; respectively). The W‐T1/2 in F1/F2‐4 were as follows: before vs. after; (F1) 98.8 ± 22.6 min vs. 107.2 ± 30.3 min; (F2‐4) 85.9 ± 23.6 min vs. 100.9 ± 28.2 min (p = 0.610, 0.004; respectively). The DSS in F1/F2‐4 were as follows: before vs. after; (F1) 1.3 ± 1.3 vs. 4.4 ± 4.7; (F2‐4) 2.6 ± 2.0 vs. 3.1 ± 3.0 (p = 0.028, 0.894; respectively). The W‐T1/2 ratio, P‐T1/2 ratio, D‐T1/2 ratio and DSS ratio in the mosapride group were lower than that in control: mosapride vs. control; 1.1 ± 0.3 vs. 1.2 ± 0.3, 0.9 ± 0.4 vs. 1.5 ± 0.9, 1.3 ± 0.5 vs. 1.3 ± 0.6, 1.0 ± 0.4 vs. 2.6 ± 2.1 (p = 0.266, 0.068, 0.977, 0.013; respectively). Conclusion: In CH‐C, early‐onset FD, particularly distal gastric motility disorder, caused by PEG‐IFN/RBV was confirmed quantitatively using SGE. Mosapride citrate tended to bring forward proximal gastric motion, and relieved subjective FD symptoms.
P667 Can Scintigraphic Protocols to Detect Gastroparesis be Shortened from 4 Hours to 3 Hours without Compromising Test Reliability? K. J. Nichols, B. Babchyck, M. Liu, C. J. Palestro; North Shore Long Island Jewish Health System, Manhasset & New Hyde Park, NY, USA. Objective: Standard protocols to assess gastric emptying recommend imaging at 0, 1, 2 & 4 hours after ingestion of a standardized radiolabeled meal (J Nucl Med Technol. 2008;36:44‐54). The objectives of this retrospective investigation were to assess whether determining gastric retention at 3 hours, or predicting results at 4 hours by extrapolating results obtained up to 3 hours, would be as accurate as the 4‐hour study. Materials and Methods: The total sample size included 175 subjects, 50 men and 125 women (mean age 54±20 years). No subject was taking medications likely to influence test results. Patients underwent a standardized 4 hour gastric emptying protocol, which included imaging at 0,1, 2, 3 & 4 hours after meal ingestion. Gastroparesis was defined as > 10% gastric retention at 4 hours. Retention values from 0‐3 hours were fit to a monoexponential function to predict percent retention at 4 hours. Receiver Operating Characteristics (ROC) curve analysis was used to determine the 3‐hour gastric retention and the 4‐hour extrapolated gastric retention values that best discriminated between patients with & without gastroparesis. Results: Actual gastric retention (gastroparesis) at four hours was > 10% in 28/175 (16%) of patients. Prevalence of gastroparesis was not influenced by age or sex. 4‐hour extrapolated gastric retention agreed with actual retention at 4 hours (8±13% versus 8±14%, p=0.06), with significant linear regression correlation (r=0.93, p<0.0001). ROC analysis indicated that optimum accuracy for 3‐hour gastric retention was obtained for a threshold of >25% (ROC area = 95%±3%). Optimum accuracy for 4‐hour extrapolated gastric retention was obtained for a threshold of >16% (ROC area = 94%±3%). Characterization of patients with actual retention at 4 hours of >10% or <10% had “good agreement” both with 3‐ hour gastric retention of >25% or <25% (kappa = 0.77; McNemar’s Δ = 2.3% with p=0.33), and with 4‐hour extrapolated gastric retention of >16% or <16% (kappa = 0.79; McNemar’s Δ = 2.9% with p=0.18). Specificity for both methods was 98%; sensitivity for both methods was 75%. Conclusion: More than 25% gastric retention at 3 hours, or more than 16% extrapolated gastric retention at 4 hours, are highly specific for gastroparesis; no additional imaging is needed. Gastric retention of 25% or less at 3 hours, or an extrapolated gastric retention of 16% or less, does not exclude gastroparesis, and testing must continue through 4 hours.
P668 Evaluation of hepatic hemangioma with technetium-99m red blood cell scintigraphy H. S. Yavuz, M. Tamam, M. Mulazimoglu, T. Kacar Guveli, S. Hacimahmutoglu, E. Uyanık, S. Erol, T. Ozpacaci; Okmeydani Training and Research Hospital, Istanbul, TURKEY. AIM: Hepatic hemangioma is the most common benign tumor of the liver. Radiologic imaging techniques, ultrasonography (USG), Computed tomography (CT) and magnetic resonance imaging (MRI) are useful in the evaluation of a suspected cavernous hemangioma. Technetium‐99m red blood cell (Tc‐99m RBC) scintigraphy plays a more prominent role in the diagnostic workup. It is also important to distinguish hemangioma from metastasis, hepatoma, abscess, cyst, hematoma, or other liver tumors so that an appropriate therapeutic course may be pursued.We report the results of Tc‐99m RBC scintigraphy in patients with suspected hemangioma following USG, CT and MRI. MATERIAL‐METHODS: From January 2006 to March 2009, Tc‐99m RBC scintigraphy was performed on 38 patients (4M,34F) (mean age: 54±9) (age range 36‐75 years) with a total of 50 focal hepatic lesions who were referred to Okmeydani Training and Research Hospital Nuclear Medicine Clinic for further evaluation of their lesions and suspicion of hemangioma. Initial technique used to detect the lesions were USG in 34 patients, CT in 15 patients, MRI in 21 patients. Lesion size ranged from 0.5 cm to 6 cm in diameter. Tc‐99m RBC scintigraphy was performed using a modified in vivo technique Final diagnosis was based on clinical follow‐up with control USG and CT at 3‐6 month periods and clinical findings for at least 12 months. RESULTS: 22 patients evaluated with Tc‐99m RBC scintigraphy were detected as hemangiomas. 1 out of 22 patients the Tc‐99m RBC scintigraphy showed halo sign around the lesion, which was interpreted as false positive. In this case, Tc‐99m RBC scintigraphy result was correlated with FDG PET‐CT, which revealed multiple metastases due to breast cancer. In the scintigraphy negative group, there were 9 true negatives (8 metastases (1patient lung ca, 1patient colon ca, 6 patients breast ca), 1 hydatid cyst ), and 7 false negative cases in whom SPECT failed to detect hemangiomas due to small size and location adjacent to the major intrahepatic vessels. The sensitivity, specificity, positive and negative predictive values of Tc‐99m RBC scintigraphy were 76%, 90%, 96% and 57% respectively CONCLUSION: As a result, although its diagnostic value is limited when lesions are smaller than 1,5 cm or are located in topographically unfavorable sites, Tc‐99m RBC scintigraphy is an accurate and highly specific noninvasive technique for the detection of hepatic hemangiomas.
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P669 51
Cr-EDTA intestinal permeability test in cirrhotic patients with spontaneous bacterial peritonitis
V. Valenza1, G. Perotti1, G. D'Errico1, L. Lo Conte1, E. Scarpellini2, A. Dal Lago2, G. Antonio2, M. Maussier1; 1Inst.of NM, Catholic Univ.of Sacred Heart, Rome, Italy, 2Inst.of Int.Med., Catholic Univ.of Sacred Heart, Rome, Italy. Aim. lmpaired intestinal permeability (IP) may be implicated in spontaneous bacterial peritonitis (SBP pathogenesis in cirrhotics. Urine 51Cr‐EDTA is a standardized test for evaluating IP. Since 51 Cr‐EDTA has a small molecular weight it can be found in peritoneal spillage in ascitcs. Aim of the study was to assess IP in cirrhotics. Methods. 48 consecutive cirrhotic pts (16 for each Child class) were enrolled; 20 pts had ascites, 10 of those had also a history of previous SBP. We also enrolled 10 healthy subjects (after informed consent). In healthy subjects 51Cr‐EDTA was <3%. After an overnight fast, pts were given to drink 1.87 MBq of 51Cr‐EDTA in 10 ml of water; two 3‐ ml samples both of 24/hours urine and ascites were measured by a gamma counter. Urine sample results were expressed as a percentage of administered dose and considered indicative of altered IP when 51Cr‐EDTA was >3%. The presence of 51Cr‐EDTA in the ascites was also evaluated. Results. 22 out of the 48 pts had an altered IP as described by 51Cr‐EDTA urine test vs no‐one of healthy controls (46 % vs 0% p<0.05). IP impairment followed progressing Child status: Child A 4/76; Chi\d B 6/76; Child C 72/76.7 2 out of 20 ascitic pts vs 10 out of 28 non‐ascitic pts had an impaired IP (60% vs 36 % p <0.05).8 out of 10 pts with ascites and SBP history had an impaired IP 51 vs 6 or.rt of the 12 ascitics without SBP history (80 % vs 50 % p;< 0.05). Cr‐EDTA was present in ascites samples from all ascitic pts with history of SBP as 2 or‐rto f the 12 pts with ascites without SBP hístory (I00 % vs 22 % p; <0 05). Conclusion. A consistent number of cirrhotics have an altered IP. IP derangement was associated with more severe disease status (ascites and history of SBP).The presence of 51Cr‐EDTA in ascites in all pts with an history of SBP suggests an altered permeability of the splancnic vessels and/or peritoneal membranes. Further studies are needed to assess a 51Cr‐EDTA urine and ascites cut‐off where SBP profilatic therapy could be indicated.
51
Intestinal permeability test with CR-EDTA in patients affected by rectal cancer: evaluation before and during chemoradiotherapy V. Valenza1, M. A. Gambacorta2, G. Perotti1, G. D'Angelo1, A. Corbosiero2, L. Lo Conte1, V. Valentini2; 1Institute of Nuclear Medicine, Catholic University of Sacred Heart, Rome, ITALY, 2Institute of Radiotherapy, Catholic University of Sacred Heart, Rome, ITALY. Background and aim: The utility of neo‐adjuvant chemo‐radiotherapy has emerged as a promising rectal cancer treatment. However, the radiotherapy on pelvic and abdominal region is associated with several complications, including diarrhea and alteration of intestinal permeability. Irradiation inflicts acute injuries to the intestinal mucosa, with a reduction of the total epithelial surface area and a consequent increased intestinal permeability. Aim of the study was to evaluate the alteration in mucosal permeability with 51Cr‐EDTA test before and after chemo‐radiotherapy in patients with rectal carcinoma. Methods: Seven patients were enrolled in the period between October 2008 and February 2009. We also enrolled 10 healthy subjects (after informed consent). After an overnight fast, patients were given to drink 1.87 MBq of 51Cr‐EDTA in 10 ml of water; the standard sample (1/50 of administered dose) and two 3‐ml samples both of 24/hours urine were measured by a gamma counter. Urine sample results were expressed as a percentage of administered dose and considered indicative of altered IP when above 3%. IP test was performed the day before radiotherapy (baseline reference), and after one and three weeks (time of hypothetical maximum damage). The other parameters investigated were: volume of small bowel receiving at least 15 Gy (V15), hematological parameteres (Hemoglobin (Hb), Haematocrite (Ht), WBC, platelet, aspartate aminotransferrase (AST), alanine aminotransferrase (ALT) and gamma‐glutamyltransferase (gammaGT) levels), and clinical symptoms (tenesmus, diarrhea). Results: 70% of patients showed increased IP before starting treatment. All of patients had increased IP at the third‐fourth week, contextually with the occurrence of gastrointestinal symptoms of toxicity. Significant association between IP pre‐treatment mean values (5.2%) and IP at the third‐fourth week mean values (7.6%) was found. Conclusions: preliminary data showed that IP is frequently altered in patients affected by rectal cancer; the IP value increased during chemo‐radiotherapy, particularly at the third‐fourth week simultaneously with gastro‐enteric symptoms. It seems possible to identify in this time the maximum chemo‐radiation toxicity and the high risk of infection due to bacterial translocation.
99m
Tc-HMPAO-leucocytes or Desease Diagnosis?
99mTc
-HIG in Inflammatory Bowel
L. Mijatovic, S. Zivancevic-Simonovic; Kragujevac, SERBIA.
Clinical
Center
Kragujevac,
The diagnosis of the inflammatory bowel disease can be made after detailed diagnostic procedures have been performed. However, even after the confirmation, it is necessary to gain information on the spread of the disease, level of the disease’s activity and possible complications. The aim of the paper is to compare the sensitivity of nonspecific polyclonal immunoglobulin G (HIG) labeled with 99mTc and 99mTc‐HMPAO‐leucocytes in abdominal scintigraphy (AS) in patients with inflammatory bowel deseases. Radiopharmaceutics were tested both in the diagnosis and in the evaluation of the course of disease as well as in the estimation of the efficacy of the therapy. AS was performed in 75 patients (48 women and 27 men, age from 19‐63 years): 37 with 99mTc‐HIG and 38 with 99mTc‐HMPAO‐leucocytes. We performed sequential AS 1 and 4 hours after the iv administration of the diagnostic dose of 370 MBq 99mTc‐ HMPAO leucocytes as well as 6 and 12 hours after the iv administration of 99mTc‐ HIG. Our results shows that the sensitivity of the 99mTc‐HIG and 99mTc‐HMPAO‐leucocytes AS was 33 and 100%, respectively.In comparison with the HIG AS with labeled leucocytes discovers greater number bowel segments affected with inflammation and gives better quality of scintigraphic visualization. According to our experience we can conclude that the AS with radiolabeled autologus lecocytes is the method of choice in the inflammatory bowel disease diagnosis. Key words: inflammatory bowel disease, abdominal scintigraphy, 99mTc‐HMPAO leucocytes, 99mTc‐ HIG
P673 Hepatobiliary scintigraphy in detection of biliary obstruction in patients with normal bilirubinemia Z. Jankovic, S. Dugonjic, D. Pucar, M. Dopudja, L. Jaukovic, B. Ajdinovic; Military Medical Academy, Belgrade, SERBIA. AIM. The aim of study was to detect partial (low grade) obstruction of main bile ducts or obstruction of lobar bile ducts in patients with normal level of serum bilirubin to confirm findings that obstruction can be present without jaundice. MATERIALS AND METHODS. Thirty eight patients (20 men and 18 women, age 36 ‐ 72 years) with hepatobiliary and pancreatic disease accompanied with increased risk of obstruction but normal bilirubinemia were selected for study (most of them with liver and pancreatic tumors, chronic pancreatitis, chronic cholecystitis, biliary anastomoses and previously treated biliary calculosis). They were subjected to hepatobiliary scintigraphy (HBS), ultrasonography and other imaging methods. HBS was performed by use of 99m Tc‐mebrofenin. Standard dynamic scintigraphy and additional static images were done. Using dynamic images biliary time activity curves were generated after subtraction of normalised paranchymal from hilar curve. Three points were selected on biliary curve (B1 ‐ first point, B2 ‐ half of the maximum and B3 ‐ the point of maximal count rate) and represented time parameters.Visual estimation of scintigrams and analysis of biliary parameters were performed. RESULTS. In 16 patients (42%) obstruction was confirmed by one or more of these imaging methods: percutaneous transhepatic cholangiography, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. The causes of obstruction were biliary stenoses, calculosis and tumor infiltration. In 22 patients obstruction was ruled out. In all patients with obstruction it was diagnosed by HBS either visually or using biliary parameters.Visual analysis revealed obstruction in 12 patients (75%). Quantitative analysis detected obstruction in 14 (87.5%) patients with normal appearance of main bile ducts (in two patients biliary curves were not generated because ducts were atypical). Visual estimation showed sensitivity 75% and specificity 100%. B1 and B2 had sensitivity 69% and specificities 100% and 95%. B3 achieved sensitivity 75% and specificity 77%. CONCLUSION. Our results show that HBS is very useful for detection of biliary obstruction in patients with normal bilirubinemia. Visual estimation is important for detection of lobar duct obstruction. Biliary curve analysis should be performed, if possible, to detect low degree of common hepatic duct or common bile duct obstruction. Combined visual and quantitative analysis enable the best detection rate of biliary obstruction in patients with normal bilirubinemia.
P674 Normal Segmental Pattern of Colonic Metabolic Activity
P671 Consensus Recommendations for Gastric Scintigraphy : Is curves fitting still needed ?.
P672
Emptying
H. Jadvar, S. Shams, L. Pourzand, W. Ye; University of Southern California, Los Angeles, CA, UNITED STATES.
P. Y. Le Roux1, S. Qzerellou1, L. Vervueren2, A. Turzo1, J. J. Lejeune2, P. Y. Salaun1, O. Couturier2; 1University Hospital of Brest, Brest, FRANCE, 2 University Hospital of Angers, Angers, FRANCE.
Objectives: We assessed the segmental pattern of normal FDG accumulation in the colon and evaluated the effect of background activity correction on this pattern. Methods: Hybrid PET‐CT with FDG was performed on 50 patients without known or suspected colonic pathology who were referred for imaging evaluation of a variety of cancers. Colon was divided into cecum, ascending, transverse, descending, and rectosigmoid segments and corresponding volumetric ROIs were drawn on CT. Descriptive statistics were calculated for colonic SUVs before and after subtraction of background hepatic activity. Corrected and uncorrected SUVs from different colonic segments were compared using Wilcoxon rank sum test. Spearman correlation coefficients between original and corrected SUVs were calculated. Results: The uncorrected range and median SUVs for colonic segments were in decreasing order: rectosigmoid (1.5‐9.9, 2.9), cecum (1.2‐6.3, 2.6), ascending (0.7‐4.0, 1.8), transverse (0.4‐4.1, 1.2), and descending (0.6‐ 3.1, 1.2). The average (+/‐sd) hepatic mean SUV was 1.92 (+/‐0.35). Background activity correction did not affect the colonic segmental metabolic rank order. The SUVs at different colonic segments were significantly different from each other (p<0.001) except for the SUVs between descending and transverse colonic segments (p>0.77). For all segments, the corrected SUV was highly correlated with the uncorrected SUV at each segment (r=0.74‐0.90, p<0.001). Conclusions: Normal colon displays predictable segmental pattern of metabolic activity with the highest activity in rectosigmoid and lowest activity in descending colon. Change in the expected segmental pattern of colonic metabolism may indicate altered underlying physiology and/or pathology.
Consensus Recommendations for Gastric Emptying Scintigraphy : Is curves fitting still needed ? Objectives: SNM Gastroenterology Council and the American Neurogastroenterology and Motility Society established recently a standardized methodology for performing gastric‐ emptying studies with imaging at 0, 1, 2, and 4 h after meal ingestion. Results consist of percentages of meal retention without time activity curve (TAC) fitting. The aim of this study was to evaluate the accuracy of this approach compared to the classical approach with numerous TAC points and curve modelling. Methods: 224 patients were retrospectively analyzed. Comparisons was done on the basis of curve parameters, after fitting a TAC with 4 points (0,1 2 and 4 h) (method A) or after fitting a TAC with a point every 15 minutes. Half‐time of emptying (T1/2), lag phase during (Tlag), effective emptying time (TRE), shape coefficient (alpha), curve fitting quality were computed from both methods. Results: More than 95% of differences between A and B parameters were included in the mean difference 95% confidence intervalle (Bland and Altman). For all the parameters tested, correlation coefficient ranges between A and B varied from 0.81 to 0.99. T1/2 and alpha of mean differences (A‐B) were respectively ‐1.66±9.4 min and ‐0.08±0.33 for solids, and ‐0.28±8.5 min and ‐0.01±0.01 for liquids . Tlag and TRE of solids mean differences (A‐B) wer respectively ‐3.35±3.87 min and 2.7±5.19 min Conclusions: The two methods gave
Poster Presentation
P670
similar results.The consensus recommendations for gastric emptying scintigraphy permit reliable estimations of both gastric emptying processes of liquids and solids.
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P675
P678
Alterations of gastric and esophageal functions in obese cases
Gastric Emptying Scintigraphy in Patients with Refractory Gastroparesis after the Implant of Gastric Electrical Pacing (Enterra™ device)
Ö. Ömür1, M. Erdoğan2, N. Mutlukoca1, F. Saygılı2, H. Özkılıç1, C. Yılmaz2; Ege University Medical Faculty Department of Nuclear Medicine, İzmir, TURKEY, 2Ege University Medical Faculty Department of Endocrinology and Metabolisma, İzmir, TURKEY. 1
OBJECTIVE: Altered gastrointestinal function has frequently been observed in obese patients. Aim of this study was investigate the degree of gastro‐esophageal reflux (GER), gastric emptying and oesophageal function by scintigraphic methods in obese patients. METHODS: Oesophageal transit, GER and gastric emptying scintigraphies were performed in 50 obese female patients (mean age: 49.6±8.1) who did not receive any treatment for weight control or gastrointestinal symptoms. Mean Body Mass Index (BMI) was 34.96±3.04 (range: 32‐39). RESULTS: The mean gastric emptying time (t1/2) in our patient group was 57.3±30 min. (Clinical reference value: 45‐90 min.), mean esophageal clearance time (t1/2) was 8.2±7.2 sec. (normal reference <10 sec). 17 of the 50 patients were found to be GER positive scintigraphically (%34). There was positive correlation between GER positivity, and t1/2 values of gastric emptying and esophageal clearance t1/2, being significantly longer in GER positive patients (p<0.05). In 19 of the patients (%38) gastric emptying time was shorter than normal. In these patients the mean esophageal clearance t1/2 was 7.2±3.5 sec. and rate of GER positivity (%15) was lower than the group average. 13 patients had esophageal clearance t1/2 was longer than 10 seconds and 8 of these patients were found to be GER positive. There was no statistically significant correlation between BMI and GER positivity, esophageal clearance and gastric emptying time. CONCLUSION: In our study GER incidence was found to be higher than the normal population and the majority of the patients had gastrointestinal motility alterations. The significance of these alterations in obesity is not fully understood, but believe that these changes can be considered as potential contributing factors in the development and maintenance of obesity and changed eating behaviour.
P676 Hepatobiliary sequence scintigraphy (HBSS) with SPECT/CT vs. contrast-enhanced CT of the abdomen: diagnostic value in the assessment of postoperative biliary injuries G. Kluge, T. Brunkhorst, W. H. Knapp, K. F. Gratz; Medizinische Hochschule Hannover, Hannover, GERMANY. The aim of this retrospective study was to have the diagnostic value of biphasic contrast‐ enhanced CT of the abdomen and hepatobiliary sequence scintigraphy with Tc‐99m‐IDA and with SPECT/CT to assess postoperative biliary injuries after liver transplantations, hemihepatectomies or cholecystectomies. During the period of June 2007 and October 2008, 20 patients with suspected biliary injury were examined with hepatobiliary sequence scintigraphy and SPECT/CT. 10 patients had a corresponding CT scan of the abdomen, which was performed between 5 days prior and 5 days after the scintigraphy. In 14 cases scintigraphic evidence of bilary injuries were present. The CT scans on the other hand, did not show the same results. In seven cases a fluid collection could be identified but due to many differential diagnoses such as biloma, hemorrhage, abscess or postoperative seroma none of the CT scans lead to the exact diagnosis. In one case the scintigraphic detected biloma was misinterpreted as the lumen of the jejunal anastomosis. In one case there was no fluid collection morphologic detectable and a bilary injury was not suspected in the CT scan. The HBSS identified the biliary leak because marked bile was present in the existing drainage, which worked sufficiently. One morphologic suspected biloma could not be identified with HBSS. Conclusion: The hepatobiliary sequence scintigraphy alone is able to locate small biliary injuries. In combination with SPECT/CT detailed anatomic information is added and the amount of misinterpretations can be reduced. Furthermore, the hepatobiliary sequence scintigraphy with SPECT/CT is more efficient in the diagnosis of postoperative biliary injuries than biphasic contrast‐enhanced CT scans of the abdomen.
P677 Evaluation of serum Obestatin/Ghrelin ratio as a new activity index in inflammatory Bowel diseases. A. S. Zissimopoulos1, E. Alexandridis2, N. Lirantzopoulos3, K. Manolas3, G. 1 Kouklakis3; University of Thrace, Alexandroupolis, GREECE, 2 Gastroenterology Department, Anticancer hospital “Theageneio, Thessaloniki, GREECE, 3First department of Surgery University of Thrace, Alexandroupolis, GREECE. ABSTRACT Crohn’s disease (CD) is a chronic, idiopathic, and relapsing form of inflammatory bowel disease (IBD). Weight loss, malnutrition, and developmental retardation are also frequently observed in inflammatory bowel disease (IBD).Obestatin and Grelin are two affiliated hormones produced from gastric fundus cells and taking part to regulation of appetite and human metabolism. The aim of this study is the cross‐correlation of obestatin and ghrelin levels in inflammatory bowel diseases, and their role in pathogenesis of IBD. Materials and methods: We measured ghrelin and obestatin levels of 31 Crohn’s disease patients and 22 patients with ulcerative colitis using commercially available RIA assay kits (Phoenix Pharmaceuticals, INC. Burlingame, CA 94010, USA).Circulating levels of the two hormones and their ratio were correlated with the disease type and activity, disease localization and treatment.Results: Mean ghrelin value was statistically significant higher in patients with active disease (402.4±462.6 pg/mL) than in patients in remission (148.2±59.6 pg/ml) p‐value=0.0290, α=0.05, whereas obestatin mean values were not (217.4±59.8 pg/ml in active disease and 189.0±46.8 pg/ml in patients with active disease p‐value=0.0607). When we evaluated the obestatin/ghrelin ratio between active and non active disease, it was found that the ratio in active disease was statistically significant lower (0.8±0.3) than in patients in remission (1.4±0.3) p‐value<0.001, α=0.05. There is also statistically significant correlation between obestatin/ghrelin ratio and activity of the disease, p<0,001.Conclusion: Ghrelin and Obestatin seem to play a significant role in IBD pathogenesis. This ratio may be used as an activity marker of inflammatory bowel diseases, but further studies needed to establish it.
R. Cantini1, I. Paglianiti1, E. Biggi1, G. Boni1, D. Volterrani1, S. Santi2, M. Rossi2, S. Marchi3, M. Bellini3, G. Mariani1; 1Regional Center on Nuclear Medicine - University of Pisa, Pisa, ITALY, 2Surgery Unit IV, A.U.O. Pisana, Pisa, ITALY, 3Gastroenterology Unit, University of Pisa, Pisa, ITALY. Gastroparesis is a symptomatic chronic disorder characterized by delayed gastric emptying in the absence of mechanical obstruction in the stomach or small intestine. Etiology of gastroparesis is multifactorial, the most common forms being diabetic, idiopathic, or postsurgical. Symptoms of gastroparesis (chronic nausea, vomiting and postprandial abdominal bloating) can be so severe so as to make everyday activities a challenge. Gastric electrical stimulation is an emerging therapy for refractory gastroparesis, and it requires minimally invasive surgery for laparoscopic insertion of a gastric pacemaker. This system consists of two small electrodes inserted into the stomach muscle wall (10 cm from the pylorus), which are connected to a pulse generator implanted in a subcutaneous pocket on the abdominal wall; the pulse generator delivers low energy trains of pulses at a frequency of 12 cycles per minute. Gastric emptying scintigraphy with a radiolabeled solid meal is the best accepted method to test for delayed gastric emptying. Aim: To explore the potential of gastric emptying scintigraphy for evaluating the efficacy of electrical stimulation of the stomach with the EnterraΤΜ device. Materials and methods: We performed gastric emptying scintigraphy in three patients with gastroparesis (idiopathic associated with gastro‐esophageal reflux in two cases, diabetic in one case). All three patients underwent gastric emptying studies at baseline, then about three months after the implant of the Enterra device. Results: Marked clinical improvement was experienced by all three patients. The gastric emptying T‐half showed a dramatic shortening in the post‐implant study versus the baseline study, respectively 115 min versus 323 min in patient 1, 159 min versus 339 min in patient 2, and 592 min versus virtual no emptying over three hours in patient 3. Conclusion: Gastric emptying scintigraphy represents a simple, non‐invasive test capable of evaluating a assessing the efficacy of gastric electric stimulator implant in patients with refractory gastroparesis refractory to conventional prokinetic medical therapy.
P679 Hepatobiliary function assessed by Tc-99m mebrofenin cholescintigraphy in the evaluation of severity of fibrosis in chronic hepatitis: Histopathological correlation M. Kula, S. Karacavus, M. Baskol, K. Deniz, U. Abdulrezzak, A. Tutus; Erciyes University, School of Medicine, Kayseri, TURKEY. The progression of liver disease in chronic HCV infection presents with a common histopathological pathway that is the formation and accumulation of fibrosis leading to the development of progressive distortion of the hepatic architecture that is the hallmark of evolution to cirrhosis. Aim of this study to evaluate the utility of non‐invasive assessment of hepatobiliary function by Tc‐99m mebrofenin cholescintigraphy in staging of chronic hepatitis. Material and Methods: The study group consisted of 60 patients with chronic hepatitis (17 males, 43 females). The patients were allocated into 3 groups according to histopathological score modified by Ishak et al. Group 1: Mild fibrosis (23 patients; Knodell grade 1‐2); Group 2: Moderate fibrosis (23 patients; Knodell grade 3‐4); and, Group 3: Severe fibrosis (14 patients; Knodell grade 5, 6). Hepatocyte mebrofenin uptake rate was calculated using the heart and liver ROIs and applying deconvolution analysis. The time required for peak activity to decrease by 50% (T1/2 peak) was obtained by applying nonlinear least‐square’s fit using the liver ROIs. Both of these parameters were calculated using software (New GMS software V5.0) developed by Toshiba Corporation. Scintigraphic parameters were correlated with biochemical and liver histopathology. Results: A significant difference in Tpeak and hepatocyte mebrofenin uptake rates was observed between the groups (p< 0.05). There was significant difference among the liver excretion T1/2 peak mean values between group 1 and groups 3. There was no significant correlation between the biochemical and scintigraphic parameters. Conclusion: Hepatobiliary function assessed by Tc‐ 99m mebrofenin cholescintigraphy correlates with the extent and progression of histopathological score. These results suggest that the potential role for Tc‐99m mebrofenin cholescintigraphy as a non‐invasive follow‐up method for disease progression in chronic hepatitis.
P680 C-14 Urea Breath Test values do not correlate with the degree of colonization by Helicobacter pylori in adults. E. Ceylan Gunay1, E. Yengel2, E. Ucbílek2, E. Altintas2, O. Sezgin2; 1Mersin University Faculty of Medicine Department of Nuclear Medicine, Mersin, TURKEY, 2Mersin University Faculty of Medicine Department of Gastroenterology, Mersin, TURKEY. Introduction: Helicobacter pylori(HP) bacterial load seems to be clinically important in determining the severity of gastritis. The aim of the study was to search if there is a correlation between C‐14 Urea Breath Test (UBT) values and histopathologically detected bacterial colonization of HP. Subjects and Methods: One‐hundred‐twenty‐five patients ( 78 women, 47 men, age range: 18‐85 ) infected by HP were evaluated. HP infection was defined by C‐14 UBT and histopathological evaluation. Breath test results were taken right after the test by using Heliprobe not only by grade, but also quantitatively by counts. Results: The count range of C‐14 UBT in all of the 125 patient was 51‐4854 ( median: 182). Patients were grouped according to bacterial colonization level as low, medium and high in which C14‐UBT counts were 51‐4854 (median:194), 56‐1986 (median:206), and 60‐433 (median: 210), respectively. No statistically significant differences were demonstrated when C‐14 UBT counts were compared between low,medium and high HP colonization groups (p> 0.05). Conclusion: No correlation was observed between C‐14 UBT values and bacterial colonization levels. Therefore we concluded that the C‐14 UBT could not estimate bacterial load and possible relation to severity of disease .
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P684
Clinical Science: endocrinology 1
Demographic data of 2000 patients with differentiated thyroid carcinoma treated and followed-up in our institute.
P681
A. T. Tonbul, T. Ozpacaci, E. Uyanik, M. Mulazimoglu, M. O. Tamam; SB Okmeydani Egitim Ve Arastirma Hastanesi, Istanbul, TURKEY.
G. W. Kaminski, A. Kowalczyk, N. Szalus, Z. Podgajny, J. Cyperling Kaminska, E. Dziuk; Military Institute of Health Services, Warsaw, POLAND. Introduction: SH affects about 1% of population at least, it courses with or without goitre. The diagnosis of this disease leans on the laboratory criteria only: decreased of thyrotropin (TSH) and normal free ‐ triiodothyronine (FT3) and ‐ thyroxine (FT4) levels. During SH the level of SHBG is often increased. This may be responsible for infertility and gynaecomastia. What’s more, there is no unequivocal procedure algorithm to manage patients with this disease. The aim of this study was to estimate an influence of treatment of SH with 131I on: achievement of euthyroid state, level of SHBG, and ThV. Materials and methods: 44 pts aged 46, with 13 months history of only autonomous endogenous SH were examined twice: before and 6 months after TSH normalization due to 131 I treatment. Average period between examinations was 13 months. The Local Ethical Committee approval for these procedures has been obtained. Results: all patients reached euthyroidism with mean dose 12 mCi of 131 I. Concentration of TSH increased from 0.16 to 1.32 mIU/l, p>0.000), but the level of SHBG decreased from 64 to 45 nmol/l (p=0.001). ThV decreased from 33 to 22 ml (p<0.000). Conclusions 1. The cure of autonomous Subclinical Hyperthyroidism with radioiodine is very effective. It normalizes both thyrotropine and sex hormone binding globuline level. 2. Subclinical Hyperthyroidism treatment with radioiodine decreases thyroid volume by approximately one third.
P682 Clinical study of bone imaging in 117 cases primary hyperparathyroidism Z. Rui-Sen; Shanghai 6th people's Hospital China, Shanghai, CHINA. Objective:The characteristics imaging of bone scintigraphy in patients with primary hyperparathyroidism(PHPT) are analyzed and compared to improve the capability of differential diagnosis in this aspect. Clinical data: 117 cases of PHPT were enrolled; there were 50 males and 67 females. Among the 117 cases, 40 had sustained fractures (34.18%); 14 cases had have calculi (11.96); 8 cases had both (6.85%); 67 cases presented with osteoporosis (52.13%), near 1/3 cases suffered from severe bone pain. Results: The bone imagings of the 117 cases could be classified into 4 categonies. Type I:Systemic(25.64%), manifested as increase uptake of 99Tcm‐MDP by the whose body bone. Type II: Localized (29.21%), abnormal bone imaging. Type IIA involes the skull and mandible bone with concentration of radioactivity; Type IIB maintains the abnormalities seen in IIB with additional metabolic derangement (fibrocystic ostitis or brown tumor); Type III: systemic plus localited metabolic derangement (4.31%).Type IV presented normal bone imaging (40.14%). Type IV and IIA are early cases, while TypeIIB and III are late PHPT cases. Type I represents the disease in progression. Conclusion: 1.Bone imaging in PHPT patients could categorized the lesions with different type and foretell the duration of the disease. 2.The 4 type are reflection of the bone lesions. 3. The characteristic changes could serve of differential diagnostic purposes.
P683 Echocardiographic functional changes in subclinical hyperthyroidism and acute hypothyroidism after L-thyroxine withdrawal in patients with thyroid cancer V. Dabbagh Kakhki1, A. Fazli Nezhad1, S. Zakavi1, E. Rahmani1, R. Sadeghi1, D. Beiki2; 1Mashhad University of Medical Sciences, Mashhad, Iran, ISLAMIC REPUBLIC OF, 2Research Institute for Nuclear Medicine , Tehran University of Medical Sciences, Tehran, IRAN, ISLAMIC REPUBLIC OF. Introduction & Aims: The studies containing information about the impressions of acute hypothyroidism on heart are limited, discordant and different in the protocols, severity of the disease, treatment duration, etc. and studies which were done by echocardiography using Tissue Doppler imaging(TDI) are rare. In order to assess the cardiovascular impact of short time overt hypothyroidism on the patients with differentiated thyroid carcinoma(DTC) underwent total thyroidectomy and radioiodine ablation; we have evaluated cardiac hemodynamics in a single cohort of these patients, before and after Levothyroxine withdrawal prior to 131I whole body scanning. Methods: 24 patients with DTC were evaluated in two phases: Phase 1: at least 4 weeks after Levothyroxine withdrawal, Phase 2: at least 8 weeks after beginning TSH suppressive therapy following the withdrawal phase. ECG was recorded, and patients underwent conventional, Doppler and Tissue Doppler echocardiography. Results: There were no differences among Left Ventricular (LV) Dimensions, LV mass, Ejection Fraction, diastolic function grades and frequency of pericardial effusion and Pulmonary artery pressure between the two statuses. In overt hypothyroidism LV end diastolic volume(p=0.011),LV end systolic volume (p=0.003) ,Early Diastolic mitral inflow velocity (E) wave(p=0.033) and Early diastolic velocity of mitral annulus [E(m)] (p <0.001) decreased, but Late inflow velocity (A) wave, E/A ratio, deceleration time, peak systolic velocity [S(m)],late diastolic velocity [A(m)] and E(m)/A(m) ratio didn't alter. Pulse rate was lower and QTc Interval was longer (p <0.001) and Both E/E(m) ratio and pulmonary capillary wedge pressure (p=0.042) were higher in hypothyroidism. However, there were no changes between diastolic function grades between the 2 conditions. Three of our patients developed mild pulmonary artery pressure hypertension in the hyperthyroid phase and also 2 of the patients had mild pericardial effusion in that phase, but it wasn't significant. Conclusion: Short term overt hypothyroidism induce undesirable cardiovascular effects in patients with DTC specially on the pulse rate, QTc interval, E wave, E(m),E/E(m) ratio and even early signs of diastolic dysfunction are manifested.
Aim: We retrospectively evaluated our patients with differentiated thyroid carcinoma to find out the incidence, the relation between age and gender, risk factors of mortality and morbidity and their relation, the prognosis of the disease and the factors effecting the treatment responce. Materials and Methods: 2000 patients with full‐filled data were included to the study. Microsoft Access 2000 was used for data collection. Classification was made according to their age at diagnosis and gender, to the data gained from their pathology reports, to TNM classification system suggested by AJCC, to the prognosis of the disease, to the surgical treatment, and to the total dose and quantity of the radioactive iodine treatment performed. Results: 1660 (83%) of the patients were female and 340 (17%) were male. Mean follow‐up was 36,48.±7,64 months. The average age at diagnosis was 43,9±13,6 years. Papillary carcinomas (87%) were followed by, follicular (11%) and differentiated (2%) types. Mean age diagnosis for papillary and follicular types were 43±13,2 and 45,4±14,2 years, respectively (p>0.05). 91% of the patients were at stage 1, 2 and 3, whereas 9% were at stage 4. 72% were T1 and T2, 18% were T3 and 10% were T4. 115 of the patients had cervical lymph node metastasis (N1). 56 (3%) patients had far metastasis (M1). Bilateral total or near total thyroidectomies were performed in 1900 (95%) patients. 40 (2%) patients had subtotal thyroidectomies and 60 (3%) patients were operated for one lobe subtotal and the other lobe total/near total thyroid excision. 280 (14%) of our patients did not receive any radioiodine treatment. Total remision was gained in 1680 (84%) and progression of the disease was noted in 60 (3%) of our patients. Gender, in relation to tumor type and being good or bad prognostic type of differentiated thyroid carcinoma did not have statistically significans (p>0.05). Good prognostic factors were noted as; age at diagnosis younger than 45 (p<0.01), differentiated carcinoma in females (p<0.05), papillary type (p<0.05), tumor size smaller than 4 cm, being grade T1 and T2, no lymph node metastasis (N0), and stage 1, 2 and 3 at diagnosis (p<0.001). Good treatment responce can be gained in papillary thyroid carcinomas with good prognostic factors. Conclusion: The results of the patients with differentiated thyroid carcinoma treated and followed up in our institute are well‐adjusted with the literature. A general decision can be made with a larger sample and a longer follow‐up.
P685 Long-term clinical outcomes after adjusted versus 131 standardized dosimetric I treatment of hyperthyroidism A. De Rooij, H. A. Romijn, O. M. Dekkers, M. P. M. Stokkel; LUMC, Leiden, NETHERLANDS. Introduction Despite long experience with radioiodine (I‐131) treatment for hyperthyroidism, controversy remains regarding the optimal method to establish treatment dose. To compare the effect on clinical outcomes of estimated versus calculated activity of radioiodine for treatment of patients with hyperthyroidism. Methods Patients with Graves’ disease or toxic multinodular goiter referred to the Leiden University Medical Center for their first I‐131 treatment between June 1995 and July 1999 were eligible for the present analysis. Two cohorts were followed for a maximum period of 5 years: 184 patients received an activity based on a 24‐hr I‐131 uptake measurement and the thyroid size estimated by palpation (adjusted group), 122 received a standardized activity, based on palpation of thyroid size solely (standardized group). Patient allocation to one of the treatment protocols was determined by time of referral. The main outcome of the present study was the comparison of treatment success (defined as euthyroidism) in the adjusted and the standardized group. A secondary outcome was the comparison of cure rates. Results Euthyroidism was found in 30% vs. 25% of all patients (adjusted vs. standardized group), hypothyroidism in 50% vs. 52% and hyperthyroidism recurred in 20% vs. 23%. None of these differences were statistically significant. The hazard ratio for successful treatment was 1.17 (95% CI 0.89‐1.53). The hazard ratio for cure of hyperthyroidism was 1.08 (95% CI 0.84‐1.40) for adjusted vs. standardized dosage method. Conclusion In hyperthyroidism, long‐term treatment outcome after standardized dose of radioiodine is comparable to the outcome after 131I‐uptake adjusted dose of radioiodine.
P686 Prevalence of cold nodules in patients with goiter in Northern Greece. T. Aggelopoulou1, N. Lytras1, E. Hilidis1, N. Papadimitriou1, G. Gerasimou1, M. Yiavropoulou2, E. Dedousi1, G. Liaros1, E. Moralidis1, F. Lizos1, J. Loulakis3, E. Papanastasiou1, K. Psarrakos1, J. Jovos2, A. GotzamaniPsarrakou1; 1Institute of Nuclear Medicine-AHEPA Hospital, Thessaloniki, GREECE, 2Endocrinology Department-AHEPA Hospital, Thessaloniki, GREECE, 3Kavala General Hospital, Kavala, GREECE. Goiter is a common feature amongst people in Northern Greece (NG). In some cases after scintigraphic evaluation of the patients, cold nodules are revealed, needing further clinical investigation. The aim of the present study is to investigate the presence of cold nodules in cases of goiter and discuss the results of their evaluation. We collected complete data from 126 patients (106 females), with a mean age of 48+6.5 years with a request form for scintigraphic evaluation of goiter. Planar scintigraphy of the thyroid gland was performed 20 minutes after iv injection of 150 MBq of Tc‐99m‐pertechnate. Medication with oral thyroxine per os was stopped at least 21 days before the procedure. In vitro tests of all patients were suggestive of euthyroid status. All patients had the scintigraphic appearance of goiter: 26 of small, 69 of medium and 31 of large size. Amongst them goiter was diagnosed as diffuse in 46 of the patients. In the remaining 80, a solitary cold nodule was revealed in 25 (31.2%) of the patients, whilst multinodular goiter with cold nodules was reported in 55 (68.8%) of them. Fine needle aspiration (FNA) was performed to all patients with solitary nodule, plus in 20 of the patients with multinodular goiter. Well differentiated carcinoma of the thyroid was diagnosed in 3 (12.5%) of the patients (2 males), all with a solitary cold nodule. All these patients underwent an operation of total thyroidectomy and are alive and in good health till now. Application of oral thyroxine was performed to all patients with euthyroid diffuse, plus in 29/55 with multinodular goiter. Patients
Poster Presentation
The influence of treatment of Subclinical Hyperthyroidism (SH) with radioiodine (131I) on achievement of euthyroid state, thyroid volume (ThV) and level of Sex Hormone Binding Globulin (SHBG).
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are followed‐up every 45‐60 days with ultrasound of the thyroid plus thyroid function tests and are all in euthyroid status. Reduction of the thyroid size after thyroxine treatment was mentioned in 45 out of 75 of the patients (60%). Thirty‐one of them had a scintigraphic report of diffuse and 14 of small sized multinodular goiter. Accordingly to the above mentioned, “success rate” with thyroxine treatment was as high as 67.4% (31/46 patients) in diffuse and 17.5% (14/80) in multinodular goiters, independently of their size. In conclusion, in patients with goiter in NG, appearance of cold nodules seems to be a common finding, with a low prevalence of thyroid malignancy. Thyroxine per os is of value, especially in cases of diffuse (mainly) and small‐sized multinodular goiters.
P690
P687 Incremental value of diagnostic SPECT/CT in intrathoracic thyroid
(11.9%) and yellow in 126 (26.0%) patients. Surgical pathologic findings revealed malignancy in 43 (8.8%) patients. The types of malignant tumors included 32 (74.4%) papillary, 8 (18.6%) follicular and in part papillary, 2 (4.7%) Hürthle cell and one anaplastic thyroid cancer. The average concentration of thyroglobulin was higher in cysts with malignant tumors then the mean value in other subjects. The macroscopic appearance of the cyst content with malignant tumor was in 28 (65.1%) subjects bloody and in 15 (34.9%) brownish. Conclusion: The cyst content analysis is of great importance in diagnosing cyst malignancies because it is an undemanding procedure with reliable results.
Tc-99m
pertechnetate
H. Shi, Y. Gu, W. Liu, S. Chen; Zhongshan Hospital, Fudan University, Shanghai, CHINA. Aims: The diagnostic value of planar imaging using Tc‐99m pertechnetate for intrathoracic was very limited. The purpose of our study is to establish an effective diagnostic methods using Tc‐ 99m pertechnetate SPECT/CT fusion imaging in the evaluation of intrathoracic thyroid.Materials and Methods: Twenty one patients (7 men, 14 women; mean age, 56.4 years +/‐ 9.2) suspected intrathoracic thyroid underwent neck and thoracic scan and SPECT/CT scan after 370MBq Tc‐99m pertechnetate injected 30min later. Two experienced nuclear medicine physicians analyzed the planar imaging and SPECT/CT fused imaging together. If no radioisotopes uptake in the intrathoracic mass, region of interesting (ROI) in the middle of the mass and muscles of chest wall were drawn individually to calculate its radiotracer counts. Results: Only 2 planar imaging showed that thyroid extended into thoracic next to the mediastinum with slightly radiotracer uptakes. Four SPECT/CT fused imagines revealed the intrathoraticic mass connected with thyroid tissues and radiotracer uptake visually. Three SPECT/CT fused imagines showed no obviously evidence that intrathoraticic mass connected with thyroid tissues but the mass had radiotracer uptake visually. Twelve SPECT/CT fused imagines showed intrathoraticic mass very clearly but no radiotracer uptake visually. The semi quantitative analyzed showed that the counts ratio of intrathoraticic mass to chest wall muscles was more than two. All those results were confirmed by histology after operation. Conclusion: Tc‐99m pertechnetate SPECT/CT fusion imaging was an effective method to evaluation of intrathoracic thyroid. Based on CT anatomy, semi quantitative intrathorcic mass radiotracer counts in fused imaging was more helpful method to improve the diagnostic accuracy.
P688 Measurement of serum thyroglobulin levels in patients with toxic adenoma and multinodular tosic goiter before and after the therapy with I-131 B. Bonefačić, S. Grbac-Ivanković, S. Petretić-Majnarić, A. Smokvina; Clinical Department of Nuclear Medicine, Clinical Hospital Centre Rijeka, Rijeka, CROATIA. The aim of study was to investigate a clinical relevance of changes in serum tyroglobulin (Tg) levels in patients with toxic nodular goiter undergoing the raidoiodine therapy (RIT). Patients and methods: In 54 patients (52 females, 2 males, mean age 70 years) with toxic adenoma (TA) (N=25) or multinodular toxic goiter (MTG) (N=29), serum Tg concentration was determined before therapy, on the day of application of RIT, and after therapy. Measurements were repeated several times, in time intervals from 3 months to one year. The patients were followed for several years (average. 5 years.) The average dose for treatment of TA was 929 MBq, and for MTG 809 MBq. The results. A significant decrease of serum Tg levels in patients (N=54) after therapy (120 ng/ml) in comparison to both therapy (451 ng/ml) and levels before therapy (388 ng/ml) was found. A persistence of hyperthyroid status after RIT was observed in 6 (11%) pts, and 7 (13%) developed hypothyroidism. All other patients became euthyroid. In patients who remained hyperthyroid after RIT, high Tg levels persisted. In some pts Tg concentration increased before RIT, despite thyreostatic therapy, with slow decrease observed after RIT. In another subgroup of pts, after the RIT there was an initial decrease, followed by subsequent increase of Tg concentration, indicating a possible recurrence of the disease. From the obtained results, we conclude that serum Tg concentration measurements is a useful and a clinically relevant tool in follow up of patients with TA and MTG, because it can be used in predicting of the disease course and planning of control visits.
P689 The importance of content's analysis in composite cysts of thyroid gland A. Valkovic-Mika, A. Smokvina; Hospital Center Rijeka, Rijeka, CROATIA. Introduction: Today great significance is given to the research and assessment of the thyroid gland nodules. Palpable nodules in the thyroid gland are present in 8% to 15% of the total population. The prevalence of cysts in the palpable nodule is 30% to 40%, while the incidence of malignancies in composite cysts is up to 10% and depending mainly on the selected study group. Malignant tumors of the thyroid gland account for approximately 85% of all endocrinologic carcinomas and thus the evaluation of the thyroid gland is of utmost importance. Aim: Our objective was to assess whether the analysis of the composite thyroid cyst content will facilitate early detection of malignancy. Subjects and Methods: Workup of all patients with palpable thyroid nodule was performed. Of the 486 subjects 322 (66.3%) were women and 164 (33.7%) were men. Ages of the patients ranged from 16 to 80 year. Their mean age was 48.56 ± 1.34 years. All patients underwent clinical and ultrasound examination. Ultrasonographic fine‐needle aspiration of the lesion and scintigraphy of the thyroid gland were performed. Written informed consent was required before the examination was performed. Results: In all patients the concentration of thyroid hormones was within normal values. Scintigraphy with 99mTc‐ pertehnetate reveled “cold” nodules in 371 patients and in 115 moderately “cold” nodules. The ultrasonographic structure of the nodules presented anechoic in 198 (40.7%) patients, anechoic and in part solid in 102 (21.0%) and hypoechoic and in part anechoic in 186 (38.3%) of the patients. Aspirates were assessed macroscopically as brownish in 302 (62.1%), bloody in 58
Clinical Significance of Diffusely Increased incidental F-18 FDG Uptake in the Thyroid Gland Y. Jeong, S. Lim, M. Sohn, J. Jeong, D. Kim; Chonbuk National University Hospital, Jeonju, REPUBLIC OF KOREA. Objective : This study was to evaluate the clinical significance of diffuse F‐18 FDG incidental uptake in the thyroid. Materials & Methods : Fifty nine healthy subjects and 116 patients with cancer (breast : 113 , gastric : 3) who had no prior history of thyroid disease underwent F‐18 FDG PET/CT, ultrasound and thyroid function test (TFT‐TSH, FT4, T3) within 2 weeks. Antithyroid antibodies (anti‐TPO and anti‐TSH‐receptor antibody) levels were also measured in 18 of 175 subjects. Thyroid lesion was defined as diffuse thyroid uptake of on PET/CT images, and it was divided into three groups (hypo‐, iso‐ and hyperintensity) according to the thyroid activity compared with mediastinal blood pool. Results : Of the 175 subjects, 70 (40%) ‐ hypointensity (15 subjects), isointensity (25) and hyperintensity (30) ‐ showed diffusely increased thyroid uptakes. Thirty six (51.4%) of the 70 subjects had abnormality in TFT. Especially 22 (73.3%) of the 30 subjects who demonstrated hyperintense uptake, had abnormality in TFT. Eighteen of the 175 subjects had elevated TSH levels and 8 had decreased TSH levels. Of the 18 subjects who had elevated TSH levels, 13 showed diffuse thyroid uptakes. And of the 8 subjects who had decreased TSH levels, 3 showed diffuse thyroid uptakes. This finding suggested the pattern that the more TSH levels were elevated, the more thyroid uptakes were increased. Sixteen of the 18 subjects (88.9%) who had Hashimoto’s thyroiditis, showed diffuse thyroid uptakes. Conclusion : Our data suggested that diffuse thyroid uptake was associated with the elevation of TSH level. In case of someone who had no prior thyroid disease showed diffuse thyroid uptakes in F‐18 FDG PET/CT scan, it should be considered to check the TFT. Especially, if thyroid showed hyperintense uptake compared with mediastinal blood pool activity, clinician must considered TFT.
P691 Scintigraphy In Primary Hyperparathyroidism By Adenoma. Value On Each Exploratory Step And Correlation With Metabolic Factors And Morphological Techniques J. Pou, A. Serena, M. Álvarez, F. Loira, J. Barandela, L. Campos; Hospital Do Meixoeiro (CHUVI), Vigo, SPAIN. Objectives: To assess the sensitivity (SS) and specificity (SP) of Parathyroid Scintigraphy (ScG) in patients who underwent surgery due to adenoma causing primary hyperparathyroidism (PHP) and their performance relative to morphological imaging. To identify scintigraphic patterns and display the relative value of each imaging technique/steps: Double phase (DPh;99mTc‐sestamibi) vs. dual tracer (DTz;99mTc‐sestamibi/99mTc‐perthecnetate); and oblique views, in diagnosis and the accurate localization of adenomatous glands in order to possible use of minimally invasive surgery techniques. To determine the anatomical and/or metabolic factors which may affect the test performance. Material and methods: Retrospective observational study: review of ScG scans and patients who underwent surgery for PHP in the 2001‐07 period. Planar scintigraphy: DPh (99mTc‐MIBI, 370 MBq, images at 15 min. and 2h); DTz: same day, 99mTc‐pertechnetate (185MBq). Pin‐hole neck, anterior and oblique views. Criteria: Dual phase MIBI: area of high uptake and/or delayed retention; patterns graded acording to Siegel; DTz: nodular discrepancy between initial MIBI(+) and Pertechnetate(‐) scans. Correlation to analytical parameters, size and weight of the adenoma. Comparison with morphological diagnostic methods (ultrasound/TC/MR). Results: 95 subjects were operated (77 women, 18 men); all of them monoglandular disease: 91 eutopic adenomas, 4 ectopic (1 retroclavicular, 3 posterior cervical); average weight: 1,8gr, size 2,1cm. PTHi correlated with adenoma weight (r: 0504) and size (r = 0,396).
Diagnostic Yield Location (side/upper/lower) SS
SP
Acc
SS
SP
Acc
ScG
88,4 95,8 92,1 ScG
75,8 94
89,5
Dphase
70,7 98,9 84,8 ‐‐
‐‐
‐‐
‐‐
DTracer
70,4 96,3 88,3 ‐‐
‐‐
‐‐
‐‐
US/Others 58,5 90,8 74,1 US/Others 30,7 88,4 74 DPh Pattern: (I) 56, (II) 26, (III) 6, (IV) 7 cases; DPh correlated with adenoma weight (Rho:‐0,412) and size (Rho:‐0,262); DPh works better on weight and size above median values. There were not differences in ScG/DPh/DTz/US performance according to sex, age, PTH, Calcium, and Phosphorus levels in groups segmented above/below median values. In 79% of cases oblique views were useful allowing diagnosis of occult posterior (DTz) or ectopic adenomas. Conclusions: This historic series confirms the excellent performance of the ScG in diagnosis and localization of adenomas in PHP and, in our hands, its superiority over morphological techniques. DPh planar with late (120min) image, frequently requires of thyroid tracer scan to improve sensitivity; oblique views provides information on depth. Maybe with current techniques like 99mTcMIBI SPECT (or better SPECT‐CT) at 45‐60 min., to maximize washout differences, will allow a single tracer/one step study without lower performance.
P692 Is thyroid-stimulating hormone (TSH) alone sufficient to identify autonomous functioning thyroid nodule or toxic multinodular goitre?
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AIM: recent guidelines for the evaluation of thyroid nodules recommend ultrasonography (US), and fine‐needle aspiration biopsy (FNAB) to discriminate between benign and malignant lesions. Thyroid scintigraphy (TS) is indicated only in case of low TSH value, even if in region with iodine deficiency the use of TS is widespread. In our daily clinical practice we observed that many patients with autonomous functioning thyroid nodule (AFTN) or toxic multinodular goitre (MG) detected by scintigraphy do not have abnormal TSH value. Aim of this study was to analyze prevalence of subclinical hyperthyroidism and relationship between thyroid hormonal status and TS. MATERIALS AND METHODS: we retrospectively analyzed 381 TS performed in our Hospital between February 2008 and February 2009. Sixty‐two (16%) patients (54F and 8M; mean age 65,8 yrs; range 33‐82) presented AFTN (22 pts, 35%) and MG (40 pts, 65%). All patients underwent TSH, FT3 and FT4 assay and Doppler US obtained the day of TS. Patients were divided into two groups: group 1 (25 pts; 11 AFTN, 14 MG) with normal TSH, and group 2 (37 pts; 9 AFTN, 28 MG) with low TSH. RESULTS: in group 1 mean TSH was 1.08 ± 0.49 μIU/ml, FT3 3.09 ± 0.68 pg/ml, FT4 8.14 ± 4.66 pg/ml, respectively. The mean nodule diameter was 19.8 ± 9.4 mm; nine nodules were isoechoic, two hyperechoic, nine hypoechoic, and five mixed, respectively. Vascular pattern was type I in four pts, type II in six, type II‐III in eight, and type III in seven. TS showed partial inhibition in 18 pts and total in 7 pts, respectively. In group 2 mean TSH was 0.15 ± 0.11 μIU/ml, FT3 4.2 ± 1.5 pg/ml, FT4 12.9 ± 7.09 pg/ml, respectively. The mean nodule diameter was 28.6 ± 14.2 mm; 15 nodules were isoechoic, five hyperechoic, five hypoechoic, and 12 mixed, respectively. Vascular pattern was type I in 10 pts, type II in 11, type II‐III in 11, and type III in five. TS showed partial inhibition in 15 pts and total in 22 pts, respectively. Statistical analysis demonstrated significant difference between two groups only regarding TSH (p <0.001), FT3 (p <0.02) and FT4 (p <0.04) CONCLUSION: our results suggest that TS should not be confined to patients with subnormal TSH values to confirm the diagnosis of AFTN or MG. In our study, TSH value alone was not sufficient to identify "hot" nodules in 40% of patients.
P693 Rosiglitazone treatment in patients with TDC, rised Tg and negative body scan. M. Molina, T. Cambil, T. Martín, A. Gentil, A. Torres, A. Fernández, J. Castro; H.U.Virgen Macarena, Sevilla, SPAIN. 131
Aim:To assess the utility of Glitazones in stimulation of I uptake in patients with Thyroid Differenciated Carcinoma (TDC), rised Thyroglobulins and poor or null 131I uptake. Material and Methods: Fourteen patients (5 men, 9 women: average age is 53,3 years old) whom fulfill inclusion criteria were finally included. These criteria were: TDC (2 Hurtle cell thyroid cancer and 12 papillary thyroid cancer), with ablation surgery and high‐dose 131I treatment, cumulative 131I doses < 600mCi and, at the time of inclusion, negative scanning, rised Tg and metastasic disease confirmed by imaging. Rosiglitazone treatment was started in all patients, 4mg/d during one month and 8 mg/d up to 3 months, monitoring hepatic function and glycemia. After completing this cycle, post‐treatment scanning was carried out using 150 mCi de 131I and assessing TSH, T4L, Tg anti‐Tg Ab and a visual analysis of the scan. According to these, patients were classified as with or without 131I uptake in the post‐treatment scan. Results: In the post‐treatment scan, 131I uptake was observed 11 patients (78,5%), lacking in 3 patients (21,5%). Treatment was well tolerated in all patients and hypoglyceima symptoms or hepatic disorders were not reported. Conclusions:Treatment with Rosiglitazone may induce 131I uptake in those patients with TDC, rised Tg and high‐dose negative scans, acting as an adjuvant in patients whom are retreated with radioiodine.
P694 Calcitonin Measurement in Needle Washout of Cervical Masses in Patients with Medullary Carcinoma M. Franceschi, S. Rončević, L. Lukinac, T. Halec, Z. Kusić; U.H."Sestre Milosrdnice", Zagreb, CROATIA. The study was conducted to assesss the usefulness of calcitonin (CT) measurement in fine needle washout for the detection of cervical lymph node metastases and/or reccurences in patients (pts) with operated medullary thyroid carcinoma (MTC). Ultrasonography (US) of the neck was obtained in 67 pts with MTC after total thyroidectomy. US‐guided fine needle aspiration biopsy (FNAB) with cytology was performed when suspicious cervical lymph nodes or masses in the thyroid bed were detected. Immediately after obtaining smears for cytology, needles were rinsed with 0.5 ml of multi assay diluent and CT was determined in these washouts (FNAB‐CT). FNAB‐CT as well as CT in serum of our pts were measured by CLIA method. Neck US revealed 55 suspicious masses ranging in size from 5 mm to 37 mm in 31 pts. Elevated FNAB‐CT concentration (from 1342 pg/mL to 98050 pg/mL) indicating metastases and/or recurrences was measured in 17 nodes in 11 pts. Serum CT levels in these pts ranged from 213 pg/mL to 79040 pg/mL. Cytology findings were positive for MTC neck malignancies in 15 nodes in 9 pts. Cytology was false negative in 2 pts. In one patient with a mass in thyroid bed, FNAB‐CT value of 40800 pg/mL indicated recurrence and in the second patient with an US suspected node in the lower jugular chain, a FNAB‐CT of 10500 indicated metastasis. FNAB‐CT levels were low (from ‹ 2 pg/mL to 40 pg/mL) in 39 nodes in 20 pts were cytology revealed reactive lymph nodes or scar tissue. Our results suggest that FNAB‐CT measurement is useful additional tool in detection of MTC cervical lymph node metastases and/or reccurences. The combined use of US, US‐guided FNAB with cytology and FNAB‐CT determination is proposed for the neck evaluation of pts with MTC.
P695 Combine use of Sestamibi (MIBI) and Tetrofosmine (TF) in detection of Parathyroid Tissue (PT) in patients with Primary Hyperparathyroidism (PH) and total thyroidectomy.
T. Athanasoulis, A. Vezirgianni, K. Archondaki, K. Karamagioli, O. Karamini, F. Athanasouli, E. Kounadi, C. Zerva; 'Alexandras' University Hospital, Athens, GREECE. It is well known that the differential washout of MIBI between PT and thyroid tissue (TT) is not found when TF is used mainly due to slower TF washout (WO) from TT. The aim of the study was to test the hypothesis that a direct comparison of MIBI and TF WO from a suspect lesion in the neck in patients with PH and thyroidectomy and unable discontinue thyroxine for performing a thyroid scan, allows its identification as PT when TF demonstrates similar or faster than MIBI WO and as TT when TF WO is significantly slower. Material and methods. In a study group of 16 patients with thyroidectomy and PH MIBI and TF scan were performed and early and late images were obtained at 10 min and 120 min post injection respectively. A ROI was drawn over the suspect lesion and mean count rate in early (Ec) and late (Lc) MIBI and TF images were determined. After background correction MIBI and TF WO were calculated from the formula WO=(Ec‐Lc)/EcX100 and the percentage difference between MIBI and TF WO (WO Pd) was calculated from the formula WO Pd= ‐(MIBI WO‐TF WO)/MIBI WO X100. As reference group 17 patients with PH was used in whom the same protocol using MIBI and TF had been previously performed and subsequently a PT was surgically found. Mean value of WO Pd in the PT of the reference group was +8,0%±11,5. In the study group when the WO Pd of the suspected lesion was higher than ‐15% (ie WO Pd mean value of the reference group minus two times the standard deviation ) then we considered the lesion to be PT otherwise we considered it to be TT. Results. In 13/16 patients a PT was surgically removed and all were correctly predicted. The lowest WO Pd value was ‐7% (mean value= +10,9%±11,4). The remaining 3/16 patients had WO Pd ‐36%, ‐26% and ‐34% respectively. Two patients had surgery and confirmed residual TT. In one of these surgery failed to find the PT and in the other PT was found in another position. The third patient refused surgery. Conclusion. These results indicate that in patients with PH and thyroidectomy who cannot discontinue thyroxine a direct comparison of MIBI and TF WO allows confident discrimination between PT and residual TT.
P696 Radioiodine therapy in patients with amiodarone-induced thyrotoxicosis A. Czarnywojtek, R. Czepczyński, M. Ruchała, M. ZgorzalewiczStachowiak, E. Szczepanek, H. Zamysłowska, Z. Bartkowiak, J. Sowiński; Poznan University of Medical Sciences, Poznań, POLAND. The use of radioiodine therapy (RIT) in amiodarone‐induced hyperthyroidism (AIT) with low radioactive iodine uptake (RIU) is controversial. In these patients therapeutic choices for refractory cases include surgery, antithyroid drugs, or glucocorticosteroids. Aim: The aim of the study was the evaluation of efficacy of RIT in AIT patients with low RIU. Patients and methods: 40 patients (25 men and 15 women) aged from 63 to 83 years were subjected to the study. The therapy including AM was essential for the underlying heart disorder. RIT therapy was chosen because of agranulocytosis post anti‐thyroid drugs (6 cases), diabetes mellitus (8 cases) (contraindication to glucocorticoid therapy), in 4 cases (16%) surgery was contraindicated and in the remaining cases intolerance to anti‐thyroid medication (hepatic failure) occurred. Forty seven toxic multinodular goiter (TMNG) patients (39 women and 8 men), matched for age (67 ± 12 yr; range 54‐89 yr) and gender, were enrolled in the study as the control group. The diagnostic procedures included baseline thyroid function test (fT3, fT4 and TSH levels), thyroid autoantibodies (TgAb, TPOAb, TRAb), ultrasonography, thyroid scan, and RIU measurement. Results: Serum values of TSH were undetectable in both groups. In AIT group serum fT4, fT3 were as follows: fT4 27.1±5.8 pmol/l; fT3 4.7±1.4 pmol/l. In TMNG patients the values were: fT4 25,3 ± 5,8 pmol/l and fT3 4,2±0,2. Mean RIU after 5‐h and 24‐h RIU values in AIT patients were: 2.3±0.5 and 3.1±0.9% and in TMNG: 18,0 ± 3,8 and 35,7 ± 9,1% respectively (P < 0.001). In all patients of both groups, a dose of 800 MBq of 131I was administered. During 2 years of follow‐up a recurrence of hyperthyroidism was observed in 2 patients (5%) with TMNG. At the end of the follow‐up none of the patients with AIT required a second 131 I dose, and only 1 patient (2.5%) 6 months post ablative 131 I dose required anti‐thyroid medication. Transient hypothyroidism was observed in only 2 patients (5%) with AIT, though not observed in TMNG 2 years post therapy. During follow‐up, no sudden deaths in AIT patients were observed, one patient was diagnosed with prostate cancer not associated with RIT and in one patient acute toxic hepatitis after AM occurred. Conclusion: Radioiodine therapy can be an efficient method of treatment in patients AIT despite low radioiodine uptake.
P697 Imaging of Neuroendocrine Tumors using 1
1
1
111
In Pentetreotide
1
V. Artiko , S. Novosel , N. Petrovic , S. Pavlovic , D. Sobic-Saranovic1, E. Jaksic1, M. Petakov2, D. Macut2, B. Popovic2, S. Damjanovic2, V. Obradovic1, A. Koljevic-Markovic3; 1Centre for Nuclear Medicine CCS, Belgrade, SERBIA, 2Clinic for Endocrinology, Diabetes and Metabolic Diseases CCS, Belgrade, Serbia, 3Institute for Oncology and Radiology, Belgrade, SERBIA. Aim: The aim of the study is detection of primary and metastatic neuroendocrine tumors (NETs). Patients and Methods: The total of 47 patients was investigated. Whole body scintigraphy and tomography was performed 4h ‐ 48 h after i.v. administration of 111MBq 111In pentetreotide. Results: From 14 neuroendocrine carcinomas of unknown origin, there were 12 true positive (TP) findings (8 with liver metastases, one with liver, lung, and bone metastases, one with liver and mediastinal lymph node metastases and 2 with liver and retroperitoneal lymph node metastases), while 2 were false negative (FN) (poorly differentiated carcinoma). In 6 patients scintigraphy influenced further patient management. From 16 pancreatic NETs, in 10 neuroendocrine pancreatic carcinomas there were 8 TP (6 with liver metastases) and 2 FN (poorly differentiated). In one patient with pancreatic carcinoma and carcinoid of appendix, finding was true negative (TN) after surgery. In 3 patients with pancreatic gastrinomas findings were TP, while in 2 patients with insulinoma one was TP and in the other TN. In 6 patients scintigraphy influenced further patient management while in 4 contributed. From 7 neuroendocrine lung tumors there were 5 TP all with bronchial carcinoids (one without, two with liver and two with liver, lung and bone metastases), one TN (patient with atypical lung carcinoid after surgery), while in one with neuroendocrine lung tumor (ACTH secreting) it was FN (small mediastinal tumor). In 2 patients scintigraphy influenced further patient management while in 2 contributed. In one patient with laringeal NET, finding was TN after surgery. In one patient with gastric NET
Poster Presentation
R. Mazza1, F. Ianni2, C. Carrozza3, G. Perotti1, S. Palumbo3, M. Lavalle1, S. M. Corsello2, V. Valenza1, A. Pontecorvi2, M. Salvatori1; 1Institute of Nuclear Medicine, Catholic University of Sacred Heart, Rome, ITALY, 2Division of Endocrinology, Catholic University of Sacred Heart, Rome, ITALY, 3Institute of Clinical Biochemistry, Catholic University of Sacred Heart, Rome, ITALY.
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and liver metastases it was FN (tumor necrosis) and TN in one patient with paraduodenal gastrinoma (after surgery). From 3 patients with rectal NET tumors, one patient was TP (rectal NET tumor), one TN (carcinoid after surgery) and one FN (carcinoid poorly differentiated). From the group of 4 patients with gut carcinoids, one was TP, two were TN (ileal carcinoids after surgery) and one FN (ileal carcinoid and liver metastases) (dediferentiation of the tumor). Sensitivity was 79%, specificity 100%, positive predictive value 100% and negative predictive value 50%. Six patients were indicated for radionuclide therapy with 90Y‐DOTA TATE. Conclusion: Scintigraphy of neuroendocrine tumors is a useful method in diagnosis, staging and follow up of the patients suspected to have neuroendocrine tumors in the lungs. It is also helpful in the appropriate choice of therapy, including the radionuclide one.
P698 Frequency of contralateral thyroid lobe involvement by differentiated thyroid cancer found at completion thyroidectomy A. Santra, C. Bal; All India Institute of Medical Sciences, New Delhi, INDIA. Purpose of this study was to determine the incidence of contralateral lobe malignancy in differenciated thyroid cancer found at completion thyroidectomy and the rate of permanent complication(s)due to second operation. Method: The records of all hemithyroidectomy (HT) patients, who underwent completion thyroidectomy (CT) and subsequently treated in our thyroid clinic from 1984 to 2008 were reviewed. Preoperative investigations, histopathological reports and records of major surgical complications were analyzed. Rates of contralateral malignant involvement and permanent complication were calculated. Result: Total number of CT patients were 373 (M=85, F=288) with mean age of 36.2±1.16 years. Primary presentation was STN in 356 and MNG in17 patients. Papillary thyroid histology was in 292(78%) and follicular in 81(22%) patients. Histopathology after CT revealed malignancy in 102 patients (27.3%). Malignant foci in contralateral lobe found in 92 (24.6%) and normal thyroid with metastatic lymphnode in 10 patients (2.7%). Six patients (1.6%) had only microscopic (<10 mm) disease. Contralateral lobe involvement was found more in patients with suspicious FNAC (?Pap ca) group than others(41% vs 24‐27%, though statistically not significant). Average time gap between two surgeries in malignancy positive group (278.21±134.12 days) was also not significantly varied from those who were negative (217.60 ±71.84 days). The surgical complications of completion thyroidectomy were permanent hypoparathyroidism in 4 patients (1.07%) and permanent recurrent laryngeal nerve palsy in 2 patients (0.53%).Conclusion: Overall positive yield of completion thyroidectomy for contraleteral lobe malignancy in thyroid cancer patients was 27.3% at the expense of permanent complication rate of 1.6% in our study population group.
P699 Iodine-induced Hyperthyroidism from Amiadorone.The role of thyroid scintigraphy for the correct treatment I. Armeniakos, X. Geronikola-Trapali, P. Karabina, V. Lyra, S. Bakalis, P. Zotou, A. Stefanoyiannis, A. Prentakis; University General Hospital "Attikon", Nuclear Medicine Department, Chaidari, GREECE. Aim:This study was perfomed to determine the role of thyroid scintigrarhy for the correct treatment in patients with Amiadorone‐ thyrotoxicosis.The iodine containing drug most commonly associated with iodine induced hyperthyroidism is amiadorone,an antiarrythmic cardiac drug used for refractory arrythmias .Its iodine content is 75 mgr per 200 mgr tablet.Amiadorone causes thyrotoxicosis by two possible mechanisms:directly via iodine ‐induced hyperthyroidism per se,orindirectlyby inducing adesructive thyroiditis.In all cases os iodine‐ induced hyperthyroidism,the thyroid hormone levels are elevated,the TSH level is suppressed and the RAIU determinations are low. Materials and methods:Thyroid scan 99mTcO4 was perfomed in 13 patients,8 males,5 females with range age 47‐68 years,with amiadorone‐induced hyperthyroidism.The results were compared with several clinical and biochemical data including TSH,FT4,FT3,thyroid sonography and thyroid radiodine uptake (RAIU) Results :All patients had undetectable uptake in thyroid scintigraphy.5 received therapy with antithyroid drugs without response in 2 cases,6 treatment with corticosteroids and antithyroid drugs with normalization all and 2 only with corticosteroids responsed to the treatment. Conclusion:Iodine‐induced hyperthyroidism from Amiadorone destructive thyroiditis and undetectable uptake in thyroid scintigraphy, requires treatment with corticosteroids and antithyroid drugs with or without the addition of potassium perchlorate,which blocks furher iodine uptake by the gland.
P700 Retrospective Analysis of Radioiodine Differentiated Thyroid Cancer Patients
Therapy
for
B. Gunes, M. Demir, B. Kanmaz, L. Kabasakal, H. Sayman, C. Onsel, I. Uslu; Istanbul University Cerrahpasa Medical Faculty Nuclear Medicine Dept., Istanbul, TURKEY. Aim: We retrospectively analysed differentiated thyroid cancer (DTC) patients treated with radioiodine I‐131 in our nuclear medicine ward between 2005 and 2008. Materials and methods: We randomly selected 335 patients with DTC treated with total or near‐total thyroidectomy followed by I‐131 radioiodine ablation, corresponding to 68 male (20%) and 267 female (80%).The mean age of enrolled patients was 43,6±13,7 yr (range, 13‐84 yr). The histopathological types included 302 papillary carcinomas (90,15%) and 33 follicular carcinomas (9,85%; including 8 Hürthle cell carcinomas). Results: TSH levels 4‐6 weeks after surgery were 73±29 mIU/ml for 320 patients (94,5%) excluding 15 patients (4.5%) with TSH levels >100 mIU/ml. Thyroglobulin (Tg) levels just before radioiodine therapy (RIT) were 25±81 ng/ml for 328 patients (97,5%) excluding 5 patients with Tg levels >300 ng/ml (1,5%) and 2 patients with Tg levels <0,1 ng/ml (1%). 24‐hr uptake values were <1% for 29% of patients, <2% for 38% of patients, <5% for 31% of patients and <10% for 2% of patients. 40 patients had lymph node metastases (39 patients with papillary carcinoma, 1 patient with Hürthle cell carcinoma) and one patient had thoracal 11 vertebra metastasis (papillary carcinoma) at the time of diagnosis. One year follow‐up without RIT was defined as successful. 265 patients had RIT only once (79%), 50 patients had ablation therapy two times (15%), 14 patients had RIT three times (4%),6 patients had ablation therapy more than three times (2%). Among 70 patients with RIT more than one
time, 62 patients were papillary carcinoma (20,5% of patients with papillary carcinoma) and 8 patients were follicular carcinoma (24,2% of patients with follicular carcinoma). Among 40 patients with lymph node metastases, 19 patients had only one ablation therapy. 8 patients with negative I‐131 scan and increased Tg levels had PET‐CT scan with multiple metastases. Conclusions: Similar with previous studies, these results show us that RIT is more successful with high TSH levels and low 24‐hr uptake values with a success rate of 79% (RIT only one time).
P701 99m
Tc-sestaMIBI dual-phase scintigraphy and ultrasound in presurgical evaluation of secondary hyperparathyroidism: usefulness of combined approach.
I. Bruno1, C. Vulpio2, D. Di Giuda1, M. V. Mattoli1, R. Mazza1, G. Perotti1, D. P. Dambra1, F. Cocciolillo1, L. Zagaria1, A. Giordano1; 1Nuclear Medicine Institute, Catholic University of Sacred Heart, Rome, ITALY, 2Institute of Clinical Surgery, Catholic University of Sacred Heart, Rome, ITALY. Aim The aim of this study was to evaluate the diagnostic accuracy of combined 99mTc‐ methoxyisobutylnitrile (99mTc‐sestaMIBI) parathyroid scintigraphy (PS) and ultrasound (US) in detecting parathyroid glands (PTG) and their usefulness in presurgical assessment of secondary hyperparathyroidism (sHPT). Materials and methods We studied 19 haemodialysis patients with uremic sHPT (7m, 12f; mean age: 46+18). All patients failed to respond to vitamin D therapy and underwent parathyroidectomy (PTX) after preoperative US and PS examinations. Presurgical intact parathyroid hormone (iPTH), calcium, phosphate, alkaline phosphatise measures were obtained. All patients had elevated iPTH (range: 500‐700 pg/ml). US and PS results were compared with histopathologic findings. Images of the neck were acquired using a pin‐hole collimator at 5 and 120 minutes after injection of 99mTc‐sestaMIBI (370 MBq); at 20 minutes, high resolution parallel‐hole collimator was used to record an image of the mediastinum; at 170 minutes thyroid scintigraphy was performed (148 MBq 99mTc‐pertechnetate i.v.) using pin‐hole collimator. Early MIBI uptake was classified as follows: mild (equal or slightly superior to thyroid); medium (moderately superior); high (markedly superior). Radiotracer wash‐out was defined as rapid (without residual delayed uptake) or slow (with residual delayed uptake). Results The sensitivity of PS and US was 61% and 56%, respectively, while the specificity was 90% for both procedures. The overall sensitivity of combined approach was 72%, significantly higher than US or PS alone (p<0.05). PS detected 6/7 PTG in atypical localisation whereas US was always negative. Despite a similar diameter, US and PS detected a higher number of inferior PTG (US:79%; PS:73%; p<0.05) than superior PTG (US:45%; PS:42%; p<0.05). Seven patients (37%) showed concomitant thyroid nodular disease with thyroid carcinoma in 2 cases. When US and PS were both positive, the number of frozen section required by the surgeon was significantly lower than in cases of discrepancy (p<0.05). Histopathology revealed 71 hyperplastic PTG. MIBI high uptake and slow wash‐out were related to a nodular hyperplasia pattern at histopathologic analysis, whereas MIBI mild uptake and rapid wash‐out PTG showed a diffuse type hyperplasia. Conclusions The combined approach of PS and US in the presurgical evaluation of sHPT showed a higher sensitivity than US or PS alone and increased the confidence of surgeon as demonstrated by significantly lower number of frozen section, with a cost reduction. Furthermore PS has a distinctive role in the detection of ectopic PTG, whose misdiagnosis is related to a high number of disease relapse and surgical failure.
P702 Changes of thyroidal Tc-99m MIBI uptake and wash-out in patients with and Graves’ disease E. Ruksen1, G. Gumuser1, Z. Hekimsoy2, F. Aras1, E. Sayit1; 1Celal Bayar University, Medical Faculty, Nuclear Medicine, Manisa, TURKEY, 2Celal Bayar University, Medical Faculty, Internal Medicine, Manisa, TURKEY. Purpose: The aim of this study was to investigate the changes of thyroidal Tc‐99m MIBI uptake and wash‐out in patients with Graves’ disease, thus to evaluate the usefulness of Tc‐99m MIBI thyroid scintigraphy in these patients. Materials and methods: Twenty patients with Graves’ disease (14 females, 6 males; mean age=36.9 ± 11.7 years) and 10 euthyroid controls (4 females, 6 males; mean age=49.6±14.5 years) were included in the study. We performed Tc 99m‐MIBI thyroid scintigraphy to the two groups. Dynamic images were acquired during for 20 min, and static images (100.000 counts) were obtained 20, 60, 120 min after the injection of Tc‐99m MIBI (740 MBq). An image with 100,000 counts 5 min after injection was extracted from the dynamic images. Five, 20, 60, and 120 min uptake, time to maximal uptake (Tmax) and T1/2 of tracer clearance were calculated. Images were acquired by using a dual headed gamma camera (Infinia, GE, Tirat, Hacarmel, Israel) with LEHR collimators, on a 128x128 matrix. Additionally, we performed Tc‐99m pertechnetate thyroid scintigraphy at least 2 days after. Results: All the Graves’ disease patients had elevated FT3 and FT4 and decreased TSH levels. Tc 99m‐MIBI thyroid clearance of Graves’ disease is faster than euthyroid volunteers (p<0.05). No statistically significant difference was detected on the basis of Tmax values between euthyroid controls and Graves’ disease (p<0.05). In the two groups, there was no significant correlation between FT3, FT4, TSH levels, and Tc‐99m MIBI uptake and wash‐out rate. In the Graves’ disease group, Tc‐99m MIBI uptake and wash‐out rate was not affected from thyroid hormone therapy. Conclusion: We suggest that increased Tc‐99m MIBI uptake and faster wash‐out rate are based on the histopathological findings of Graves’ disease: increased number of mitochondria and the inflammatory infiltrate. Our findings suggest that Tc‐99m MIBI could be used as an alternative radiopharmaceutical for thyroid gland scintigraphy in patients with Graves’ diseases without stopping thyroid hormone therapy.
P703 The Role of MRI in Intraarticuler application of Beta-emitting Radionuclides in the Treatment of Haemophilic Joint Diseases H. Kaya1, B. Kizilkan Bellur1, O. Ayyildiz2, N. Aguloglu1, H. Gumus3, A. Kapukaya4; 1Dicle University School of Medicine the Department of Nuclear Medicine, Diyarbakir, TURKEY, 2Dicle University School of Medicine the Department of Hemathology, Diyarbakir, TURKEY, 3Dicle University School of Medicine the Department of Radiology, Diyarbakir, TURKEY, 4Dicle
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Introduction:Radiosynovectomy is a local intra‐articular injection of beta‐emitting radionuclid in collodial form radiotherapy. Intra‐articular bleeding called haemarthroses occured the most frequent haemorrhages in haemophilia. Chronic haemophilic synovitis is characterized by persistant joint swelling and proliferative synovitis. Degenerative joint disease caused by chronical synovitis is a very important reason for morbidity of patients with severe haemophilia. Synovectomy is the procedure of choice to break this cycle, and should be performed in joint damage occurences. Radioisotope synovectomy has gained acceptance to reduce the frequency of recurrent haemarthroses and preventing persistant joint disabilities in haemophilia with chronic synovitis. Aim: The purpose of this study we investigated the role of MRI in intraarticular application of Beta‐emitting Radionuclides in the Treatment of Haemophilic Joint Diseases. Material‐Method: From January 2006 to March 2009, 17 persons with haemophilia underwent 19 knee radiosynoviorthesis at our institution. A detailed self‐report of haemorrhage history, plain X‐ray and MRI studies of the joint were performed pre and post radiosynoviorthesis. 16 of them had Haemophilia A and 1 had Haemophilia B. Their mean age was 16 years (range:6‐50 years). Patients were injected intraarticular 5 mCi of Y‐90. After this injection intraarticular steroid was injected. Patients were immobilized for 48 hours. 6 months after radiosinovectomy all the patients had performed control MRI and compared with previous MRI. Results: Nineteen joint in 17 patients were evaluated with MRI pre and post procedure. A locally designed MRI joint score considering seven parameters (1 joint effusion, 2 synovial membrane thickening, 3 haemosiderin deposits, 4 joint cartilage injury, 5 subchondral bone erosion, 6‐subchondral bone cyst, 7 osteonecrosis) was used (max score:13 points). MR scans were performed in 19 joints(knee). Mean pre‐procedure MR score was 6.5 , post‐procedure MR score was 5.5. At the 6 months follow‐up improvement had occured in bleeding frequency. Conclusions: The MR findings in our cases of advanced joint disease were not predictive of clinical response to radiosynoviorthesis. The severity of synovial hyperpylasia was generally unchanged during 6 months post‐procedure despite an improvement in haemorrhage frequency.
P704 Presentation of diffuse sclerosing variant of papillary thyroid carcinoma Z. Bence-Zigman, D. Dodig, Z. Hutinec; Clinical Hospital Centre Zagreb, Zagreb, CROATIA. AIM: Evaluation of presentation of the diffuse sclerosing variant of papillary thyroid carcinoma (DSVPTC). MATERIALS & METHODS: DSVPTC was diagnosed in 8 patients between 2002‐2008 (1% of 838 pts treated for PTC in our department from 1970 to 2008). Seven were females and one male, aged 11 to 37 years (mean 22 years, median 20 years). RESULTS: All pts had autoimmune thyroid disease (AITD). The youngest pt was 11 year old girl with low growth velocity and severe hypothyroidism. Ultrasound examination showed typical presentation of chronic thyroidits, only discrete punctiform echoes were visible in the whole right lobe. Cytological finding from both lobes was lympocitic thyroidits. But, carcinoma was recognized by lymph nodes. On the right side of the neck some small lymph nodules showed pathological echostructure and CDFI showed pathological increased vascularisation. Fine needle guided biopsy revealed metastases of papillary carcinoma. Histology confirmed DSVPTC. Two small foci of tumour, 2 and 4 mm in diameter, were found in the right lobe and multiple pssamoma bodies in the whole right lobe with lymph node metastases on the right lateral side of the neck. One patient (17 year old girl) was treated because of hyperthyroidism, two had mild hypothyroidism and four were euthyroid. In one male patient tumour was presented in four months what was confirmed by previous ultrasound examination. None of the pts had nodules, US showed hypoechogenic structure of the thyroids, but scattered microcalcifications were visible in all pts as well as lymph node metastases. Diffuse usually bilateral involvement of the gland was presented histologically, micropapillary formations located within cleft‐like spaces consistent with lymph vessels, large number of psammoma bodies, marked lymphocytic infiltration and fibrosis. Extrathyroidal extension was found in all pts (except one) as well as bilateral lymph node metastases. Lung metastases were found in only one pt (17 year old girl) by 131‐I whole body scan. CONCLUSION: DSVPTC is rare and occurs in young pts with AITD. Previous studies have not comprehensively evaluated this variant of PTC. The question is: Is this variant of PTC a new entity or it was not verified as special variant of PTC, because of it’s rare appearance? The diagnosis of DSVPTC is difficult because there are no nodule in thyroid. Nowadays the diagnosis of this cancer is possible by ultrasound examination when scattered microcalcifictions are detected as well as lymph node metastases, especially in children and young patients with AITD.
P705 99mTc-Sestamibi Parathyroid Scintigraphy in the Presurgical Evaluation of Patients with Primary Hyperparathyroidism C. Oliveira1, J. Neto1, A. Curvo-Semedo1, M. Martinho2, T. Azevedo2, T. Martins2, F. Rodrigues2, P. Messias3, A. Neves3, C. Cruz3, P. Figueiredo4, M. Lacerda5; 1Nuclear Medicine Department of Portuguese Institute of Oncology Francisco Gentil, IPOCFG, EPE, Coimbra, PORTUGAL, 2Endocrinology Department of Portuguese Institute of Oncology Francisco Gentil, IPOCFG, EPE, Coimbra, PORTUGAL, 3Surgery Department of Portuguese Institute of Oncology Francisco Gentil, IPOCFG, EPE, Coimbra, PORTUGAL, 4 Pathologic Anatomy Department of Portuguese Institute of Oncology Francisco Gentil, IPOCFG, EPE, Coimbra, PORTUGAL, 5Pathologic Anantomy Department of Portuguese Institute of Oncology Francisco Gentil, IPOCFG, EPE, Coimbra, PORTUGAL. Aim As the leading cause of hypercalcemia, primary hyperparathyroidism affects 1 of every 1000 persons, being detected accidentally in the great majority of cases. It is generally caused by adenoma (80 % of cases), less frequently by hyperplasia and rarely by carcinoma. Parathyroidectomy is the only chance of cure, and it may take advantage of a previous parathyroid scan to better localize the affected gland, mainly when one suspect of ectopic tissue or intend to do radioguided surgery. Our aim is to evaluate the sensitivity of the parathyroid scintigraphy in identifying the gland responsible for primary hyperparathyroidism in a group of patients subjected to subsequent parathyroidectomy. Materials and methods We studied
retrospectively a group of 37 patients (33 female and 4 man, mean age 59±16 years) with primary hyperparathyroidism submitted to 99mTc‐sestamibi parathyroid scintigraphy between 2005 and 2008, 32 of whom having also a thyroid echography, who underwent subsequent surgery. The scintigraphic study utilized a Siemens® gamma camera with low energy high resolution collimators. After verifying the anatomopathologic results, we determined the sensitivity of the parathyroid scintigraphy. We also calculated the sensitivity of the echography for parathyroid pathology. Results There were 30 true positives for parathyroid scintigraphy, that is, whose scintigraphically abnormal parathyroid gland had histological confirmation of adenoma (26 cases) or hyperplasia (4 cases). On the other hand, there were 5 false negatives, meaning that the parathyroid scan failed in detecting 5 histologically confirmed adenoma situations. The calculated sensitivity of the parathyroid scintigraphy was therefore 85,7%. This method gave raise to a false positive, the scintigraphically suspected gland having normal histology (however, after surgery we verified normalization of analytic values of parathyroid hormone and calcium). With thyroid echography, there were 22 true positives, corresponding to 20 cases of adenoma and 2 cases of hyperplasia, and 10 false negatives, which were 8 cases of adenoma and 5 of hyperplasia. According to this, the echographic method sensitivity was 68,6%. Conclusions Our data showed a good sensitivity of the parathyroid scintigraphy (85,7%) for localizing the diseased parathyroid gland. According to our study, the echography is also a valuable method in the same clinical situation (with a calculated sensitivity of 68,6%).
P75 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: endocrinology 2
P706 The importance of thyroid scan and aspiration biopsy in the preoperative evaluation of thyroid carcinoma Z. Petrovski, K. Trajkovska, M. Tashkovska; Clinical Hospital-Bitola, Bitola, Macedonia, The Former Yugoslav Republic of. Aim: The purpose of the study was to evaluate the role of thyroid scintigraphy and fine needle aspiration biopsy in the preoperative investigation of solitary thyroid nodules for diagnostic of thyroid carcinoma. Material and Methods: We studied 124 operated patients (28 male, 96 female, age range 14 ‐ 69 years) with thyroid solitary nodules.All patients (pts) underwent Tc‐ 99m pertehnetat thyroid scan, fine needle aspiration biopsy, ultrasonography and thyroid function tests ( TSH, FT4, FT3).On thyroid scan 59 pts had cold nodules, 30 pts hot nodules and 35 izofixated nodules. Results: 47 (37%) pts out of 124 operated pts showed carcinoma on histological specimen.Trying to assess the usefulness of varios diagnostic for selecting pts for surgery, we divided into three groups: group I ‐ 60 pts with positive or suspection findings for malignancy of aspiration biopsy (45 pts were malignant on histology), group II ‐ with cold nodules on thyroid scan (28 pts had positive findings for carcinoma on histology), group III ‐ 57 pts with positive or suspections aspiration biopsy and cold nodules (47 were histologically malignant).These results showed that malignant or suspection aspiration biopsy (group I) is the most reliable diagnostic procedure 60/45 (75%), in compare to group II ‐ thyroid scan (cold nodules) who is reliable in 59/28 (47,5%) of cases.In group III ‐ submitted to both thyroid scan and aspiration biopsy, diagnostic accuracy is 57/47 (82,5%). Conclusion: Fine needle aspiration biopsy provides adequate procedure for surgery in 75% of cases with thyroid carcinoma, but when thyroid scintigraphy is employed in addition to the preoperative assessment of solitary nodules, overall percentage of correct diagnostic increased to 82,5%.
P707 The Prognostic Role of Tc-99m Pertechnetate Thyroid Scintigraphy Before Fixed Dose Radioiodine Therapy of Toxic Multinodular Goiter for Outcome D. Yüksel, S. Kirac, O. Yaylali, I. Uğuz; Pamukkale University, Medical Faculty, Denizli, TURKEY. Aim: We investigated the prognostic role of pretreatment Tc‐99m pertechnetate thyroid scintigraphy in patients with toxic multinodular goiter (TMNG) treated by fixed I‐131 dose regimen. Material & Methods: A total of 28 TMNG patients (18 F / 10M; mean age ± SD = 63 ± 11 years) treated with 740 MBq I‐131 in the period between 2002‐08 and followed‐up for a minimum of 6 months were evaluated retrospectively. Recorded information included: age at the time of therapy, thyroid size by palpation, Tc‐99m pertechnetate thyroid scintigraphy findings (the size and number of nodules and severity of extranodular parenchymal suppression), antithyroid medication status, thyroidal hormonal profile and clinical status before I‐131 treatment. Tc‐99m pertechnetate thyroid scintigraphy in our department is performed by means of gamma camera equipped with pinhole collimator. Anterior thyroid images are obtained at 20 min after intravenous injection of 5 mCi (185 MBq) Tc‐99m pertechnetate. It is acquired 150000 counts on thyroid. The recorded neck images acquired before radioiodine therapy were used to set regions of interest (ROIs) over the hot nodules, salivary glands and the background. The average counts per pixel in the background were subtracted from the average counts per pixel in the nodule and the salivary gland to calculate the net nodule counts and the net salivary counts. After that, nodule / salivary and nodule / background ratios were found. Net counts or ratios of patients with hypothyroidism after radioiodine therapy were compared with that of euthyroid patients, statistically. Results: All of patients have received antithyroid medication. They give up antithyroid medication 1 week ago imaging. We detected the hyperthyroidism in one patient, euthyroidism in 19 patients and the hypothyroidism in 8 patients 6 months after radioiodine treatment. Net mean nodule counts (34.8 ± 14.1 counts) in the patients developed hypothyroidism were significantly higher than that of euthyroid patients (26.8 ± 11.0 counts) (p= 0.014). Other three parameters (the net salivary counts, nodule/salivary ratio and nodule/ background ratio) did not showed significant difference between hypothyroid and euthyroid patients. Conclusion: In the patients with TMNG, the development of possible hypothyroidism after the fixed I‐131 dose treatment may be predicted by the Tc‐99m pertechnetate uptake level of hot nodules in thyroid scintigraphy before radioiodine therapy. However, it is necessary to evaluate in the large series and calculated the threshold value for the clinical usage.
Poster Presentation
University School of Medicine the Department of Orthopedic and Trauma Surgery, Diyarbakir, TURKEY.
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P708 Radioiodine Therapy in Hepatitis C Patients with Interferon-αInduced Hyperthyroidism A. Czarnywojtek, R. Czepczyński, M. Ruchała, E. Szczepanek, M. Zgorzalewicz-Stachowiak, I. Bereszyńska, J. Sowiński; Poznan University of Medical Sciences, Poznań, POLAND. Introduction. Interferon‐α‐induced hyperthyroidism (IIH) in patients with viral hepatitis C may develop into Graves’ disease or initial phase of autoimmune thyroiditis. In patients with contraindications for anti‐thyroid drugs, due to liver disfunction, radioiodine treatment is recommended. The aim of the study was to evaluate the effectiveness of radioiodine therapy in patients with viral hepatitis C in IIH. Material and methods. 106 patients with viral hepatitis C with IIH were analyzed (75 women and 31 men, aged from 23 to 59 years; mean: 39 years). Patients were divided into 3 groups: A ‐ IIH with low iodine uptake (n = 36; 33.9 %), B ‐ IIH with normal and elevated iodine uptake (n = 54; 51%), C ‐the group of patients with elevated level of TSHRAbs (n = 16; 15.1%). All patients received INF‐α‐2b or Pegylated‐INF α‐2b in combination with ribavirin (Rebetol). After diagnosis of hyperthyroidism in the span of 3 months in all patients the following measurements were performed: level of thyroid hormones (fT3, fT4 and TSH), level of antibodies (TPOAbs, TgAbs and TSHRAbs), thyroid ultrasound, thyroid scintigraphy, and iodine uptake after 5 and 24 hours. Results. Based on these measurements 35 (33%) patients [i.e. 21 (19,8 %) from group B, and 14 (13,2%) from group C] were qualified for radioiodine treatment. Euthyroidism was achieved after 2 months in 8 (22.8%) of patients, after 6 months in further 11 (31.4%) cases , and after one year in further 6 (17.2%) patients. Transient hypothyroidism was noted in 8 (22,8%) of patients, and persistent hypothyroidism was observed in 2 (5,8%) cases after one year. Conclusion. After one‐year follow‐up of patients with IIH qualified to radioiodine therapy, very good therapeutic effect was achieved.
P709 Comparison of dynamic contrast-enhanced MRI parameters with 99mTc-sestamibi uptake ratios in benign thyroid pathologies. N. Tuncbilek1, A. Sarikaya2, Ü. Korkmaz2, N. Torun2, E. Aytekin2; 1Trakya University Medical Faculty Department of Radiology, Edirne, TURKEY, 2 Trakya University Medical Faculty Department of Nuclear Medicine, Edirne, TURKEY. Objective. The aim of this study was to investigate dynamic contrast‐enhanced magnetic resonance imaging (DCE‐MRI) for the noninvasive differential diagnosis of benign thyroid pathologies by correlation with Tc‐99m sestamibi uptake. Materials and Methods. The study group included 16 patients (5 males,11 females; mean age: 44.5) with three types thyroid benign lesions. They all had proven pathologies [adenematous goiter (8), follicular adenoma (4) and nonmicrobial chronic/subacute thyroiditis (4)]. Patients were examined using thyroid DCE‐MRI and Tc99m sestamibi scintigraphy. Hemodynamic parameters obtained by DCE‐MRI included peak time enhancement in the first minute (Emax/1) after contrast administration, second minute (Emax/2), third minute (Emax/3), fourth minute (Emax/4), and fifth minute (Emax/5), maximum peak enhancement (Emax), and the steepest slope. Early and late 99mTc‐sestamibi uptake ratios (EUR and LUR) of thyroid were measured semiquantitatively ( maximum lesion‐to‐nonlesion ratios). Results and Conclusions. The mean EUR, LUR, Emax/1, Emax/2, Emax/3, Emax/4, Emax/5, Emax and steepest slope were 2.33+/‐2.80, 1.29+/‐0.70, 121.9+/‐47.8, 106.9+/‐45.2, 86.3+/‐30.7, 77.7+/‐26.4, 71.5+/‐23.0, 121.9+/47.8, 5.94+/‐1.68 for adenematous goiter, and 1.14+/‐0.56, 1.11+/‐0.38, 118.5+/‐52.6, 108.6+/‐55.4, 102.6+/‐52.6, 96.0+/‐51.9, 90.0+/‐51.2, 118.5+/52.6, 5.07+/‐1.04 for follicular adenomas, and 1.56+/‐0.64, 1.46+/‐0.60, 104.4+/‐15.6, 91.2+/‐20.0, 78.4+/‐22.5, 74.7+/‐25.4, 70.8+/‐23.5, 109.7+/17.1, 4.91+/‐2.01 for thyroiditis, respectively. Statistically significant correlations were not seen between DCE‐MRI parameters and scintigraphic uptake ratios. In order to determine discrimination all of the lesions using DCE‐MRI parameters, EUR and LUR, logistic regression was applied to the above mentioned data.When combined these parameters had a 75% of overall accuracy in classifying final pathological diagnosis by the DCE‐ MRI parameters.Whereas discriminant analysis correctly predicted final pathological diagnosis 56.3% of patients when using scintigraphic uptake ratios. .
P710 Incidental thyroid lesions detected with PET/CT M. Ono1, K. Kobayashi1, Y. Miyatake1, H. Kimura1, T. Katoh1, W. Ko1, T. Ushimi1, T. Kojima1, S. Yasuda2; 1Yotsuya Medical Cube, Tokyo, JAPAN, 2 Tokai University School of Medicine, Kanagawa, JAPAN. Objectives: High FDG uptake is occasionally observed in the thyroid during PET/CT study. The aim of the study was to determine the frequency of high FDG uptake in the thyroid and the diseases that can be incidentally detected with PET/CT. Methods: From Aug 2005 to Dec 2008, 3282 asymptomatic subjects (1903 M, 1379 F, 54.4±11.9 yo) underwent PET/CT at our institution. PET/CT was performed 60 min after inj. of 200 MBq of FDG (Discovery ST, GE Healthcare). PET/CT images were visually evaluated prospectively, and classified into 3 groups. 1) diffuse thyroidal FDG uptake, 2) localized thyroidal FDG uptake, and 3) negative: no increased uptake. Subjects with diffuse uptake were further evaluated by serum hormonal and antibodies’ studies with or without US. Subjects with localized uptake were further evaluated by US with or without aspiration cytology. PET findings were compared to final diagnoses. Results: Diffuse FDG uptake was observed in 156 of 3282 subjects (4.8%) (Table). Further studies revealed 90.6% of them were chronic thyroiditis, although no abnormality was recognized in 9.4% of them. Localized uptake was observed in 40 subjects (1.2%), and 34.6% of them were thyroidal carcinomas. As a whole, PET‐positive rates were 6.0% in our study group, and PPV in detecting thyroidal lesions was 92.8% (84 of 78 subjects). Conclusions: Because FDG accumulation in the thyroid correctly points to the presence of thyroid lesions, further studies should be conducted considering the patterns of FDG uptake. No of subjects
PET
Diffuse 156 (4.8%)
No of subjects with final diagnosis
Final diagnosis
64
chronic thyroiditis 58 (58/64,
90.6%) no abnormality 6
Localize 40 (1.2%)
Negative
3086 (94.0%)
Total
3282 (100%)
carcinoma 9 (9/26, 34.6%) benign tumor 17 (include chronic thyroiditis 4)
26 NE
NE
NE: not evaluated
P711 Association of autonomously functioning thyroid nodules (AFTNs) with Hashimoto’s thyroiditis (HT). A. Campenni'1, R. M. Ruggeri2, A. Sindoni2, S. Castorina1, M. Raniolo1, F. Trimarchi2, S. Benvenga2, S. Baldari1; 1Dep of Radiological Science, Unit of Nuclear Medicine, Università di Messina, Messina, ITALY, 2Unit of Endocrinology, Università di Messina, Messina, ITALY. The proportion of patients with HT and associated thyroid nodules is relevant in iodine‐deficient areas as our geographic area. In such areas, AFTNs are a relatively common finding and represent the main cause of hyperthyroidism. Nevertheless, few reports are available on the presence of AFTNs in HT, and most focus on the misleading interpretation of scintigraphy, warning that the “hot” nodule is just thyroid tissue spared by lymphocytic infiltration not true AFTN. We reviewed the records of patients admitted to our Division (Messina, Sicily) for thyroid nodules from 1990 through 2008. On these patients, we routinely perform thyroid ultrasonography (US) and measure serum FT3, FT4, TSH, TgAb and TPOAb. A 131I scintigraphy was performed, once hormone assay indicated a condition of either overt or subclinical hyperthyroidism (low or suppressed TSH). Eighty HT patients [15 men and 65 women; age 57+15 years; F:M ratio 4.5:1] had single (90%) or multiple (10%) AFTNs (group A). In all patients, the “hot” nodule(s) corresponded to well‐defined nodular lesion(s) at US examination. Except 9 patients, who were taking methimazole, all had suppressed (<0.01 mIU/L) or low (<0.4 mIU/L) TSH; 17 of them had also increased FT4 and/or FT3 (24%). TgAb were +ve more frequently than TPOAb (53% vs 34,7%, χ2=4.79, P=0.029). Data from group A were compared with two contemporary series of patients: (i) with non‐HT‐associated AFTNs (group B n=267), and (ii) with typical HT (group C, n=3575). In group A hyperthyroidism was predominantly subclinical (76% vs 24%), while in group B and C hyperthyroidism was mostly overt (50.8% vs 49.2%, χ2=12.686 and 97.4% vs 2.6%, χ2=81.653, respectively; p<0.001). Neither age nor F:M ratio differed in group A compared to group B (age 57.8±13 years; F:M ratio 4.0:1; p>0.05). In contrast, compared to group C (age 41±12.5 ys; F:M ratio 11.2:1), group A patients displayed an older age (p<0.001) and a lower F:M ratio (p<0.001), as well as a greater prevalence of TgAb positiveness over TPOAb positiveness. A positive correlation between serum thyroid hormones values and nodular diameter was observed (p<0.01) in both groups A and B. In group B ‐ but not group A ‐the maximum diameter of the AFTNs correlated significantly with patients’ age. Our data ‐ the first in the literature‐ demonstrate that AFTNs may occur in HT. Thus, hyperthyroidism of HT is not always transient (Hashitoxicosis) but it can also be long‐standing (most often subclinical) due to coexisting AFTNs.
P712 THE ROLE of IGF-1 and IGF-BP3 in THYROID NODULE DEVELOPMENT H. Kaya1, N. Aguloglu1, Y. Dag1, Y. Celik2; 1Dicle University School of Medicine the Department of Nuclear Medicine, Diyarbakir, Turkey, 2Dicle University School of Medicine the Dept. of Statistics, Diyarbakir, TURKEY. Aims: IGF‐1(insulin like growth factor) is a mitogenic and antiapopitotic peptid hormone,but IGF‐ BP3 (insulin like growth factor binding protein) is an antiproliferative protein which inhibits the mitogenic effects of IGF 1 by stimulating the apopitosis. The presence of IGF reseptors in thyroid gland cells and the role of growing effects in thyroid nodule development were reported in literature. The aim of this study is to compare the IGF‐1 and IGF‐BP3 values of the patients who have thyroid nodules and healthy control group diagnosed by USG and thyroid scintigrphy. Methods: 30‐50 age,116 patients (33M ; 83F) were studied. 96 of them have thyroid nodules (one or more), and the rest, have no nodule, as control group. Thyroid nodules of 97 patients were diagnosed by Tc‐99m pertecnetat thyroid gland scintigraphy and USG. In thyroid scintigraphy the function, location and the number of nodules were evaluated .The size and the location of nodules were also evaluated by USG. The serum specimen was analyzed with IGF‐1 and IGF‐BP3 by RIA(Radioimmunassey) method in the Dicle University, Faculty of Medicine, Nuclear Medicine Laboratory. IGF‐1 and IGF‐BP3 levels of the patients who have nodules and who have no nodule were compared. Then, the IGF‐1 and IGF‐BP3 levels of the patients who have only one nodule and who have multinodules were compared. In the statistical analyses the means of three groups were compared by using ANOVA, and significant results were followed by using post‐hoc test of Bonferroni. Results: The means ± SD of IGF‐1 in three groups as follows; 235.1±143.7, 249.3±134.8, 359.8±218.7 were found significantly different by ANOVA (p=0.01). Bonferroni test was used to analyze the means which are significantly different from each other. According to the results of Bonferroni test; the mean value GR‐I and GR‐III, GR‐II and GR‐III were significantly different (p<0.05), while the means of GR‐I and GRII were not significant (p>0.05). However, the means ± SD of IGF‐BP3 in three groups (3605.7±1534.3, 4043.0 ± 1439.0, 3965.3 ±2007.6) were not significantly different (p=0.395).
single nodule multiple nodules Control
Variable Group I s# x±SD* IGF‐I
Group II X±SD*
235.1±143.7a 249.3±134.8b
F
P
Group III X±SD*
359.8±218.7
4.78 0.010
IGF‐BPIII 3605.7±1534.3 4043.0 ± 1439.0 3965.3 ±2007.6 0.937 0.395 Conclusions: As a result, it is seen that, IGF‐1 has an important role in the thyroid gland nodule development.
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P716
Diagnostic value of SPECT/CT fusion imaging in patients with thyroid nodules
How often are parathyroid adenomas expressing the same 99m Tc- Sestamibi wash-out compare to adjacent thyroid parenchyma?
Aims: T o evaluate the diagnostic value of Tc‐99m pertechnetate SPECT/CT fusion imaging in patients with thyroid nodules. Materials and Methods: Twenty four patients (7 men, 17 women; mean age, 36.7 years +/‐ 10.8) with thyroid nodules underwent Tc‐99m pertechnetate planar imaging and SPECT/CT examinations. Two experienced nuclear medicine physicians analyzed the planar imaging and SPECT/CT fusion imaging together. All patients performed operation in two weeks after thyroid imaging. Results: Five hot nodules were found in planar imaging, but another 4 hot nodules were found in SPECT/CT fusion imagines. Eleven warm nodules were found in planar imaging. Four of them were cold nodules in SPECT/CT fusion imagines. And another three warm nodules were found in this group patient. Four cold nodules were found in planar imaging, two of them were cool nodules in SPECT/CT fusion imaging and another one cold nodule was found. Six cool nodules were found in planar imaging but another three cool nodules were found in SPECT/CT fusion imagines. At the same time calcium lesions were found in 5 cases.Conclusion: SPECT/CT fusion imaging overcame the partial volume effective and had high resolution over SPECT. So Tc‐99m pertechnetate SPECT/CT fusion imaging was a more accurate method to evaluate thyroid nodules than regular planar imaging.
P714 Is alkaline phosphatase (ALP) a prognostic factor in patients with disseminated gastroenteropancreatic tumours (GEPs)? initial study. Z. Podgajny1, N. Szalus1, G. Kaminski1, E. Andrysuak - Mamos2, A. Syrenicz2; 1Military Insitute of Health Services, Warsaw, Poland, 2 Pomeranian Medical University, Stettin, POLAND. Introduce: The liver is one of the most common sites of metastases for NETs, and the presence of liver metastases is a primary determinant of decreased survival. The diagnosis of GEPs is based on clinical symptoms, hormone concentration, radiological and nuclear medicine imaging, and histological confirmation. One of the useful blood test is plasma chromogranin A (CgA) concentration, but it is unclear how accurate this is in monitoring progression of disease and response to treatment. So we have started to look for new prognostic factors, for ALP example. Material and method: Eleven patients(pts) with disseminated GEPs (liver metastases) underwent radionuclide therapy (90Y‐DOTA‐TATE or 177Lu‐DOTA‐TATE). Before treatment we marked plasma ALP concentration (normal range 45‐122U/l) and estimate extensiveness disease. All pts had liver metastases, 3 bony metastases, and 1 lymph nodes metastases. We divided pts for 5 groups. Groups no.1: metastatic lesions take more than 50%(7pts), 2pts had bony metastases additionally; group no.2: metastatic lesions take more than 25‐50%(4pts), 1 pt had bony metastases additionally, 1 pt had lymph nodes metastases; group no.3: after treatment was obtain stabilization disease (SD) (4pts); group no.4: after treatment was obtain complete or partial remission (CR+PR), (4pts); group no.5: after treatment was obtain progressive disease (PD), (3pts). We compared groups no.1 with no.2 and groups no.3, 4 with no.5. Results: mean range of ALP was 140U/l (median 101U/l) in all pts. Mean plasma ALP level was higher in group no.1 (mean 180U/l, median 101U/l ) than in group no.2 (mean 71U/l, median 72U/l ). Pts in group no. 5 (PD)had the highest plasma ALP levels (mean 279U/l, median 275U/l ) compared with group no.3 (SD)(mean 102U/l, median 69U/l ) and group no.4 (PR+CR)(mean 76U/l, median 93U/l ), but all pts in group no.5 had bony metastases. Conclusion: plasma alkaline phosphatase can be useful factor to forecasting response to treatment and estimation extensiveness
P715 Outcome of patients with autonomous thyroid nodules after radioiodine therapy: a comparison between patients with suppressed and non-suppressed extranodular thyroid tissue J. Correia1, R. Macedo1, F. Azevedo-Silva1, G. Costa1, A. Albuquerque1, C. Ribeiro2, A. Vieira3, J. Santos2, F. Carrilho3, M. Carvalheiro3, J. PedrosoLima1; 1Serviço de Medicina Nuclear - Hospitais da Universidade de Coimbra, Coimbra, PORTUGAL, 2Serviço de Endocrinologia- Hospitais da Universidade de Coimbra, Coimbra, Portugal, 3Serviço de Endocrinologia Hospitais da Universidade de Coimbra, Coimbra, PORTUGAL. Objectives: Radioiodine represents an effective therapy for hyperthyroidism due to hot nodules, although the risk of hypothyroidism is a possible outcome. The purpose of this work is to access the impact of scintigraphic extranodular radioiodine uptake in the incidence of hypothyroidism in 131 two groups of patients with autonomous nodules, one with suppressed extranodular thyroid I uptake and the other with extranodular activity. Methods: From May 2004 to December 2007, 76 patients (67 women, 9 men; 26‐91 years, average 63,9 years) with nodular hyperthyroidism received radioiodine treatment, 52 with solitary autonomous nodule and 24 with toxic nodular goiter. Patients were divided into two groups according to the scintigraphic findings: group I of 51 patients with hot nodules that inhibits extranodular uptake and group II including 25 patients with nodules that fails to suppress normal thyroid tissue. The mean calculated activity of 131I was 492,1MBq (13,3mCi). Thyroid function was followed up with TSH, FT3 and FT4. Results: In group I, 41/51 patients (80,4%) achieved euthyroidism within 6 months, 2/51 (3,9%) maintained hyperthyroidism and 8/51 (15,7%) became hypothyroid (6 of these with subclinical hypothyroidism with only a slightly increased in TSH) but the latter had large goiter with extensive multinodular disease. In group II we found 14/25 euthyroid patients (56%), 1/25 (4%) hyperthyroid and 10/25 (40%) hypothyroid. Conclusions: Radioiodine treatment for toxic thyroid nodules is related to a high incidence of euthyroidism, with an overall incidence of 72,3%. The failure rate is similar in both groups (~4%) but the incidence of hypothyroidism is significantly higher in group II due to irradiation of incomplete suppressed normal thyroid tissue. In patients with this scintigraphic pattern, hypothyroidism could be the outcome after 131I therapy.
A. Doumas1, I. Iakovou1, D. Boundas2, T. Christoforidis1, V. Nikos1, D. Lo Presti1, S. Georga1, N. Karatzas1; 13d Nuclear Medicine dept. of the Aristotle University, General Hospital “G. Papageorgiou”, Thessaloniki, Greece, 2 Hippocrates Nuclear Medicine Center, Thessaloniki, GREECE. Aim: Due to quite common false negative parathyroid dual phase 99mTc‐ Sestamibi (DS) scans observed by our surgery department, we tried to determine whether parathyroid adenomas are not always expressing a slower 99mTc‐Sestamibi wash out than adjacent thyroid gland and to find a method to overcome the problem. Method: 52 patients with high serum Ca and PTH and low serum P levels were imaged during the last 2 years before surgical neck exploration. Thyroid imaging using 15 mCi 99mTcO4 was performed after the completion of standard DS protocol. The early DS image was compared to the thyroid scan and any area of incongruency was considered “suspicious” for parathyroid adenoma. If the same area appeared prominent in the late DS phase the image was considered definite for parathyroid adenoma localization. On the other hand, if there was no residual 99mTc‐Sestamibi activity in the late DS imaging the area remained under scrutiny for the pathology after surgery. Results: DS scan was definitely positive in 31 (59,6%) patients also confirmed by surgery. From the “suspicious” lesions thyroid scintigraphy revealed 6 more parathyroid adenomas. All lesions were larger than 1,3 cm and most of them located at the lower poles of thyroid gland. 3 more adenomas were found at the surgical speciments and all of them were intrathyroidal. Conclusion: Almost 12 % of parathyroid adenomas express 99mTc‐ Sestamibi wash‐out comparable to adjacent thyroid parenchyma. Simple thyroid imaging after the completion of standard DS protocol proved to be a useful cost effective and easy to perform imaging maneuver.
P717 Usefulness of routine early 99mTc-MIBI SPECT in pre-surgical localization in patients with hyperparathyroidism P. García- Talavera1, M. E. Martín1, E. Martín1, C. González1, P. Tamayo1, R. Ruano1, F. Gómez- Caminero1, D. García1, J. Moreta2, L. Santiago3; 1 Hospital Universitario de Salamanca, Salamanca, SPAIN, 2Hospital Ntra Sra de Sonsoles, Salamanca, Spain, 3Hospital Virgen de la Concha, Salamanca, SPAIN. The role of the SPECT in parathyroid surgery is controverted. Some authors support the use of SPECT only in ectopic localizations. The aim of this study is to evaluate the additional value of performing a 99mTc‐MIBI SPECT after early image of the double phase sestamibi and before surgery in hyperparathyroidism patients. Material and Methods: 132 patients underwent an early 99mTc‐MIBI SPECT of neck and thorax, 20 minutes after tracer injection (128x128 matrix, 120 images, 25 sec/imag) between November 2007 and December 2008. A double head gamma camera with a low energy and high resolution parallel‐hole collimator was used (SKY‐LIGHT. PHILIPS). After the pre‐operatory imaging, 22 of these patients were operated. Results: In 87 patients (66%) both images (planar and SPECT) were concordant. In 7 of these cases SPECT confirmed doubtful foci in planar images; in 8 more cases, SPECT proved very helpful to localize ectopic glands; and in one, SPECT helped to determine the correct pole. Discordant planar‐SPECT information was obtained in 45 patients (34%). In 31 cases the planar image was negative and the SPECT positive, although in 17 of them localizations were doubtful; in one case the planar image was positive and the SPECT negative; in 5 cases SPECT helped to localize rapid washout parathyroid glands; in one case SPECT localized an intrathyroid‐parathyroid gland; finally, in 6 cases, planar and SPECT found the same localization in one gland, but while in 4 of them the SPECT found an extra pathological gland, in two, the planar image and not the SPECT localized the second gland. In total, 22 of our patients were operated and histological diagnosis confirmations were obtained. In 4 cases the planar images were negative but SPECT found the right localization; in one case SPECT detected an extra pathological gland; in 3 patients SPECT improved ectopic glands localization; in one case, SPECT confirmed the doubtful focus in the planar image; in 12 cases SPECT and planar image showed the same localization; one false positive of SPECT was found due to nodular thyroid pathology. Conclusion: In 36% of the patients who underwent surgery, SPECT was helpful in localizing false negative glands of planar images, improving ectopic glands localization, and confirming a doubtful focus of planar images. Therefore, even though our series of patients with histological diagnosis confirmation is short, we support the usefulness of performing an early SPECT in all patients previous to the surgery.
P718 Use of Thyroid Doppler Ultrasound and Ab-Examinations in Follow-Up of Patients with Mild and Subclinical Hashimoto’s Thyroiditis K. Zaplatnikov1, V. Soukhov2, W. Wiedemann1; 1Clinic of Nuclear Medicine, Nuremberg, Germany, 2Military Medical Academy, St.Petersburg, RUSSIAN FEDERATION. Aim Patients with Hashimoto’s thyroiditis (HT) show typically decreased echogenicity at thyroid ultrasonography (US). In this study, we investigated the association between the US pattern (including Doppler flow in thyroid parenchyma), TSH values and level of thyroid antibodies (anti‐ TPO/Tg‐Ab) in order to evaluate the usefulness of US/Doppler for HT screening. Methods In study we included 190 consecutive pts with suspected HT (164 f, 26 m, mean age 47±27 yrs) and control group of 54 pts (16 f, 8 m, mean age 34±13 yrs). Peripheral blood samples were analysed for thyroid‐Ab, TSH and thyroid hormones. US with Doppler ‐ maximal Flow Mapping and determination of the Resistance‐Index and Scintigraphy of the thyroid were performed in follow up (3 and 6 mos). Spearman‐Korrelation was used for statistical processing. Results Patients with decreased echogenicity and excessive thyroid autoantibodes (n=90, Gr.I) had a higher mean TSH (2.95 mIU/l) and increased Doppler flow compared with pts having normal echogenicity and non‐ raised levels of thyroid autoantibodes (n=31, Gr. II) (TSH 1.41 mU/l, P<0.0005). Pts with normal echogenicity, but with mean antiTPO‐Ab (131±42 ng/ml) and antiTg‐Ab (82±35 ng/ml) (n=29, Gr.
Poster Presentation
H. Shi, Y. Gu, W. Liu; Zhongshan Hospital, Fudan University, Shanghai, CHINA.
S450 III), had normal flow at Doppler US. Pts. with decreased echogenicity (Gr. I) had a higher level of thyroid autoantibodies (anti‐TPO,Tg‐Ab) than subjects from Gr. III (P<0.0001). It was no statistical difference in thyroid Uptake and scintigraphic appearance of the gland in both groups. Conclusion We found a strong association between variety of thyroid US/Doppler parameters and increased levels of serum TSH/thyroid ABs in pts suffering from HT. Our results suggested that a decreased echogenicity represents a reliable sign of HT. However, normal echo pattern cannot exclude a HT. This indicates a possible use of thyroid US with Doppler and thyroid Ab‐ examinations in follow up in detecting high risk pts with mild and subclinical HT.
P719 Thyroglobulin variations 3 and 7 days after post-operative 131-iodine treatments for patients with differentiated thyroid carcinomas P. Bourgeois1, M. Paesmans1, P. Bergmann2; 1Jules Bordet, Brussels, Belgium, 2Chu Brugmann, Brussels, BELGIUM. Objectives: Because the relative increase of the Thyroglobulin 5 day after a first ablative radioiodine treatment in patients with differentiated thyroid carcinoma (DTC) was reported as a new potential prognostic indicator of (131)I treatment efficacy in such patients, the present study aimed to assess the increases in serum thyroglobulin (Tg) level at different times in such patients. Material and methods: Biological as well as dosimetric analysis were prospectively performed in 76 patients (21 men with a mean age equal to 51,7 years old and 55 women with a mean age equal to 44,1 years old: M1 excluded) with (except in one case) at least one iodine foci of uptake in the neck area who received their first post‐operative treatment. Thyroglobulin (Tg) and Tg antibodies were measured the day of the therapeutic Iodine administration (D0) as well as 3 (D3) and 7 (D7) days later. Tg antibodies were found positive (> 60 UI/mL) in 16 patients and Tg undetectable (< 0.3 ng/mL) in 13 (in 8 of the anti Tg positive). Ratios of Tg D3/D0 and D7/D0 were thereafter calculated. Tg values at D3 and D7 were considered not different if they were included within 90% and 110% of their mean. Results: Tg increase after treatment was the highest at D3 in 60,3% of the whole series but in 71,1% of the women (mean ratio D3/D0 = 75,5) and in 30,4% of the men (mean ratio D3/D0 = 44,3). Conversely, TgD7 was higher than TgD3 in 27,4% of the series but in 47.6% of the men (mean ratio D7/D0 = 177,4) and in only 15.4% of the women (mean ratio D7/D0 = 74,3). This gender difference appears statistically significant (2p < 0.001) and remains present with the same level of statistical significance if the 55 patients with Tg higher than 0,3 ng/mL and Tg antibodies under 60 UI/mL are selected. Conclusions: Our study demonstrate that Tg release by thyroid tissues after post‐operative therapeutic dose of radio‐ iodine for DTC occurs more frequently later in men than in women. These results might support the hypothesis that thyroid cells of men differ from those of women in their sensitivity to radio‐ iodine effects and might explain why, according to several authors, men with DTC were reported to have a worse prognosis than women.
P720 Salivary glands retention on the I-131 diagnostic WBS for patients with differentiated thyroid carcinoma with a single or multiple I-131 therapies S. Saranti, D. Antoniou, K. Diamantakis, D. Papadouli, K. Rethymniotakis, V. Moschoyiannis, A. Georgakopoulos, K. Pateniotis, E. Matselas, E. Trivizaki; Metaxa Cancer Hospital, Piraeus, GREECE. Aim: To investigate the presence of I‐131 salivary glands retention (SGR) after either a single or multiple I ‐131 treatments and estimate the possibility of retention changes through the time in patients with differentiated thyroid carcinoma. Patients and methods: The nuclear medicine records of 142 DTC patients with 1 iodine treatment (80‐100 mCi) and 71 patients with multiple iodine treatments (2 to 5 treatments per patient, totally 168 treatments) of 80‐150 mCi were reviewed. Qualitative estimation of SGR was made for the baseline post surgical diagnostic WBS (DxWBS), as well as for all the post treatments available DxWBS for a follow up time range from 12 to 76 months. The salivary glands status was scored from 0 to 2 according to absence, slight or intense iodine retention respectively. Lemon candies and gum were part of both the diagnostic and therapeutic I‐131 procedure. Results: I‐131 salivary glands retention (SGR) was developed for 37/142 (26%) patients with a single iodine treatment (group I) and 42/71(59%) patients with multiple treatments (group II). For group I, parotids, submandibular and mixted parotid‐ submandibular involvement occurred in 24/37 (65%), 7/37 (19%) and 6/37 (16%) respectively. The I‐131 SGR was mostly unilateral (72%). For group II, the SGR was temporal or improved by the time for 24/42 (57%) and definitely permanent for 18/42 (43%) patients. Parotid glands were mostly affected (64%) while mixed parotid‐submandibular involvement occurred in 21% of patients. Unilateral retention was favorable (62%).There was not statistical difference for SGR between the subgroups with 2 to 5 I‐131 therapies respectively. Remarkable point is the SGR after either the baseline post surgical 5 mCi diagnostic I‐131 dose (2.9%) or after a 5 mCi I‐131 diagnostic dose given significant time (more than 12 months) after the last iodine therapy (2.1%). Conclusion: According to our results, SGR was mostly related with multiple I‐131 therapies and was not an absolutely permanent phenomenon. The SGR was not proportional to multiple therapies escallation. Parotids were mostly affected and the retention was favorably unilateral. Radiation SGR can be also provoked by the minimal 5 mCi diagnostic I‐131 dose.
P721 Determination of Thyroid Dysfunction in the Postpartum Period by Colour Flow Doppler Sonography S. Gaberscek, K. Zaletel, J. Osolnik, N. Bedernjak Bajuk, E. Pirnat, S. Hojker; University Medical Centre Ljubljana, Ljubljana, SLOVENIA. Objectives. The aim was to evaluate the feasibility of colour flow Doppler sonography (CFDS) for use in the diagnostics of thyroid dysfunction in the postpartum period. Methods. We included 89 women with thyroid dysfunction in the first postpartum year, among them 34 women in hyperthyroid phase of postpartum thyroiditis (group 1), 35 women in hypothyroid phase of postpartum thyroiditis (group 2), and 20 women with Graves' disease, first diagnosed in the postpartum period (group 3). In all women, TSH, free thyroid hormones, thyroid peroxidase antibodies (antiTPO), thyroglobulin antibodies (antiTg) and thyroid receptor antibodies
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 (humanTRAK) were measured. By using a 7.5 MHz linear transducer, we measured thyroid volume and estimated CFDS patterns 0, I, II and III, where thyroid vascularity increased from pattern 0 to III. Additionally, we measured peak systolic velocity (PSV) at the level of intrathyroid arteries. Results. Hyperthyroid phase appeared 4.5 ± 2.0 months after delivery, hypothyroid phase 6.6 ± 2.1 months after delivery, while Graves' disease appeared 6.7 ± 2.9 months after delivery. Thyroid volume in group 1 (9.7 ± 6.2 mL) was significantly lower than in groups 2 (14.7 ± 10.2 mL, P = 0.028) and 3 (19.4 ± 10.2 mL, P = 0.001). Estimating CFDS patterns, we did not observe CFDS pattern 0 in groups 2 and 3. Only one woman in group 1 had CFDS pattern III. The most frequent CFDS pattern in group 1 was I (64.7%), while in groups 2 and 3 the most frequent CFDS pattern was II (65.7% and 55%, respectively). Similarly, in group 1, PSV (9.5 ± 3.5 cm/s) was significantly lower than in groups 2 (14.5 ± 3.8 cm/s, P < 0.001) and 3 (20 ± 6.8 cm/s, P < 0.001). Conclusions. Our results demonstrate that CFDS is a useful method for distinction between hyperthyroid and hypothyroid phase of postpartum thyroiditis as well as between hyperthyroid phase of postpartum thyroditis and Graves' disease. However, CFDS cannot differentiate between hypothyroid phase of postpartum thyroiditis and Graves' disease. The present findings are supposed to contribute to the prompt and correct diagnostics of thyroid dysfunction in the postpartum period.
P722 Comparison of early-late plenar and late SPECT imaging in patients with hyperparathyrodism G. Daglioz Gorur, S. Isgoren, A. Oc, C. Haksan, H. Demir, F. Berk; Kocaeli University Medical Faculty, Kocaeli, TURKEY. AIM: This study was undertaken to compare two different protocols for preoperative Tc99m‐MIBI imaging of the neck in patients with hyperparathyroidism: early and late planar and late single photon emission computed tomography (SPECT) imaging. METHODS: 65 patients with hyperparathyroidism underwent preoperative Tc99m‐MIBI parathyroid imaging. The protocol included early‐late planar imaging and late SPECT imaging. Two nuclear physicians, without knowledge of other test results or final diagnoses, interpreted studies independently; in cases of discrepancy final diagnosis reached by concensus. For both planar and SPECT images, focally increased Tc99m‐MIBI accumulation outside the normal tracer biodistribution that persisted or increased in intensity was interpreted as positive for a parathyroid lesion. Final diagnoses were operatively confirmed in all patients. RESULTS: 65 patients (10 male, 55 female) ranging in age 11 to 85 years (mean age 51±13) were enrolled. 76 parathyroid lesions were resected from 65 patients. 51 had single gland disease. 10 patients had multigland disease: 6 had 2 lesions, 3 had 3 lesions and 1 had 4 lesions. 46 patients had parathyroid adenoma (4 ectopic) and 15 patients had hyperplasia of parathyroid gland (1 ectopic). 65% of parathyroid lesions were in lower quadrants while 29% were in upper quadrants. Pathological examination of 4 patents did not reveal any parathyroid disease (lymph node, thyroid nodule was resected). The sensitivity of SPECT and planar imaging was 83% and 64% respectively in the whole patients. When we group the patients into single gland and multigland disease, the sensitivities respectively for SPECT and planar imaging were 94%, 78%; 60%, 40%. In the single gland group there were 41 adenomas and 8 hyperplasia where as multigland disease group consisted of 6 adenomas and 19 hyperplasia. CONCLUSION: Precise preoperative localication parathyroid adenomas are important for operative success. According to our results, late SPECT imaging is more sensitive than early‐late planar imaging especially in single gland disease. In multi gland disease mostly hyperplasia, both protocols have lower sensitivity values though late SPECT seems more successful.
P723 Can 99mTc-sestamibi thyroid scintigraphy make the difference in the differential diagnosis of amiodarone-induced thyrotoxicosis? H. Q. F. Fernandes, S. B. Souto, P. Oliveira, J. P. Patricio, A. Oliveira, D. Braga, J. G. Pereira, J. L. Medina; Hospital S.joão, Porto, PORTUGAL. Aim: Amiodarone induced thyrotoxicosis (AIT) can be caused by an excessive hormone synthesis and release (AIT type I; in patients with underlying thyroid disease), by a destructive process (AIT type II), or can be of a mixed type. The management of type I AIT centers on anti‐thyroid drugs, while type II responds better to steroid therapy. The mixed type can be treated with both. Generally, all patients get medicated with both drugs. The identification of the type of AIT would allow for a more rational and appropriate management strategy. Recently, Piga M. et al, 2008, have shown the usefulness of 99mTc‐sestamibi thyroid scintigraphy (STS) in the differential diagnosis of AIT. They consistently found AIT type I to be characterized by a diffuse and persistent uptake of sestamibi (without significant washout), while AIT type II was characterized by the absence of significant uptake. When a faint persistent sestamibi uptake with no significant washout or a considerable uptake with a quick washout were found, the AIT was reported as being of an indeterminate type. The aim of this paper is to report the authors' experience with STS and AIT. Material and Methods: The authors present three patients with AIT, all examined in the Endocrinology Department and referred for colour‐flow Doppler sonography (CFDS) and STS. Patient Age (years) Gender CFDS 1
62
STS
M
Normal No uptake
AIT diagnosis Type II
2
54
M
Uptake; Indeterminate Normal Rapid washout Type
3
64
M
Normal
Uptake; Indeterminate Rapid washout Type
Patient 1: STS showed no significant uptake, consistent with AIT type II. Patient 2 and 3: STS revealed initial thyroid uptake with significant washout, consistent with indeterminate type of AIT. All patients had normal blood flow on CFDS. Conclusion: In all three patients, STS was decisive to the determination of the AIT type and, consequently, to their therapeutic management. Larger series' data confirming STS as an accurate diagnostic tool in AIT would allow for its incorporation in the routine evaluation of all such patients, and the avoidance of relevant side effects and unnecessary costs.
S451
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Outcome in well-differentiated follicular thyroid carcinoma after radioiodine ablation therapy K. Biermann, H. Brockmann, S. Ezziddin, H. Ahmadzadehfar, T. Haslerud, A. Sabet, H. J. Biersack; University Hospital Bonn, Bonn, GERMANY. Aim: The aim of this retrospective study was to investigate the impact of several prognostic factors on recurrent/persistent disease and tumor‐related survival in well‐differentiated follicular thyroid carcinoma (FTC) after radioiodine ablation therapy. Methods: The institutional database was retrospectively searched for patients with FTC, whose initial therapy consisted of thyroidectomy and radioiodine therapy. Poorly differentiated thyroid carcinoma in histology and unknown survival status at the end of follow‐up were exclusion criteria. Results: N = 262 patients with FTC were included. The median follow‐up was 7.9 years. Distant metastases (DM) occurred significantly more often in age ≥ 45 years, male gender, high T‐ and initial N1‐classification (p=0.001, p=0.006, p<0.0001 and p<0.0001) whereas persistent/recurrent disease in M0‐patients was only significantly associated with age ≥ 45 years, high T‐ and initial N1‐classification (p=0.025, p<0.0001 and p<0.0001). Only age ≥ 45 years, a high T‐classification, N1‐ and M1‐classification were significantly associated with FTC‐related death (p<0.0001 in each case). The 10‐year survival rate in patients with DM was 56 % and those with metachronous DM showed significantly impaired survival compared to patients with synchronous DM (p=0.037). Conclusions: Age ≥ 45 years, male gender, high T‐ and initial N1‐classification are significantly associated with occurrence of distant metastases and, besides gender, with persistent/recurrent disease in M0‐ patients. Age ≥ 45 years, a high T‐classification, N1‐ and M1‐classification, especially in case of metachronous distant metastases, are significantly related to impaired survival.
P725 Outcome of 265 patients with well-differentiated thyroid carcinomas ≤ 1 cm in diameter K. Biermann, S. Ezziddin, H. Brockmann, H. Ahmadzadehfar, M. Muckle, A. Sabet, H. J. Biersack; University Hospital Bonn, Bonn, GERMANY. Objectives: Especially patients with small well‐differentiated thyroid carcinomas (DTC) show excellent prognosis in general. However, in some cases metastases and/or recurrent disease can be observed. The aim of this retrospective study was the evaluation of patients’ outcome with DTC ≤ 1 cm in diameter. Methods: The institutional database was retrospectively searched for patients with DTC ≤ 1 cm in diameter and a follow‐up of at least one year. Poorly differentiated thyroid carcinoma in histology and unknown survival status at the end of follow‐up were exclusion criteria. Results: The median follow‐up was 8.1 years. 237/265 patients (89.4 %) suffered from papillary and 28/265 patients (10.6 %) from follicular thyroid carcinoma. 21 patients (7.9 %) suffered from lymph node metastases, which all were present at the time of diagnosis of DTC. In contrast to gender and histology, age ≤ 45 years was significantly associated with N1‐classification. 2 patients (0.8 %) suffered from solitary bone metastases, which were both successfully treated by surgery and I‐131‐therapy. Except of three further patients (one patient with local extensive disease, one with recurrent lymph node metastasis and one with persistently elevated thyroglobulin) none relapsed. Conclusions: As expected prognosis in patients with DTC ≤ 1 cm in diameter is excellent. In the present study the rate of complete remission (undetectable thyroglobulin, normal I‐131‐scans and normal ultrasound) after initial therapy was 98.5 %. Nevertheless, lymph node metastases occur in 8 % and even extensive disease can be observed in isolated cases.
P726 Effect of smoking and alcohol on serum calcitonin values F. Hajos, E. Trifina, P. Hoffmann, R. Dudczak, S. Li; Medical University of Vienna, Vienna, AUSTRIA. Aims: Previous studies have shown that smoking and alcohol may have influence on serum calcitonin levels. However, no data is available about the effects of smoking and alcohol on the serum calcitonin in patients of Vienna population. In this study we evaluated serum calcitonin in smoking and alcoholic patients of Vienna population. Materials and Methods: 49 smoking patients and 41 alcoholic patients (daily alcohol consumption > 100 g ) were included in the study. 241 non‐smoking patients with daily alcohol consumption less than 10 g were used as control. The basal serum calcitonin, free triiodothyronine (fT3 ), free thyronine (fT4) and TSH were measured in all patients. Results: compared with control group (serum calcitonin: 2.6 +/‐ 0.2 pg/ml), no significant difference (p=0.14) was found in basal serum calcitonin values in smoking patients (1.8 +/‐ 0.3 pg/ml). There is also no significant difference (p=0.36) in basal serum calcitonin values between alcoholic patients (2.1 +/‐ 0.3 pg/ml) and the control group. No significant change (p=0.45) was demonstrated between smoking patients and alcoholic patients. Conclusion: our preliminary results suggest that no significant effects of smoking and alcohol on basal serum calcitonin values were found in the patients of Vienna population. However, studies with larger numbers of patients of Vienna population are needed.
P727 Can we simplified the parathyroid gland gammagraphic technique to the exclusively use of SPECT-MIBI-Tc99m? C. C. JOSE MANUEL, L. Celmira, M. Antonio, C. Francisco, A. María Angeles, O. Jose, M. Mauricio, V. Jose, C. Octavio; Hospital Universitario San Juan, Alicante, SPAIN. AIM Traditionally, the double‐phase gammagraphy has been the chosen parathyroid gland gammagraphic detection technique, with additional thyroid subtraction if necessary. However, recent studies have shown how single photon emission computed tomography (SPECT) for assessing parotid gland function could improve the detection of pathologic parathyroid glands. Our objective is to evaluate if pathologic parotid gland localization by SPECT MIBI‐Tc99m can be a suitable substitute for the double‐phase thyroid gammagraphy technique. MATERIALS & METHODS This study included 55 patients with hyperparathyroidism that were evaluated by both SPECT and double‐phase gammagraphy using MIBI‐Tc99m. Out of the 55 patients, 26 (22 females
with an average age 57±13) went under surgery. All the pre‐intervention studies consisted on an early neck planar image at 10 min. followed by SPECT at 30 min. and a delayed planar image at 120 min. Planar images carried out using a pin‐hole collimator and a 5 min. pre‐selection. Tomographic images were performed using a 32‐projection SPECT with 32 seconds per image and a 128x128 matrix. A retrospective and a double‐blinded analysis was done side by side comparing early/delayed double‐phase or SPECT studies performed on the 26 surgical patients. RESULTS Histological analysis confirmed the presence of 24 adenomas as well as 2 parotid hyperplasias. The double‐phase detected 22 adenomas and the SPECT 23, including one false‐negative 0.3 gr. adenoma detection. The average detection rate for the double‐phase study was 91.6%, whereas the SPECT achieved a 95.8%. Finally, both techniques were equally consistent for the detection and localization of the 2 hyperplasias, averaging both a 50% detection rate. CONCLUSIONS In conclusion, this study could not find significant differences on localization diagnostics if performed exclusively by SPECT imaging, being SPECT even more sensitive. Therefore, according to our study, we conclude that parathyroid gland gammagraphic detection technique could be simplified to the exclusively use of SPECT imaging. However, it would be needed a more broad study by increasing the number of subjects in order to fully support our hypothesis.
P728 Predictive value of serum thyroglobulin levels after thyroidectomy for early prediction of persistent and recurrence of the disease in patients with differentiated thyroid carcinoma B. Gunes, O. Topuz, C. Onsel, H. Sayman, L. Kabasakal, K. Sonmezoglu, B. Kanmaz, M. Halac, I. Uslu; Istanbul University, Cerrahpasa Medical School, Nuclear Medicine Department, Istanbul, TURKEY. Aim: Our aim is to find out the best cut‐off value of serum thyroglobulin (Tg) levels for early persistence and recurrence of disease after total or near total thyroidectomy in the prognosis of patients with differentiated thyroid carcinoma (DTC). Material and methods: Two hundred sixty seven consecutive patients (227 women, 40 men) with DTC treated were included in the study. The mean age was 45.9±13.7yr (range, 13‐84yr). The histopathological types were 244 (93%) papillary carcinomas, 17 (6.3%) follicular carcinomas, 6 (2.2%) Hürthle cell carcinomas). All patients underwent total or near total thyroidectomy followed by radioiodine remnant ablation between 2004 and 2009. Thirty two patients had neck dissection because of lymph node metastases. Patients with anti‐tg antibodies and TSH 29mIU/ml were excluded. All patients were administrated 3.7‐5.5GBq of radioiodine ablation dose. Serum Tg levels were measured in all patients just before radioiodine ablation. A postablation high dose whole body scan (WBS) was obtained 4‐5 days after the ablative dose. All patients were undergone T4 suppressive therapy just after the remnant ablation. Six months following the ablative dose serum TSH and serum Tg measurements were performed. In addition, a diagnostic WBS with 185 MBq was obtained in patients with serum Tg≥2ng/ml. Successful ablation was defined by serum Tg level ≤ 2 ng/ml and absent uptake in thyroid bed on DWBS. Three cut‐off values of serum Tg levels (2, 10, 20 ng/ml) were assessed to predict the persistence and recurrence of DTC. Results: Two hundred thirty two patients received one dose of radioiodine were successfully ablated. Twenty six patients, eight patients and one patient were received 2, 3 and four times of radioiodine for ablation respectively. Twenty patients (7.4%) had persistence or recurrence of disease. The positive predictive value for persistence or recurrence in patients with serum Tg level greater than 2 ng/ml, 10 ng/ml and 20ng/ml were found to be 11% (17 of 158 patients), 18 % (15 of 84 patients) and 23% (11 of 47patients) respectively. The negative predictive value for persistence and recurrence in patients with serum Tg level less than 2ng/ml, 10ml and 20ng/ml were found to be 99% (108 of 109 patients), 98% (180 of 183 patients) and 97% (213 of 220 patients) respectively. Conclusion: Our results show that Tg level after thyroidectomy just before the first radioiodine ablation had an significant role for predicting persistence or recurrence of DTC.
P729 Scintigraphic findings of the thyroid in patients with newly diagnosed thyroiditis K. Demirel1, A. Baskin1, G. Koca1, M. Korkmaz1, C. Culha2; 1Ankara Education and Research Hospital, Department of Nuclear Medicine, Ankara, TURKEY, 2Ankara Education and Research Hospital, Department of Endocrinology and Metabolic Diseases, Ankara, TURKEY. Aim: Scintigraphy is useful in demonstrating the functional state of the thyroid. The aim of this study was to assess the scintigraphic findings of the thyroid in patients with newly diagnosed thyroiditis. Material and methods: Thyroid scintigraphy, I‐131 uptake, and ultrasonography of the thyroid gland were performed in 69 patients with newly diagnosed thyroiditis. A comprehensive history, physical examination, serum thyroid function tests were available for each patient. Thyroid scintigraphy was performed by intravenous injection of 5 mCi of Tc‐99m sodium pertechnetate. A 200000 count routine thyroid static scan using a pinhole collimator was acquired at 20 min after injection. I‐131 uptake was determined with a thyroid uptake probe 4 hour and 24 hour after oral administration of 5 µci of I‐131 radiotracer. Results: At the time of initial diagnosis, most patients had subacute thyroiditis or silent thyroiditis. Thyroid function tests of patients were hyperthyroid (40.58%), subclinical hyperthyroid (40.58%), euthyroid (10.14%), and hypothyroid (8.7%). Radioactive iodine uptake of thyroid was very low in the 78% all of patients. Similarly, thyroid scintigraphy demonstrates reduced uptake within the gland in the 63.77% all of patients. In the 4 patients (5.8%) was increased uptake in the thyroid scintigraphy. Eleven (15.9%) patients had cold multinodular goiter, 4 had isolated cold nodules, and 2 had hot nodules. With ultrasonography was show hypoechoic areas in 52 patients. Conclusion: In this study, the most frequently observed reduced uptake within thyroid gland in the scintigraphy of patients with newly diagnosed thyroiditis.
Poster Presentation
P724
S452 P76 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: metabolic studies
P730 Correlations of serum levels of bone turnover markers with clinical and imaging prognostic factors in prostate cancer patients with bone only metastases A. Zafeirakis1, G. Papatheodorou1, G. S. Limouris2; 1401 Army Hospital of Athens, Athens, Greece, 2Araiteion University Hospital, Athens, GREECE. AIM: To show any correlations of bone turnover markers serum levels among them and among other clinical prognostic indicators, such as pain scoring and extend of bone disease, in patients suffering from bone only metastases from prostate cancer. MATERIALS‐METHODS: Thirty six males with prostate carcinoma (median age 71 years, range 43‐82 years), with bone only metastases and no history of therapies, drugs or diseases that affect bone metabolism, were studied. For each patient, the following variables were entered in multivariate analysis: Osteocalcin (OC), bone alkaline phosphatase (BALP) amino‐terminal and carboxy‐terminal propeptides (PINP and PICP) and telopeptides (NTx and CTx) of type I collagen, pain scoring (PSI; performed by multiplying the severity of pain by its frequency). Scintigraphic estimation of skeletal disease (EOD) by the Bone Scan Index method (BSI) was also applied and the resulting values were analysed. Twelve apparently healthy volunteers of the same age, with no history of factors affecting bone metabolism were also established as the control group. RESULTS: With only the exception of OC, bone marker values of patients were significantly increased compared to the upper reference limits, ie the cut‐off of 2SD above the mean values of controls (respective values: BALP; 31.1±26.2 ng/ml vs 11.2±3.3 ng/ml, P< 0.0001, PINP; 87.4±93.6 ng/ml, vs. 40.2±31.4 ng/ml, P = 0.012, PICP; 294.6±139.7 ng/ml vs. 214±42.6 ng/ml, P = 0.0023, NTx; 34.4±19.4 nmol/L BCE/L vs. 19.6±3.8 nmol/L BCE/L, P< 0.0001 and CTx; 0.500±0.465 ng/ml vs. 0.326±0.136 ng/ml, P = 0.04). All six markers showed significant paired correlations (r = 0.389‐ 0.895, P< 0.019). Regarding the extent of bone metastases all bone markers virtually indicated linear increases with advancing severity of the metastatic involvement of the skeletal system according to the BSI values (mean BSI = 8.2+/‐6.4, range 0.5‐25.3, r = 0.358‐0.541, P< 0.032). Finally, none of the measured markers correlated significantly with pain levels, considering for various PSI cut‐offs. CONCLUSIONS: In the present study, biochemical markers of bone formation and resorption are not only remarkably elevated in the serum of prostate cancer patients with metastatic bone disease, but also correlate with EOD and furthermore express a significant correlation among them, thus suggesting an accelerated but proportional (coupled) bone metabolism. Therefore, serial measurements of bone markers, in the serum of such patients should be performed routinely at regular intervals based on their advantages; they are non‐ invasive, inexpensive, reflect turnover in the whole skeleton, and allow repeated evaluation.
P731 A longitudinal study on bone metabolism in HIV patients treated with highly active antiretroviral therapy (HAART) G. Madeddu1, A. Spanu2, F. Chessa2, G. M. Calia1, C. Lovigu1, M. Mannazzu1, D. Sanna2, F. Cambosu1, G. Ferrandu1, M. S. Mura1, G. Madeddu2; 1Department of Infectious Diseases. University of Sassari, Sassari, ITALY, 2Department of Nuclear Medicine. University of Sassari, Sassari, ITALY. Aim: Conflicting data have been reported concerning HAART effect on bone metabolism in HIV patients in whom osteoporosis/osteopenia can occur. Thus, in HIV patients followed in a long follow‐up we further investigated whether HAART may represent a risk factor for bone mass loss. Methods: In a series of 180 adult HIV patients on HAART, 60 (33 males and 27 females; mean age 39.2±7.2 yrs), were followed in a long longitudinal study continuing treatment. In all cases, at the first observation and after 51‐64 mths, BMD (g/cm2) in lumbar spine and in femur by DEXA (QDR, 4500A, Hologic) was measured; according WHO criteria the patients were classified as normal (T‐ score >‐1.0), osteopenic (T‐score ≤‐1.0 and ≥‐2.5) and osteoporotic (T‐score <‐2.5); bone alkaline phosphatase (BAP, ng/ml) in serum by IRMA and pyridinuline and deoxypyridinuline (PYD&DPD, nM/mM creatinine) in urine by EIA were also assayed. Results: At the first observation 54/60 (90%) patients were on HAART (mean CD4 cell count 594±291 cells/μL and HIV‐RNA 4.81±5.42), and 6/60 (10%) were naïve; moreover, 10/60 (16.7%) were osteoporotic and 18/60 (30%) osteopenic, while 32/60 (53.3%) had normal BMD values. During follow‐up, 31 patients (Group A), including 5 osteoporotic and 12 osteopenic, received protease inhibitors (PI) plus nucleoside reverse transcriptase inhibitors (NRTI) and 29 patients (Group B), including 4 osteoporotic and 6 osteopenic, received non nucleoside reverse transcriptase inhibitors (NNRTI) plus NRTI or triple NRTI. Group A patients showed no significant change in BMD values in lumbar spine, while they had a significant (p<0.01) BMD reduction in femur than basal values; Group B patients had unmodified BMD values in both spine and femur. In particular, 3/18 (16.7%) Group A patients, osteopenic at baseline, underwent osteoporosis during follow up and 12/32 (37.5%) with normal BMD, 9 Group A and 3 Group B, developed osteopenia in spine and/or in femur. BAP levels increased in both Group A and B and PYD&DPD levels only in Group A, but not significantly than basal values. Conclusions: This study confirms that osteopenia/osteoporosis with accelerated turnover can occur in HIV patients on HAART which could be an aggravating factor on bone mass reduction due to the disease itself. Bone mass loss persisted over time continuing treatment in our cases and further worsened in some of these, in particular if received PI. Thus, HIV patients on HAART should accurately be monitored to select those cases with high risk of osteoporosis who need specific treatment.
P732 Adynamic bone disease in patients with chronic renal impairment. Is quantitive Tc99m Methylene Diphosphonate (MDP) bone scan has a role?
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 A. M. A. A. Abd El-Ghany1, A. M. A. a. Abo-zahra2, T. M. F. F. Fayad2, S. A. G. H. Harb2; 1Nemrok, Faculty of medicine , Cairo university, Cairo, EGYPT, 2 Internal medicine, faculty of medicine , Cairo university, Cairo, EGYPT. INTRODUCTION Changes in bone metabolism are universal concomitant of renal impairment. Known types of renal bone disease: osteitis fibrosa cystica, osteomalacia, Adynamic bone disorder (AD.B.D.) in which bone turnover is low and mixed osteodystrophy. Symptoms due to these disorders generally do not occur until the patient is already on maintenance dialysis; however subclinical changes in bone remodeling begin early. Aim of work Our study is aiming to characterize this type of renal osteodystrophy known as (AD.B.D.) in two forms of patients with chronic renal impairment by using Tc‐99m MDP qualitative and quantitive bone scintigraphy. Patients and methods This study included: Group (1): 15 patients with chronic renal impairment without dialysis (12 men, 4 women; mean age 50.8 ± 14.8y) and Group (2):15 patients on regular hemodialysis (12 men, 3women; mean age 48.7±10.3 y). They were subjected to clinical examination, Laboratory assessment (serum PTH concentration, calcium, phosphorus, alkaline phosphatase and others) and 99mTc‐MDP bone scintigraphy (555mBq injected intravenously). Imaging was done after 4‐5 hours with quantification of bone to soft tissue ratios (B/ST) by drawing ROIs on the skull, lumbar spine, femoral neck and medial parts of the thigh. Results Qualitative assessment of the bone scan studies (30 cases) revealed 17(56.7%) with no abnormalities and 13 (43.3%) found to be abnormal (8 sacroiliitis, 3 metabolic superscan, 1 vertebral collapse fracture and 1 metastatic calcification). The (B/ST) ratio was abnormal in the group with no abnormality, in which the PTH mean value was 351 ± 335. 5 pg/ ml (n. 10‐65 5pg/ ml), while the alkaline phosphatase was 304.3 ± 110.6 U/L (n. up to 133.4 U/L). The (B/ST) ratios for the femoral neck and the skull correlate with the PTH and alkaline phosphatase (r= 0.6, p‐ value= 0.02 & r= 0.7, p‐value= 0.03 respectively). The same applies for the calcium‐ phosphorus byproduct that was 50.4 ± 1.87 (p‐value 0.03). The C.I. of the forementioned correlations was 1.0‐ 1.1. Conclusion Our data suggest that when no abnormalities are detected in the Tc‐99m MDP bone scan of a patient with chronic renal impairment, this does not exclude metabolic bone changes and (AD.B.D.) is strongly raised especially when PTH, alkaline phosphatase and calcium‐ phosphorus byproduct are abnormal. The quantitive bone scintigraphy, based on the (B/ST) ratios especially in the femoral neck and the skull, is remarkably supportive in diagnosis of (AD.B.D.) in earlier stage before being notable by mere qualitative bone scan.
P733 Bone mineral density in postmenopausal women under thyroxine therapy. Correlation between thyrotropin, aminoterminal propeptide of type 1 procollagen and bone densitometry P. Valsamaki1, A. Zanglis1, E. Georgiou2, G. Fountos3, D. Papamichail1, S. Gerali1; 1“Pammakaristos” General Hospital, Athens, Greece, 2“National and Kapodistrian University of Athens Medical School, Athens, Greece, 3 “Technological Education Institute of Athens (TEI)”, Athens, GREECE. Aim: The association between thyroid disorders (overt or subclinical hyperthyroidism) and bone density status is a well explored fact. This study was designed to assess the effects of the long‐ term (ten to fifteen years) thyroid hormone administration on bone turnover, by determining the serum thyrotropin (TSH), aminoterminal propeptide of type 1 procollagen (P1NP) and bone mineral density (BMD) measurements. Materials and Methods: Twenty nine postmenopausal females (68±6.8 years old, mean±SD) receiving thyroxine therapy for thyroid disease (goiter) were randomly selected. Patients were subjected to BMD measurements (hip and/or lumbar spine) and divided into two groups based on their serum TSH levels. Seventeen patients (group A) had serum TSH within normal range (mean±SD: 1.14±0.22 μIU/mL), while 12 patients exhibited therapy‐induced subclinical hyperthyroidism (group B) with TSH < 0.4 μIU/mL (mean±SD: 0.13±0.09 μIU/mL). Seven/17 group A patients and 6/12 group B patients were on anti‐resorptive treatment. Thyroid hormones and serum bone parameters (including TSH and P1NP) were measured with the Elecsys analyzer (Roche Diagnostics, Basel, Switzerland). Bone densitometry was conducted with the Dual Energy X‐Ray Absorptiometry (DEXA) technique (Hologic QDR 4000). Statistical analysis of the data was performed using the MedCalc™ software package. Results: The P1NP values in both groups were normally distributed (D’ Agostino‐Pearson test) and the respective confidence intervals calculated were: for group A, 31.8±16.2 μg/L and for group B, 24.0±12.6 μg/L (mean±SD). The log‐transformed data showed no statistical significant difference between the mean P1NP values (p=0.1908) of the two groups (Welch t‐test). The group A patients under anti‐resorptive treatment showed significantly lower P1NP values (Anova, log‐transformed data, p=0.027), while for group B patients, no such effect was observed (p=0.784). The BMD measurements of the two groups showed a tendency for lower BMD values in group B patients (T score: mean±SD=86.3±11.4 %) compared with the BMD values of group A patients (T score: mean±SD=93.9±18.4 %), although this difference did not reach statistical significance. Conclusions: Postmenopausal females, under thyroid hormone therapy, seem to require maintenance of their serum TSH levels within normal range to avoid bone loss, although this difference did not reach statistical significance in this study. However, the anti‐resorptive treatment was shown to have a statistically significant decrease in the P1NP values of the group A patients, indicating either treatment failure or compliance problems. Hence, the serum P1NP, besides the BMD measurement, offers the clinicians an early intervention tool for a better clinical outcome in patients under thyroxine treatment.
P77 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: miscellaneous
P734 Development of a non invasive imaging technique enabling the monitoring of the dysferlin’s functionality P. D. Chaumet-Riffaud1, P. Borel2, D. Deliu3, M. Cherrar2, M. Bessodes4, A. Prigent1, D. Scherman5, D. Stockholm2; 1Chu de Bicêtre, Université Paris Sud 11 EA4046, Le Kremlin Bicêtre, France, 2Généthon, 1 rue de l'Internationale Evry, Evry, France, 3CHU de Bicêtre, Service de Médecine
S453
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Non‐invasive imaging techniques for muscular diseases are needed for understanding the pathophysiology. This kind of tool will enable to assess the evolution of the disease and especially during clinical trials. In muscular dystrophies like dystrophinopathies, dysferlinopathy or sarcoglycanopathies, membranes of muscle fibers are fragile or unable to reseal, leading to their death. Such defect can be demonstrated in mice model by the use of a membrane integrity assay based on Evan's blue dye, which is known to bind to albumin in blood. After injecting Evans blue dye intraperitoneally, the labeled albumin penetrates in damaged muscle fibers, and histological assessment of membrane permeability can be done. This type of assay is however impossible in human beings because of the toxicity of the fluorophore. Our approach is based on the use of a small animal dedicated gamma‐camera SPEC‐CT device (Biospace®, France) to measure the albumin uptake in order to mimic some aspects of the Evans Blue Assay. By using technetium (99mTc) labeled albumin (Vasculocis®, CisBio IBA), we were able to follow and quantify in real time muscle uptake on planar images acquisitions and SPECT‐CT acquisitions. Labeled albumin was injected by intravenous route in control mice (C57B6, n=32) and diseased animals (Bla/J model, KO Sarco model, n=16). Data that we obtained from scintigraphic acquisitions were compared to direct counting of activities in different muscles and organs (11 samples per animal) after the sacrifice of animals 60 min after administration of the radiopharmaceutical (biodistribution data after sacrifice of animals). Technetium albumin would be safely usable in the living animal and in humans and would provide kinetics data on the permeabilisation of fiber muscle membranes at the resolution of the organ level. Furthermore, scintigraphy imaging is highly sensitive and allows quantitative detailed images of the biodistribution of the radiopharmaceutical.
P735 Histopathologic Correlation of Adenoma and Suspicious Adenoma in Parathyroid Scintigraphy S. Yildirim, K. Demirel, A. Baskin, G. Koca, M. Korkmaz; Ministry of Health, Ankara Training and Research Hospital, Department of Nuclear Medicine, Ankara, TURKEY. Purpose: The aim of this study was to evaluate the histopathology outcomes of cases reported as adenoma and suspicious adenoma in Tc‐99m MIBI dual phase scintigraphy. Methods: Thirty‐four patients (25 female, 9 male, average age: 46.91 ± 19.21 years) who had increased radioactivity accumulation in parathyroid region at second hour in MIBI scintigraphy, were included to our study. Preset time (10 min) static images from anterior neck region were acquired with LEGP collimator at 20 minutes and 2 hours after the injection of 740 MBq Tc‐99m MIBI. Second hour definite radioactivity accumulation in parathyroid region was interpreted as adenoma and relatively low radioactivity accumulation in parathyroid region was interpreted as suspicious adenoma. All cases were also underwent blood tests for calcium (Ca), phosphat, (P) and parathormon (PTH). Results: Twenty‐four out of 34 cases (70.5 %) with increased radioactivity retention at 2nd hour in MIBI scintigraphy were confirmed as adenoma in histopathologic evaluation. Parathyroid scintigraphy interpreted 21 definite adenoma and 13 suspicious adenoma. The histopathology results from 21 patients whose parathyroid scintigraphy interpreted as adenoma were as follows: 15 adenomas (71.4 %), 3 hyperplasia (14.3 %), 2 hashimoto's thyroiditis and a normal case (4.8 %). The histopathology results from 13 patients whose parathyroid scintigraphy interpreted as suspicious adenoma were as follows: 9 adenoma (69.2 %), 2 hyperplasia (15.4 %), and 2 normal case (15.4 %). And there was no significant statistical difference between Ca, P and PTH levels. Conclusion: In our study either definite or relatively low radioactivity retention at 2nd hour in parathyroid scintigraphy has the same histopathologic incidence for parathyroid adenoma. Therefore, we think that even relatively low nd radioactivity retention in 2 hour in MIBI parathyroid scintigraphy should be considered as adenoma.
P78 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: bone and joints
P736 Diagnostic Value and Clinical Usefulness of FDG-PET, In-111 Leukocyte Imaging and Three Phase Bone Scintigraphy in Differentiating Periprosthetic Joint Infection from Aseptic Loosening B. GUNALP, E. Alagoz, U. E. Eren, O. Emer, A. Ayan, O. Karacalioglu, N. Arslan, S. Ilgan, M. A. Ozguven; Gulhane Military Medical Academy and Faculty, Ankara, TURKEY. Differentiating prosthetic joint infection from aseptic loosening is very important for appropriate patient management and is difficult clinically since laboratory tests, radiography and joint aspiration are usually inconclusive. CT and MRI are hampered by artifacts produced by the prosthetic devices Purpose: We evaluated diagnostic value and usefulness of FDG‐PET, In‐111 Leukocyte and three phase bone scintigraphy in the differential diagnosis of prosthetic joint infection from aseptic loosening in routine clinical practice. Material and Methods: Twelve lower limb prostheses in seven patients in whom infection was suspected were evaluated by FDG‐PET, In‐111 leukocyte scan and three phase bone scintigraphy. FDG‐PET images were obtained 60 min after an I.V. injection of 300‐400 MBq FDG. Criteria of positivity to diagnose prosthetic joint infection: increased FDG uptake in the periprosthetic soft tissue and at the bone‐prosthetic interface (BPI), (for the hip prostheses increased FDG uptake at the soft tissues adjacent to the neck of the prosthesis is not considered positive for infection); increased leukocyte accumulation around the prosthesis in In‐111 Leukocyte scan; and increased uptake in the all phases of bone scintigraphy has been accepted as positive findings for infection. Prostheses were considered infected if aspiration cultures grew organisms or if infection was verified at surgery. A final
diagnosis was made by surgical exploration or clinical follow‐up for 6 months. Arthroplasties that did not require surgical exploration during the follow‐up period were considered uninfected. Results: Sensitivity and specificity of FDG‐PET, In‐111 leukocyte imaging and Tc‐99m MDP three phase bone scintigraphy for the detection of prosthetic hip or knee joint infection were 85.7%, 100%; 60%, 100%; 40%, 50%, respectively. Although both FDG‐PET and In‐111 leukocytes have high specificity for the detection of infection, FDG PET has been found more sensitive and useful test, since In‐111 leukocyte Scintigraphy is labor‐intensive, time consuming and carries risk of direct handling of blood products. Conclusion: FDG‐PET has been found the most accurate and useful diagnostic procedure in differential diagnosis of periprosthetic infection from aseptic loosening.
P737 Bone scan in the SAPHO syndrome: evaluation of efficacy of Alendronate as treatment of choice L. Burroni1, A. Petraglia2, L. Cantarini2, A. Fioravanti2, M. Galeazzi2, A. G. Vattimo1; 1Dept. of Nuclear Medicine, University of Siena, Siena, ITALY, 2 Dept. of Rheumatology, University of Siena, Siena, ITALY. The SAPHO syndrome (Synovitis, Acne, Pustolosis, Hyperostosis and Osteitis) is a clinical‐ radiological entity combining skin, bone and joint manifestations. A twenty‐year‐old girl came under our observation in March 2001 for low back pain, stiffness, malaise and weight loss; during this same period popular erythematous and desquamative skin lesions had appeared on both palmoplantar regions. Her indexes of inflammation were increased.Plain radiography of the pelvis showed areas with erosion in the right sacroiliac joint and sclerosis in the adjacent iliac bone. Skin biopsy of palmoplantar cutaneous lesions showed a pattern of pustulosis and psoriasis vulgaris. The patient was diagnosed with SAPHO syndrome and started treatment with NSAIDs and sulfasalazine. Approximately one year after the sulfasalazine treatment had stopped, the patient returned because of the appearance of a conspicuous swelling and painful on the right clavicle. The patient did not have a recent history of fever or rash, and the pustular lesions on her palms and soles had disappeared. ESR was 20 mm/h, CRP was 2.15 mg/dl and urinary hydroxyproline had increased (70.2 mg/24h). Conventional radiography of the sternocostoclavicular region showed only a sclerotic and hyperostotic bone and a typical “plate‐ like” ossification of the medial part of the clavicle. Tc‐99m MDP bone scintigraphy showed an increased tracer uptake in the right clavicle and the sacroiliac region. A MRI showed sclerotic bone and some areas of inflammatory oedema well delineated. Histology showed chronic osteomyelitis with a predominance of lymphocytes in the inflammatory infiltrates. Cultures of biopsy tissue specimens were sterile. In June 2004 the patient started treatment with oral alendronate and analgesics if needed for pain. Three months after the patient reported a marked improvement of the pain and the indexes of inflammation were already normal. Bone scan revealed a complete normalization in tracer uptake in the right sacroiliac region; the right clavicular lesion appeared reduced in extension and in the uptake level. In a semiquantitative evaluation, a bone index (B.I = right clavicle/4th lumbar vertebra) revealed regression in comparison to the previous scintigraphic study (3.24 to 1.66). Standard treatment includes NSAIDs, analgesics, corticosteroids and sulfasalazine. In our case treatment with oral alendronate brought about the resolution of the painful symptoms after three months, and led to a marked clinical and scintigraphic improvement after one year.
P738 Skeletal brucellosis: scintigraphic findings Z. Rajkovaca, D. Stanimirovic, J. Mijatovic, S. Stankovic, L. Grahovac, N. Stevandic; Deaprtmen of Nuclear Medicine Clinical Center, Banja Luka, BOSNIA AND HERZEGOVINA. BACKGROUND: Brucellosis is worldwide infection disease of animals which can be transmitted to humans. It is a systemic infection in which any organ or system of the body can be involved. Osteoarticular involvement is the most common complication of brucellosis. Knowledge of the location and distribution of osteoarticular involvement may be valuable in patient treatment and management. The aim of this study is to assess the usefulness of bone scintigraphy in the detection of bone and joint abnormalities in brucellosis and show the frequency of such abnormalities at scintigraphy. MATHERIAL AND METHODS: 42 patients (8 females, 34 males; age range, 27‐74 years) with diagnosed osteoarticular brucellosis were investigated. All patients were evaluated with Tc‐DPD bone scintigraphy. Quantification of sacroiliac joint uptake was performed to improve the sensitivity for the detection of sacroiliitis. RESULTS: Bone scans were abnormal in 38 patients (90.48%). Multiple skeletal abnormalities had 29 patients (78.4%). The frequency of osteoarticular involvement was 75.7% (28 of 37 patients) and the joints most affected were sacroiliac 29 (78.4%) of 37 patients. The second most affected joints in patients with osteoarticular involvement were shoulders (66.7%). The most affected bones were spine and sternum. In spine the abnormal scintigrams showed either focal increased uptake in affected vertebral or diffuse increased uptake in adjacent vertebrae seen in 4 cervical and thoracic vertebrae and lumbal vertebrae in 14 patients. There was no significant difference between the rate of bilateral and unilateral involvement Plain radiographs were abnormal in 8 of 37 patients (21.6%). CONCLUSION: Bone scan is a useful method in detection of skeletal brucellosis. Spine and sacroiliac joints involvement have the widest range of scintigraphic findings.
P739 SPECT /CT in management knee and foot pathology E. Urbanova1, J. Vizda1, D. Zitko2; 1Nuclear Medicine University Hospital, Hradec Kralove, CZECH REPUBLIC, 2Orthopaedic Dep. University Hospital, Hradec Kralove, CZECH REPUBLIC. With regard to skeletal and soft tissue abnormalities, SPECT/CT appears to be extremely useful because it combines the advantages of both techniques (high sensitivity and high‐resolution imaging of bone morphology). Hybrid imaging using dual heads allows scan to be performed without changing the patient position. It is resulting in correct image fusion. Method: In our study were 53 pts. (25 male, 28 female age range 17 ‐68). The reason for examination was the pain in the foot, ankle or knee region. In all patients three‐phase bone scintigraphy was performed after i.v. injection of 500‐700 MBq of 99mTc‐MDP. Later whole body scan, planar scintigrams and SPECT/ CT were done (SPECT camera integrated with a 4‐slice CT scanner in one gantry). The
Poster Presentation
nucléaire, Le Kremlin bicêtre, France, 4Unité de Pharmacologie Chimique et Génétique, CNRS UMR8151 Inserm U640, Université René Descartes Paris 5 , France, 5Généthon Evry, Unité de Pharmacologie Chimique et Génétique CNRS UMR8151 Inserm U640, Université René Descartes Paris 5, FRANCE.
S454 exact anatomical localisation and number of lesions was read in consensus by staff from nuclear medicine and radiology. In second group 13 pts. (7 male and 6 female) were reffered for scintigraphy with labelled leukocytes with symptoms resulting from suspicions for infection. Results: The final diagnoses in the first group were: arthrosis, fracture, rheumatoid arthritis, calcanear spur. For confirmation of diagnosis from bone scintigraphy two patients were referred for scintigraphy with autologous labelled leukocytes and diabetic foot was confirmed by one and Charcot arthropathy by one (later also due to biopsy). In the second group osteomyelitis (OM) of the talus, OM of the tibia was confirmed. Additional information provided by hybrid SPECT/CT scanning influenced therapeutic procedures altogether in 23%. Conclusion: Bone scan, leukocyte scan provide unique information about the status of the skeleton. Both have typical strengths and weaknesses, which can lead to the loss of time for final diagnosis. New devices for hybrid imaging ‐ SPECT/CT allow direct fusion of morphological (CT) and functional (SPECT) data sets. SPECT/CT should be applied whenever equivocal findings of planar bone imaging occur. It also helps to improve accuracy of leukocyte scanning to detect/exclude osteomyelitis and to define sites of inflammation.
P740 18
F-FDG PET findings of pelvic insufficiency fracture
K. Koyama1, T. Okamura2, N. Ozawa2, Y. Hamazawa3, H. Seura2, Y. Miki1; 1 Osaka City University Graduate School of Medicine, Osaka, Japan, 2PET Center, Saiseikai Nakatsu Hospital, Osaka, JAPAN, 3Department of Radiology, Saiseikai Nakatsu Hospital, Osaka, JAPAN. Objectives: Increased 18F‐FDG uptake in pelvic insufficiency fracture (PIF) is occasionally recognized as an incidental finding when PET scan is performed for staging of malignancies or for other purposes. There is a possibility of misinterpretating such uptakes as pathological osseous 18 processes. The purpose of this study is to retrospectively examine the F‐FDG PET findings of PIF. Methods: Of a total of 9000 patients performed dual‐time‐point 18F‐FDG PET or PET/CT scanning in the PET center of Saiseikai Nakatsu Hospital from April 2005 to February 2008, 6 patients who had been diagnosed clinically to have PIF were investigated in this study. Four patients were performed 18F‐FDG PET/CT scanning and the other 2 patients were performed 18F‐FDG PET scanning and multi‐detector CT scanning performed within 1 week before or after 18F‐FDG PET scanning. 18F‐FDG PET or PET/CT images were examined visually and statistically. The relationship between the 18F‐FDG uptake and interval time between injury and PET or PET/CT scan estimated using medical records and pre‐examination interview sheets was also investigated. Results: In both early and delayed images, high 18F‐FDG uptakes in the sacro‐iliac joints and sacrum were seen in 3/6 (50%) of the patients with PIF, whereas faint uptakes were seen in the remaining 3 patients (50%). The shape of 18F‐FDG uptakes showed the H pattern in 4/6 (67%). Standardized uptake values (SUVs) in early images ranged from 1.8 to 5.4 (mean, 3.48 ± 1.50) and those in delayed images ranged from 2.1 to 5.4 (mean, 3.57 ± 1.40). Statistically, there was no significant difference between these values, although the SUV was higher in delayed images in 3/6 (50%) of the patients. The SUV at 1 month after injury was the highest, while it was lower when obtained within 1 month or at 2 months after injury. When SUVs were compared by the timing of imaging, SUVs were similar in both early and delayed images at 1 month, but early images showed higher values than delayed images when taken within 1 month or at 2 months after injury. Abnormal FDG uptakes were also recognized in the pubic bones and/or ischial bones in 5/6 (83%) of patients with bone fractures associated with PIF. Conclusions: The majority of PIF cases showed H‐shaped abnormal 18F‐FDG uptakes, and SUV was the highest at 1 month after injury. Statistically, however, there was no significant difference in SUVs between early and delayed images.
P741 Antigranulocyte Scintigraphy and Three-Phase Bone Scintigraphy on the Management of Patients with Painful Hip and Knee Prostheses: A Retrospective Evaluation J. A. Sequeira1, S. Carmona1, A. Prata1, P. Almeida2, M. Tapadinhas2, A. I. Santos1; 1Hospital Garcia de Orta -Serviço de Medicina Nuclear, Almada, PORTUGAL, 2Hospital Garcia de Orta -Serviço de Ortopedia, Almada, PORTUGAL. Aim of the Study: Infection of joint prostheses is a major complication and needs to be accurately diagnosed. The aim of this study was to evaluate the diagnostic utility of the combination of a three phase bone scintigraphy (3FBS) and antigranulocyte scintigraphy on the management of patients with painful joint prostheses. Material and Methods: Nineteen patients (pts), 12 female and 7 male (= 66±9 years), with painful joint prostheses (15 knee prostheses, 4 hip prostheses) were evaluated. 3FBS was performed with 740 MBq of 99mTc‐ HMDP. Antigranulocyte scintigraphy was performed after e.v. injection of 555 MBq of 99mTc‐BW 250/183. 2 and 4‐6 hr p.i. scans were done with 3 min per view; in 9 cases, 24 hr imaging was also obtained. Both scintigraphic studies were interpreted visually by four nuclear medicine physicians with a score of normal, mild, moderate or intense hyperactivity. Interpretation criteria for bone infection were antigranulocyte uptake in a moderate or large sized area, with congruent hyperactivity on the bone scan. Mild uptake with antigranulocyte scintigraphy was considered nonspecific, associated to nonseptic conditions. Quantitative interpretation of the time‐activity course was also employed, based on regions of interest over the affected areas. Infection was diagnosed when activity around the prosthesis increased, compared with contralateral side, while a decreasing uptake intensity pattern was considered as a negative result. In 4 cases bone marrow scintigraphy was also performed. Diagnostic confirmation procedures were surgery and culture (11 pts) and follow‐up at 12 months (8 pts). There was no therapeutic intervention between both exams. Results: All six septic joints were correctly identified. In 3 pts the antibody scan was «false positive» (allergic reaction, mechanical loosening, arthrofibrosis). Negative studies (10/19 pts) were very helpful for the exclusion of infection. In 8/9 pts with positive studies reoperation was performed, motivated by scintigraphic results. We found a sensitivity and a negative predictive value both of 100%, a specificity of 77%, a positive predictive value of 67% and an accuracy of 84%. Conclusions: Monoclonal antibody scintigraphy seems to be a high sensitive modality for confirmation/exclusion of joint prosthetic infection, in association with 3‐ phase bone scintigraphy. A normal or mildly abnormal antigranulocyte image makes the presence of infection most unlikely.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P742 Metastatic Calcification detected on Bone Scan - a rare case H. Q. F. Fernandes, J. P. Patricio, P. Oliveira, A. Oliveira, T. Faria, J. G. Pereira; Hospital S. João, Porto, PORTUGAL. Aim: Metastatic calcification describes the calcification of viable undamaged normal tissue as a result of hypercalcemia and/or hyperphosphatemia. Metastatic calcification may be divided according to its location into two types: visceral (which includes lungs, stomach and kidneys) and non‐visceral (e.g. articular). Bone scan is very useful in depicting metastatic calcification, and is probably the most sensitive technique in detecting early changes (even earlier than the radiological techniques). The aim of this study was to show the value of bone scan in diagnosing metastatic calcification in end‐stage renal insufficiency. Materials and Methods: The authors present a fifty‐one‐year‐old male with terminal renal insufficiency of hypertensive renovascular etiology, on hemodialysis for the last 10 years, referred for a bone scan because of osteoarticulary complaints. Results: Whole‐body bone scan (HMDP‐99mTc, 925MBq) showed increased uptake in the lower half of both lungs, the stomach and renal parenchyma, compatible with metastatic calcification. It also revealed uptake in both coxofemoral, knee and tarsic articulations, corresponding to osteoarticular involvement. Conclusion: Bone scintigraphy, due to its high sensitivity, even in early stage, might be an useful instrument in the inicial evaluation and follow‐up of patients with high risk of developing metastatic calcification.
P743 The Influence of Tc-99m and F-18 on Dual Energy X-ray Absorptiometry Measurements of Bone Mineral Density and Body Composition in a Whole Body Phantom L. Alslev, B. Zerahn; Herlev Hospital, Herlev, DENMARK. Aim: Dual energy X‐ray absorptiometry (DXA) is used to diagnose osteoporosis and monitor the development in bone mineral density (BMD) during therapy as well as for quantification of body composition. Whenever DXA is requested in close‐time proximity to a nuclear medicine procedure, it is important to know whether the gamma‐rays emitted by the radiopharmaceutical interfere with the detection of the X‐rays used in the DXA systems. The aim of this study was to determine how tracers marked with Tc‐99m (HDP) and F‐18 (FDG) affect bone mineral density and body composition measurements in a whole body phantom. Materials and methods: A urinary bladder phantom containing 40 ml of radioisotope solution was placed upon the pelvic region of a whole body phantom (Hologic), after which a series of DXA‐scans was performed and analyzed using a Lunar Prodigy scanner. The range of activity evaluated in this study was for Tc‐ 99m: 5 to 205 MBq (68 measurements) and for F‐18: 0.1 to 177 MBq (45 measurements). 16 control scans were performed on the whole body phantom without a radioactive isotope present. The mean values of BMD, tissue, fat and fat free mass from the control scans were subtracted from the measured values from scans influenced by either Tc‐99m or F‐18. The correlation between activity in MBq and the change in BMD, tissue, fat and fat free mass respectively was analyzed using linear regression. Results: BMD was not significantly affected by the presence of Tc‐99m in the selected range of activity, whereas F‐18 reduced BMD values significantly at activities from approximately 20 MBq. Even minute amounts of either isotope caused falsely increased lean mass as well as decreased fat mass and total tissue values. All variables correlated significantly with the amount of radioactivity (p < 0.001). Conclusion: The results of a DXA‐scan are influenced by the presence of Tc‐99m and F‐18. These findings should be taken into consideration when DXA is performed in close‐time proximity to a nuclear medicine procedure.
P744 Diagnostic and prognostic value of bone scintigraphy in osteoporotic vertebral fractures A. Kapishnikov, E. Alekhin; Samara State Medical University, Samara, RUSSIAN FEDERATION. The aim of this work was to investigate of possibilities of bone scintigraphy in recognition of osteoporotic vertebral fractures and their interrelation with anatomical and metabolic parameters. Methods: We examined 34 patients with an osteoporosis (age 50‐76 years). Bone scintigraphy was performed with 99mTc‐MDP ("Diamed"; 500‐700 MBq). Results of radionuclide imaging were compared with x‐ray, CT, DEXA (T‐score). At 19 patients research was carried out repeatedly in 2‐3 months. Computer processing included an estimation of average values at ROI; for correct comparison of the data counted relative level of accumulation in the hot spot by comparison with activity accumulation in cervical vertebras. The analysis of image fusion of planar bone scintigraphy and radiographs was in addition carried out in a semi‐automatic mode of positioning after threshold processing. The correlation between scintigraphic data, results of dynamic observation, CT findings and T‐score (DEXA) was performed with regression and discriminant analysis. Results: Results of research allow to conclude that osteoporotic vertebral fractures are shown by intensive linear increased activity uptake in a vertebra, and at 9 (26,4 %) the persons having considerable deformations of vertebras on radiographs, there was no raised accumulation of the indicator in the given zone. Definite correlation was found between T‐score (DEXA) and: 1) intensity of accumulation 99mTc‐MDP; 2) change of activity in the hot spots at repeated research; 3) probabilities of occurrence of the new increased bone uptake. No definite correlation was found between scintigraphic findings and serum calcium level. Conclusion: Bone scintigraphy is a necessary method of diagnostics of osteoporotic vertebral fractures. Initial level uptake of Tc‐99m MDP and change of this parameter can be used for definition of ageing of fractures in osteoporotic patients. The indication for bone scintigraphy at an osteoporosis are deformation of vertebras, and also presence of the expressed osteoporosis in the absence of changes of a configuration of vertebra in radiographs.
S455
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
Clinical Science: infection / infl ammation
P745 The utility of 18F-FDG PET/CT in the manegement of the paraplegic patient affected by bed-sores G. Agnese1, L. Di Ciolo1, M. Ottonello2, F. Bertolotto2, F. Gandolfo1, E. Piccardo1, A. Massone2, L. Bertolazzi1; 1Nuclear Medicine Unit - Santa Corona Hospital, Pietra Ligure (SV), ITALY, 2Spinal Cord Unit - Santa Corona Hospital, Pietra Ligure (SV), ITALY. Aims The bed‐sores are an important problem of morbidity in patients affected by spinal cord lesion. In spite of systemic antibiotic therapy and daily surgical medications, the recurrences are high (20 ‐ 25 %) and probably due to an underlying osteitis but recently has been proposed a more radical surgery. So the staging of the lesion is important to guide the surgeon for a radical intervention about the infected bone. The usual staging is performed by clinical visit and imaging methods (RX, bone scintigraphy, MRI and CT) but our study try to demonstrate the possible utility of PET/CT. Materials/methods In the last year, 20 patients (14 males and 6 females, mean age 42 +/‐ 5 yrs) with spinal cord disease and affected by bed‐sores , after a variable time of antibiotic therapy and daily medications without benefit, underwent to a PET/CT scan. All patients were asked to fast for six hours and, about one hour p.i. (0,14 mCi/Kg of 18F‐FDG), was performed an acquisition of 3 min./bed by a Biograph 6 (Siemens). 11 patients had performed a dynamic bone scintigraphy, 8 a MRI and 5 a CT; only 4 patients performed a bone scan and a MRI and 1 a bone scan and a CT. Within one week, all patients underwent to a radical surgery also about underlying bone tissue and the PET results were compared with the microbiologic and anatomy results. Results In 17 patients (85%) PET/CT showed intense uptake of 18F‐FDG involving also the deep regional bone while in 3 cases (15%) there was no uptake in the bone tissue. In the first group, the anatomic and microbiologic examination was positive in 15 cases (75% TP) and negative in 2 cases (10% FP); the second group showed agreement in 2 cases (10% TN) and in 1 case there was disagreement (5% FN). These results showed a sensibility value of PET/CT of about 94%. Conclusions The diagnosis of osteitis, as complication of the bed‐sores, is often difficult and require an integrated clinical and instrumental approach to program a correct treatment with the goal to remove infection of the regional bone tissue. Our observations did not underwent to a statistic analysis because we have a little group of patients and with an eterogeneus diagnostic approach but future research may be focused about the role of PET/CT in the change of the surgeon attitude (about 40% of our cases).
P746 Efficacy of Tc-99m-HMPAO labelled leucocyte scan for monitoring response to antibiotic treatment in diabetics with pedal osteomyelitis S. Georga1, C. Manes2, I. Iakovou1, D. Lo-Presti1, D. Skoutas2, V. Nikos1, T. Christoforidis1, A. Doumas1, N. Karatzas1; 13rd Dept of Nuclear Medicine, Aristotle University Medical School, Papageorgiou Hospital, Thessaloniki, Greece, 2Diabetes Center, Papageorgiou Hospital, Thessaloniki, GREECE. Introduction‐Aim: Pedal osteomyelitis (OM) in diabetics usually treated by prolonged antimicrobial therapy, combined or not with bone debridement. However, confirmation of cure of OM and determination of the correct time for antibiotic treatment discontinuation is often difficult in clinical practice. Among commonly used imaging methods, radiography, MRI and bone scan are not helpful in assessing response to therapy as they remain positive for many months even after susseccful therapy. In our study, we evaluate the efficacy of Tc99m‐HMPAO‐labelled leucocyte scan (HMPAO‐LS) for monitoring response to antibiotic treatment in diabetic patients with pedal OM. Patients and methods: Twenty five diabetic patients (12 men, aged 61.3 ± 8.3 years) with radiographic evidence of pedal OM were enrolled in the study. All patients were on antibiotic treatment (mean treatment duration 3.9 ± 3.4 months) and all had abnormal findings on three phase bone scan. HMPAO‐LS of the feet were performed in all patients. Images were acquired 4hours after injection. Focally increased bone uptake of labelled leucocytes was considered as sign of persistent OM. Leucocyte scan was considered negative for active OM when no pedal leucocyte accumulation was observed or when there was abnormal leucocyte uptake disconcordant with the focus of increased uptake on bone scan. Final evaluation was based on long‐term clinical follow‐up or bone biopsy in patients eventually underwent amputation. Results : HMPAO‐LS showed no pedal accumulation in 20/25 patients. Focal leucocyte accumulation, compatible with persistent OM, was observed in 5 patients. HMPAO‐LS results were as follows: TN 19, TP 5, FN 1, FP 0. In a patient with persistent OM confirmed by histopathologal examination of the bone specimen, HMPAO‐LS falsely suggested that the infection was confined to the overlying pedal ulcer. This false negative result may be due to reduced inflow of circulating leucocytes to the focus of chronic OM. Sensitivity, specificity and accuracy of HMPAO‐LS for diagnosing active OM in patients receiving antibiotic therapy were 83.3 %, 100 % and 96 % respectively. Positive and negative predictive value of HMPAO‐LS were 100 % and 95 % respectively. Conclusion: With an accuracy of 96%, Tc99m‐HMPAO‐labelled leucocyte scan is the most useful imaging modality for monitoring response to medical therapy and thus proving the cure or the persistence of diabetic foot OM. Pathological findings on leucocyte scan revert to normal quickly after successful treatment of OM, so a negative study could be useful as a guide to discontinue antibiotic treatment.
P747
51
Evaluation of intestinal permeability with “ CR-EDTA test” as predictor of pouchitis in patients submitted to ileal pouch-anal anastomosis V. Valenza1, G. Brisinda2, G. Perotti1, S. Vanella2, D. Di Giuda1, G. Maria2, G. D’Angelo1, M. Maussier1, G. D’Errico1; 1Institute of Nuclear Medicine, Catholic University of Sacred Heart, Rome, ITALY, 2Institute of Surgery, Catholic University of Sacred Heart, Rome, ITALY.
Aim Ileal pouch‐anal anastomosis (IPAA) is now the procedure of choice for patients who require proctocolectomy for ulcerative colitis. The chronic pouchitis is a frequent problem after IPAA (prevalence 30‐46%). Pouches of different configurations have been advocated by various surgical groups. However, the pouch of 15‐20cm in length is easiest to construct and has functional outcomes identical to those of the more complex designs. Both handsewn and doublestapled IPAA improved the quality of life, but double‐stapled IPAA may better preserve the anal canal. Pouchitis is a non‐specific inflammation of the ileal pouch, which can be recurrent and unresponsive to therapy. The cause of pouchitis is not fully understood. The problem is believed to be caused by stasis of faeces in the pouch with overgrowth of anaerobic organisms. In fact, pouchitis is very often responsiveness to antibiotic therapy. Matherials & Methods To evaluate the role of mucosal permeability on the onset of pouchitis, as measured by 51Cr‐EDTA, we have studied during a ten‐year period, six months after ileostomy closure, 11 patients who underwent double‐stapled small J‐pouch (12 cm length) for ulcerative colitis. The study group also comprised six patients, who underwent J‐pouch 15‐20cm in length, and ten healthy subjects, as normal control group. All patients received, after an overnight fast, 1.85 MBq of 51Cr‐EDTA in 10 ml of water and told to collect their urine for 24hrs. The percentage of the isotope excreted in a 24‐ hour urinary specimen was the measure of permeability and was considered positive if the value was >3%. Results Compared with results in control subjects (2.06±0.9%), abnormal permeability was found in all the patients. Particularly, a borderline pattern (3.79±0.5%) was found in patients who underwent small J‐pouch, whereas percentage of the isotope excreted in a 24‐hour urinary specimen was significantly higher (11.75±3.5, p< 0.001) in patients with J‐pouch 15‐20cm in length. No episode of pouchitis was found in small J‐pouch patients during a follow‐up period of 12 months. Between the patients who underwent J‐pouch 15‐20cm in length, four had pouchitis during the follow‐up. Conclusion We believe that the size of the pouch has a significant influence on the incidence of pouchitis: the larger the pouch, the greater the incidence of pouchitis. We think that a smaller pouch usually empties better than a larger pouch and therefore may be less susceptible to pouchitis. The 51Cr‐EDTA test is a simple and effective method to identify the pouchitis.
P748 PET/CT scan with F18-FDG: a new clinical tool to evaluate treatment response in patients with retroperitoneal fibrosis A. Douroukas1, V. Arena2, C. Carbonero3, D. Penna2, F. Ragni4, G. B. Piccolo5, E. Pelosi2; 1Nuc. Med. Unit, Major Hospital San Giovanni Battista, University of Turin, Turin, ITALY, 2PET Centre, IRMET S.p.A., Turin, ITALY, 3 Nuc. Med. Unit, Asl To-5, Moncalieri, turin, ITALY, 4Dept. of Urology, Hospital San Luigi Gonzaga, Orbassano, Turin, ITALY, 5Dept. of Urology, Hospital San Luigi Gonzaga, University of Turin, Turin, ITALY. Aim: Retroperitoneal fibrosis is a complex clinical entity, characterised by fibro‐inflammatory reaction, around the abdominal aorta and the iliac arteries, extended into the retroperitoneum. No biochemical marker correlates with the disease severity and progression and imaging data may fail in discriminating between fibrotic and florid lesions. Positron emission tomography (PET) was recently suggested as a promising tool to evaluate disease activity. The aim of this study was to evaluate the role of the F18‐FDG PET/CT scan in estimating the metabolic activity of the disease and monitoring the response to the treatment in 7 consecutive patients. Materials and methods: seven consecutive patients with retroperitoneal fibrosis (5 males and 2 females; mean age: 65 years; SD±12,4) were included. At the diagnosis, all patients presented increased levels of acute phase reactants and of creatinin. Due to bilateral ureteral involvement, witch caused renal failure, all patients underwent intra‐ureteral stent implantation; medical therapy with corticosteroids and/or immunosuppressors was also set. An F18‐FDG‐PET/CT study was performed before the treatment start, in order to evaluate disease extension and activity. After a minimum follow‐up period of 2 months, a PET/CT scan was repeated in order to evaluate the residual inflammatory tissue and the metabolic activity of the disease. Results: before the medical treatment, pathological FDG uptakes in the retroperitoneum (mean SUVmax: 7.6; SD±3.7) were found in all patients. The following PET studies revealed a progressive reduction and normalization of the SUV, in 6 cases. In one of these 6 cases, a clinical relapse was evidenced and confirmed by clinical data and PET study; medical treatment was restarted and the following clinical, laboratory and PET results, showed a complete response. In the last case, the PET study showed a reduction but not a normalization of the pathological activity in the retroperitoneum; the patient is still under treatment. In all seven cases, PET findings resulted in agreement with the clinical and laboratory tests data. Conclusions: PET/CT study with F18‐FDG could be an helpful tool in evaluating the treatment response in patients with retroperitoneal fibrosis.
P749 99m
Tc-MDP bone SPECT in the investigation involvement in chronic rhinosinusitis
of
bone
I. I. Iakovou1, I. Konstantinidis2, V. Nikos1, T. Christoforidis1, S. Georga1, D. Lo Presti1, A. Doumas1, N. Karatzas1; 13d Nuclear Medicine Dept. of the Aristotle University, General Hospital “G. Papageorgiou”, Thessaloniki, Greece, 22nd Academic ORL Department General Hospital “G. Papageorgiou”, Thessaloniki, GREECE. AIM: To evaluate the use of 99mTc‐MDP bone SPECT in the investigation of bone involvement in chronic rhinosinusitis (CRS), in comparison with computed tomography scan as the well established imaging study of choice. METHODS: 21 patients with symptoms suggestive of CRS (mean age: 67 ±6 years, 9 females/12 males) enrolled in this study. They underwent both CT and SPECT scan of the paranasal sinuses. No patient had prior nasal surgery. Sinus CT scans were scored according to the Lund‐MacKay system (LMS). Increased 99mTc‐MDP bone uptake and LMS were compared. RESULTS: SPECT imaging was abnormal in 17/21 patients while CT was abnormal in 18/21 patients. CT was negative in 2/17 patients with a positive SPECT. Correlation between CT and SPECT findings were best at the level of the ethmoid sinuses. SPECT positive predictive value (PPV) for mucosal inflammation on CT was 82.3%. A significant positive correlation was noticed between the LMS and the number of SPECT positive sinuses within the same patient (p <0.01). CONCLUSION: Bone 99mTc‐MDP SPECT scan in patients with CRS proved to be a valuable tool the investigation of bone involvement in chronic rhinosinusitis. Bone involvement of paranasal sinuses in bone SPECT without CT findings is a fact that should be considered by the clinicians in the management of atypical facial pain.
Poster Presentation
P79 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
S456
P750 FDG-PET in inflammatory bowel diseases E. Cossalter1, A. Di Sabatino2, M. Carena1; 1Salvatore Maugeri Foundation (IRCCS)Scientific Institute of Pavia, Pavia, ITALY, 2Internal Medicine IRCCS Policlinico San Matteo, Pavia, ITALY. Aim. Crohn’s disease (CD) and ulcerative colitis (UC) are two chronic inflammatory bowel diseases (IBD). Patients affected are subject to frequent periods of clinical relapses and remission; detection of disease activity is crucial for diagnosis, treatment and control of complications (strictures and fistulas). Clinical, radiologic and endoscopic tests are used to assess intestinal lesions, but they are either indirect or invasive, thus an accurate non‐invasive method would represent a significant advance in the care of these patients. PET using FDG has been shown to be effective in the evaluation of disease with high glycolitic rates, including neoplastic, infective and inflammatory lesions. The aim of this study is to describe our experience using FDG‐PET to evaluate the activity of IBD. Methods. Between April 2007 and March 2009, 75 patients were enrolled in our study (38 males and 37 females; median age 43 years, with a range from 18 to 71 years): 49 patients were affected by CD, 14 by UC and 12 were suspicious for IBD. Patients fasted for at least 6 hours, were hydrated by 500 ml of saline e.v. or 500 ml oral water and injected with hoscine‐N‐buthlbromide 20 mg to reduce the physiological intestinal uptake. All the patients had serum glucose level below 120 mg/dl and, after intravenous administration of 1.7 MBq FDG/Kg, they were left waiting for 1 hour in a quiet room. Every exam was scanned using C‐PET Plus ‐ Philips Medical System, that operates in 3D mode. The images were interpreted visually and compared to clinical, echografic and endoscopic results. In all patients FDG‐PET was performed without side effects. Results. A total of 89 exams were performed; 13 patients received a second evaluation after biological treatment. FDG‐PET well correlated to clinical and ecographic results: 31 scans were negative because patients were in remission of disease. The test was sensitive in assessment of active lesions, in particular fistulas and FDG uptake was very accurate in monitoring response to biological treatment. Conclusion. Our first experience in using FDG‐PET in detection of intestinal and colonic segments with moderate to severe mucosal lesions and evaluation of its activity suggests that this method should be a reliable noninvasive tool for studying patients with IBD, well correlated to the clinical, endoscopic and biologic activity; it could be useful to assess the efficacy of biological therapy. However the potential impact of this promising tool need to be evaluated in prospective studies.
P751 Use of SPECT-CT in infection/inflammation: How useful is it? Z. A. Khan, C. Low, J. Cullis, M. Pandit, A. Notghi; City Hospital, Birmingham, UNITED KINGDOM. SPECT‐CT is shown to be superior to planar images in bone scans. However the routine use of SPECT‐CT in infection and inflammation is not reported. We have looked at our experience of SPECT‐CT in these conditions and give examples of change in management using this technique. We now recommend use of SPECT‐ CT in all difficult cases for better diagnostic yield. Since December 2007 we have performed 37 investigations looking for foci of infection and inflammation using gallium and wbc labelled scan. All patients had planar images. Additional SPECT‐CT was performed in 10 of these patients. Another SPECT‐CT was also performed following a leukoscan for possible infected joint prosthesis. The report was influenced by the availability of SPECT‐CT in 10 out of these 11 cases. In 8 of these cases, SPECT‐CT localised and provided correct diagnosis which was otherwise not possible. In 2 cases, the focus of infection was only demonstrated on SPECT‐CT. In 1 case, SPECT‐CT confirmed absence of lesion adding more confidence to the report. Here we present six pertinent example cases where the correct diagnosis could not be achieved without the SPECT‐CT. 1. Histologically proven ileal Crohn’s disease, , negative on barium follow‐through and conventional CT, unclear on planar Tc99m HMPAO white cell scan but confirmed only by SPECT‐CT. 2. A complicated case of Crohn’s disease with and non‐Hodgkin’s lymphoma, where the Tc99m HMPAO white cell planar uptake was shown to be in the abdominal wall surgical scar by SPECT‐CT, thereby avoiding unwarranted surgery. 3. Planar labelled white cell scan in a patient with diagnosis‐defying chronic inflammatory condition showed focal uptake in left upper quadrant separate from spleen shown by SPECT‐CT to be within a splenunculus thus preventing mis‐diagnosis of an abscess. 4. Sarcoidosis studied with Gallium study with doubtful uptake in the lung on planar images elegantly shown by SPECT‐CT to be confined to pulmonary and pleural‐based active sarcoid deposits. 5. Suspected infected knee prosthesis with negative bone scan and inconclusive MRI, with extent of the infection demonstrated on a Leukoscan with SPECT‐CT. 6. Sub‐hepatic uptake on white cell scan, confirmed by SPECT‐CT to be within the gallbladder containing stones. SPECT‐CT significantly improved the diagnostic accuracy of the test in all cases. Despite the additional time burden, we recommend use of SPECT ‐CT in infection/inflammation imaging for better diagnostic yield.
P752 Tc99m-HMPAO-labelled leucocyte scan in the diagnosis of infected hip and knee joint prostheses S. Georga1, I. Iakovou1, V. Nikos1, M. Potoupnis2, D. Lo-Presti1, T. Christoforidis1, A. Doumas1, G. Kapetanos2, N. Karatzas1; 1Dept of Nuclear Medicine, Aristotle University Medical School, Papageorgiou Hospital, Thessaloniki, GREECE, 23rd Clinic of Orthopaedic Surgery, Aristotle University Medical School, Papageorgiou Hospital, Thessaloniki, GREECE. Introduction‐Aim: Differentiation between aseptic loosening and infection of lower extremity joint prostheses is often difficult to establish. The aim of the study was to evaluate the value of Tc99m‐HMPAO‐labelled leucocyte scan, alone and in combination with bone marrow scan, in the diagnosis of infected lower extremity joint prostheses.Patients and methods: Seventy four patients (60 women), aged 68.1 ± 11 years, with painful lower extremity joint replacements (34 hip and 40 knee) were enrolled in the study. All underwent Tc99m‐HMPAO‐labelled leucocyte scan (LS) followed by Tc‐99m phytate colloid bone marrow scan (BMS) after 48‐72 hours. LS images were interpreted alone and in conjunction with BMS images. Increased periprosthetic leucocyte activity was considered compatible with infection. Activity on LS images without corresponding activity on BMS images (incongruent LS/BMS images) indicated infection, while congruent LS/BMS images suggested the presence of active bone marrow. Final diagnosis was
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 based on surgical, histological and bacteriological data or clinical follow‐up. Results: Among the 74 prostheses investigated, 25 infected (11 hip, 14 knee) and 49 uninfected (23 hip, 26.knee) prostheses were finally diagnosed. Overall sensitivity, specificity and accuracy of LS alone for diagnosing infected joint prostheses were 88%, 83.7 % and 85.1% respectively. In cases of knee prostheses, sensitivity, specificity and accuracy of LS alone were 92.8%, 84.6% and 87.5% respectively. The same parameters were 81.8%, 82.6% and 82.4% respectively, for hip prostheses. The addition of BMS was not improved the results of LS in cases of knee replacements. Sensitivity, specificity and accuracy of combined LS/BMS for diagnosing infected knee prostheses were 76.9%, 86.9% and 83.3% respectively. Conversely, in hip replacements the additional performance of BMS improved specificity and accuracy of LS from 82.6% to 94.4% and from 82.4% to 88.5% respectively, reducing false positive results on LS due to reactive or displaced bone marrow as a result of surgery.Conclusion: Tc99m‐HMPAO‐labelled leucocyte scan is a reliable imaging modality for differentiating aseptic loosening from infection of lower extremity joint prostheses. We suggest that Tc99m‐HMPAO‐labelled leucocyte scan should be the first radionuclide imaging performed in cases with painful lower extremity joint prostheses. Addition of bone marrow scan is useful in case of an uncertain positive leucocyte scan. However, in knee prostheses LS alone is usually accurate for establishing the correct diagnosis. Conversely, combined LS/BMS is the most optimal procedure to diagnose infection of hip prostheses.
P753 Malignant External Otitis(MEO):Scintigraphic tomographic studies(SPECT) with Tc-99m-MDP and Ga-67 in comparison of CT and MRI in elderly diabetic patients I. Armeniakos, X. Geronikola-Trapali, P. Karabina, V. Lyra, S. Bakalis, P. Zotou, A. Stefanoyiannis, A. Prentakis; University General Hospital "Attikon", Nuclear Medicine Department, Chaidari, GREECE. Aim: Malignant external otitis (MEO) is a benign but severe infective disorder,generally due to Pseudomonas aeruginosa,which most often affects elderly diabetics patients.The clinical features rarely permit exact diagnosis of MEO to be made prompty and initially at least they are difficult to distinguish from those of external otitis.Imaging has great diagnostic relevance:Routine radiographs are often negative,CT and MRI are very usefull for spatial resolution,while SPECT(Tc‐ 99m‐MDP and Ga‐67) are superior for detecting early osteitis and monitoring response to therapy. Materials and methods:The last three years 12 elderly diabetic patients( 9 men,3 women)(mean age 75 year from 68‐82 years) with the clinical diagnosis of MEO were referred for diagnostic imaging.All had unilateral ear pain and pseudomonas aeruginosa directed by in vitro testing.CT and MRI of the head and SPECT imaging of the cranial distributionof Tc‐99m‐MDP and Ga‐67. Results:All 12 patients underwent local and systemic antibiotic therapy for a minimum of 6 weeks.Five patients should total clinical resolution of inflammatory involvement. The remaining 7 patients showed incomplete clinical response to therapy.CT was abnormal and suggestive of osteomyelitis at the initial presentation in four of twelve patients studied.MRI also in nine to twelve patients. Eight patients were referred for follow up technetium and gallium scintigraphy after two months of systemic antibiotic therapy.Both Tc‐99m‐MDP and Ga‐67 SPECT were positive at the time of initial presentation in all patients.(100%sensitivity).Conclusion:Tc‐99m‐ MDP SPECT and Ga‐67 SPECT provide a more sensitive technicue than CT and MRI for the detection of temporal bone osteomyelitis,facilitates the diagnosis of malignant external otitis and provides a stronger indication than clinical suspicion for the aggressive therapy.Also SPECT images better define deep‐seated involvement obscured by overlying normal or abnormal bone and soft‐tissue activity.Gallium scintigraphy appears to be more specific for follow up evaluation of these patients.
P754 PET-CT scan with 68ga-citrate for the evaluation of the response to therapy in patients affected by discitis and osteomyelitis: preliminary results. L. Fantini, C. Nanni, C. Errani, L. Boriani, V. Allegri, P. Castellucci, G. Montini, V. Ambrosini, S. Nicolini, P. Caroli, C. Fuccio, C. Pettinato, A. Rizzello, R. Franchi, S. Fanti; Azienda Ospedaliero-Universitaria di Bologna, Sant' Orsola Malpighi University Hospital, Bologna, ITALY. Background and Aim: Since the 70’s, 67Ga‐citrate has been used in the diagnostic of inflammatory‐infectious diseases. 67Ga‐citrate scintigraphy presents some practical disadvantages and low quality images. A Ge/Ga generator has been recently commercialized. Ga68 is a positron emitting isotope with short half life, high‐energy photons, high spatial resolution, low costs, low dosimetry and short time procedure. Aim of the study: PET‐CT scan role using 68Ga‐citrate for the evaluation of the antibiotic therapy response in patients with discitis and osteomyelitis. Material and Method: 5 patients (mean age 44, 4 males and 1 female). 3 osteomyelitis (1 left knee, 1 left tibia, 1 right humerus) and 2 spondilodiscitis. Beside the standard diagnostic work‐up (including all or some of the following tests: MR, XR, bone scintigraphy, 67Ga scintigraphy, WBC scintigraphy, inflammation indexes), patients underwent a 68Ga‐citrate PET‐CT scan before and after therapy (systemic antibiotic ± surgical courettage). The clinical status was monitored for a mean time of 3 months after therapy. A mean dose of 165 MBq (range 100‐205) was slowly iv injected; uptake time was 60 to 90 min. Each exam was acquired for 4 to 6 min/bed position and the FOV was focused on the pathological area. Both a visual and a semi‐quantitative (SUVmax) assessment was performed. No complications. PET images of the two scans were analysed, interpreted and compared to each others, to the clinical status and to the standard diagnostic procedures carried out pre and post‐therapy by a nuclear medicine doctor. Each PET scan was called positive in case a focal area of visually increased tracer uptake was present in the site consistent with the infection. Results: All patients had a positive 68Ga‐citrate PET‐CT before therapy. Mean SUVmax was 6,2 in patients with discitis and 3,5 in patients with osteomyelitis. In all patients, post therapy PET‐CT showed a complete normalization of the tracer uptake in the flogistic areas. PET result was confirmed by the clinical status of the patient after therapy, and, when available, by the standard diagnostic procedures. Discussion and Conclusions: Although very preliminary, these data confirm the possible role of 68Ga‐citrate PET‐CT scan for the evaluation of the response to therapy in discitis and osteomyelitis, making it a possible tracer to be used in the diagnosis of bone infection and its response to therapy. Despite that, these are only preliminary results and must be confirmed by further data. Furthermore, a comparison to FDG will be important.
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Detection of vascular graft infections using Tc99m-HMPAOlabelled leucocyte scan S. Georga, I. Iakovou, D. Lo-Presti, A. Doumas, N. Karatzas; 3rd Dept of Nuclear Medicine, Aristotle University Medical School, Papageorgiou Hospital, Thessaloniki, GREECE. Introduction‐Aim: Infection of prosthetic graft is a relatively rare but serious complication of vascular surgery. Delay in establishing the correct diagnosis is associated with high morbidity and mortality. Therefore, early diagnosis of vascular graft infection is essential for successful treatment and clinical outcome. The aim of the study was to evaluate the value of Tc99m‐ HMPAO‐labelled leucocyte scan (HMPAO‐LS) for diagnosing infection of vascular grafts. Patients and methods: Twelve patients (all males, aged 63 ± 11.7 years) with clinical suspicion of vascular graft infection underwent HMPAO‐LS. There were 4 patients with aortic grafts, 6 with aortobifemoral, 1 with aortofemoral and 1 with ileofemoral grafts. HMPAO‐LS images were acquired 1, 2 and 4hours after injection of labelled leucocytes and occasionally 24h p.i. SPECT imaging was additionally performed in 4 patients. Focal increased leucocyte accumulation in the region of the vascular graft, greater than the surrounding blood vessels or the contralateral site, was considered as positive for infection. Final diagnosis was based on surgical and microbiological data or long‐term (at least 12 months) clinical follow‐up. Results : Among 12 vascular grafts investigated, 6 infected and 6 uninfected grafts were finally diagnosed. Increased leucocyte accumulation, compatible with infection, was observed in 5/12 patients. HMPAO‐LS results were as follows: TN 6, TP 5, FN 1, FP 0. HMPAO‐LS correctly diagnosed infection in 5/6 patients with surgically proven infections. The addition of SPECT imaging was helpful in the determination of the extent of infection, while the addition of 24h images was useful for detecting low grade infection in one patient with aortic graft. There was only one FN result in a patient with persistent low‐grade fever and surgically proven aortobifemoral graft infection, which may be attributed to slow rate of leucocyte accumulation at site of chronic low‐grade infection. All of the (6) patients who did not have infected grafts, as evidenced by long term clinical follow‐up, had negative scans.In our study, the sensitivity, specificity and accuracy of HMPAO‐LS for diagnosing vascular graft infection were 83.3 %, 100 % and 91.7 % respectively. The positive and negative predictive value of HMPAO‐LS were 100 % and 85.7% respectively. Conclusion: Our results suggest that Tc99m‐HMPAO‐labelled leucocyte scan, with an accuracy of 91.7%, is an effective imaging modality for establishing the presence or absence of vascular graft infection. Furthermore, the addition of SPECT imaging may improve localisation and determination of the extent of infection.
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difference in the median levels of ESR and CRP in the two groups. Antinuclear and other autoantibodies were positive in comparable proportions in the two groups. No significant difference was found between the two groups in the frequency of acute renal failure due to obstructive uropathy (respectively 35.7% and 44.4% of the cases). Disease relapses were observed in 6/14 patients (42.9%) with and in 6/27 (22.2%) without thoracic involvement, with a significant difference in relapse‐free survival using the Kaplan‐Meier method(p=0.04). CONCLUSIONS: Our data suggest that a subset of CP patients have a systemic large‐artery involvement and that they are at higher risk of relapse. FDG PET/CT plays an important role in the evaluation of the involved large vessels showing the disease extent and activity.
P758 Usefulness of Tc-99m Ciprofloxacin Scintigraphy in Diabetic Foot Infections D. Yörük Atík; Zonguldak Karaelmas Univercity, Zonguldak, TURKEY. Objectives: Tc‐99m ciprofloxacin which is a radiopharmaceutical localizing at sites of active bacterial infections has been used to image infection for almost nearly a decade. In this prospective study we aimed to evaluate the usefullness of Tc‐99m ciprofloxacin scan in diabetic foot infections. Materials and Methods: Twenty‐nine patients (13 women, 16 men) with suspected diabetic foot infection were included in the study. All patients had type II diabetes mellitus. All scans were performed within at least a two day interval. We compared the findings of ciprofloxacin scan, in combination with the data obtained from clinical outcome, four‐phase bone scan, Tc‐99m white blood cell scan and deep tissue biopsy. All images were interpreted visually. Results: In 29 patients, 36 sites of suspected infection were examined. Eighteen of them were evaluated as acute osteomyelitis (AOM), 8 as chronic osteomyelitis (COM), 7 were associated with soft tissue infection and 3 with noninfectious processes. According to these results ciprofloxacin scintigraphy defined all AOM lesions successfully. Two out of 8 COM, 5 out of 7 soft tissue lesions were clearly defined as well with Tc‐99m ciprofloxacin scan. Diagnostic accuracy of Tc‐99m ciprofloxacin scintigraphy in AOM, COM and soft tissue infections were found to be 100%, 25% and 71.4%, respectively. The sensitivity, specificity, positive predictive value and negative predictive value for acute osteomyelitis of Tc‐99m ciprofloxacin scan were found to be 100%, 75%, 90% and 100%, respectively. Conclusion: The diagnostic accuracy of Tc‐99m ciprofloxacin scintigraphy was found to be extremely high in acute osteomyelitis and soft tissue infections, but lower than expected in COM. We conclude that Tc‐99m ciprofloxacin might be a good candidate for diagnosis of acute osteomyelitis in diabetic foot.
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A Secondary F-18 FDG PET\CT Finding of Infection: Increased Spleen Activity
Diagnostic Value of Tc-99m MDP three phase bone and Tc99m labeled HMPAO white blood cell scintigraphies in musculoskeletal infection
T. A. Balci1, H. Komek2, Z. P. Koc1, H. Kaya3; 1Firat University Medical Faculty, Department of Nuclear Medicine, Elazig, TURKEY, 2State Hospital, Department of Nuclear Medicine, Diyarbakir, TURKEY, 3Dicle University Medical Faculty, Department of Nuclear Medicine, Diyarbakir, TURKEY.
M. Yıldız1, S. Sağlam1, T. Atay2, B. Baykal2; 1Süleyman Demirel University School of Medicine Departman of Nuclear Medicine, Isparta, TURKEY, 2 Süleyman Demirel University School of Medicine Clinic of Orthopaedic Surgery, Isparta, TURKEY.
Aim: Some secondary findings have been found in F‐18 FDG PET\CT studies, which were done for another reason. These findings are usually considered unexpected and unwanted but they may help in differentiating malignant process from infectious. Aim of this preliminary report is, as a new finding, to show the relation of the “increased spleen activity” and infection in F‐18 FDG PET\CT studies. Materials‐Method: We evaluated three patients who were referred for pulmonary mass evaluation to F‐18 FDG PET\CT scanning. One of the patients was referred for solitary pulmonary mass; two had primary malignity and suspicion of pulmonary metastasis. Results: For the patient with solitary pulmonary mass, there was significantly increased FDG accumulation in the lesion. The other patient with operated breast cancer showed mildly increased uptake in the pulmonary lesion. There was mildly increased uptake in the pulmonary lesion of the third patient with esophagus cancer. All of the patients treated as pneumonia. After reevaluation of their images, we noticed a secondary finding: increased spleen activity. We decided to increased activity by comparing liver to spleen ratio, which was given approximately 1.5‐2 in some literature. In our patients, however, spleen to liver ratio was approximately 1.5 times increased in spleen’s favour. Conclusion: A probable consequence of an infectious process in any part of the body may be increased splenic uptake in F‐18 FDG PET\CT study and guide us to infection rather than malignity.
Aim: The aim of this prospective study was to evaluate the value of Tc‐99m MDP three phase bone(TPB) and Tc‐99m labeled HMPAO white blood cell (WBC) scintigraphies in musculoskeletal infection. Bone infections are complex and detecting a muscle and/or bone infection may be difficult. The diagnosis of musculoskletal infection/inflammation is based on clinical presentation, tissue culture, laboratory investigations and organ imaging. Material and Methods: This study was include 21 patients (5 hip and 2 knee prostheses, 3 fixators, 3 fevers of unknown orgin,1 diabetic foot, 5 bone infections after travma and bone operation, 2 bone infections with clinical parameters). TPB and WBC scintigraphy have been performed to all patients.These scintigraphies have been performed 2 days interval. Final diagnosis of the infections was based on surgical, histological and bacteriological data and clinical follow up. Results: TPB was negatif uptake three patients and pozitif uptake on all other patients. TPB scintigraphy was false pozitive on three patients. Sensitivity, specificity and positive predictive value of TPB scintigraphy was found %94, %40 and %84 respectively. Fifteen of 21 patients showed pozitif accumulation in WBC scintigraphy (true pozitive), 2 patients were false negative. WBC scintigraphy sensitivity, specificity and positive predictive value have been found %88, %75 and %93 respectively. TPB scintigraphy is high sensitive metod but specificity is low. WBC scintigraphy together with TPB scintigraphy demostrated a higher specificity and positive predictive value when compared with TPB scintigraphy only (specificity %56, positive predictive value %88.5). Only 1 of these patients with diabetes mellitus. Pozitif uptake in TPB scintigraphy on bilateral tarsal bones and 1. phalax of right foot. But we showed radyotracer accumulation in WBC scintigraphy only 1. phalax of right foot. The findings on the bilateral tarsal bones were diabetic neuropathic arthropathy (charcot’s foot). One patient who had ülcers on the 4. and 5. phalaxes of left foot, false negative for both TPB and WBC scintigraphy. Conclusion: In this study we showed that WBC scintigraphy plus TPB scintigraphy have higher specificity and positive predictive value than compared with TPB scintigraphy only on the diagnosis of the musculoskelatal infection
P757 Large-vessel inflammatory pattern in chronic periaortitis: the role of FDG PET E. Calandri1, F. Giunta1, A. Vaglio2, A. Palmisano2, N. Pipitone1, C. Buzio2, C. Salvarani1, A. Versari1, D. Salvo1; 1AO S. Maria Nuova, Reggio Emilia, ITALY, 2University Hospital, Parma, ITALY. BACKGROUND: Chronic periaortitis (CP) is a rare disease, characterised by a fibro‐inflammatory tissue surrounding the abdominal aorta and the iliac vessels. Rare cases of involvement of the thoracic aorta and its major branches are also known. Aim of this study is to explore systemic large vessel involvement in CP patients. METHODS: 41 consecutive CP patients between 2003‐ 2007 were enrolled. CP was diagnosed by abdominal CT/MRI; all patients underwent routine laboratory tests including erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP), and a panel of autoantibodies. Whole‐body fluorodeoxyglucose (FDG) PET/CT was performed at the time of diagnosis in 36 patients, whereas the remaining 5 underwent whole‐body angio‐CT/MRI. All patients were treated with prednisone (PDN) for the first month and then continued with tapering PDN and/or immunosuppressants, according to ongoing protocols. The median follow‐ up period was 28 months (range 4‐58). RESULTS: The abdominal aorta and the iliac arteries were involved in all patients, as shown by CT/MRI (presence of a perivascular soft‐tissue mass) and PET/CT (increased FDG uptake). Fourteen patients (34.1%) also had involvement of the thoracic aorta or its branches: 9 had thoracic periaortitis, 2 thoracic periaortitis associated with pericarotid involvement, and 3 thoracic aortic aneurysm without periaortitis. PET‐CT showed increased FDG uptake around the thoracic aorta in 9/14 cases, and in the remaining 5 cases of thoracic vascular involvement were disclosed by angio‐CT/MRI. There was no significant
P760 Usefulness of SPECT/CT with 99mTc-HMPAO labeled leucocytes in the management of the diabetic foot: Preliminary study J. Cardona-Arboniés, E. Vañó Galván, J. Mucientes Rasilla, E. Capilla Cabezuelo, L. Izarduy, G. Salazar Andía, A. Prieto Soriano, R. DelgadoBolton, M. Gonzalez Vega, J. Carreras Delgado; Hospital Universitario Clínico San Carlos de Madrid, Las Rozas de Madrid, SPAIN. Introduction Diabetic foot is a frequent chronic complication of patients with diabetes mellitus, with a high sociosanitary cost (due to long hospitalization / rehabilitation) and morbility. Thus, prevention, early diagnosis and treatment are imperative. The main factors in the pathogenesis of diabetic foot are vasculopathy, neuropathy, orthopaedic factor and infection, particularly osteomyelitis, which determines prognosis and treatment. Aim The main aim of this study is to evaluate the usefulness of SPECT/CT with 99mTc‐HMPAO labeled leucocytes in the management of the diabetic foot. Material and Methods In 14 patients with symptoms and signs of
Poster Presentation
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neuropathic arthropathy referred to rule out osteomyelitis, we performed a SPECT/CT (G.E. Infinia Hawkeye 4), 2‐3 hours after the injection of 370 MBq 99mTc‐HMPAO labelled leucocytes, obtaining tomographic SPECT images, CT and fusions, and evaluating abnormal uptake in bone or soft tissues. In these same patients, and in an interval not longer than 5 days, we performed a MR scan. In 4 patients a second SPECT/CT were performed in order to evaluate the treatment. As a validation method we performed a clinical follow‐up in which we evaluated outcome, treatment received and cultures. Results Clinical follow‐up proved a correct diagnosis with SPECT/CT in all the patients of this study, but in one patient there were technical problems because of the patient´s movement. Osteomyelitis was proved in 8 patients (prevalence of 53%). Taking into account the clinical follow‐up, SPECT/CT improved significantly the MRI diagnostic information in 9 patients, confirming, excluding or modifying the extension of the osseous or soft tissue infection. A new SPECT/CT was carried out in 4 patients after 1 to 2 months of treatment. Improvement in the recovery of deposits was observed with regard to the previous study. Conclusions The SPECT/CT with 99mTc‐HMPAO labeled leucocytes has proven to be a very efficient tool when treating the diabetic foot. Not only in order to determine the appropriate treatment, but for monitoring purposes as well. The SPECT/CT with 99mTc‐HMPAO labeled leucocytes completes the non specific findings in the MRI, such as the edema and the enhancement of the contrast between the bone and the soft tissue.
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TL-Chloride scintigraphy in the differential diagnosis of inflammations and malignant neoplasms of locomotor system V. D. Zavadovskaya1, A. P. Kourazhov1, O. Y. Kilina1, O. V. Rodionova1, E. Choinzonov2, V. I. Chernov2, E. Slonimskaya2, A. Bogoutdinova2; 1Siberian State Medical University, Tomsk, RUSSIAN FEDERATION, 2Institute of oncology, Tomsk, RUSSIAN FEDERATION. Purpose: evaluation of the differential diagnostics efficacy of non‐specific inflammatory and 199 malignant neoplastic processes of locomotor system using Tl‐chloride scintigraphy. Material and methods. 57 patients (26 males, 31 females, aged 10‐88 years) with 71 focuses of either inflammatory (n=36) or tumoral (n=23) locomotor system diseases or absent of them (n=12) were studied. The results were verified morphologically (n=57), compared with X‐ray study (n=62), ultrasonography (n=24), CT (n=22), MRI (n=9), 3‐phase bone scan (n=11), WBC‐ scintigraphy (n=5). Planar scan (67 focuses) and SPECT (4 focuses), including intravenous injection 185MBq 199Tl‐chloride for adults or 1.85MBq/kg for children, were performed in the early (20 min) and delayed (180 min) phases. Visual and quantitative evaluations were performed. Sharp contours of thallium‐199 accumulation’s focuses were estimated visually. Quantitative evaluation included definition of ER and DR (ratios «lesion/contralateral or adjacent intact region» in the early and delayed phases of scintigraphy, respectively), and retention index (RI=DR/ER). Results. The lesions were visualized in 56/59 (94.9%) causes (33/36 ‐ inflammations, 23/23 ‐ malignant neoplasms). The sharpness of the focus’s contours of thallium‐199 accumulation in the early phase scintigraphy was bigger than in the delayed phase in the inflammations, otherwise in the tumors. Structure of the thallium‐199 accumulation’s focuses in inflammations was usually homogeneous, otherwise in the tumors. There were correlations between ER and RI in the inflammations (r=‐0.74, p<0.05) and the tumors (r=‐0.35, p<0.05). There were differences between the regression patterns in the inflammations and the malignant tumors (RI=‐ 0.050ER+0.892 and RI=‐0.044ER+1.066, respectively). Thus, the quantitative border between the inflammatory and the malignant neoplastic processes was obtained: RI=‐0.047ER+0.979. The signs of the inflammatory processes were: 1) bigger sharpness of the focus’s contours of 199Tl‐ chloride accumulation in the early phase scintigraphy compared with delayed phase, 2) homogeneous structure of 199Tl‐chloride accumulation focus’s, 3) RI<‐0.047ER+0.979. Inflammatory processes were diagnosed in the presence of no less than two of three these signs, otherwise malignant neoplastic processes. Summary, sensitivity, specificity and accuracy of 199Tl‐ chloride scintigraphy in the detection of the inflammatory processes were 91.7%, 88.6% and 90.1%, respectively. Sensitivity, specificity and accuracy in the detection of the neoplastic processes were 91.3%, 95.8% and 94.4%, respectively. Differential diagnosis of inflammations and malignant neoplasms was succeed in 54/59 (91.5%) causes. There were difficulties in the differential diagnosis of the metastatic lesions and the chronic inflammatory processes. 199 Conclusion. Tl‐chloride scintigraphy showed high efficacy of the differential diagnosis of the non‐specific inflammations and malignant neoplasms of locomotor system.
P762 WBC-scintigraphy and sonography inflammatory changes in joints
in
revealing
the
O. Y. Kilina, M. A. Zorkaltsev, N. L. Klimentenko, V. D. Zavadovskaya; Siberian State Medical University, Tomsk, RUSSIAN FEDERATION. Purpose: to compare the results obtained by the WBC‐99mTc‐Nanocolloid scintigraphy (WBC‐ 99m Tc‐Nanocolloid) and the sonography (SG) of the RA ‐patients' joints. Materials and methods: 23 RA‐patients (15 female and 8 male of mean age of 43.4±4.5 years) meeting the ARA criteria have been surveyed with the use of both the WBC‐scintigraphy (740MBq) and the SG. A condition of patients' knee and ankle joints (totally, 92 joints) have been analyzed. Results. In WBC‐ scintigraphy, an uptake of radiotracer has been found in 54 of 92 joints. Two types of the radiotracer distribution in knee and ankle joints have been revealed: (i) diffusive distributions of which correspond to a widespread uptake of radiotracer observed in a joint projection (n=14), and (ii) local distributions which demonstrate a local uptake of radiotracer in the articulate cavities projection (n=40). The WBC‐scintigraphy results and the clinical survey data agreed well in 89% cases. In 20% of clinically inactive joints, an uptake of radiotracer has been found. In 1% of clinically active joints, the radiotracer uptake was not found. The sensitivity and the specificity of WBC‐scintigraphy in revealing the sinovitis are estimated as 98 % and 97 %, respectively. The SG of knee and ankle joints has been carried out at all the patients. The presence of synovitis sonographic signs (a sinovial layer proliferation and liquid in a joint cavity) are found in 36 joints. In most (26) cases, a diffusive proliferation was observed, while a focal one was presented in 8 observations, only. In 2 of 36 cases, a small amount of liquid in a joint cavity without the sinovial layer proliferation signs was observed. The SG sensitivity and specificity in revealing the sinovitis is estimated as 73 % and 96%, respectively. The WBC‐scintigraphy and SG data agree well in 80 % of cases. By the WBC scintigraphy, in 20 % of joints without sonographic sinovitis signs an uptake of radiotracer is found. Also, the WBC‐scintigraphy has revealed the local distribution of radiotracer in the majority of patients (in 30 of 34) with both the diffusive proliferation and the
focal sinovial layer proliferation. Conclusion: The WBC‐scintigraphy is of greater sensitivity in the visualization of inflamed joints at RA‐patients than the SG. The local uptake of radiotracer in articulate cavities observed by the WBC‐scintigraphy can be associated with the presence of the sinovial layer proliferation that are detected by the SG.
P763 Assessment of disease activity with FDG-PET/CT rheumatoid arthritis after biopharmaceutical therapy
in
M. Nisho1, T. Tamaki2, K. Omi3, M. Takeuchi4, H. Takagi4, M. Hara5, Y. Shibamoto5; 1Nagoya PET Imaging Cneter, Nagoya, JAPAN, 2Nagoya East Imaging diagnosis Cneter, Nagoya, JAPAN, 3Nagoya East Imaging diagnosis Center, Nagoya, JAPAN, 4Nagoya Kyouritsu Hospital, Nagoya, JAPAN, 5Nagoya City University, Nagoya, JAPAN. Purpose: Biopharmaceutical products have proven to be efficacious in the treatment of rheumatoid arthritis (RA), but methods for evaluation of treatment efficacy have not yet been well established. Clinical assessment of remission, including serum markers, does not appear to be completely reliable. FDG‐PET has been reported to be a sensitive non‐invasive method to visualize disease activity in RA. The purpose of this study was to evaluate the usefulness of FDG‐ PET for the decision of terminating the biopharmaceutical treatment in RA patients who achieved clinical remission. Methods: 15 RA patients with a disease activity score (DAS) > 5.1 despite the use of disease‐modifying anti‐rheumatic drugs were investigated. DAS‐28 scores were obtained before and at 6,12 and 24 months after the initiation of treatment. Following i. v. injection of 270 MBq FDG, PET scans of the whole body and hands and wrists were performed before and at 6,12 and 24 months after the treatment. PET data were compared with clinical data. Results: All patients had various degrees of accumulation of FDG in some joints. Interestingly, accumulation was also seen in joints without any symptom. All the joint accumulation decreased to various extents with the improvement of the symptom after treatment. In one case, slight accumulation persisted in hand and knee joints after treatment despite clinical remission. Based on the clinical complete response, treatment was stopped, but the joint symptom recurred within 1 month. This case indicated that clinical assessment alone is not sufficient for judgment of remission and imaging assessment may be important for decision of treatment termination. Conclusion: FDG‐ PET appears to be useful for evaluation of the efficacy of RA treatment and for deciding the termination of biopharmaceutical treatment.
P764 Comparision of three phase bone scintigraphy and Tc-99m ciprofloxacin scintigraphy for the diagnosis of the septic and aseptic prosthesis loosening S. Karyagar1, T. Ozpacacı1, M. Mulazımoglu1, E. Uyanık1, S. Ergur2, R. Uslu1, S. Erol1; 1Okmeydanı Training and Research Hospital, Istanbul, TURKEY, 2Denizli Training and Research Hospital, Denizli, TURKEY. Purpose: The results of three phase bone scintigraphy and Tc‐99m ciprofloxacin scintigraphy were assesed comperatively in the septic and aseptic loosening diagnosis. Material and Method: 50 patients those were referred to our clinic with the infection pre‐dignosis were included to the study. 38 of the patients (% 76) were women and 12 of them (% 24) were men, with an average age of 61 (33‐87). 32 of the patients (% 64) had hip prothesis, 18 of them (% 36) had knee prothesis. The detailed anamnesis info, labaratory findings, histopathological and bacteriological results of all patients, included in the study were recorded and for all the patients in the study group and three phase bone scintigraphy and Tc‐99m ciprofloxacin scintigraphy were applied at least 3‐5 days cessation in our clinic. Results: Three phase bone scintigraphy applied to 50 patients was reported as, 23 of them (% 46) positive and 27 of them (% 54) negative in terms of infection. Tc‐99m ciprofloxacin scintigraphy applied to 50 patients was reported as, on 19 of them (% 54) positive and on 31 of them (% 62) negative. The definite diagnosis was realized by the aspiration liquid and/or by the microbialogical culture results taken during the operation on 18 of the patients (% 36), while on 32 of them (% 54), it was realized by clinical following findings taken at least 6 at most 26 months cessation (13,3 ± 5,6 months). When the results of the operations and the results obtained by the clinical followings accepted as gold standart, the sensitivity and specifity for the three phase bone scintigraphy was found to be % 100 and % 77,5. It was % 86,6 and % 82,8 (P<0,05) for the Tc‐99m ciprofloxacin scintigraphy. Positive predictive value was % 65,2 to % 68,4 (P>0,05); negative predictive value was % 100 to % 93,5 (P<0,05); accuracy was % 84 to % 84 (P>0,05).Conclusion: According to the results we obtained from all patients carrying prothesis infection doubt, the three phase bone scintigraphy can be used safely on retracting the infection occurrance. Since the specifity of Tc‐99m ciprofloxacin scintigraphy is higher when compared to three phase bone scintigraphy, for the patients assesed in terms of septic‐aseptic loosening separation, the use of both methods is appropriate.
P80 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: haematology
P765 Influence of overweight on red cell mass results : definition of new thresholds for polycythaemia diagnosis. J. Riedinger, C. Touzery, A. Berriolo-Riedinger, M. Toubeau, A. Cochet, I. Dygai Cochet, M. Mantelin, B. Collin, F. Brunotte; Centre Georges François Leclerc, Dijon, FRANCE. Background. The aim of this study was to assess, for red cell mass (RCM) expressed in ml/kg of real body weight (RCMw), reference ranges and thresholds specific to the overall population and subgroups of patients defined by their index of overweight (IO) (<‐5%; ‐5% to +5%; +5% to +15%; +15% to +25%; +25% to +35%; +35% to +45%; +45% to +55%; >+55%). Patients and methods. We retrospectively reviewed 323 consecutive males referred for RCM determination with Cr‐51 red blood cell labelling between 1997 and 2008. Optimal values of RCM were determined using
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P766 Non-myeloblative radioimmunotherapy as consolidation treatment after remission induction for a patient with relapsed CD20 positive B-cell non-Hodgkin’s lymphoma L. Tran1, A. Huitema2, J. de Boer3, C. Hoefnagel3, H. Maessen3, M. Kersten4, J. Beijnen2, J. Baars3; 1Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital-Slotervaart Hospital, Amsterdam, NETHERLANDS, 2 Slotervaart Hospital, Amsterdam, NETHERLANDS, 3Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, NETHERLANDS, 4 Academic Medical Center, Amsterdam, NETHERLANDS. Aim Radioimmunotherapy is a target‐oriented strategy for the treatment of CD20 positive B‐cell non‐Hodgkin’s lymphomas (NHL). In this study, the CD20 targeted monoclonal antibody rituximab was coupled to 131Iodine for non‐myeloablative radioimmunotherapy. We here report the feasibility and pharmacokinetics of this approach in the first patient. Material and Methods Eligible were patients with CD20+ B‐cell NHL who relapsed after one or more lines of treatment. Patient received a remission induction treatment of three cycles. Full restaging was conducted after the second cycle. In case of a partial or complete remission non‐myeloablative radioimmunotherapy consisting of 3700 MBq 131I‐rituximab was scheduled. A diagnostic dose of 185 MBq of 131I‐rituximab was administered intravenously, after infusion of 2.5 mg/kg unlabeled rituximab. Sequential whole body images were performed to estimate radiation dose. 131I‐ rituximab dose (maximum 3700 MBq) was calculated based on a total body dose of 75 cGy. Blood and urine samples were collected for radioactivity measurements, moreover serum levels of unlabeled rituximab were measured by an enzyme‐linked immunosorbent assay. Whole body imaging scans were performed daily. The patient was discharged when the dose rate was below 20 μSv/hr on 1 metre distance. Hematological assessment with full blood counts and thyroid function monitoring was carried out weekly. Results The patient was a 65 year‐old male with a relapsed follicular CD20+ B‐cell NHL. After two cycles of induction treatment a partial remission was obtained with remaining lesions in the right axilla. Dosimetric calculations determined a maximum therapeutic dose of 1000 MBq for administration. The patient was nursed at a radiation protected isolation room with waste storage facility for 6 days. Subsequently, scans were performed at 24, 48, 72, and 138hrs.These scans showed a pathological accumulation in the right axilla (Table 1). We found an effective half‐life of 131I‐rituximab of 6.25 days and a biological half‐life of 28.5 days. Unlabeled rituximab had a half‐life of approximately 30 days. Toxicity was principally hematological; anemia (grade 1), trombocytopenia (grade 1), neutropenia (grade 3‐4), and leucopenia (grade 3) was observed. Additionally, an elevated thyroid stimulating hormone level was present during 4 weeks after administration of the therapeutic dose of 131I‐rituximab. Conclusion Biological half‐life of 131I‐rituximab corresponded to the half‐life of unlabeled 131 rituximab. Analyis of urine samples confirmed the in vivo stability of I‐rituximab. Whole body scans demonstrated localization of 131I‐rituximab in the tumor area, which supported the specific targeting of 131I‐rituximab. Table 1 Results from the total body scans/urine samples
collected 30 health normal controlled cases due to health check‐up. Sixty malignant underlying patients, whose initial diagnostic TNM stage was above stage II, or suspicion of malignance were included. All of them received standard protocol of FDG PETCT by GE 16 DST. Imaging was interpreted by two experienced nuclear medicine physician. The femoral SUVmax was calculated by Xeleris program system. The statistic analysis was compared by student t test. Results: The average of SUVmax of femoral FDG activity is 0.5 to 0.8 and always bilateral symmetrical pattern in health normal controlled group. There is higher average of SUVmax of femoral FDG activity up to 0.8 to 1.5 among the malignant follow‐up group. Statistic significance (p< 0.01) is noted. Most imaging pattern of femoral reactive marrow is symmetrically increased activity on FDG PETCT. Focally spotty high grade of FDG avidity (SUVmax up to 2.0) in femoral marrow cavity should be carefully suspicious as neoplasm metastasis, especially accompanied with other axial bone/ marrow metastasis. Conclusion: There is statistic significance of FDG avid peripheral femoral marrow activity between health controlled and malignant follow‐up group, especially in distal metastasis. We would clarify the etiology in future. Focally spotty high grade of FDG avidity in femoral marrow cavity and additional other bone marrow involvement should be carefully suspicious as neoplasm metastasis.
P768 51-Cr labelled red blood cells (RBC) kinetics in paroxysmal nocturnal hemoglobinuria (PNH) patients with suboptimal response to the complement inhibitor eculizumab: physiopathologic insights and therapeutic suggestions P. Tabacco1, A. M. Risitano2, E. Seneca2, L. Marando2, F. Barbano1, G. Valle1, G. Ritrovato1, A. M. Carella3, B. Rotoli2; 1Nuclear Medicine, Research Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo, ITALY, 2 Hematology, Department of Biochemistry and Medical Biotechnologies, Federico II University, Napoli, ITALY, 3Hematology, Research Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo, ITALY. Background & Aim: PNH is a hematological clonal disorder characterized by the lack of the glycosylphosphatidylinositol‐anchored surface proteins including the complement regulators CD55 and CD59. This makes RBC vulnerable to activated complement, resulting in chronic intravascular hemolysis. Recently, Eculizumab, a humanized monoclonal antibody against complement fraction 5 (C5), demonstrated to be useful in the therapy of transfusion‐dependent PNH due to the inhibition of the membrane attack complex (MAC) formation. Aim of our study has been the evaluation of the kinetics of RBC in subjects with suboptimal response to Eculizumab in order to verify the hypothesis of an extravascular hemolysis mediated by effector mechanisms other than MAC. Patients and methods: Three patients with uncomplete response to Eculizumab while still on treatement underwent a 51‐Cr RBC survival study. All subjects were included in a larger study (in press) that demonstrated a C3 coating of RBC of all PNH Eculizumab treated patients. Briefly, radioactivity was recorded in RBC samples drawn up to the tenth day after reinjection of autologous RBC labelled with 3.1 MBq of sodium chromate (51Cr) allowing the determination of the RBC life half‐time. Meantime radioactivity determinations were recorded in selected areas over liver, spleen and heart allowed the plotting of spleen and liver time/activity curves and the calculation of the spleen/liver (S/L) erythrocatheresis ratio. In one patient the procedure was repeated after splenectomy. Results: All the 3 patients showed a complete blockade of intravascular hemolysis. However, none of them achieved the normalization of Hb level. The three patients, while on eculizumab, showed markedly reduced (10 days) RBC half‐life with excess counts on spleen and liver despite the S/L ratio resulted normal. All the 3 patients showed a large fraction of PNH (CD59‐) RBCs which were bound by C3. Our hypothesis of ongoing extravascular hemolysis was also confirmed by the increase in bilirubinemia and erythropoiesis. A paradigmatic patient who underwent splenectomy got transfusional independence and hemoglobin level normalization, definitively proving the extravascular nature of such residual hemolysis. Discussion: Our data demonstrate that in patients with suboptimal response to Eculizumab an extravascular hemolysis is present both in liver and spleen, possibly consequent to C3 RBC binding and subsequent entrapment in the reticulo‐endothelial system through the complement receptors. Consequently, it is reasonable to hypothesize that Eculizumab suboptimal responders can benefit from additional therapeutical strategies targeting the extravascular hemolysis, such as splenectomy or low dose steroids.
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Total body retention
Total radioactivity in collected 24‐hrs urine (corrected for decay)
(hours) (% of injected dose)
(% of injected dose)
(MBq)
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24
0.17
104
47.4
Usefulness of isotopic lymphography in the lower limb edema
48
0.21
103
48.6
72
0.19
92
47.1
138
0.2
92
29.5
Time
Radioactive uptake in right axilla
P767 Does reactive marrow activity in femoral shaft provide the detection sensitivity of neoplasm relation on FDG PETCT? Y. Chen1, Y. Lai1, M. Yu2, M. Hou3; 1Kaohsiung Medical University Hospital, Department of Nuclear Medicine., Kaohsiung, TAIWAN, 2Kaohsiung Medical University Hospital, Department of Internal Medicine, Kaohsiung, TAIWAN, 3 Kaohsiung Medical University Hospital, Department of Surgery. Cancer Center, Kaohsiung, TAIWAN. FDG PETCT is the sensitive imaging modality to evaluate marrow metabolism. Reactive marrow activity in femoral shaft is not rare finding in malignant follow‐up on FDG PETCT. According to this issue, we will compare the SUVmax of FDG in femoral marrow cavity between adult health normal controlled and malignant group. The imaging pattern of FDG avidity in bilateral femoral marrow cavity will be analysis and discussed. Patients and Method: During period of time, we
Clinical Science: lymphoscintigraphy
M. P. Orduña, E. Aracil, J. M. Castro, V. Castillo, A. Crespo; Ramón y Cajal Hospital, Madrid, SPAIN. Aim: To analyze the clinical usefulness of the lymphoscintigraphy in patients with lower extremity edema. Materials and methods: Thirty patients, 25 women and 5 men, with lower extremity edema, were seen at Vascular Surgery service. They all showed a normal eco‐doppler of the lower limbs. After that, the patients underwent to a lymphoscintigraphy of the lower extremity. Technetium 99m nanocolloid was inyected subcutaneously (activity:2x185 MBq/0.2ml) and images were obtained at 30 and 120 minutes. The scintigrams were analyzed for visualization of lymph vessels and lymph nodes, lymphatic morphology (hiperplasy and hipertrophy), dermal backflow and radioactive isotope migration time. Results: After the qualitative interpretation we found: A) 12 patients with normal bilateral lymphoscintigraphy. B) 9 patients showed unilateral abnormal lymphatic function. C) 6 patients without unilateral radioactive isotope migration from the inyection point. D) 3 patients with bilateral abnormal lymphatic function. A group was diagnosticated of lipedema or ortostatic edema. B and D groups was treated with postural mesures and compression stockings. C group was diagnosticated of primary/secundary lymphedema and derivated to a rehabilitation service. Conclusion: the lymphoscintigraphy is very useful in the discovery of lymphatic abnormalities. It helps to establish a proper treatment in each case.
Poster Presentation
RCMw method and Pearson’s table (RCMP). Patients with RCM above 125% of RCMP are considered as polycythaemic and the cut‐off used with RCMw method was 36 ml/g. RCMw values were correlated with ΔRCM(%) calculated as follows ΔRCM=(RCM‐RCMP)/RCMP in overall population and each subgroup. Regression equations were used to calculate optimal RCMw values and their 98% confidence interval corresponding respectively to RCMP and 125% and 75% of RCMP value. Receiver operating characteristics curves (ROC) were used to define the thresholds of RBCW in view of differentiating of normal and polycythaemic patients. Results. There was a high prevalence of overweight in males (60.0%). On the overall population RCMw and Pearson’s methods disagreed in 20.1% of cases. A half of polycythaemic patients have a RCMw under 36 ml/kg. The disagreement rate increased with the degree of patient overweight (p<0.0001). In the overall population a RCMw of 36 ml/kg correspond to a ΔRCM equal to +39.8% (instead of +25%), RCMw optimal values were equal to 25.6 ml/kg (instead of 30 ml/kg) and optimal cut‐of was of 32 ml/kg (instead of 36 ml/kg). In the different subgroups a RCMw of 36 ml/kg correspond to ΔRCM ranging from +26% to +61%, RCMw optimal values ranged from 22 to 29 ml/kg and optimal cut‐of ranged from 28 to 37 ml/kg. Using these specific thresholds polycythemia is predicted with an accuracy of 98% versus 80% and 91% using a cut‐of value respectively equal to 36 and 32 ml/kg . Conclusion. Overweight is a common confounding factor is the interpretation of RCMw values. The threshold value of 36 ml/kg should be abandoned. Only the use of specific thresholds to the degree of overweight allows the diagnosis of polycythemia with an accuracy of 98 %.
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P770 The role of lymphoscintigraphy in the evaluation of lower extremities edema A. Balsa, P. Garcia, C. Paniagua, A. Mariana, S. Vasquez, F. J. Penin, C. PEY; Hospital Universitario de Getafe. Nuclear Medicine, Getafe. (Madrid), SPAIN. Lymphedema is the abnormal accumulation of interstitial protein‐rich fluid caused by a congenital malformation (primary lymphedema) or as a result of lymphatic obstruction or disruption (secondary lymphedema) of the lymphatic vessels. Diagnosis of lymphedema, particularly in more advanced stages, is typically made trough clinical presentation and history. Earlier stages, however, can be more difficult to differentiate from other common causes of limb edema. The purpose of this study was reviewing the results of lymphoscintigraphy in patients with suspected to have lymphedema of the lower extremities. Patients: 202 patients (145 F, 57 M), complaining of swelling one or both lower extremities were studied. 28 patients had associated pathologies: 9 neoplasms, 7 venous pathology, 3 leg trauma and 9 other possible causes of lymphedema. Method: The lymphoscintigraphy studies were performed by interstitial injection of 74 MBq (2 mCi) 99mTc‐Sulphur microcolloid or nanocolloid, divided into two equal portions of 0.1 ‐ 0.2 ml, into the first web space of both feet. Whole body images were obtained at 20 minutes and 2‐4 hours after injection. Qualitative assessment of images was performed. Criteria for the diagnosis of lymphatic dysfunction include delay, asymmetric or absent visualization of regional lymph nodes, dermal blak‐flow, asymmetric visualization of lymphatic channels, collateral lymphatic channels, interrupted vascular structures and visualization of the lymph nodes of the deep lymphatic system (i.e popliteal lymph nodes).The diagnostic categories ranged from: normal, hypoplastic, aplastic, “hyperplastic” or megalymphatics and dermal back‐ flow. Results: In 49 patients there were no signs of lymphedema. In 153 patients the presence of lymphedema was diagnosed. In 70/153 patients hypoplastic or aplastic lymphedema was found and “hyperplastic” in 55/153. In 28/153 patients dermal back‐flow was the main finding observed. In all patients with neoplasm and in 5 patients with vascular problems in lower extremities, lymphatic involvement was showed by scintigraphy. Conclusion: In patients with limb swelling, lymphoscintigraphy is a noninvasive, simple and useful procedure in the differential diagnosis of lymphedema from other sources of edema.
P771 Is there potentially internal mammary lymph metastasis in breast cancer? comparison study between presurgery sentinel lymphoscintigraphy and follow-up FDG PET CT. Y. Chen1, C. Chang1, F. Chen2, M. Hou2; 1Kaohsiung Medical University Hospital, Department of Nuclear Medicine, Kaohsiung, TAIWAN, 2Kaohsiung Medical University Hospital, Department of Surgery., Kaohsiung, TAIWAN. Presurgery sentinel lymphoscintigraphy provides localization of sentinel nodal biopsy and direction of lymphatic drainage from localized quadrant of breast tumor. In this study, we compare the result of prior sentinel lymphoscitigraphic nodal localization/ nodal stage with follow‐up FDG PETCT to demonstrate potential risk factor of tumor localization in inner quadrants. Since 2003 to 2007 duration, we enrolled forty‐two breast cancer patients who had initial presurgery sentinel lympho‐scintigraphy and follow‐up FDG PETCT under suspicious recurrence. The mean duration of both exams was 12 to 24 months. All of them were not palpable axillary lymph nodes and tumor size under 4cm when initial diagnosis. The presurgery sentinel lymphoscintigraphy was based on our hospital protocol as peritumor/ subdermal injection technique of Tc99m sulfur colloid and vertical 90 degree dual imaging at 30 min to two hr (Siemens E. CAM). Sentinel lymph node biopsy and axillary lymph node dissection were performed simultaneously. Follow‐up FDG PETCT was done as dual phase study by GE 16 DST. There are 35 % patients with tumor localization in inner quadrants of breast. The detection rate of presurgery sentinel lymphoscintigraphy is 95%. Only two of patients have both axillary and internal mammary lymph nodal activity, the rest of them with axillary nodal activity. In our study, true positive nodal metastasis is around 20% after surgery. Thirteen patients (30%) were diagnosed locoregional nodal and distal bone metastasis by follow‐up FDG PETCT. Half of them (53%) with original tumor in inner half of breast have axillary nodal activity of presurgery lymphoscitigraphy, except one without detectable nodal activity and nodal negative. Presurgery sentinel lymphoscintigraphy of inner quadrants localization of breast cancer is not consistent with prediction of internal mammary nodal activity, in additional final axillary nodal stage is negative. Potentially risk of metastasis via indistinct internal mammary lymph spreading, FDG PETCT should be considered the choice of follow‐up in inner quadrants localization of breast cancer first.
P772 The Value of Sentinel Lymph Node Biopsy in Squamous Cell Carcinoma of Head and Neck U. Yararbas, M. Argon, A. Aliyev, S. Akyıldız; Ege University Hospital, Izmir, TURKEY. Aim: The aim of the study is to evaluate the value of sentinel lymph node biopsy (SLNB) in N0 squamous cell carcinoma of head and neck. Material and Method: A total of 24 neck dissections were conducted in 22 patients (7 female, 15 male). Mean age of the patients was 56.5. Twelve of the patients had lower lip and oral cavity cancer (Group A) and 10 patients had larynx cancer (Group B). Tc‐99m nanocolloid was injected submucously at 4 quadrants around the tumor. Each injection contained 0.25 mCi radiocolloid in 0.2 ml. Radiocolloid injection was performed the day before surgery in Group A and just before the operation after the induction of the general anesthesia in Group B patients. Group A patients were imaged 30 minute after the injection at anterior and lateral projections. All patients underwent gamma probe guided SLNB following primary tumor excision. SLNB was then followed with appropriate neck dissection according to the tumor characteristic. Sentinel lymph nodes (SLN) were evaluated with frozen section. Results: In Group A SLNs were successfully imaged in 11 of 12 cases on lymphoscintigraphies. Gamma probe detected SLNs in all patients in this group. In Group B gamma probe detected SLNs in 10 of 10 patients. In 22 patients a total of 77 SLNs were harvested (mean: 3.2). Seven SLNs of 6 patients were malignant according to frozen section analysis. Among 22 patients false negative
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 SLN was detected only in 1 larynx cancer patient. No discordance was detected between frozen section and final pathology report. Among patients with positive SLNs 3 had metastasis only in SLNs. When 24 neck dissections were taken into consideration; negative predictive value was calculated as 97.7% and positive predictive value as 100%. Conclusion: Results of our study shows that SLNB can replace neck dissections in N0 squamous cell carcinoma of head and neck.
P773 Lymphoscintigraphic evolutions of primary lymphedemas: retrospective review of 11 cases.
lower
limb
P. Bourgeois, J. Belgrado, S. Michelini, D. Munck, T. Lambert, O. Leduc, A. Leduc; Jules Bordet, Brussels, BELGIUM. Background: The diagnosis of primary lower limb lymphedema is usually based on clinical data and they are associated with several lymphoscintigraphic abnormalities. However, there are few data concerning how the lymphatic system is evolving in these patients. Aim of the study, material and methods: 11 patients (10 women and one man: age ranging from 11 to 65 years: 7 with bilateral edema: 2 with unilateral edema: one with right and later left edema: one with left then bilateral edema) were reviewed for whose we had 2 or 3 lymphoscintigraphic investigation of the lower limbs (3 investigations in 3 subjetcs: minimum interval between first and last investigation = 22 months: maximum interval = 12 years) and we tried to identify some specific evolutions based on these pictures. Abormalities observed at the time of the first investigation (11 patients and 18 limbs): Decreased extraction of the tracer at the level of the injected sites: 4 patients and 5 limbs Popliteal lymph nodes present: 4 patients and 6 limbs LN absent: 7 patients and 11 limbs Dermal back flow from inguinal nodes: 2 patients and 2 limbs Peripheral superficial collateralisation: 2 patients and 2 limbs Kinds of evolution observed (10 patients and 18 limbs: one case unchanged): Decreased extraction of the tracer at the level of the injected sites: 7 patients and 9 limbs Appearance of popliteal lymph nodes: 1 patient and 2 limbs Disappearance of LN or progression of LN disappearance: 5 patients and 8 limbs Dermal back flow from inguinal nodes: 2 patients and 2 limbs Development or extension of superficial dermic collateralisation: 5 patients and 8 limbs Abormalities observed at the time of the last investigation (11 patients and 19 limbs): LN absent: 9 patients and 16 limbs Decreased extraction of the tracer at the level of the injected sites: 9 patients and 13 limbs Peripheral superficial collateralisation: 6 patients and 8 limbs Popliteal lymph nodes present: 5 patients and 8 limbs Dermal back flow from inguinal nodes: 2 patients and 2 limbs Conclusion: In this limited series of patient with primary LL lymhedema, the first and main abnormality seems to be the involution of LN. Decreasing lymphatic extraction of the tracer then follows with the development or extension of superficial dermic collateralisation.
P774 Lymphoscintigraphic abnormalities in primary "praecox" lower limb edemas P. Bourgeois, J. Belgrado, D. Munck, T. Lambert, C. Becker, O. Leduc, A. Leduc; Jules Bordet, Brussels, BELGIUM. Background: Primary (1ary) “praecox” Lower Limb Lymphedemas (LLLE) occur in patients not older than 35 years and their diagnosis is usually “easy”, based on clinical data. They are associated with several lymphoscintigraphic (Lysc) abnormalities but the “specifities” of these Lysc criteria are not well established. Aim of the study, material and methods: Thus, we analyzed the Lysc abnormalities present in 58 patients with “unmistakable” primary “praecox” LLLE and, in order to approach their sensitivities, we checked them amongst our population of patients not older than 35 years who were refered for evaluation of lower limb edema(s) of undefined etiology. Results Decreased extraction (DE) of the tracer was present in 53 patients with 1ary praecox LLLE (91.4%) and associated with peripheral superficial collateralisation (PSC) in 38 (65.5%), lymphatic reflux in 1 (1.7%) and popliteal lymph nodes (LN) in 11 (19%). On the other hand, DE was normal in 5 patients (8.6%) but popliteal LN(s) were present in 3 (5%), lymphatic reflux in 1 (1.7%) and PSC in 1 (1.7%). In patients not older than 35 years old in our data base, PSC, when present, was always associated with another explanatory origin. On the other hand, DE, observed in 21% of the right limbs, 22.5% of the left limbs and 14% of the patients bilaterally, appears, when viewed in the context, “falsely” positive in “only” 19%, 27.6% and 16.7%. With regard to popliteal LN (present in 22.5% of these young patients), they were “falsely” positive in 31%. Conclusion: The “specificities” of the above mentioned Lysc criteria range thus from 69 to 100%. However, it has to be taken in mind that these “false positive” findings were observed in patients referred for limb edema(s) and that they might represent the first “sign” of the lymphatic disease.
P775 Lymph Vessel Detection Technique using a mixture consistent of Tc-99m pertechnetate nano-colloid and a paramagnetic contrast agent:A Novel device for Lymphatics Imaging? E. Dimakakos, M. Paphiti, A. Stavraka, A. Gouliamos, G. S. Limouris; A Radiology Dep. Nuclear Medicine Division, 'Aretaieion' University Hospital, Athens Medical Faculty, Hellas, Athens, GREECE. Aim:To evaluate a new technique by the use of a mixture consisted of radionuclide and paramagnetic contrast agent, in certain analogies, in order to visualize artificial vessels (phantom) consecutively in gamma camera and magnetic tomography system. Material and Methods: Tc‐ 99m pertechnetate nano‐colloid (0.1ml) in a dosage of 20.35MBq (550μCi) mixed with gadobutrol (0.1ml) in different concentrations of 1:1, 1:2, and 1:5 respectively, have been injected in very fine capillary tubes in a distance of 1cm from each other, positioned secured in a 20cm tissue equivalent material.This phantom‐like device was placed and scanned under a gamma camera (Elscint APEX SPX4) and a magnetic tomograph (Philips Gyroscan NT Intera) consecutively; for MRI imaging a 3D gradient echo sequence (volumetric interpolated breath hold procedure) was performed thereafter. Results: Clear images were obtained for all dosages in gamma camera and magnetic tomography in turn. Conclusion:The detection of a lymphatic vessel‐like‐model (phantom) using in a mixture commercially available radionuclide as well as
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P82 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: lung
P776 Assessment of pulmonary embolism using V/Q lung scan (Planar &SPECT) and MS spiral CT M. A. H. S. Abdelgalil; Faculty of Medicine- Zagazig University, ZagazigSharkia, EGYPT. Aim: Pulmonary embolism is a common and serious disease. Clinical signs and symptoms are insufficient to diagnose or rule out the condition. This thesis aimed at a balanced comparison between V/Q lung scintigraphy by both planar and SPECT technique with MS CT using advanced imaging techniques for both modalities. Material & Methods: 68 patients were studies over a period of 30 months from march 2006 to September 2008. All the patient underwent V/Q scan by both planar and SPECT technique (Group I), Among those patient 25 patients underwent CT pulmonary angiography using MS spiral CT, in addition to Planar and SPECT V/Q lung scan (Group II). Results : On SPECT 25 % increase in the number of the defects detected to all the study population compared with planar which reflect that SPECT have more power in defects identification. all embolus seen on CT angiography (n=9) induce perfusion defects either sizeable and seen on both planar and SPECT technique (n=7) or small subsegmental which may be hidden and seen only on SPECT not on planar scans (n=2). Conclusion: CT angiography is an accurate method for PE diagnosis. Because of the valuable data it provides, SPECT V/Q lung scintigraphy should be applied whenever possible when assessing patients with history suggesting pulmonary embolism. People in Nuclear medicine field must be accounted about the use of SPECT, when and How to interpret . In order to achieve such goal more frequent usage for this tool is needed to be more familial with its interpretation. Key words (Pulmonary embolism ; V/Q scan ; SPECT ; CT angiography)
the group with pleural plaques (893.8±575.2 ng per milliliter vs. 312±112.4 ng per milliliter, p<0.05), but there were no significant differences in mean (±SD) serum OPN levels between the group with MPM and the group with benign pleural effusion (695±70.0 ng per milliliter). The SUVs max in the group with benign pleural disease (pleural plaques and benign pleural effusion) correlated well with plasma OPN levels in the same group (r = 0.75, P<0.01), but the SUVs max in the group with MPM did not correlate with plasma OPN levels in the same group. Conclusions: This pilot study suggests that semiquantitative analysis of 18F‐FDG PET/CT may be more useful than serum OPN levels to distinguish subjects with benign pleural effusion from those with MPM, and the SUVs max in the group with benign pleural disease may reflect changes in the chronic inflammation of pleura.
P779 Evaluation of lung perfusion SPECT-CT imaging in the diagnosis of pulmonary thromboembolism. F. P. Dellepiane, M. Negre, N. Kisiel, S. Aguade-Bruix, E. Mariscal, M. Barios, J. Castell-Conesa; Hospital Universitari Vall D'Hebron, Barcelona, SPAIN.
Usefulness of quantitative lung perfusion scintigraphy in patients with pulmonary artery stenosis.
Objective: To evaluate the efficacy of lung perfusion SPECT‐CT imaging in the evaluation of pulmonary thromboembolism (PTE). Methods: 39 patients referred to rule out PTE were prospectively included (19 men; mean age: 55.5 ± 18.4 years). Planar ventilation‐perfusion (V/Q) 6 views images were obtained after technetium 99m aerosol (Venticis®) and i.v. technetium 99m macroagregates injection (250 MBq). After the conventional scintigraphy, simultaneously SPECT‐ CT (Hawkeye 4) was obtained. Images were acquired in a double head Infina Hawkeye 4 (GE) that 2 includes a non‐diagnostic four slices 512 matrix CT, using LEHR collimator, 180 seconds/image with 2562 matrix for planars and 15 seconds/image with1282 matrix for 360º SPECT. Planar V/Q images, tomographic perfusion slices, CT (air structure 3D volume render), transaxials, coronals and sagitals CT slices with lung window and fusion perfusion/CT images were independently assessed by two experienced observers, blind to clinical statement. Final diagnosis was obtained after follow up and other complementary imaging techniques: multislice contrast CT (12 patients). All sets of images were categorized in: normal, PTE and indeterminate pattern. Results: 13 patients presented final diagnosis of PTE, all of them had a PTE pattern in SPECT‐CT images, while 12/13 in planar V/Q images. 22 patients presented concordant results between planar and SPECT‐CT images (11 normal, 11 PTE). 17 patients presented discordant results (7 patients with PTE): 7 False Negative in V/Q with True Positives in SPECT‐CT. SPECT‐CT images presented 10 False Positives in regard to final clinical diagnosis. Conclusions: SPECT‐CT lung perfusion images has/have a high sensitivity in detecting PTE, mainly converting indeterminate V/Q patterns in PTE patterns. Nevertheless, its specificity is suboptimal.
M. P. Orduña, J. M. Castro, V. Castillo, A. Crespo; Ramón y Cajal Hospital, Madrid, SPAIN.
P780
P777
Aim: To demonstrate the usefulness of the quantitative lung perfusion in patients with stenosis of the pulmonary artery. Materials and methods: we studied 12 patients referred to pediatric cardiology service with a diagnosis of stenosis of the pulmonary artery. They were subjected to a 99mTc‐macroaggregates of albumin scintigraphy (pediatric dose) of the lungs that found a lack of perfusion lung affection. The patients underwent surgical treatment and 72 hours of it were subjected to a quantified lung perfusion scintigraphy after treatment. Subsequently, six months after surgery was third. Results: The first scan revealed perfusion defect in all the affected lungs (100%). The second one introduced different rates of infusion (perfusion of the affected lung increased significantly) (91.7%) except in 1 patient where there was no response to surgical treatment (8.3%). The last scan was performed in 11 patients (91.7%), and found improvement in 6 (54.5%), maintenance of perfusion scintigraphy similar to post‐treatment at 3 (27.2%), 1 showed a deterioration compared to previous study (9%) and one patient showed no perfusion in the affected lung (9%). Conclusion: The perfusion lung scans established the diagnosis of perfusion defects in patients with pulmonary artery stenosis, evaluated the effectiveness of surgical treatment and was useful in monitoring these patients.
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Clinical assessment of F-FDG PET/CT and plasma osteopontin levels in patients with asbestos-related pleural disease S. Kurata1, M. Ishibashi1, H. Kaida1, K. Azuma2, M. Kobayashi1, Y. Hirose1, S. Takamori3, H. Aizawa2, N. Hayabuchi4; 1Division of Nuclear Medicine and PET center, Department of Radiology, Kurume University School of Medicine, Kurume, JAPAN, 2Division of Respirology, Neurology, and Rheumatology, Department of Medicine, Kurume University School of Medicine, Kurume, JAPAN, 3Department of Surgery, Kurume University School of Medicine, Kurume, JAPAN, 4Department of Radiology, Kurume University School of Medicine, Kurume, JAPAN. Objective: The most common manifestation of asbestos exposure is pleural disease, including pleural plaques, pleural thickening, benign pleural effusion, and malignant pleural mesothelioma (MPM). 18F‐FDG PET/CT has been shown to accurately differentiate benign pleural disease from MPM. Clinically, plasma osteopontin (OPN) levels are elevated in many diseases characterized by chronic inflammation as well as several types of cancer. OPN has also recently been shown to be a biomarker of MPM. The purpose of this pilot study was to directly compare the results of semiquantitative analysis of 18F‐FDG PET/CT with plasma OPN levels in the same asbestos‐related pleural disease population. Material and Methods: Seventeen patients with asbestos‐related pleural disease were prospectively recruited and underwent 18F‐FDG PET/CT, and plasma OPN levels were measured by an enzyme‐linked immunosorbent assay between April 2007 and December 2008. The maximum standardized uptake values (SUVs max) were determined from the most active pleural lesion in each patient. Diagnosis was based on histopathologic findings by direct thoracoscopic biopsy, surgical resection, or clinical follow‐up. Results: MPM was histopathologically proven in six patients (5 epithelial type, 1 biphasic type). Eleven patients had proven benign pleural disease (7 pleural plaques, 4 benign pleural effusion). The mean (±SD) SUVs max was significantly higher in the group with MPM than in that with benign pleural effusion (8.3±5.7 vs. 2.4±0.9, p<0.05) and in that with pleural plaques (8.3±5.7 vs. 1.3±0.3, p<0.01). The mean (±SD) serum OPN level was significantly higher in the group with MPM than in
99mTc-EDDA/HYNIC-TOC and assessment of solitary lung lesions
99mTc-Depreotid
in
D. P. Sobic-Saranovic1, L. Bojic1, S. Pavlovic1, V. Artiko1, L. NagorniObradovic2, D. Subotic2, N. Kozarevic1, E. Jaksic1, M. Todorovic-Tirnanic1, V. Obradovic1; 1Institute of Nuclear Medicine,CCS, Belgrade, SERBIA, 2 Institute for Lung Diseases,CCS, Belgrade, SERBIA. Background and Aim: Various somatostatin analogues have been used in attempt to evaluate solitary lesion in the lungs and early detection of malignant lesions. The aim of this study was to assess clinical utility of 99mTc‐EDDA/HYNIC‐TOC and 99mTc‐Depreotid scintigraphy for evaluation of various solitary lesions in the lungs. Material and Methods: 29 patients (24 men, mean age 52 years) with pathological findings on chest radiography (Rtg) and CT were included in the study. Single photon emission computed tomography (SPECT) of the thorax and whole body 99m 99m scintigraphy (WBS) were performed using Tc‐EDDA/HYNIC‐TOC (in 10 patients) and Tc‐ Depreotid (in 19 patients). Visual assessment was complemented by semi quantitative evaluation based on tumor to non‐tumor (T/NT) ratio in a case of positive finding. Histological findings served as the standard for comparison. Results: In 29 patients 34 solitary lung lesions were detected on RTG and CT. Enhanced tracer uptake was observed on both SPECT and WBS in 27 lesions confirmed as malignant on histology‐true positive. Among 7 lesions without accumulation of 99mTc‐EDDA/HYNIC‐TOC and 99mTc‐Depreotid, 6 were benign ‐true negative, and 1 was false negative (lung metastasis from renal cancer). Overall sensitivity (Sn) for both scintigraphies was 93%, specificity (Sp) 100% and accuracy (Acc) 93%. T/NT ratios were significantly higher on SPECT than whole body images (SPECT: 2.82±0.44 vs. WBS: 1.52±0.24, p<0.01).There was no statistical difference found in Sn, Sp, Acc and T/NT ratio between 99mTc‐EDDA/HYNIC‐TOC and 99mTc‐ Depreotid scintigraphies (Sn: 90% vs. 94%, Sp: 100%, Acc 92% vs. 95%, T/NT SPECT: 2.79±0.64 vs.2.89±0.65, WBS: 1.54±0.34 vs. 1.50±0.23, p<0.01, respectively). Conclusion: 99mTc‐ EDDA/HYNIC‐TOC and 99mTc‐Depreotid scintigraphies are useful for differentiating lung cancer from non‐malignant lesions. SPECT provides better visualization of lung lesions then WBS.
P781 Moving from V/Q planar to lung SPECT studies: the learning curve A. P. M. Moreira, J. Isidoro, M. Martins, J. M. P. Lima; Coimbra University Hospital, Coimbra, PORTUGAL. Aim: To compare, in patients with suspected pulmonary emboli (PE), the probabilistic information provided by V/Q planar scintigraphy to the results obtained with a new home‐made lung SPECT methodology. Materials and Methods: 97 consecutive patients (40 M, 57 F; age 69 yrs +/‐ 16) referred to V/Q scintigraphy for clinically suspected PE, were studied between March and September 2008. Planar and SPECT ventilation (Technegas) and perfusion images were sequentially obtained in each patient. Reports were only based on planar imaging and respected PIOPED criteria. Lung SPECT images were retrospectively interpreted according to holistic criteria and using home‐made software. SPECT results were compared to the PIOPED interpretation and to the final clinical diagnosis. Results: SPECT showed PE in 56 (57.7%) of the 97 patients studied, and was negative in 41 (42.3%). SPECT was positive for PE in all patients with a clinical decision to treat PE; none of the negative cases was treated for PE. SPECT showed PE in 49.3% of patients with a low probability report; in 41% of patients from this SPECT positive group, the clinical
Poster Presentation
paramagnetic contrast agent may give the opportunity of a new and cheep technique so as to map and evaluate in one study both anatomically and functionally, the lymphatic vessel net.
S462 decision was to treat PE. In the intermediate probability group, SPECT showed PE in 87.5% and, from these, 71% were treated for PE. All the 14 patients in the high probability group had a positive SPECT and were treated. Conclusion: Our preliminary results show that lung SPECT is more sensitive than planar imaging for the detection of pulmonary emboli and that there is a good agreement between SPECT information and the final diagnosis.
P782 Assessment of alveolar epithelial permeability with Tc-99m DTPA aerosol scintigraphy in patients with sjogren syndrome T. Pirildar1, G. Gumuser2, E. Ruksen2, A. Sakar3, G. Dinc4, E. Sayit2; 1Celal Bayar University, Medical Faculty, Internal Medicine, Manisa, TURKEY, 2 Celal Bayar University, Medical Faculty, Nuclear Medicine, Manisa, TURKEY, 3Celal Bayar University, Medical Faculty, Chest Disease, Manisa, TURKEY, 4Celal Bayar University, Medical Faculty, Public Health, Manisa, TURKEY. Aim: Sjögren's syndrome (SjS) is a systemic autoimmune disease that mainly affects the exocrine glands and usually presents as persistent dryness of the mouth and eyes. Lung disease in SjS has been reported to occur early following clinical presentation of the disease. In this study, technetium‐99m diethylene triamine penta‐acetic acid (Tc‐99m DTPA) aerosol inhalation scintigraphy, was used to assess the pulmonary membrane permeability in patients with primary SjS. Methods: Eighteen patients with primary SjS and 13 healthy controls were investigated. Clinical evaluation, chest X‐ray examination, pulmonary function tests, Tc‐99m DTPA aerosol scintigraphy were performed in all the cases. The presence of respiratory symptoms (dyspnea and cough), duration of sicca symptoms were recorded. Subjects inhaled 1480MBq of 99mTc‐DTPA for 4 minutes in supine position. Scintigraphic data were recorded dynamically (1frame/min) in posterior projection on a 64x64 matrix for a 30 min period using with a double headed gamma camera (Infinia, GE, Tirat Hacarmel, Israel) equipped with a low‐energy all purpose parallel hole colimator. Half time of 99mTc‐DTPA clearance (T1/2) were calculated by placing a mono‐ exponential fit on the curves. Penetration index (PI) was also calculated by dividing the peripheral total counts by the sum of the peripheral and central total counts on the first minute image, in order to quantify the distribution of the inhaled aerosol. Results: The clearance half time of Tc‐ 99m DTPA radioaerosols in patients with SjS (20.49±2.56min) was faster compared to normal controls (42.32±13.28min) (p=0.000) which means there is a significant increase in lung permeability in patients with SjS compared to the controls. There is also a significant difference between PI of patients with SjS (0.34±0.09) and that of controls (0.42±0.07) (p=0.012). When the results of PFT between the SjS patients and the controls were compared, there was no significant difference between the two groups (p>0.05). No correlation was found between the mean T1/2 values of Tc‐99m DTPA clearance and the spirometric measurements in SjS patients. PI values were not correlated with PFT in SjS patients (p>0.05). Conclusion: According to the results of our preliminary study, one can detect pulmonary involvement by Tc‐99m DTPA aerosol inhalation scintigraphy in patients with primary SjS.
P783 Application of SPECT/CT with attenuation correction in preoperative V/Q scintigraphy for prediction of post-operative lung function: An Initial Experience E. Y. C. Leung, W. Zeng, R. Wassenaar; The Ottawa Hospital, Ottawa, ON, CANADA. Aim: To investigate feasibility and potential improvement of quantifying lung function by separation into anatomically correct lobes, compared with traditional planar imaging. Materials & methods: Five consenting adult patients underwent lung scintigraphy on a Siemens Symbia T as part of routine workup for potentially resectable NSCLC. Following inhalation of 37 MBq Technegas, 500 kcnt anterior and posterior planar images of lung ventilation were acquired, and followed by hybrid SPECT/CT (64 view, 20 s/view). Following intravenous injection of Tc‐99m 185 MBq MAA, planar and SPECT/CT (64 view, 10 s/view) imaging was repeated for lung perfusion. Geometric means of planar images were divided into thirds for the right lung and halves for the left lung to approximate individual lobe function. Each hybrid CT was then coregistered to a contemporaneous diagnostic CT (DxCT) with rigid transformations using a Hermes workstation. This transformation was applied to fuse the corresponding SPECT data with DxCT. Individual lobe VOIs were defined by identifying major and minor fissures on DxCT and then applying to the attenuation correction SPECT data to quantify lobe function. Paired t‐test analyzed the difference in function between planar and SPECT for each lobe, as well as for the whole lung. 2‐way ANOVA between subjects and lobes was performed. Results: SPECT/CT measured higher lung function in both RUL and RLL, and lower function in the RML (p<0.05), compared to planar. LUL and LLL lung function were not significantly different between planar and SPECT/CT. 2‐way ANOVA between subjects and lobes found significant variation between lobes, but not subjects. There was no difference in SPECT/CT compared with planar values for whole lung function. Differences between SPECT/CT and planar for lobes containing the primary carcinoma ranged from ‐16% to +9% (p>0.05). Conclusion: SPECT/CT quantified right lung function differently compared to traditional planar, but with no significant change in left lung or whole lung split function. However, based on location of the primary carcinoma, SPECT/CT would have potentially altered the post‐operative predicted function by as much as 16%. Larger studies, compared to a post‐ operative FEV1 gold standard, are needed to assess the ability of SPECT/CT to predict post‐op function.
P784 Quantitative Ventilation Scintigraphy In Bronchial Asthma In Children On Inhaled Corticosteroids R. K. Karri; Post Graduate Institute of Medical Education and Research, Chandigarh, INDIA. Aim: To evaluate the changes in ventilation patterns in asthmatic children and assess the role of quantitative scintigraphy in follow‐up of these patients. Material and Methods: A prospective longitudinal study in 58 children (14 F, 44 M) of age 6 to 12 years was conducted. Ventilation scan was performed with 99mTcDTPA aerosols and images acquired on a dual head gamma camera
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 (Siemens, ECam). Follow up study was performed after atleast 4 weeks of inhaled corticosteroid therapy. Central and peripheral regions of interest were drawn on the ventilation images in baseline and follow up studies and ratios of geometric means of the average counts per pixel from the central to peripheral regions (C:P) were estimated. The C:P ratio was compared with routine clinical parameters of symptom scores and peak expiratory flow rates (PEFR%). Results: Attrition of 11 patients was noted in the study. On visual assessment a pattern of predominantly central airway deposition was noted in 29 patients in the baseline study. Of these 12, who presented for follow up, showed completely homogeneous ventilation; 7 showed improvement with minimal central deposition. A second pattern of inhomogeneous ventilation was noted in 5 patients in baseline, 3 of who showed improvement on follow up. Homogeneous ventilation was noted in 24 patients in baseline, of whom 3 showed worsening. The C:P ratio in the subjects with central deposition was significantly higher (1.89) compared to the group with homogeneous ventilation (1.26, p<0.01) Symptom score improved in all the patients while the mean PEFR and the C:P ratio also showed improvement. There was a mean 79% decrease in the C:P ratio in the subjects showing improvement on follow up. Conclusion: Scintigraphy can visually and semi‐ quantitatively demonstrate various patterns in ventilation and their improvement following therapy. Due to effort dependence and lack of adequate co‐operation, spirometric and PEFR values are not adequately reliable and reproducible in children. The definite advantage of scintigraphy is that it provides a simple, non invasive objective, effort independent and quantifiable means of monitoring the airway status that may be used to guide therapy in children with asthma.
P785 Patent foramen ovale on ventilation-perfusion scintigraphy referrals: is it a risk factor for pulmonary embolism? J. G. Santos, A. I. Santos, S. Carmona; Hospital Garcia de Orta - Serviço de Medicina Nuclear, Almada, PORTUGAL. Aim of the Study: To study the prevalence of pulmonary embolism (PE) and patent foramen ovale (PFO) among patients referred for ventilation‐perfusion scintigraphy (V/QS) in order to evaluate whether in this population, PFO may be a risk factor for PE. Population and Methods: We made a retrospective analysis of 476 exams, performed between January 2006 and December 2008, due to clinical suspicion of acute PE. Exams were subdivided into two groups, as either “Negative for PE” (NPE) or “Positive for PE” (PPE), according to their interpretation and conclusion reports, based in PIOPED criteria. The exams with an “Intermediate probability for PE” were discarded from the study. Patients were also classified as either “Known PFO” (KPFO) or “Unknown PFO” (UkPFO) according to clinical history and echocardiogram results, if available. The odds ratio between these categories was calculated. Results: Of the 476 exams studied, 10 were performed on patients with KPFO; of these, 6 were NPE and 2 were PPE. Of the exams performed on patients with UkPFO, 272 were NPE and 155 were PPE. Forty‐nine exams were discarded, 2 of KPFO patients. The calculated odds ratio was 0.58, with a confidence interval ranging from 0.12 to 2.85 (for a confidence coefficient of 0.95). Conclusion: We have encountered very few patients with KPFO among our V/QS referrals. Of these, only 20% were PPE, while almost 33% of UkPFO patients were PPE. The calculated odds ratio was less than 1; however, its confidence interval does not allow us to conclude that having KPFO is either a protective trait or a risk factor for PE.
P786 Radionuclide assessment of right ventricle dysfunction in patients with pulmonary embolism Y. B. Lishmanov, K. W. Zavadovskiy, A. N. Pankova; Institute of Cardiology, Tomsk, RUSSIAN FEDERATION. Aim: to investigate the condition of pulmonary microcirculation and right ventricle (RV) haemodynamics in patients with pulmonary embolism. Materials and methods: 50 patients were examined in the course of investigation. Among them ‐ 15 patients (average age 59±9) suffering from coronary heart disease (NYHA I‐III); 35 patients (average age 62±11) with suspicion of pulmonary embolism (PE). Radionuclide evaluation included realization of quantitative blood pool single photon emission computer tomography (QBS) and lung perfusion scintigraphy (LPS). There was defined the following indices: ejection fraction (EF), right ventricle end systolic and diastolic volume (ESV and EDV), peak ejection and filling rates (PER and PFR), mean filling rate for first third of cardiac cycle (MFR/3). According to perfusion lung scintigraphy and QBS there was defined U/L index reflecting correlation of impulse count of upper and lower parts of the lungs. Results: values of ejection fraction of right ventricle were revealed to be significantly low in the group of patients with PE. EDV and ESV values between the groups did not differentiate significantly. It was revealed that patients with PE had significantly lower values of RV stroke volume. Main differences between the groups were revealed according to diastolic index. Pulmonary blood filling in patient without PE equally increased from base of lungs to apical parts. In patients with signs of PE there were observed signs of pulmonary blood flow redistribution. There was revealed positive correlation between U/L index defined by means of perfusion pulmonary scintigraphy and QBS. In the areas of the lungs corresponding with pool of embolized pulmonary artery the blood flow was authentically low in comparison with conventionally intact area. We do not find any correlation between extent of PE and right ventricle dysfunction indices. In patients with PE extent less than 50% the normal right ventricle can be interpreted as the sign of acute PE. On the other hand, right ventricle dysfunction is typical for chronic tromboembolic pulmonary hypertension. Conclusion: Development of pulmonary embolism is accompanied by significant lowering of diastolic RV function. QBS allows to define pulmonary blood flow and semiquantitatively estimate pulmonary embolism intensity. Right ventricle dysfunction in case of pulmonary embolism extent less than 50% is typical for chronic tromboembolic pulmonary hypertension.
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Can Perfusion SPECT improve the accuracy of CTPA? D. Gradinscak, P. J. Roach, G. Schembri, D. Bailey, E. Bailey; Royal North Shore Hospital, Sydney, AUSTRALIA. AIM: To determine whether fusion of perfusion SPECT and CTPA improves the diagnostic accuracy of CTPA. METHODS: 35 patients with suspected PE who underwent both CTPA and SPECT V/Q within 48 hours were included. The clinical reports of CTPA were reviewed and pulmonary emboli tabulated based on anatomical location. A second radiologist, blinded to the results of the clinical read and the V/Q SPECT scan, reviewed the CTPA with and without perfusion SPECT fusion for assistance. RESULTS: On CTPA alone, a total 57 PE were reported on the clinical reports and 60 PE identified on the blinded read. Fused CTPA / perfusion SPECT images identified a further 5 PE not identified on the clinical read (8% increase) and 2 not identified on the blinded read (3% increase). The additional emboli detected on fused CTPA / perfusion SPECT resulted in a change in final diagnosis from PE negative to PE positive in 2 patients (6%) compared to clinical read CTPA and 1 patient (3%) compared with the blinded (research) CTPA read. CONCLUSION: Fused CTPA‐SPECT perfusion is more sensitive than CTPA alone for the detection of PE. Fused data may help guide the radiologist to identify sites of PE on CTPA.
P788 Can CT Coregistration Improve the Accuracy of Segmental Localisation on V/Q SPECT? D. Gradinscak, P. Roach, G. Schembri, E. Bailey; Royal North Shore Hospital, Sydney, AUSTRALIA. AIM: To determine the accuracy of anatomical localisation of mismatched perfusion defects on V/Q SPECT using CT. METHODS: 30 patients with suspected pulmonary emboli (PE) and positive SPECT VQ scans who also underwent CTPA within 48 hours were included. Perfusion defects on SPECT were localised by 2 experienced Nuclear Medicine physicians to pulmonary segments using a normal lung tomographic segmental lung chart as a guide. Perfusion SPECT and the CTPA were fused on a HERMES workstation and the CT data used to determine the accuracy of their anatomical localisation of perfusion defects in each patient. RESULTS: A total 96 mismatched perfusion defects were reported. Using CTPA fusion, anatomical localisation on SPECT alone was concordant with the individual patient’s anatomy on CTPA in 78/96 (81%) cases. 18/96 (19%) perfusion defects localised to discordant pulmonary segments on CTPA. Discrepancies were most commonly seen in the mid‐zone segments of each lung (RML segments, superior LL’s and lingula LUL) and were most noticeable in patients with evidence of lower lobe volume loss on CT. CONCLUSION: The addition of CT improves anatomical localisation of perfusion abnormalities on V/Q SPECT in approximately 20% of cases. Improved localisation was particularly noted in patients with lower lobe parenchymal abnormalities associated with volume loss on CT.
P789 Retrospective Evaluation of Pulmonary Perfusion Scintigraphy for suspected Pulmonary Thromboembolism in Emergency Department G. H. Kaplan1, N. B. Talay1, Z. P. Koç2, A. O. Öner1, Y. Çete1, T. Özdemir1, B. Karayalçın1; 1Akdeniz University Faculty of Medicine, Antalya, TURKEY, 2 Fırat University Faculty of Medicine, Elazığ, TURKEY. Objective: The aim of this study is to evaluate retrospectively the result of perfusion lung scintigraphy of patients with suspected pulmonary thromboembolism (PTE) in Emergency Department (ED) with CT‐angiography results and clinical follow‐up and to investigate the role of the result of perfusion lung scintigraphy in the diagnosis of PTE. Material and Methods: Perfusion lung scintigraphy (Tc99m‐MAA) was performed in 91 patients (57 female, 34 male; mean age 54.3 years; range 20 to 85 years) with suspected PTE. According to the result of perfusion lung scintigraphy, 52/91 patients were performed ventilation scintigraphy (Technegas aeresol). Patients were classified as high, moderate, low probability and normal according to PIOPED II criteria. CT‐angiography was applied for 21 (23%) patients. D‐dimer were examined in 85/91 patients. 31/91 patients with clinically high suspicion of PTE were hospitalized. Results: Patients admitted to ED had chest pain (76%), dyspnea (48%) and palpitation (5%). Risk factors were current surgeries (18%), immobilization (13%), deep vein thrombosis (11%), malignite (7%) and use of oral contraceptives (5%). Based upon clinical observation and imaging techniques, 21/91 patients (23%) diagnosed PTE. Among these patients 17 had dyspnea, 15 had chest pain. 76% of the patients had at least one risk factor. D‐dimer was high 14/17 patients. According to PIOPED II criteria, patients were categorised as high probability (21/91; 23%), moderate probability (7/91; 8%), low probability (32/91; 35%) and normal (31/91; 34%). Among 21 patients diagnosed as PTE, 12/21 had high probability (57%), 7/21 had low probability (33%), 2/21 had moderate probability (10%) of PTE. Nobody was diagnosed as PTE in the normal group. CT‐ angiography examination ratio for patients in moderate (57%) and low probability (41%) group was higher than patients in high probability group (10%). Conclusion: In the literature, PTE is diagnosed in 10‐17% of patients admitted to the ED suspected of PTE; in our study this ratio was 23%. This difference may be due to the selection of the patients. We observed that moderate and low probability groups need more CT‐angiography examination. In most clinics, sensitivity and specificity of ventilation/perfusion scintigraphy are increased by modification of PIOPED criteria. As a result of our study, evaluation criteria for moderate and low probability groups need to be renewed with prospective studies.
P790 Contribution of CT scan to the performance of lung ventilation-perfusion scintigraphy W. J. G. E. Pilloy, V. Lens; CHL, Luxemburg, LUXEMBOURG. Aim: To identify in which circumstances the addition of a CT scan enhances the diagnostic value of lung ventilation‐perfusion scintigraphy (VQ scan). Material & Method: For 15 years, lung VQ
tomography is routinely performed at our institution: 16 frames are recorded over 360 degrees, first after Technegas inhalation (40 mCi) and next after macro‐aggregates injection (10 mCi) ‐ in the same supine position‐ for a total acquisition time of 18 min. OSEM reconstruction (after multiplication by a factor 10 of V data) follows; V & Q data are concurrently displayed in 3 axes. Since 2002, more than 80 VQ scans have been supplemented by a chest CT scan ‐ either a contrast spiral CT scan recorded independently for reasons of cancer staging or exclusion of pulmonary embolism, or a non‐contrast enhanced CT recorded during tidal breathing for the specific purpose of co‐registration (dedicated CT) either on a Radiology machine or on a 2 slice‐CT integrated in a PET‐CT machine (Gemini). Q slices and CT slices (retrieved from PACS) are then automatically co‐registered by Hermes software as described before (1). In a limited number of cases, VQ scans have been recorded for pre‐operative lobar quantification, and co‐registered to FDG PET‐CT (chest) data. All CT data were read by a nuclear physician to assess parenchymatous conditions only Results: 100% of Q data and 85% of V data were of diagnostic quality: the remaining 15% were invalidated by poor inhalation rather than by bronchial impaction. Quite significant (on CT) pleural effusions could go undetected on VQ scans. Lung areas affected by emphysema would appear as diffusely under‐perfused and could otherwise lead to indeterminate diagnosis. CT was invaluable in case of chest deformity to rule out pseudo‐defects. The simultaneous display of co‐registered CT, Q and FDG slices made the definition of the impact of a tumor on lobar perfusion luminous and its quantification more realistic. Conclusion: Even in the specific case where no hybrid SPECT‐CT camera is available and even in the hands of a nuclear physician without specific training, the addition of a non‐contrast CT considerably enhances the confidence in the interpretation of VQ scans and can sometimes replace the V scan. It will soon become indispensable and a source of new applications. (1) Comparison of spiral CT and tomographic Ventilation‐Perfusion scintigraphy for the detection of pulmonary embolism. WJ Pilloy et al. Poster EANM Congress 2003
P83 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Clinical Science: miscellaneous
P791 Scintigraphic evaluation of salivary glands function in patients with cancers of head and neck treated by intensity modulated radiotherapy (IMRT) J. Dąbrowski1, R. Bibik2, J. Siennicki3, J. Fijuth2, J. Kuśmierek1; 1Department of Nuclear Medicine Medical University of Lodz, Lodz, POLAND, 2 Department of Radiotherapy University of Lodz, Lodz, POLAND, 3 Department of Quality Control and Radiological Protection University of Lodz, Lodz, POLAND. The aim of the study was elaboration of several methods for scintigraphy of salivary glands and selection of optimal procedure for evaluation of impairment of their secretory function by IMRT. Material and methods The study involved 22 patients: 14 with carcinomas of the glottis and 8 with neoplasms of the throat, treated by parotid‐sparing IMRT. Mean absorbed doses in paratoid and submandibular salivary glands were 28,4 and 55,7Gy, respectively. The scintigraphy of salivary glands was made after i.v. administration of pertechnetate. The results were quantitatively processed in 3 ways namely: Method 1: from the image acquired 20min after injection an uptake quotient was calculated i.e. a ratio of counts over the salivary gland to that of the background. Method 2: a time activity curve over the gland was recorded within 25min, at 21st minute of the study sialogogue was administrated orally and the index of ejection was calculated. Method 3: a quotient of saliva secretion was calculated from images recorded at 20min and 25min of the follow‐up. Results The results are presented in table below Statistically significant differences signed: * ‐ p<0.05; ** ‐ p< 0.001; *** ‐ p< 0.0001 when related to pretherapy results. Statistically significant differences related to investigation repeated after 1 month signed: # ‐ p<0.05; ## ‐ p< 0.01; ### ‐ p < 0.0001. Conclusions 1 In the investigation performed one month after radiotherapy there was enhanced uptake of the radiopharmaceutical both in parotid and submandibular glands accompanied by significantly impaired secretion of saliva. 2 At six months post IMRT there was a substantial improvement of parotid salivary glands function i.e. normalization of pertechnetate uptake and partial disappearance of saliva secretion impairment. However, there was a progressive impairment of saliva secretion and reduction of pertechnetate uptake below the initial values in submandibular glands; these symptoms seem to indicate that there is a progressive fibrosis. 3 There are different impairment modes of RF uptake and saliva secretion. Both functions should be separately evaluated after radiotherapy. 4 Due to similarity of diagnostic informations provided by method 2 and 3 the scintigraphic protocol could be limited to acquisition of two one‐minute images in the 20th and 25thmin. Table. Mean values of the quotients obtained by 3 methods. Parotid salivary glands
Before radiotherapy
One month after IMRT
6 months after IMRT
Method1 Method2(%) Method3(%)
3.84 49.83 52.73
4.38* 27.93*** 26.78***
3.93 33.74*** # 35.74***##
Submandibular salivary glands
Method1 Method2(%) Method3(%)
4.53 36.13 32.28
5.46** 19.21*** 15.39***
4.13*### 12.63***## 6.94***###
P792 Identification of dystonic muscles in idiopathic cervical dystonia using FDG PET/CT: comparison with EMG mapping M. Cheon1, J. Choi1, D. Sung2, S. Hyun1, J. Lee1, S. Cho1, J. Yoo1, S. Lee1, K. Lee1, B. Kim1; 1Samsung Medical Center, Sungkwunkwan University School of Medicine, Department of Nuclear Medicine, Seoul, REPUBLIC OF KOREA, 2Samsung Medical Center, Sungkwunkwan University School of
Poster Presentation
P787
S464 Medicine, Department of Physical Medicine and Rehabilitation, Seoul, REPUBLIC OF KOREA. Objectives: Previously, we reported 18F‐fluorodeoxyglucose (FDG) PET/CT was potentially useful for identifying dystonic cervical muscles for Botox therapy in patients with idiopathic cervical dystonia (ICD). The purpose of this study was to compare FDG PET/CT and electromyographic (EMG) mapping in patients with ICD to find dystonic muscles. Methods: FDG PET/CT and EMG mapping was performed in 14 patients with ICD. Due to a limited access ability of EMG mapping, only 4 superficial cervical muscles including the splenius capitis, upper trapezius, sternocleidomastoid, and leavator scapulae muscles were compared. FDG uptake and EMG activities of each muscle were compared with rotation angle measurement (RAM) as a golden standard. Results: Of 112 superficial cervical muscles, 8 (7.1%) had a contribution to abnormal posture based on RAM. Increased FDG uptake was found in 10 of 112 muscles (8.9%). Abnormal muscle contraction by EMG was found in 16 of 112 muscles (14.3%). Sensitivity, specificity and accuracy for detecting dystonic muscles were 75.0% (6/8), 99.0% (103/104) and 97.3% (109/112) for PET, and 100% (8/8), 93.3% (97/104) and 93.8% (105/112) for EMG mapping. Conclusions: Based on RAM, FDG PET/CT may be more specific and accurate than EMG mapping to find superficial dystonic cervical muscles. Further comparative study using therapeutic response data is necessary.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 from the lacrimal sac to the nasolacrimal duct (class III). Result: Schirmer‐1 and BUT values of the patients in the advanced‐stage of primary SS significantly decreased, Rose Bengal and OSDI values significantly increased when compared with the early‐stage of primary SS. Class I dacryoscintigraphy findings were most commonly observed in early‐stage disease. An inverse correlation existed between the dacryoscintigraphic types and both the Schirmer‐1 test and BUT value in all subjects. However, there was a greater positive correlation between both the rose bengal ocular surface staining values and OSDI scores and the dacryoscintigraphic types in all cases. Dacryoscintigraphic findings and ophthalmologic test ratios were significantly different between the early‐ and the advanced‐stage primary SS. Conclusion: The results indicate that dacryoscintigraphy appears to be a useful method for the assessment of the lacrimal gland function in patients with primary SS. Dacryoscintigraphic findings and ophthalmologic test ratios can be used for differentiating disease severity in primary SS. Keywords: dacryoscintigraphy; Tc‐ 99m pertechnetate; primary Sjögren’s Syndrome; clinical stage
P84 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
General topics: economics & radiation protection
P793
P795
Quantitative evaluation of salivary gland dysfunction and thyroid uptake in patients with Primary Sjögren’s Syndrome using salivary gland scintigraphy and comparison with histopathologic stage
The isotope supply crisis: causes and required long-term actions
S. Erhamamcı Gunel1, S. Yılmaz2, A. Aktas3; 1Department of Nuclear Medicine, Faculty of Medicine, Baskent University, Konya, TURKEY, 2 Division of Rheumatology, Selcuklu Faculty of Medicine, Selcuk University, Konya, TURKEY, 3Department of Nuclear Medicine, Faculty of Medicine, Baskent University, Ankara, TURKEY. Purpose: To evaluate quantitative salivary gland function and thyroid uptake in patients with primary Sjögren’s Syndrome (SS) using salivary gland scintigraphy and to compare scintigraphic findings with histopathologic stage of primary SS. Methods: Salivary gland scintigraphy was performed in 27 patients (21 F, 6 M; age range 33 to 80 years) with SS. The patients were clinically diagnosed as having SS based on their histories and the results of physical and laboratory tests, including a labial biopsy. Based on the biopsy results, 16 patients with a histopathologic grade of 1 or 2 were regarded as having early‐stage SS, and 11 patients with a grade of 3 or 4 were regarded as having an advanced‐stage. Free thyroxine (T4), triiodothyronine (T3), thyroid‐stimulating hormone (TSH), anti‐thyroid peroxidase antibody, and antithyroglobulin antibody blood levels were determined. Ten healthy age and sex matched persons were included as a control group. After the administration of 370 MBq (10 mCi) Tc‐99m pertechnetate, dynamic salivary gland scintigraphy was performed for 20 minutes and then static images were obtained. Lemon juice was used to stimulate the salivary glands at 25 minutes. The thyroid uptake ratio and glandular functional parameters ‐namely uptake ratio (UR) and maximum secretion (MS) of the parotid and submandibular glands‐ were calculated. The results in healthy controls, patients with early‐stage and those with advanced‐stage SS were compared. Result: Statistically significant differences existed for the functional parameters of the parotid and submandibular glands between early‐ and advanced‐stage group. The submandibular glands were more frequently affected than the parotid glands. Asymmetric uptake pattern was more common in the parotid glands during early stages of primary SS. When compared with the control group, the thyroid uptake ratio of the early‐stage primary SS and advanced‐stage group was not significantly different. Conclusion: The results indicate that quantitative salivary gland scintigraphy is a useful method for evaluating salivary gland dysfunction and also for determining disease severity in primary SS and can replace labial biopsy. Thyroid uptake ratio was not sensitive enough for distinguishing disease severity in this patient group. Asymmetric activity pattern in the parotid glands commonly observed during the early‐stage of disease can be a predictor of progression. Keywords: Primary Sjögren’s syndrome; salivary gland scintigraphy; quantitative indices; thyroid uptake
P794 The clinical value of dacryoscintigraphy in the evaluation of lacrimal gland function in patients with Primary Sjögren’s Syndrome and comparison with histopathologic stage S. Erhamamcı Gunel1, A. Karalezli2, S. Yılmaz3, A. Aktas4, Y. Akova5; Department of Nuclear Medicine, Faculty of Medicine, Baskent University, Konya, TURKEY, 2Department of Ophtalmology, Faculty of Medicine, Baskent University, Konya, TURKEY, 3Division of Rheumatology, Selcuklu Faculty of Medicine, Selcuk University, Konya, TURKEY, 4Department of Nuclear Medicine, Faculty of Medicine, Baskent University, Ankara, TURKEY, 5Department of Ophtalmology, Faculty of Medicine, Baskent University, Ankara, TURKEY. 1
Purpose: To evaluate the lacrimal gland function in patients with Primary Sjögren’s syndrome (SS) using dacryoscintigraphy and to determine the relationship between clinical stage of primary SS and dacryoscintigraphic findings. Methods: We investigated 70 eyes of 35 patients (29 women, 6 man; age range 33 to 80 years) with primary SS. The patients were clinically diagnosed as having primary SS based on their histories and the results of physical and laboratory tests, including labial biopsy. Based on the labial biopsy findings, 23 patients with a histopathologic grade 1 or 2 were regarded as having early‐stage of SS, and 12 patients with a grade 3 or 4 were regarded as having an advanced‐stage. Ten healthy age‐and sex matched persons were included as a control group. Dacryoscintigraphy, Schirmer‐1 test, break‐up time (BUT), and Rose bengal ocular surface vital staining, and functional parameters including ocular surface disease index (OSDI) scores were performed in all cases. All patients were seated in front of the pinhole collimator of the gamma camera and dynamic images were recorded every 60 seconds for 30 minutes. Dacryoscintigraphy results were cassified as; delayed visualisation of distal nasolacrimal duct (class I); delay in the proximal nasolacrimal duct visualisation (class II), and delayed secretion
F. Deconinck1, B. Ponsard2; 1Vrije Universiteit Brussel, Brussels, BELGIUM, 2 Belgian Nuclear Research Centre, Mol, BELGIUM. Last autumn saw a major worldwide crisis in the availability of Mo‐99/Tc‐99m generators for diagnostic nuclear medicine. We will shortly analyse the causes of the shortage and point to necessary long‐term measures to avoid future crisis. The most widely used production scheme for Mo‐99 involves the irradiation of highly enriched U targets in research reactors. Currently, the irradiation of the U targets is performed in only 6 (MTR) reactors: the NRU reactor in Chalk River, Canada; the HFR in Petten, The Netherlands; BR2 in Mol, Belgium; OSIRIS in Saclay, France and SAFARI in Pelindaba, South Africa. All are older than 40y. They allow the production of more than 90% of the available Mo‐99. The separation of the Mo‐99 out of those targets is performed at 4 centres: AECL separates the Mo‐99 in Chalk River and MDS‐Nordion purifies it in Kanata, Canada; Covidien in Petten, The Netherlands; IRE in Fleurus, Belgium and NECSA‐NTP in Pelindaba, South Africa. In August 2008, the operation of the HFR reactor in Petten was stopped while the other reactors were in maintenance. Independently, an incident occurred at IRE. During a period of several weeks there was a worldwide shortage of isotope supply and hundreds of thousands patients were denied diagnostic imaging tests based on Tc‐99m. The crisis points to the alarming lack of production facilities for reactor produced medical isotopes. The paper will review the current and future situation of the reactors used or planned for the Mo‐99 production. The paper will also analyse the current cost structure of the Tc‐99m generators and show that it is the underlying reason for the recent crisis. Indeed, the price asked for irradiation does not cover the marginal cost, and certainly does not take the reactor investment and decommissioning costs into account. The irradiation price, roughly estimated to be between 5 and 10% of the cost of the generator is heavily subsidized. In short, and for many years to come, the European isotope production, and certainly the target irradiation phase, is mainly subsidised by the Belgian, Dutch and French taxpayers. In our opinion, it would be more than fair to share the cost of irradiation for medical isotope production at the European level, rather than by the taxpayers of the countries that provide this essential contribution to human healthcare worldwide.
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I Activity in Shower Water of Radioiodine Therapy Patients with Benign and Malignant Thyroid Diseases C. Happel1, G. L. Fängewisch2, W. T. Kranert1, F. Grünwald1; 1Department of Nuclear Medicine; Hospital of the Johann-Wolfgang Goethe University, Frankfurt / Main, GERMANY, 2Department of Nuclear Medicine; Hospital of the University Giessen and Marburg, Giessen, GERMANY. Aim: Following radioiodine therapy (RIT) 131I is excreted via bladder and gastrointestinal tract as well as perspiration and salivary glands. Therefore, all sewage water is contaminated and may not be fed into canalization uncontrolled. The purpose of this study was to investigate the shower water of RIT patients in order to determine the mean‐ respectively highest 131I activity concentration during the first shower as well as the average relative amount of separated activity to administered activity subdivided disease specific. Methods: In order to analyse the relative amount of the administered activity the treated patients were subdivided into malignant (differentiated thyroid cancer (DTC)) and benign (graves disease, plummers disease, goitre) thyroid diseases. For benign diseases between 250 and 1,500 MBq 131I, and for malignant diseases 3,700 MBq 131I were administered. The complete shower water of 13 patients (10 benign, 3 malignant) (first shower after administration) was collected and samples of 10 ml each were examined in a 131I calibrated multi canal well counter. 131I activity detected in the water was related to the administered activity. Results: The highest activities were observed in DTC patients (Median 1.3 % of administered activity; Range 1.1 ‐ 1.5 %). The excreted activity of one DTC patient amounts ~ 6 % of administered activity; this could be explained by a urine contamination of the water. The results of this patient were not considered in further evaluation. The patients with benign diseases showed a median amount of separated activity of 0.02 % of administered activity (Range 0.004 ‐ 0.9 %). The highest detected activity amounted 3 kBq/ml, the overall mean activity for the first shower after administration 0.4 kBq/ml. Conclusions: Skin activity separation contaminates the shower water 1.3 % of the administered activity for malignant RIT patients and 0.02 % of the administered activity for benign RIT patients leading to mean concentrations of activity in the water of 1,6 kBq/ml (malignant) respectively 0,15 kBq/ml (benigne). In individual cases much higher activities (urine contamination) may result. Therefore, the water needs to be stored respectively decontaminated before feeding into canalization. High excretion of activity via skin also indicates careful handling of the clothes worn directly on the skin.
S465
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
99m
Tc-Technegas Contamination and Incorporation during Ventilation Scintigraphy
C. Happel, I. Selkinski, M. Middendorp, P. N. Truong, J. Gessler, J. Diener, W. T. Kranert, F. Grünwald; Department of Nuclear Medicine; Hospital of the Johann-Wolfgang Goethe University, Frankfurt / Main, GERMANY. Aim: Because of the escape of 99mTc‐Technegas the ventilation scintigraphy of the lung may cause contaminations and incorporation for the staff. Venture correlates depending on quality of the generator used for inhalation, the air filter in the treatment chamber, performance of the inhalation and collaboration of the patient (H.Vanbilloen et al; Europ J Nucl Med 1999). Material and Methods: The used 99mTc‐Technegas is an ultra tenuous 99mTc‐labelled aerosol generated by evaporation in a Technegas‐generator (Tetley‐Technologies Pty. Ltd). For filling the crucible high concentrated solutions of 1‐2 GBq 99mTc were used. All of the examined patients were wearing nose‐clips during the inhalation to avoid bypass of the mouthpiece while exhalation. Towards the last inhalation remaining 99mTc‐Technegas in the connection tube was eliminated by exhaling at least five times through the mouth‐piece. To evaluate incorporation and contamination of the staff the operators of five Examinations were “imaged” scintigraphically directly following the patients inhalation (5‐15min after inhalation) with an uncollimated scintillation‐camera (DST‐Xli; GE). To discriminate between contamination and incorporation static acquisitions (scantime: 180s; matrix: 128x128) of the thorax were examined with and without white coat (new coats before inhalation). Background radiation, respectively absorbance of natural surrounding radiation, was determined by measuring of a “not‐contaminated” operator after each examination and taken into consideration for the calculation of incorporation and contamination. Calibration of the system was executed by measurement of 99mTc‐contaminated cellulose‐ handkerchiefs. Results: For a mean efficiency of the uncollimated scintillation‐camera of 176±2 % cps/kBq for 99mTc (linear for a range of 4‐120 kBq) the mean ascertained contamination on the white coat worn during inhalation amounted 2.88 kBq (range 0.15‐7.05 kBq; median 1 kBq). Mean incorporation caused of inhalation amounted 0.94 kBq (range 0.12‐1.76 kBq) (calculated without considering of shielding). Assuming a potential incorporation of 0.94 kBq (mean incorporation during experiment) and a frequency of one lung ventilation per day the potential incorporable activity for the performance of lung ventilation scintigraphy amounts 217 kBq/a (230 working days per year) leading to a potential whole body dose of ~ 0.005 mSv/a (dose coefficient e = 2x10‐11 Sv/Bq incorporated activity for 99mTc). Conclusion: Calculated maximal potential whole body dose for incorporation is very low (<< 0.5 mSv/a). Because of the in individual cases noticed surpassing high contaminations we suggest to wear a long sleeved, collar closed coat during the inhalation anyway.
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Efficacy of Anti-X Gloves and Anti-X Apron in Lu-DOTATOC 90 177 90 Lu and Y and Y-DOTATOC handling: exposure tests to sources. E. Grassi1, F. Fioroni1, M. A. Sarti1, D. Farioli2, A. Versari2, D. Salvo2, G. Borasi1; 1S. Maria Nuova Hospital - Medical Physics Dept., Reggio Emilia, ITALY, 2S. Maria Nuova Hospital - Nuclear Medicine Dept., Reggio Emilia, ITALY. Aim: evaluation of the efficacy of anti‐X gloves and anti‐X apron to be employed in preparation and application of 177Lu‐DOTATOC and 90Y‐DOTATOC in Radionuclide Therapy Unit. Material and Methods: different anti‐X gloves as regards thickness and manufacture (Euromedical Srl, Chieti, Italy and RFB Latex Limited, Noida, India) were studied in relation to the exposure to 90Y and 177Lu well‐known sources in a vial. Measurements were performed with an unshielded source and then by shielding the same vial with a 1cm thick plexiglass shield. Transmission coefficients (T%) were then computed. The same measurements were performed with a 0.25mm Pbeq anti‐X apron usually employed when administering 90Y‐DOTATOC with good results. The transmission measurements were performed with a Victoreen GM Pancake Probe, model 489‐110D to detect both beta rays and photons, and with a Victoreen 450P ionization chamber (IC), to detect principally photons. Results: the gloves attenuation of beta rays depends on their thickness (heavy, medium and light defined for photon transmission) and on the materials content the gloves are made up. The heavy model is the most effective to attenuate beta rays from 90Y: T%=77% without plexiglass, T%=35% with the plexiglass shield (GM); T%=80% with and without the plexiglass shield (IC). The same heavy model is not so effective to 177Lu: T%=115% without plexiglass, T%=80% with the plexiglass shield (GM); T%=84% without plexiglass and T%=55% with plexiglass (IC). The 0.25mm Pbeq apron results for 177Lu are: T%=37% (distance= 0cm); T%=39% (d= 30cm), T%=50% (d= 50cm) without plexiglass (GM) and T%=41% (distance= 0cm); T%=76% (d= 30cm), T%=52% (d= 50cm) without plexiglass (IC); whereas T%=43% (distance= 0cm); T%=46% (d= 30cm), T%=46% (d= 50cm) with plexiglass (GM) and T%=52% (distance= 0cm); T%=65% (d= 30cm), T%=62% (d= 50cm) with plexiglass (IC). The 0.25mm apron efficacy for 90Y was proved by a series of measurements during administrations: T%<2% for both photons and beta. Conclusion: the study confirms the efficacy of both the protection devices for use with 90Y source. The use of an anti‐X apron when handling 177Lu source, instead, is likely effective, while anti‐X gloves are not. The protective effect of the anti‐X apron is more pronounced anyway in 90Y exposure. This is probably due to the different emission spectra of the two isotopes and to the different materials the protection devices are made up.
P799 Radioprotective effects of hesperidin as a flavonoid against 99m Tc-MIBI in human cultured genotoxic effects of lymphocytes D. Beiki1, S. J. Hosseinimehr2, A. Ahmadi2, E. Habibi2, A. Mahmoudzadeh3, B. Fallahi1; 1Research Institute for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, Iran, ISLAMIC REPUBLIC OF, 2Department of Radiopharmacy, Faculty of Pharmacy and Pharmaceutical Research Center, Mazandaran University of Medical Sciences, Sari, Iran, ISLAMIC REPUBLIC OF, 3Novin Radiation Institute, Tehran, Iran, ISLAMIC REPUBLIC OF.
Aim: Radiopharmaceuticals have been widely used as a nuclear tracer for myocardial perfusion imaging. The purpose of this study was to investigate the radioprotective effects of hesperidin as a flavonoid against genotoxic effects of 99mTc‐MIBI in human cultured lymphocytes. Materials and Methods: The whole blood of human volunteers was incubated with hesperidin at doses 10, 50 and 100 µmol. After one hour incubation, the lymphocytes were incubated with 99mTc‐MIBI (200 µCi/2ml) for 3 h. The lymphocytes cultured with mitogenic stimulation to determine the micronuclei in cytokinesis blocked binucleated cell. Incubation of lymphocytes with 99mTc‐MIBI at this high dose induces additional genotoxicity and increasing the frequencies of micronuclei in human lymphocytes. Results and Conclusion: There were observed concentration‐dependent decrease in the incidence of micronuclei in lymphocytes after incubation with hesperidin. The data showed that the frequencies of micronuclei found in the hesperidin treated cells groups were significantly much lower than samples treated with 99mTc‐MIBI. The observations made in all volunteers in this study clearly demonstrated the reduction in the incidence of micronuclei in their lymphocytes with hesperidin at all doses, as compared samples treated with 99mTc‐MIBI without hesperidin. The data suggest that hesperidin acts effectively as a free radical scavenger, since the radioprotection by radical scavenging would be expected to be concentration dependent. There is a maximum leukocyte protection at concentration 100 µmol after hesperidin treatment. Hesperidin alone was not showed any genotoxicity at concentration 100 µmol on cultured lymphocytes. In this study we showed that hesperidin significantly protects genotoxicity induced by radiotracer 99mTc‐MIBI in lymphocytes cells. Since hesperidin has been used extensively as an phlebotropic drug, in addition to being safe; this drug can be a useful candidate for protection in occupational, where patients undergoing medical practice such as nuclear medicine.
P800 Does vitamin-E Decrease Salivary Gland Damage After Radioiodine Therapy in Patients with Thyroid Cancer? D. Beiki, B. Fallahi, S. M. Abedi, B. Mokarami, A. Fard-Esfahani, M. Eftekhari, K. Ansari Gilani, A. Gholamrezanezhad, M. Saghari; Research Institute for Nuclear Medicine, Tehran University of Medical Sciences, Tehran, Iran, ISLAMIC REPUBLIC OF. Aims: Salivary gland impairment after high‐dose radioiodine treatment is well recognized. The aim of this study was to determine the protective effect of vitamin‐E on radiation‐induced salivary gland dysfunction in patients received radioiodine (131I) for treatment of differentiated thyroid cancer. Materials and Methods: Thirty six patients enrolled in the study which are randomly divided in two groups, Vitamin E‐group (19 patients) and control‐group (17 patients). They received 131I (100 ‐ 150 mCi) for radioiodine therapy. Patients of vitamin E group received 800 Iu/day vitamin E for 5 weeks (from one week before to 4 weeks after of radioiodine therapy). Both groups were treaded with radioiodine as ward routine. Salivary gland function assessed with scintigraphy immediately before and then 6 months after radioiodine therapy by intravenous injection of 10mCi 99mTco4‐. The uptake and secretion indices of both stages were measured and then compared between two groups with Mann‐Whitney U Test. Results: There were no statistically significant differences between uptake and secretion indices of groups in pre‐ treatment study which indicated that both groups selected from the same population with equal distribution. Maximum secretion percentage (MSP) of right and left parotid glands of vitamin E‐ group were decreased more than 10% in post‐treatment salivary scintigraphy compared with the pre‐treatment scan in 5.3% and 10.5% of patients, respectively. But in control‐group these findings were seen in 11.8% and 23.5% of patients, respectively. However, the differences were not statistically significant. First Uptake Ratio (FUR), Maximum Uptake Ratio (MUR), Maximum Secretion Percentage (MSP) and Excretion Fraction (EF) of each salivary gland show no statistically significant differences between two groups. Conclusion: The study demonstrated no radioprotective benefit of Vitamin E consumption against radiation induced salivary gland dysfunction during radioiodine therapy among patients with differentiated thyroid cancer. However we recommend further study with larger patients group and higher radioiodine doses.
P801 Evaluation of staff whole body doses and extremity doses during PET-procedures before and after the introduction of automated dispensing and injection P. Covens1, D. Berus1, V. Caveliers1, F. Vanhavere2; 1Vrije Universiteit Brussel and UZ Brussel, Brussel, BELGIUM, 2Belgian Nuclear Research Centre, Mol, BELGIUM. It is generally known that significant staff exposure is expected during PET‐ and PET/CT‐ applications. As well whole body doses as extremity doses are usually higher compared to SPECT‐ applications. Dispensing individual patient doses and manual injection involves high extremity doses even when heavy weighted syringe shields are used. In some cases the external radiation causes an exposure to the fingertips of more than 500mSv/y. Whole body doses per procedure are relatively lower compared to extremity doses and are generally spread over the entire procedure i.e. during injection, escorting and positioning the patient on the camera. Optimisation of the individual technologist workload is often used to restrict staff doses. Many PET‐centres face however the need for further optimisation to reduce staff doses to an acceptable level. During this study the use of an automated dispensing and injection system for 18FDG was evaluated. Detailed dosimetry studies using thermoluminescent and direct ion storage dosimetry were carried out before and after the introduction of this system. The results show that the extremity doses can be reduced by more than 99% up to a median level of 4µSv per handled GBq. At the same time whole body doses can be halved during injection of the tracer which results in a dose reduction of 20% during the PET‐procedure of injection, escorting and positioning. In this way, the study shows that with the use of automated dispensing and injection a considerable staff dose reduction can be obtained.
Poster Presentation
P797
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P802 Occupation Exposure Doses in the Clinic of Nuclear Medicine at the Clinical Center of Sarajevo University A. Skopljak-Beganovic1, B. Basic2, A. Beganovic1, E. Kucukalic-Selimovic3, B. Tukic3; 1Department of Medical Physics and Radiation Safety, Clinical Centre of Sarajevo University, Sarajevo, BOSNIA AND HERZEGOVINA, 2 Radiation Protection Centre, Institute of Public Health, Sarajevo, BOSNIA AND HERZEGOVINA, 3Clinic of Nuclear Medicine, Clinical Centre of Sarajevo University, Sarajevo, BOSNIA AND HERZEGOVINA. Dose monitoring of professionally exposed workers is an essential regulatory measure in radiation protection. Use of unsealed radiation sources is limited to medical applications in nuclear medicine. The number of nuclear medicine examinations in the Clinical Centre is increasing every year. The aim of this study was to estimate the dose to occupationally exposed staff members of the Clinic of Nuclear Medicine in five‐year period and to compare these values with the number of nuclear medicine investigation obtained in that period. Radiation Protection Centre of the Institute of Public Health is institution performing personal dosimetry service. From 2004 until 2008 39 staff members were monitored in Clinic of Nuclear Medicine of Clinical Centre of Sarajevo University using thermoluminescent dosimetry. TLD readings were obtained using Harshaw 4500 TLD reader on a monthly basis. Values of doses below minimum detectable dose (MDL) are reported as measured. All nuclear medicine diagnostic and therapy procedures were summarized and compared with TLD values. The value of MDL is 0.10 mSv. Collective dose in five‐ year (2004 ‐ 2008) period was 79 personmSv. Annual values of collective doses were calculated as follows: 21 personmSv in 2004; 12 personmSv in 2005; 14 personmSv in 2006; 15 personmSv in 2007; 17 personmSv in 2008. The average annual effective dose per monitored worker was 0.74 mSv, 0.40 mSv, 0.48 mSv, 0.41 mSv, 0.50 mSv from year 2004 to 2008, respectively. The number of procedures, diagnostic and therapeutic, increased from 4316 in 2004 to 7216 procedures in 2008 or 67% in five‐year period, while collective dose decreased by 20% in the same period. During this period number of employees has increased by 25%. Only few staff members received higher doses that more significantly attribute to the collective dose. In 2004 49% of the collective dose is received by 18% of personnel (5 persons), while in 2008 same persons received 34% of the dose. Most of the newly employed personnel work in low dose areas receiving doses below MDL. It is safe to say that collective dose highly depends on few persons that receive higher doses. Increased awareness and use of radiation protection equipment helped reduction of mean effective dose received by these persons. Their contribution caused decrease in collective dose even though number of procedures significantly increased. Dose values for all monitored workers are below internationally recommended limits.
P803 Risk evaluation and radiation protection during the 18 quantitative evaluation of bone remodelling using F-NaF V. Pirlet1, C. Bernard2; 1University of Liege, Liege, BELGIUM, 2University Hospital of Liege, Liege, BELGIUM. The Patlak analysis used to quantify bone remodelling with 18F‐NaF requires the presence of many staff of a nuclear medicine department. The time course of plasma concentration necessary for the method needs frequent samples to be taken off from the patient. The personnel in the immediate neighbourhood of the patient could be more exposed than in a standard exam using 18F. Radiation protection requires the knowledge of the absorbed doses linked to every application of the nuclear medicine practices. The aim of these measurements was to assure that staffs do not receive significant radiation exposure during the protocol and to propose appropriate protection devices or adapted procedures. For risk evaluation associated with this procedure, an ion chamber, electronic and thermoluminescence dosimeters were used to determine the effective and equivalent hand doses. The technologist performed the injection using a standard 18F shielding device of tungsten. Close to the arm of the patient where sampling is done, the mean dose rate is 150 µSv/h after 5 minutes, compared to 1.2 mSv/h for the injection process. It decreases with time to reach 60 µSv/h after 1 hour. The electronic dosimeter indicates 20 to 26 µSv for the total time of sampling, corresponding to a mean dose rate of 40 to 52 µSv/h also measured with the ion chamber. At 1 m distance, 20 µSv/h is usually measured around the patient. In addition, information about activity distributed within the patient was available through the measured dose rates. The values were linked to the Body Mass Index of the patient. Although a stronger shielding of the syringe would be helpful to decrease the mean equivalent dose of 4.5 mSv for the fingers considering all the operations, such heavy global device is not foreseen for practical reasons. Even if the time spends during sampling is extended compared to standard diagnostic exams and the dose rate not negligible as the effective dose is about 8 % of the dose that could be received in one week, the injection step of the radiopharmaceutical for this protocol is still the most irradiating step requiring the use of appropriate shielding and the application of the usual radiation protection rules. The procedure was adapted with time. Injection could take place in the injection room, instead of direct injection in the PET‐CT room allowing the personnel to take some distance and better optimisation of the protection.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 monitoring system. All measurements were in addition to routine staff dose monitoring using TLD film badges and ring monitors. Results: The average wholebody dose received by technologists per patient handled was 2.88±0.75 µSv assuming an administered activity of 375MBq 18F‐FDG. The results show that the relative contributions to whole body dose are as follows; injecting 56.3% (31.2%‐75.6%), patient contact 24.2% (3.6% ‐ 47.3%) and dose manipulations 6.5% (1.7%‐ 18.4%). These results were supported by independent dose rate measurements that recorded dose rates up to 200 µSv/hr during injecting, 15‐20 µSv/hr during dose manipulations and up to 50 µSv/hr when in close contact to patients. Conclusion: Preliminary results from the live time extremity dose monitoring system indicate that finger doses are likely to be the dominant limiting factor when attempting to keep staff doses as low as reasonably practicable. These results also highlight the requirement to continually assess radioactive source manipulation techniques, consider additional shielding requirements, investigate the use of alternative equipment and monitor staffing levels and rotation.
P805 Radiation Doses to Technologists Working with PET Center with High Patient Potential
18
F FDG in a
M. Demir1, B. Demir1, H. Sayman1, B. Kanmaz1, A. Ahmed1, M. Halac1, D. Yasar2, I. Uslu1; 1Istanbul University, Istanbul, TURKEY, 2Turkey Atomic Energy Agency, ISTANBUL, TURKEY. Aim: The increasing numbers of PET studies for routine diagnosis propose a real hazard to the radiation workers. The aim of this study is to estimate the annual whole body and finger radiation dose to technologists working with 18F‐FDG in a PET center with high patient potential. Material and Method: In our PET center, the number of PET imaging has increased almost to 5000 studies per year. Our standard dose for tumor imaging is 518 MBq (14 mCi) of 18F‐FDG. Five technologists performing all steps of 18F‐FDG imaging (5 patients per technologist in a day) were officially involved round the week for handling and injecting 18F‐FDG to patients. Whole‐body and finger dose measurements with TLDs were performed for two different time periods; i) before shielding precautions during the first 6 months (without a shielding for sterile syringe and without a lead container for shielded syringe) and ii) after shielding precautions during the next 6 months (with a shielding for sterile syringe and with a lead container for shielded syringe). Results: Average annual whole body radiation dose for one technologist before shielding precautions was 7.82 mSv and after shielding precautions was 5.76 mSv. On the other hand, while average annual finger radiation doses for one technologist before shielding precautions were 210.36 and 293.72 mSv for right and left hand, after shielding precautions were 158.16 and 217.58 mSv for right and left hand, respectively. Conclusion: According to our results, if one technologist performs whole body PET imaging of 5 patients per day, the annual radiation dose to this technologist will not exceed the recommended limits by ICRP.
P806 Simplified Whole Body Counting for Operators Performing Maintenance of PET Cyclotrons N. Terranova1, R. Testoni1, G. Cicoria2, D. Pancaldi2, S. Boschi2, D. Mostacci1, M. Marengo2; 1DIENCA University of Bologna, Bologna, ITALY, 2 S.Orsola - Malpighi Hospital, Bologna, ITALY.
Whole body and extremity live time dose rate monitoring of technologists in a new PET-CT facility.
Aim Workers performing maintenance of biomedical cyclotrons are typically controlled for external exposure to radiation; only seldom they are controlled for internal contamination as well. In this work we evaluate the need for a specific programme on internal contamination monitoring and adapt a technique of rapid, approximate whole body counting widely used in emergency situations, to be used as an exclusion test of contamination for the operators involved in maintenance of cyclotrons for PET radionuclide production. Materials and Methods Radionuclides potentially significant as risk sources for internal contamination were selected by a preventive study of nuclear reactions on cyclotron components. Samples of powder in the chamber of the cyclotron at maintenance as well as powders resulting from cleaning of the ion source were collected and analyzed by high resolution gamma ray spectrometry. Activation 18 ‐ radionuclides in F target components were also considered. Assessment of the need for a specific programme of monitoring was performed according to the IAEA Safety Guide no. RS‐G‐ 1.2 model. A simplified technique of whole body counting has been devised using a portable spectrometer with a NaI(Tl) detector (Exlporanium GR135, distributed in Italy by TEMASinergie), based on a method widely used in emergency situations. Experimental measurements were taken during periodic preventive maintenance of the 16.5 MeV GE PETtrace cyclotron installed at out Hospital. Results Relevant contaminants of interest include 57Co (vacuum chamber, target filters, Havar foils), 181W (beam collimators), 182Ta (ion source). The decision factor calculated on the basis of the IAEA model resulted to be 0.84 for field engineers dedicated to cyclotron maintenance, and 0.26 for hospital physicists. Accordingly, an individual monitoring programme resulted to be not strictly necessary. Nevertheless, the risk level should not be underlooked and the availability of a rapid test to semi‐quantitatively asses or exclude an internal contamination is a useful optimization tool. The Minimum Detectable Activity (MDA) value for the simplified technique is of about 500 Bq for a counting time of 300 seconds. Measurements on the operators performing maintenance at our site, allow the exclude any contamination above the MDA. Conclusions The risk of internal contamination for operators involved in maintenance of PET cyclotrons is limited and can be prevented through appropriate procedures. However, careful evaluation and a case by case assessment are advised. The simplified counting method presented allows a rapid exclusion test and the selection of cases in which a timely, accurate whole body counting is required.
A. Jones, R. Meades, D. Woodhouse, D. J. Towey, A. Al-Nahhas, K. S. Nijran; Imperial College Healthcare NHS Trust, London, UNITED KINGDOM.
P807
P804
Aims: The introduction of a new PET‐CT facility at our centre has led to an inevitable increase in technologists’ radiation doses. The aim of this study was to assess the relative contributions to technologists’ doses from the various working operations during daily routine 18F‐FDG PET‐CT scanning. Method: 8 technologists working on a rota in the PET‐CT facility over a period of 5 months were issued with personal instantaneous dose rate monitors (Radeye G‐10, Thermo Scientific). Procedural situations expected to result in an exposure were identified with their timing and duration for each technologist being recorded. These operations were divided accordingly into three categories; i) dose manipulations, ii) injecting and iii) patient contact. Further measurements were also made of extremity doses using the AEGIS ED2 extremity dose
Radiation Protection for Accompaniment Person in PET/CT S. Nisli1, M. Demir2, B. Demir3, B. Kanmaz1, A. Tugrul4, G. Yılmaz4, M. Halac1, S. Sager1, I. Uslu1; 1Istanbul University Cerrahpasa Medical Faculty Nuclear Medicine Dept., Istanbul, TURKEY, 2Istanbul University Cerrahpasa Medical Faculty Nuclear Medicine Dept., Istanbul, TURKEY, 3Istanbul University Science Faculty Nuclear Physics, Istanbul, TURKEY, 4Istanbul Technical University Energy Institute, Istanbul, TURKEY.
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P808 Dose reduction in PET/CT using thin overlying bismuth radioprotective shielding (BRS): our preliminary results. S. Cimini, A. Moretti, G. Giorgetti, C. Giovannini, R. Galassi, A. Maraldi, A. Zoli, A. Marzullo, C. Bedei, F. Matteucci, M. Bertocco; Pierantoni Morgagni Hospital, Forlì, ITALY. Aim: PET/CT represents an important and useful integrated system of imaging, combining the morphological informations of CT with the metabolic data of PET, but the problem is that also the radiation dose for the patient is high. This problem became very important if we consider that a large number of oncological patients are submitted to frequent examinations and that it’s impossible to reduce the radiation dose in some type of examination such as diagnostic CT, requiring a high quality of images. In PET/CT, in which CT is used for the attenuation correction, it’s possible to reduce the radiation dose, modifying the quantitative parameters (mA, KV, pitch). Moreover the breasts receive high dose because of their superficial location. Other superficial radiosensitive organs are likewise needlessly irradiated during radiologic procedures to include the thyroid gland, the lens of the eye, and the testes. The aim of our study is to evaluate the ability of shields of Bismut (BS) to reduce the x‐ray dose to radiosensitive superficial organs during PET/CT without affecting diagnostic efficacy. Materials and methods: We studied 20 female patients (mean age 42,7±5,21; mean weight 75,8±2,20), submitted to PET/CT for oncological disease, utilizing the BS positionated over the neck, the eyes and the breasts. The shields consists of 4 layer of bismuth; each layer has a surface density of 0.85 grams of bismuth per cm2 . All pts were submitted to PET/CT with standard protocols, utilizing the same qantitative parameters for attenuation CT (80mA; 120KV) with BS. Results: In our group the average radiation dose in PET examination is about 4‐7 mSv, while the average radiation dose for attenuation CT is about 15‐22 mSv with an average total radiation dose for a single exam of PET/CT about 19‐29 mSv (percentage contribution of CT 72‐79%). The mean radiation dose, measured in each patients with and without BS, were respectively 4,37 ±0,20 vs 5,50±0,65 for the lens of the eyes, 4,90±4,14 vs 6,58±0,62 for thyroid and 4,63±0,21 vs 5,75±0,28 for breast. The percentuage reduction was respectively of 20%, 25% and 19%. Conclusions: Our data seems to prove that BS would lead to a reduction in dose, without affecting the quality of the image; the BRS proved easy to use and did not increase the examination time.
P809 Estimation of the effective doses for Medical workers operating in a PET/CT department K. Dalianis, F. Vlachou, D. Savidou, L. Gogou, R. Efthimiadou, K. Gogos, O. Karamini, K. Archondaki, J. Andreou, V. Prassopoulos; Department of PET/CT D.T.C.A. Hygeia Hospital, Athnes, GREECE. Aim: The most commonly used radionuclide in PET/CT departments is 18F fluorodeoxyglucose (FDG). The FDG PET/CT applications have been continuously increasing for diagnostic procedures. Although such an increase is a positive trend for the benefit of patients, the associated risk of radiation exposure of staff needs to be properly evaluated. The aim of this study was to measure the radiation exposure of the staff and evaluate the doses in the first PET/CT department in Greece at D.T.C.A. Hygeia after 5 years and compare the reduction of the doses for each year. Material‐Methods: To estimate the effective dose from external exposure all 6 members of the staff (2 nurses, 2 medical physicists, 2 technologists, had TLD badges worn at the upper pocket of their overall, TLD rings on the second finger of each hand constning of disk measuring diameter by 0,9 mm thickness. The nurses are the one that inject the patients and covering the most common procedures and the medical physicist are responsible for dose drawing from a multidose 18 F fluorodeoxyglucose (FDG) vial. Results: In the period of March 2004 to March 2009 a total of 4976 PET/CT studies procedures were performed. Dose values of PET personnel measured over 5 years of clinical activity consisting of a workload of about 20‐25 patients /week which received 350‐410MBq of 18F‐FDG were. The following table summarizes the whole body doses in mSv for workers for each year
2004 2005 2006 2007 2008
Nurse 1
2,1 2,2
2,1 2,0 1,9
Nurse 2
2,5 2,7
2,4 2,3 2,1
Medical Physicist1 2,04 2,12 2,05 2,0 2,0 Medical Physicist 2 2,01 2,22 2,09 1,98 1,97 Technologist1
0,95 1,12 0,99 0,94 0,92
Technologist 2
0,96 1,03 0,99 0,99 0,98
As for the hand doses Nurse 1 received 2,6 ‐ 2,9 ‐ 2,6 ‐ 2,2 ‐2,0 mSv for each year (2004‐2008), Nurse 2 received 3,1 ‐ 3,4 ‐ 3,2 ‐ 3,1 ‐ 3,0 mSv respectively, for medical physicist 1 the dose values were 2,97 ‐ 3,1 ‐ 2,92 ‐ 2,7 ‐2,7 mSv hand dose for each year (2004‐2008) and medical physicist 2 received 2,01 ‐ 2,22 ‐ 2,09 ‐ 1,98 ‐ 1,97 .mSv and 2,2 ‐ 2,6 ‐ 2,2 ‐ 2,1 ‐ 2,0 .mSv respectively. Conclusion: The personnel dose results are significantly less than the recommended annual dose by International Commission for Radiological Protection. The reduction of the dose through each year is attributable to additional radiation safety precautions and the experience of the workers through each year.
P810 Automated Dispenser Radiopharmaceuticals
for
Ga-68-DOTATOC
M. Li; Institute of Nuclear Energy Research, Taoyuan, TAIWAN. Objectives: Traditional dispenser for Ga‐68‐DOTATOC radiopharmaceuticals mostly is used for small scale dispensing in laboratory. It is not only inconvenient but also functionally limited. Without continuous operation its dispensing cost is high. So mass production is difficult. This study is related to an automated dispenser for radiopharmaceuticals. Especially it refers to a situation that hand contact with Ga‐68‐DOTATOC radiopharmaceuticals is avoided and exposure to radioactive materials is reduced for operators. Methods: To achieve the above objectives and functions, the technical approaches include: one platform with at least one supporting plane at top; one drug bottle at one side of the platform; one moving mechanism located on the supporting plane to drive a syringe clamp to hold a syringe and move it in space repeatedly, and rotate around an axis in the parallel direction to make the syringe to move from outside to the position for a needle to insert; a syringe driving mechanism to move simultaneously with the syringe clamp driven by the moving mechanism and to have a driving rod on it to drive the syringe cylinder for withdrawing drug. Results: An automated dispenser for Ga‐68‐DOTATOC radiopharmaceuticals is mainly for a platform to have a moving mechanism being able to move three‐dimensionally back and forth, a syringe holder and a bottle holder. The syringe holder is for holding a plural number of syringes. The bottle holder has a reverse drug bottle. The moving mechanism has a syringe clamp rotatable around a horizontal axis and a syringe driving mechanism. The syringe clamp is activated to hold a syringe and move it to where the syringe needle is inserted to the drug bottle. The syringe driving mechanism and the syringe clamp are simultaneously associated with the syringe for drug‐withdrawing action. Conclusions: The present dispenser provides a fully automated controlled system, employed for distribution radiopharmaceutical to single unit dose, or injection of radioisotope to several reaction bottles to get chemical reaction. It employs a personal computer interfaced to five axis step motors, and a sterile syringe. Only the sterile syringe contacts with the radiopharmaceutical. The sterile syringe is disposable. A novel transport safe is employed to further reduce radiation exposure.
P811 An Innovative Synthesizer for I-123-ADAM Labelling M. Li; Institute of Nuclear Energy Research, Taoyuan, TAIWAN. Aims: The purpose of this study is to develop a fully automated controlled system that can reduce the environmental radiation and to enhance the stability for the synthesis of I‐123‐ADAM, with a compact synthesizer module. Methods: Main procedures of the process include: (1) the injection of I‐123 nuclides; (2)oxidation reaction; (3) quench and neutralization with NaHCO3; (4)separations; and (5) collections. Results: The advantages of this fabricated synthesizer module are illustrated as follows. Firstly, the whole processes are operated in a closed system with a charcoal trapper used to absorb the release gas of radioactive I‐123 that can reduce the environmental radiation. Secondly, the assembly of the module is made as small as possible. Thirdly, this module is functioned with a fully automated control for synthesis of making I‐123‐ ADAM. The process time is about 20mins. The products obtained with purity of greater than 95% is sufficient to meet the requirements of the specifications for I‐123‐ADAM in nuclear medicine applications. The control software was designed step by step precisely for fully automatic I‐123‐ ADAM labelling process. Conclusions: During the process performance, the analogue signal, pressure and variation of radiation dose can be monitored and recorded simultaneously to reflect the reaction situation at that time. For the purpose of process validation, every recorded data are filed and reserved automatically to compliant with the regulation of cGMP/PICS. The present invention relates to a manufacturing method and an automatic manufacturing device thereof, especially to a manufacturing method for I‐123‐ADAM and an automatic manufacturing device thereof applied to brain SPECT imaging in nuclear medicine.
P812 Hand Skin Dose During Administration of FDG M. Fülöp1, P. Povinec2, D. Baček2, P. Vlk2; 1Slovak Medical University, Bratislava, SLOVAKIA, 2PET centre, Biont Inc., Bratislava, SLOVAKIA. Physician hands are mainly irradiated due to manipulation with syringe in process of FDG administration to patients. The ratio of maximum skin dose to ring dosimeter response is usually greater than a value of 10 with an uncertainty of about 50% because of its sensitivity on syringe position in physician hand. Doses at the limit level should be measured with uncertainties not exceeding of about 20%. The aim of the presentation is to search a possible new position of ring dosimeter for monitoring of maximum skin dose with higher precision. The presentation was sponsored by the ORAMED project of the 7th EU Framework Programme and by the project of the Ministry of Health SR No. 2005/26‐SZU‐04. Geometry of hand irradiation was specified by analyse of video records of physician hand with syringe during FDG administration to patients. In accordance to the irradiation geometry hand phantoms were made for measurements of hand dose distribution. Monte Carlo simulations for some ring dosimeter locations on hand have been chosen to undertake a sensitivity study of maximum skin dose distribution with regard to possible syringe positions at various places on its axis and on vertical. Choice of suitable locations for maximum skin dose monitoring is based on value of standard deviation of monitored doses for various syringe positions. Simulation and measurement preliminar results corresponding to one of the selected hand positions are presented in the paper.
Poster Presentation
Aim: The purpose of present study is to determine the 18Flor‐Fluorodeoxiglucose radioactivity amount in the urine of patients, to measure the external exposure dose rates as a function of distance from parents and to discuss the necessary precautions for radiation protection. Method: Thirty patients were injected intravenously with 14.1 mCi 18Flor‐Florodeoxiglucose. Urines of patients were taken at 43, 62, 87, 117, 238, 362 minutes after injection and activity of these urines were determined by taking sample from urine. External exposure dose rates as a function of distance from parents were measured using a Geiger Müller detector and total radiation dose from patients to accompaniment person of the patients were calculated. Results: While activity concentration of 18Flor‐Fluorodeoxiglucose in urine at 43 minute was 75.4 MBq/ml, activity concentration was decreased to 41.8 MBq/ml at 117 minute. According to our results, a part of 18.4 % of 18Flor‐Fluorodeoxiglucose in the body was spent by way of urinating up to 117 min after injection. At 117 min after injection, external exposure dose rates at 0, 0.25, 0.50, 1.0 and 2.0 m were determined as 39, 12, 6, 2, and 0.6 mR/h, respectively. Total radiation doses up to 117 min were calculated as 2.42 mSv at 0 m, 1.11 mSv at 0.25 m and 0.50 mSv at 0.5 m. Conclusion: Within the first two hours after injection, it was determined that an important part (18.4 %) of 18Flor‐Fluorodeoxiglucose radioactivity injected to the body was spent by way of urinating and a high level radiation from patients up to 0.5 m was determined. Thus, the people living with patients imagined by means of PET using 18Flor‐Fluorodeoxiglucose should take necessary precautions for radiation protection within these two hours, and there is no need for any protection precautions after that time.
S468 P85 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
General topics: regulations and harmonisation
P813 Development of a Procedure Guideline for Planar Radionuclide Cardiac Ventriculogram for the Assessment of Left Ventricular Systolic Function A. Nicol1, M. Avison2, M. Harbinson3, S. Jeans4, W. Waddington5, S. Woldman5; 1Southern General Hospital, Glasgow, UNITED KINGDOM, 2 Bradford Royal Infirmary, Bradford, UNITED KINGDOM, 3Queens University, Belfast, UNITED KINGDOM, 4Christie Hospital NHS Foundation Trust, Manchester, UNITED KINGDOM, 5UCL Hospitals NHS Foundation Trust, London, UNITED KINGDOM. A procedure guideline has been developed for the purpose of assisting UK specialists in nuclear medicine in recommending, performing, interpreting and reporting planar gated radionuclide cardiac ventriculograms (RNVG) for the assessment of left ventricular systolic function. The aim of this guideline is to obtain consistent and quality results. This is particularly desirable since, within the UK, the National Institute for Health and Clinical Excellence (NICE) has mandated national protocols for the pre‐assessment and monitoring of patients undergoing certain chemotherapy regimes, based on specific left ventricular ejection fraction criteria. The writing group consisted of medical and scientific staff experienced in RNVGs. Members of the British Nuclear Cardiology Society Committee(BNCS), British Nuclear Medicine Society (BNMS) Professional Standards & Education Committee, Institute of Physics and Engineering in Medicine (IPEM) Nuclear Medicine Special Interest Group and the UK Radiopharmacy Group provided comments on drafts of the guideline. The final document has been endorsed by the BNCS, BNMS and IPEM. The guidelines were based on a systematic literature search with relevant data being reviewed by members of the writing group and discrepancies reconciled by consensus. The guidelines document addresses: guideline indications, radiopharmaceutical & administration, data acquisition & analysis, data review (prior to clinical evaluation as a quality assurance procedure), data to be available for operator undertaking clinical evaluation, interpretation of the RNVG and controversies / issues requiring further clarification. It is hoped that these guidelines will assist medical, technical & scientific staff carrying out RNVG procedures. Further guidelines produced by the multi‐disciplinary staff groups in nuclear medicine are encouraged.
P814 The impact of regulatory stringency on the R&D governance of global Radiopharmaceutical firms M. Li; Institute of Nuclear Energy Research, Taoyuan, TAIWAN. Objectives: This paper studies the degree to which country differences in regulatory stringency, including both the intellectual property rights (IPRs) government protection and drug approval regulations (DARs) government control, the trade‐off relation affects the choice of partners for a particular mode of international inter‐firm R&D partnering within the radiopharmaceutical industry. Methods: We used the ReCap.com database to select companies that formed inter‐firm R&D collaborations in the radiopharmaceutical industry. We are also linking regulatory stringency measures to the countries of these R&D collaborations. Results: We developed theoretical propositions departing from innovation and network theories. We argue that the preference of radiopharmaceutical companies for an interdependent spectrum from an equity joint venture to a contractual partnership. Besides, the higher R&D collaborative interdependence a radiopharmaceutical firm has with other partner is inversely related the stage of technological innovation. Proposition 1 : The more inter‐organizational interdependence in an international R&D collaboration is inversely related to the level of intellectual property rights protection in the home country of its partner. Proposition 2 : The more inter‐organizational interdependence in an international R&D collaboration is positively related to the level of regulatory stringency of drug approval systems in the home country of its partner. Conclusions: Taking the radiopharmaceutical industry as a case study will draw attention to highlight the crucial necessity of assessing regulations before and after implementation. Cross‐national regulatory differences in safety, price and intellectual property protection are inherent feature of the operating environment of the global radiopharmaceutical firm. Institutional, transaction cost theories assume that regulation represents a cost to the firm; therefore firms ‘vote with their feet’ and avoid investment in stringently regulated markets.
P86 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
General topics: risk, benefit and costs
P815 Perfusion scintigraphy lung in sickle cell disease E. M. S. Y. BEN SLIMENE MED FAOUZI; Salah Azeiz, Tunis, TUNISIA. Sickle cell disease (SCD) is an inherited abnormality of the ß‐globin chain, which causes a spectrum of haemolytic anaemias. Clinical manifestations in SCD include anaemia, jaundice, recurrent vaso‐occlusive crises, and infections (particularly by encapsulated bacteria) due to functional asplenia and cerebrovascular accidents. Radiological investigations play a critical role both in the diagnosis and in the primary prevention of the complications of SCD. The lung is a common site of involvement in SCA. Injuries range from acute processes, such as pneumonia and acute chest syndrome (ACS), to chronic entities, such as pulmonary fibrosis. AIM: Pulmonary complications constitute the second leading cause of hospitalization (after acute pain crises) and are now the leading cause of death for patients with Sickle cell disease (SCA). Pulmonary vascular occlusion may also lead to acute chest syndrome. Perfusion scintigraphy play a critical role in the diagnosis of the vascular complications of SCD. METHODS: A total of 16 patients (9 male, 7 female) ranging in age from 1 to 15 years, underwent perfusion scintigraphy during an episode of acute chest syndrome, were enrolled in this retrospective study. RESULTS: Segmental pulmonary
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 artery occlusion has been noted with perfusion scintigraphy. 60% of patients have no initial radiographic abnormality. CONCLUSION: Perfusion scintigraphy play a critical role in the diagnosis and in the primary prevention of the vascular complications of SCD.
P816 A model of innovation and technology appropriability regimes: an analysis of international radiopharmaceutical firms M. Li; Institute of Nuclear Energy Research, Taoyuan, TAIWAN. Objectives: Radiopharmaceuticals discovery and development process need to permit novel drug targets to be identified, clinical trial testing to be made more efficient, and efficacious therapeutics to be approved and made widely available. Patent is one of the most important of all intangible assets in this industry, and thus cornerstone of a firm's competitiveness and its knowledge management strategy in radiopharmaceutical industry. It is necessary to review the various patenting strategies that research‐intensive firms can pursue so as to build a sustainable competitive advantage upon the foundation of technological intangible assets and to protect their R&D process outcomes. The claim strategy of patent is important, due to the complexity and systemic dimension of modern technologies and its different legal foundations. We try to explore the main technological domain within headquarters (HQ) and its subsidiary R&D emphasis through patent analysis. And then understand the subsidiary role as a type of the center of excellence in different appropriability regimes. Methods: A model of patent analysis can divide the technology portfolio into clusters of R&D emphasis, and name as the center of excellence, similar technology, as defined by the International Patent Classification (IPC) used within the patents to describe the technology. The patent portfolio analysis also comprises the center of excellence of HQ with subsidiary each other relating to complementary or substitute innovation. It can also help to identify inter‐unit knowledge inflow where complementary technology can be inflow from HQ or from other subsidiaries. Finally, we are implemented in a sample of US international radiopharmaceutical firms within US patents. Results: We find that increases in the effectiveness of patent protection increases forming propensity of the new center of excellence when subsidiaries required to bring new technologies (complementary patents) to HQ are absent. In contrast, for decreases in the effectiveness of patent protection increases forming propensity of the same as HQ’s center of excellence when subsidiaries required to implements technology development (substitute patents) to HQ are present. Countries with higher levels of intellectual property protection will have higher levels of foreign direct investment, all else being equal. Conclusions: We thus present systematic cross‐national empirical support for the proposition that the cross‐national R&D strategies analyse patents as barriers to entry, and a firm's strategies to either explore new innovative advantages or to continuously perform innovation processes in different technology appropriability regimes.
P87 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
General topics: tele-nuclear medicine - PACS
P817 Nuclear RIS-PACS an example of filmless department in Italy B. Bagni, G. Pascale, A. Casolo, M. Cucca, A. Franceschetto; Università di Modena, Modena, ITALY. There is increasing need for seamless connectivity between nuclear medicine systems and general radiology image storage and display devices. Nuclear medicine has had the advantage (and disadvantage) of being one of the pioneers in digital imaging. Picture Archiving and Communication Systems (PACS) became prevalent in radiology departments. When the DICOM standard started to come into use in radiology, the attitude of the nuclear medicine community was very higth the existing standards are much simpler to understand and implement. Unfortunately, PACS do not always preserve private elements during storage and retrieval. Vendors are improving their software routines so as to make sure that all essential fields are coded in the “public” portion of the DICOM header. Some PET systems offer the option of disguising the PET images as NM data when sending images to the PACS. Unfortunately, some quantitative information is lost in this process, and the PET workstation may have difficulty with the data if it is subsequently retrieved. Unfortunately, systems optimized for efficient interpretation of CT and MRI images may be very awkward to use when viewing nuclear medicine data. The SNM procedure guideline for Telenuclear medicine provided a reference standard for minimum display functionality for remote nuclear medicine viewing systems and the American Heart Association provided a standard for viewing myocardial perfusion images . DICOM provides a standard for exchanging nuclear medicine images. In our institution we uses from 2005 a RIS‐ PACS System from Fuji which performes a bridge from general radiology and nuclear Medicine the system perform nuclear medicine scheduling for PET‐CT SPECT‐CT and general nuclear medicine included iodine therapy . Row data and ultimate data are stored in the general storage of PACS. The terminals of the nuclear medicine devices ( CT‐PET and NM devices) are directly connected to PACS data system to retrive and store any type of images and accessory data . The PACS terminals are connected to RIS (Radiological Information System) terminals and data treatments consolles of nuclear medicine. Pacs system is connected to a writer of CD‐ROM to store data and examination pictures of the patient to avoid film and paper; the CD is written in DICOM including a DICOM reader. All the nuclear medicine device are connected to PAS‐RIS Sistem and the Nuclear medicine will be a filmless department.
P818 Double Specialist Double Read PET/CT Reporting within an European Telediagnostic Imaging Platform R. de Juan, O. Johansson, T. Ormstrup, C. Schorlemmer; European Telemedicine Clinic, Barcelona, SPAIN. Background: The development of PET/CT imaging has brought about serious professional, regulatory and technological issues between different European Union (EU) countries and even within different specialties in the same country, so that both career development, freedom of
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 movement and IT (information technology) conectivity may be effectively challenged or restricted within the EU. This is even more significant in countries where double specialist certification is not available. Material and methods:To tackle this issue from a practical point of view, a pool of nationally certified EU based nuclear medicine physicians, radiologists and double certified specialists registered both on their base and target countries working in a fully electronic double reporting clinical scenario is able to deal with all possible regulatory and IT contexts across different EU countries that may restrict professional activity. Results: The flexibility of telediagnostic double reporting provides support to imaging departments where staff is lacking or not fully competent, for quality, audit and educational purposes during and/or after working hours and regardless of the IT provider thanks to a dedicated telediagnostic multimodality imaging enabled PACS setting. Conclusion: Intraeuropean double specialist solutions may help in overcoming the shortcomings of the professional, regulatory and IT issues, which have not been fully addressed in respect to PET/CT imaging technological developments.
Registered counts were significantly higher in all brain regions in the medetomidine‐before‐tracer compared to the medetomidine‐after‐tracer condition. Regional alterations were limited to the subcortical region, where a significant decreased perfusion‐ratio (‐0,044; 95% confidence interval [‐0,07,‐0,02]) was found in the medetomidine ‐before condition (P<0,01). No significant regional differences were observed in the other regions. Conclusion Medetomidine prior to injection of 99m Tc‐ECD provokes not only a generally increased tracer uptake in all brain regions, probably due to a mainly peripheral vasoconstrictive effect, but also regional blood flow alterations in the subcortical region. Brain perfusion under medetomidine sedation can be used to compare regional brain perfusion in cortical areas but caution is needed when evaluating subcortical rCBF. Further studies are necessary to evaluate the effect of this rCBF alteration on neurotransmitter studies.
Semiquantitative SPECT to Prove the Survival of Splenic Tissue After Spleen Preserving Surgical Investigations in Canine Model
General topics: veterinary medicine
P819
18
Kinetic of F-DOPA in basal ganglia of non-human primate. G. Grassetto1, A. Massaro1, S. Cittadin1, A. Padoan2, R. Manara3, D. D'Avella4, P. Zampieri5, M. Marzola1, L. Rampin1, E. Banti1, F. Fante6, G. De Benedictis6, E. Cozzi7, E. Ancona7, D. Rubello1; 1Nuclear Medicine Service, Hospital Rovigo, Rovigo, ITALY, 2Pediatric Neurosurgery , Hospital Padova, Padova, ITALY, 3Neuroradiology Service, Hospital Padova, Padova, ITALY, 4 Department of Neurosciences, University of Padova, Padova, ITALY, 5 Neurosurgery Service, Hospital Padova, Padova, ITALY, 6Corit, Padova, Padova, ITALY, 7Surgery Service III, Hospital Padova and Department of Surgical and Gastroenterological Sciences, University of Padova, Padova, ITALY. Objective: Purpose of the study, that is part of a larger ongoing European Union study to evaluate the efficacy of staminal cells transplantation in non‐human primates with induced Parkinson, was to investigate the kinetic of 18F‐DOPA in the basal ganglia of macacus monkeys. Methods: Until now 4 adult health female macacus (weight range=2.94 ‐ 4.1 Kg, age rage= 5 ‐ 7 years) underwent a dynamic 18F‐DOPA brain PET/CT. A hybrid PET/CT 16 slices system (GE Discovery STE) was used. The FOV was electronically set‐up to 15 cm. The administered 18F‐DOPA dose was 37 MBq/Kg. The anaesthetized monkey was positioned onto the tomograph gantry (prone position with hyperextension of the neck). The exam started with brain CT, followed by the injection of an average activity of 148 MBq of 18F‐DOPA; PET acquisition immediately started and was acquired in list‐mode for a total of 90 min; data were then reframed and 9 frames of 10‐ min each were obtained. Trans‐axial, sagittal and coronal slices of the brain were reconstructed by OSEM method and, after alignment, six volumetric ROI (VOI) 5x5x5 mm in size (125 μl in volume) were automatically generated on the caudate, and the anterior and posterior putamen bilaterally. An additional VOI was drawn in the cerebellum cortex to measure BKG (dopaminergic receptors are absent in the cerebellum). For each VOI, the software allowed the automatic measurement of the maximum count that was corrected for the decay, using the formula Ct0=Ct*e‐0.693(t/T1/2) : C is the count, T1/2 is the half‐life of 18F (109.8 min) and t is the time of the phase considered. Data were then corrected for BKG also and time/activity curves were generated. Results: In all the monkeys the time/activity curve for each structure showed the same trend. In particular, for each curve calculated in the basal ganglia three different phases were observed: the first was characterised by a rapid, progressive slope until the 30th ‐40th minute, the second showed a further slower slope until about the 60th minute, and in the third a steady‐state condition was reached. Conclusion: These preliminary data show that, as expected, 18 the F‐DOPA kinetic in the basal ganglia of macacus shows a specific binding of the radiotracer due to presence of specific dopaminergic receptors. Moreover, our data show that the best timing to start the 18F‐DOPA PET/CT acquisition process for the basal ganglia of macacus is about 60 minutes after radio‐tracer injection.
P820 Medetomidine causes changes in regional cerebral blood flow measured with single photon emission computed tomography in dogs T. Waelbers1, K. Peremans1, S. Vermeire1, L. Duchateau1, K. Audenaert2, A. Dobbeleir1, I. Polis1; 1Ghent University, Merelbeke, BELGIUM, 2Ghent University, Ghent, BELGIUM. Introduction Intramuscular sedation before general anaesthesia and before intravenous tracer administration is sometimes required to handle anxious and aggressive dogs. Since sedatives have a central nervous system effect or have an effect on the circulatory system, and hence on 99m regional cerebral blood flow (rCBF), one should evaluate their effect on Tc‐ECD distribution studies. In veterinary medicine, medetomidine (Domitor®) is a frequently used sedative with alpha2 agonist properties that causes marked sedation, peripheral vasoconstriction and bradycardia. The aim of this study was to evaluate the effect of medetomidine, prior to injection of 99mTc‐ECD on rCBF. Materials and Methods The rCBF was measured in 10 adult dogs according to the following protocols. First the tracer (99mTc‐ECD) was injected 10 minutes prior to IM administration of medetomidine (1000 µg/m2 body surface area) (medetomidine‐after condition). On the second occasion the tracer was injected 15 minutes after IM medetomidine (same dosage) (medetomidine‐before condition). Anaesthesia was induced in both groups with propofol IV (1,88 ± 0,82 mg/kg) (no significant difference in dosage between both conditions) and maintained with isoflurane in oxygen using a rebreathing system. Semiquantification of the rCBF was performed by normalising the average regional counts of one region of interest (ROI), drawn over the different brain regions, to total counts of all ROIs. Differences between protocols were evaluated in eleven ROIs: bilateral frontal, temporal, parietal and occipital cortex, bulbus olfactorius, cerebellum and the subcortical region. The statistical analysis was based on the mixed model with dog as random effect and protocol as categorical fixed effect. Results
J. Varga, I. Furka, E. Sajtos, Z. Fodor, F. Kiss, T. Nagy, K. Pető, L. Galuska, I. Mikó; University of Debrecen, Debrecen, HUNGARY. Background: Spleen preserving techniques performed for the surgical treatment of traumatized spleen may prevent serious postoperative complications, such as the Overwhelming Postsplenectomy Infection (OPSI) Syndrome or the Disseminated Intravascular Coagulation (DIC). Investigating the restoration of splenic function could help the human clinical practice to find non‐invasive methods for indicating possible hyposplenic‐asplenic states. Aim: To test whether scintigraphy with denatured red blood cells (RBCs) is suitable for detecting functioning splenic tissue remnants in beagle dogs. Materials and methods: Tc‐99m labeled RBCs were denatured by stannous chloride and heat treatment adapted for dogs. The efficiency of the imaging method was tested in six experimental groups: “SH”‐sham‐operated (n=1), “SE”‐splenectomy (n=1), “R1/3”‐one‐third of the spleen resected (n=2), “R2/3”‐two‐third of the spleen resected (n=2), “AU5” and ”AU10”‐autotransplantation of 5 or 10 spleen chips into the greater omentum using Furka’s technique following splenectomy (n=2‐2). Images by a two‐headed gamma camera were started with dynamic series simultaneously from anterior and left lateral views (30 min), then SPECT acquisition followed (64 projections over 360° arc, pixel size: 3.24 mm). From the dynamic series parametric images of the change rate between the 10th and 30th min were calculated. Tomographic images reconstructed using OS‐EM algorithm were attenuation‐corrected using Chang’s method, and the total uptakes of foci accumulating radiopharmaceutical were expressed as fractions of the injected dose. Results: The parametric images of animals with some part of the spleen retained visualized only the spleen and the urinary bladder (where activity increased with time), proving that RBCs denatured by the method applied accumulate specifically in splenic tissue. Parametric images indicated the survival of functioning splenic tissue in all autotransplanted animals. With SPECT technique 77% of the autotransplanted spleen chips could be visualized with varying uptake values. Conclusion: Scintigraphy with labeled denatured RBCs proved to be capable of detecting both retained and autotransplanted functioning splenic tissue in a non‐invasive way. Grants: OTKA T‐049331, ETT 387/2006.
P89 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Molecular imaging: general
P822
131
Imaging and therapy of angiogenesis with Iodine labeled recombinant human plasminogen kringle 5: a human lung adenocarcinoma study in model mice R. Guo, B. Li, L. Dong, Y. Zhang, C. Zhu; Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, CHINA. Purpose: Angiogenesis plays a critical role in tumor formation and metastasis. Suitable radiolabeled angiogenesis inhibitor can be used for noninvasive imaging of angiogenesis and targeted radionuclide therapy. Here we investigated the feasibility of targeted tumor imaging and therapy using 131I labeled recombinant human plasminogen kringle5 (rhK5) protein, a potent angiogenesis inhibitor. Methods: rhK5 protein was expressed in E.Coli and purified by Nickel chelated agarose. 131I labeling was performed after confirmation of its bioactivity by angiogenesis inhibition experiment, rhK5 was labeled by iodogen method for biodistribution, imaging and therapy studies (A549 human adenocarcinoma xenograft model). The effects of therapy were evaluated by calculating the volum of tumor and microvessel density(MVD). Results: rhK5 gene was successfully cloned into the pET‐22b(+) vector, partly expressed as soluble form and purified with a yield of 2mg/L, got a purity of more than 95%. The purified protein is confirmed by Western blot analysis, have satisfied bioactivity and specifity. The labeling rate and radiochemical purity of of 131I‐rhK5 was 84% and 95% respectively. The tumor region was readily visualized 1 h after 131I‐rhK5 injection, the radioactivity increased as the time went by. 131I‐rhK5 inhibited tumor growth at a rate of 36.46%, while the same amount of rhK5 had no effect on it. 131I‐rhK5 treated tumor tissues showed decreased MVD. Conclusion: This study demonstrated that 131I‐rhK5 is an effective reagent for both tumor angiogenesis imaging and targeted therapy. This study provided an experimental support for applying radiolabeled rhK5 in human tumor imaging and treatment. Key words: plasminogen; kringle5; 131I; angiogenesis; radionuclide imaging; tumor therapy
P823 Effect of Gemcitabine on the Uptake of Pancreatic Carcinoma Cell Patu8988
18
F-FDG on Human
B. Yang, Y. Wu, B. Zhang; The First Affiliated Hospital of Soochow University, Suzhou, CHINA. It is essential to predict the chemotherapy efficacy of pancreatic carcinoma early and gemcitabine replaced 5‐FU as the gold standard in systemic treatment of advanced pancreatic 18 carcinoma. Objective to investigating the binding characteristic of F‐FDG with human
Poster Presentation
P88 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
P821
S470 pancreatic carcinoma cell Patu 8988 and the influence of gemcitabine on the uptake of 18F‐FDG on Patu8988 cell. Methods The binding efficiency of 18F‐FDG was determined under different conditions: 5×104~1×107 cells; 1.85~29.6 KBq 18F‐FDG; 0~11.1mmol/L glucose levels; 20~120 min incubation on 37°C. The proliferation inhibition effect were studied by MTT assay at 24h after administration of 0~60mmol/L (10μL) gemcitabine. 1×106 cells were seeded in 25cm2 flasks,the binding efficiency of 18F‐FDG after 24 hours were detected at 24h after administration of 0~60mmol/L (100μL) gemcitabine. The data was analyzed by the calculation of Pearson correlation coefficient r and using ANOVA. P<0.05 was considered significant. Results The binding efficiency was (60.60±3.05)% on the condition of 1×106cells, 3.7KBq 18F‐FDG, 5.55mmol/L glucose level, and 100min incubation on 37°C. The proliferation inhibition were (33.71±6.46)%, (96.17±1.17)%, (96.67±0.82)%, (98.00±0.89)% at 24h after administration of 5, 20, 40, 60mmol/L (10μL) gemcitabine. The binding efficiency were (58.35±2.19)%, (56.34±1.56)%, (48.92±5.91)%, (39.14±7.40)%, (29.67±4.41)% at 24h after administration of 0, 5, 20, 40, 60mmol/L (100μL) gemcitabine. The binding efficiency was negatively correlated with the dose of gemcitabine (r=‐ 0.928,P<0.01). The binding inhibition efficiency was positively correlated with the proliferation inhibition (r=0.697,P<0.01). Conclusion The binding efficiency of 18F‐FDG with human pancreatic carcinoma cell Patu 8988 decreased at 24h after administration of gemcitabine. We deduce that the chemotherapy effect of gemcitabine to pancreatic carcinoma can be predicted early by 18F‐ FDG PET scans.
P824 In Vivo Imaging Radiation-induced Tissue Apoptosis by 99m Tc(I)-his-annexin V C. C. Wu1, K. J. Lin2, Y. H. Pan1, C. S. Chiang1, J. H. Hong3, F. H. Chen1, S. Y. Fu1, Y. C. Lin1, J. M. Lo1; 1Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, TAIWAN, 2 Molecular Imaging Center, Chang-Gung Memorial Hospital, Linko, Taipei, TAIWAN, 3Department of Oncology, Chang-Gung Memorial Hospital, Linko, Taipei, TAIWAN. A recombinant annexin V with a N‐terminal extension containing six histidine residues (his‐ annexin V) was labeled with 99mTc(I)‐tricarbonyl ion. The resultant 99mTc(I)‐his‐annexin V was explored to be a potential imaging probe to detect the tissue apoptosis after radiation therapy (RT) in a C57BL/6J mouse model. Methods: [99mTc(CO)3(OH2)3]+ was prepared and subjected to directly label his‐annexin V. The binding affinity of 99mTc(I)‐his‐annexin V to apoptotic cells was assessed by a model using 20 Gy‐irradiated Jurkat T cells. The potent of 99mTc(I)‐his‐annexin V as an imaging probe was assessed using the animal model of C57BJ/6J mice treated with 0, 8, 10, and 12 Gy of whole body irradiation. Biodistribution study and nanoSPECT/CT imaging were subsequently conducted for the mice after irradiation. Results: The affinity of 99mTc(I)‐his‐annexin V to the irradiated Jurkat cells was 20‐fold higher than that to the sham‐irradiated control cells. The biodistribution results showed that the clearance of 99mTc(I)‐his‐annexin V from the blood was very rapid, being less than 0.2 %ID/g remained after 0.5 h postinjection. The kidney was the main organ for the excretion of 99mTc(I)‐his‐annexin V, as seen from the predominant accumulation of radioactivity in the organ while the accumulations of radioactivity in the liver and in the heart were relatively much lower. It was especially noticed that both of the uptakes in the spleen of the irradiated mice and of the sham‐irradiated mice were much different; the splenic uptake for the sham‐irradiated mice maintained at a low value around 0.8~0.5 %ID/g whereas the splenic uptake of the irradiated mice (10 Gy) was ca. 2.0 %ID/g, i.e., at least 2‐fold higher than the control group at 0.5 h postinjection and gradually increased to ca. 3.5 %ID/g, i.e., at least 4‐fold higher than the control group at 3 h postinjection. The nanoSPECT/CT imaging showed the accumulations of 99mTc(I)‐his‐annexin V in various organs or tissues being comparable to the biodistribution study. The ROI analysis for the splenic images indicated a similar distribution but with even higher ratios between the irradiated mice (12 Gy) and the sham‐ irradiated mice. Conclusion: This work is the first study to demonstrate that 99mTc(I)‐his‐annexin V is a potential clinical imaging agent for detecting tissue apoptosis following RT in an animal model. It is revealed that this imaging probe may be developed to detect the tissue damage of patients as early as 3 hours after RT before the clinical syndrome occurs, at usually 10~14 days later.
P825 Noninvasive imaging of gene expression using a novel artificial hSSTr2a receptor containing glycine-glycine99m Tc-binding sequences cysteine(GGC) Y. He1,3, P. Lei2, Y. Xiaomei2, Y. Shen1, X. Lan1, G. Zhang1, R. An1,M. Sadick3, S. Schönberg3, G. Shen2, Y. Zhang1; 1Dept of Nuclear Medicine,Union Hospital of Tong Ji Medical College, Hua Zhong University of Science and Technology and Hu Bei Province Key Laboratory of Molecular Imaging, Wuhan, CHINA, 2Dept of Immunology, Tong Ji Medical College, Hua Zhong University of Science and Technology, Wuhan, CHINA, 3 Inst.of Clin.Radiology and Nuc.Med., Univ. Hospital Mannheim, Univ. of Heidelberg, GERMANY. Objectives No‐invasive monitoring of gene transfer will benefit basic research and clinical patient care. An ideal imaging reporter will be a receptor or enzyme gene which is not expressed endogenously and hasn’t undesirable biological effects. Methods An artificial receptor was constructed by fusing the Glycine‐glycine‐cysteine(GGC) sequence on the extracellular N terminus of the human somatostatin receptor subtype 2a gene(GGC/hSSTr2a). This fusion receptor placed in an adenoviral vector (Ad‐GGC/hSSTr2a). The expression of Ad‐GGC/hSSTr2a was evaluated in vitro and in vivo. Results Cell‐membrane expression of hSSTr2a portion of artificial receptor was confirmed by Infection of MCF7 Human breast cancer cells with Ad‐ 99m GGC/hSSTr2a using FACS analysis, Immunofluorescent confocal microscopy and Tc‐HYNIC‐ TOCA receptor internalization. The radioactive uptake of 99mTc‐ Glucoheptonate (GH) was increased significantly in the cells infected with Ad‐GGC/hSSTr2a compared to the cells infected with Ad‐EGFP (16.16±0.96% vs 2.98±0.30, p<0.01). It demonstrated GGC motif successfully expressed and has functional transchelation effect. SPECT imaging of tumor bearing mice and ex‐ vivo biodistribution analysis detected increased tumor uptake of 99mTc‐GH due to direct intratumor injection Ad‐GGC/hSSTr2a. Conclusion These studies demonstrate the feasibility of using GGC/hSSTr2a artificial receptor for noninvasively imaging gene transfer.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P826 A Novel and Efficient Liver Targeting Agent: Biodistribution, Pharmacokinetics, SPECT/CT Imaging and Autoradiography M. H. Wang1, R. Lee2, H. M. Yu1, C. Y. Chien1, Y. C. Lee2, W. J. Lin1; Institute of Nuclear Energy Research, Taoyuan, TAIWAN, 2Johns Hopkins University, Baltimore, MD, UNITED STATES.
1
Aim:A novel liver targeting agent, 111In‐hexavalent lactoside, was synthesized and its potential for liver targeting was evaluated. Method: Hexavalent lactoside was synthesized by dimerization of trivalent lactoside, which is made by linking three lactosides to a nitrilo‐triacetic‐acid (NTA) scaffold. For liver imaging, 1.85 x 107 Bq In‐111 was reacted with DTPA‐modified hexavalent lactoside in 0.1M citric acid (pH2.1) for 30min to form 111In‐hexavalent lactoside. For pharmacokinetics and biodistribution study, mice or rat was sacrificed at 1, 3, 5, 10, 15, 30 min and 1, 24h after iv injection of 0.35MBq/100uL 111In‐hexavalent lactoside. The radioactivity in the organ was expressed as percentage of the injected dose (%ID). For microSPECT/CT imaging and autoradiography, mice or rat was anesthetized with 1.5% isoflurine, and imaging was performed at 15min after iv administration, then it was sectioned using a cryomicrotome, and exposed with an imaging plate. Time‐activity curves were derived from image region of interest (ROI) analysis. Results and Discussion: The 111In‐labelling efficiency was >99% wth specific activity of 2.5x1010Bq/mg. The labeled glycopeptide was stable for 72h. The biodistribution data indicated that liver uptake was nearly 80%, and uptake in spleen, bone marrow, muscle, brain and testis 111 was less than 1/1000 of that in liver, which demonstrated that the localization of In‐hexavalent lactoside is not via reticuloendothelial system. The pharmacokinetics study showed 111In‐ hexavalent lactoside rapidly accumulated and concentrated in liver in 3‐15min, and metabolized gradually after 1h. The residual dose in blood was less than 0.1%ID and 0.01%ID at 15min and 24h, respectively. The SPECT/CT and autoradiography images also showed the radioactivity specifically concentrated in liver. Our data indicated that 111In‐hexavalent lactoside possesses the liver targeting properties, which should be very helpful as a liver‐specific drug‐carrier enabling to focus the therapeutic effect on liver and reduce the unwanted toxicity on other normal tissues.
P827
99m
First ex vivo human study with Tc-NTP 15-5, a new radiotracer for articular cartilage imaging. F. Cachin1, C. Chauvet2, S. Boisgard3, P. Auzeloux1, A. Vidal1, M. Filaire4, S. Askenazy5, J. M. Chezal1, J. Maublant2, E. Miot-Noirault1; 1EA 4231, Medicine Faculty, Auvergne University, Clermont Ferrand, FRANCE, 2 Nuclear Medicine, Jean Perrin Cancer Center, Clermont Ferrand, FRANCE, 3 Orthopaedic, Gabriel MontPied, University Hospital, Clermont Ferrand, FRANCE, 4Anatomy , Medicine Faculty, Auvergne University, Clermont Ferrand, FRANCE, 5Cyclopharma, Clermont Ferrand, FRANCE. Aim: we develop a new tracer, the 99mTc‐NTP 15‐5, whose preclinical investigations have underlined its relevance for the functional imaging of cartilaginous disease. We also demonstrated 99mTc‐NTP 15‐5 was specifically linked to proteoglycans. The aim of this ex‐vivo study was to investigate and quantify 99mTc‐NTP 15‐5 uptake to human articular cartilage. Materials and Methods: 6 osteoarthritic tibial plateaux provided from prosthesis surgery, and two tibiofemoral joints obtained from the anatomy laboratory were incubated with 99mTc‐NTP 15‐5 during 30 min or 2h. SPECT and CT slices were acquired separately and fused thanks to fluidicial markers. For each specimen, tracer uptake was expressed respectively to the incubated dose (ID) and also as cartilage/bone uptake ratio, from based region‐growing SPECT‐CT quantification. Visual analysis of SPECT‐CT fusion slices was performed.. Results: 99mTc‐NTP 15‐5 uptake /ID were respectively 3.2±1.6% and 13.4±7 % DI after 30 mm or 2h. Visual analysis of 99m Tc‐NTP 15‐5 uptake within human fusion SPECT‐CT slices showed selective and intense articular cartilage and low uptake within bone and fat tissues. A cartilage defect visualized with CT on a medial condyle was clearly associated with a focal decreased uptake on SPECT. The cartilage/bone uptake ratio for prosthesis‐specimens and laboratory‐specimen were respectively 2.2±0.2 et 4.2 ±1, variation attributable to specimen sizes. Conclusion: our results trend to demonstrate that 99mTc‐NTP 15‐5 is potentially of interest for human cartilage molecular imaging. Clinical transfer will be first performed in osteoarthritis pathology.
P828 Evaluation of novel molecular imaging
radiolabelled
aptamer
for
tumour
J. Vialard-Miguel1, S. Da Rocha2, S. Moreau2, L. Azéma2, E. Dausse2, J. Toulmé2, H. Loiseau1, C. Ries3, S. Eimer1, M. Allard3; 1CHU Bordeaux, Pessac, FRANCE, 2Inserm U869, Institut Européen de Chimie et Biologie, Université Victor Segalen, Bordeaux, Bordeaux, FRANCE, 3UMR-CNRS 5231, Université Victor Segalen, Bordeaux, Bordeaux, FRANCE. 1. Introduction Tumour cell invasion involves a complex system of tightly regulated proteases, matrix metalloproteinases, MMPs. The objective of our study is to synthesize MMP molecular probes that could be used for cancer recognition and diagnosis. We applied SELEX (Systematic Evolution of Ligands by Exponential enrichment) to screen a nucleic acid library targeting one member of the MMP family, the MMP9, which is associated with tumour invasion and metastasis. The identified aptamer, F3B, presents high affinity and specific molecular fit with its target of interest, the MMP9. The strategy is to radiolabel F3B with technetium 99m (99mTc) to obtain novel radiotracer for the non‐invasive molecular imaging in oncology. In this preliminary study, we performed imaging of glioblastoma slices. 2. Materials & Methods F3B was identified through SELEX. An oligomer of the same length but different sequence (F3Br) that does not bind MMP9 was used as a control. F3B was first conjugated with mercaptoacétyltriglycine (MAG3) and the 99m MAG3‐conjugated F3B was radiolabelled with Tc by transchelation from labelled tartrate according to P. Winnard (Nucl Med Biol., 1997). Superfrost slices of patients’ tumour samples (glioblastoma) were incubated with the radioactive labelled F3B and subsequently qualitatively analyzed by Beta Imager. The non‐specific control aptamer, was used in adjacent tumour slices. 3. Results The synthesis of MAG3‐F3B was achieved. Radiolabelling with 99mTc was carried out and radiochemical purity was determined by Sep‐Pack chromatography as described for the
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P829 99mTc-tetrofosmin Molecular Breast Imaging (MBI) with high resolution dedicated breast camera (DBC) and breast dynamic Magnetic Resonance Imaging (MRI) in the preoperative staging of breast cancer: a comparative study A. Spanu1, F. Chessa1, D. Sanna1, G. B. Meloni2, D. Soro2, P. Cottu3, A. Manca4, S. Nuvoli1, G. Madeddu1; 1Department of Nuclear Medicine. University of Sassari, Sassari, ITALY, 2Department of Radiology. University of Sassari, Sassari, ITALY, 3Department of Surgery. University of Sassari, Sassari, ITALY, 4Department of Pathology. University of Sassari, Sassari, ITALY. Aim: Conventional diagnostic methods proved of limited value in the preoperative delineation of local disease extension in breast cancer patients. The aim of the present study was to compare the performance of 99mTc‐tetrofosmin MBI with a high resolution DBC and dynamic breast MRI in the preoperative staging of breast cancer. Methods: We studied a consecutive series of 27 female patients (38‐74 yrs) with breast lesions highly suggestive for cancer at conventional diagnostic methods scheduled to surgery. All patients preoperatively underwent both 99mTc‐ tetrofosmin MBI using a high resolution (1.6 mm spatial resolution) semiconductor (CZT) DBC mounted on a mammography unit that allowed similar projections than Mx and mild breast compression during acquisition and dynamic contrast‐enhanced breast MRI imaging at 1.5 T using a three‐dimensional gradient‐echo sequence before and after intravenous injection of gadoteridol. MBI images were compared to those of MRI and both of these were correlated in all cases with the definitive histopathological findings which were considered the gold standard. Results: MBI and MRI were positive in 26/27 (96.3%) and in 25/27 (92.6%) BC patients, respectively. Both procedures were false negative in a patient who had a T1b invasive ductal carcinoma, whereas only MRI was negative in a further patient with a DCIS. MBI correctly assessed breast cancer extent in 23/26 (88.5%) and MRI in 20/25 (80%) of positive cases. The 2 procedures were concordant in correctly staging local disease in 19 cases. Only MBI correctly staged 4 further patients, including the patient with a DCIS false negative at MRI and 3 patients with an invasive tumor each overstaged at MRI. On the contrary, the correct staging was achieved only by MRI in one patient who resulted dowstaged by MBI which missed the intraductal component around an invasive carcinoma. Moreover, both procedures were concordant in overstaging a patient with an invasive carcinoma and in downstaging a patient in whom they missed the intraductal component around an invasive tumor. Conclusion: Our preliminary data seem to suggest that both 99mTc‐tetrofosmin MBI with high resolution DBC and breast dynamic MRI are valuable diagnostic tools in the preoperative staging of breast cancer. However, MBI demonstrated a better performance than MRI which showed a higher tendency to overstaging local disease in respect of surgical findings in the present study. These data need to be confirmed in larger series of patients.
P830 Molecular breast imaging (MBI) with high resolution dedicated breast camera (DBC) in the work up of patients with breast lesions A. Spanu1, F. Chessa1, D. Sanna1, P. Marongiu1, P. Cottu2, A. Manca3, S. Nuvoli1, G. Madeddu1; 1Department of Nuclear Medicine. University of Sassari, Sassari, ITALY, 2Department of Surgery. University of Sassari, Sassari, ITALY, 3Department of Pathology. University of Sassari, Sassari, ITALY. Aim: The aim of the study was to evaluate the usefulness of MBI with high resolution DBC in the work‐up of patients with breast lesions as complementary procedure to mammography (Mx). Methods: A consecutive series of 343 patients (26‐81 yrs) with breast lesions at physical examination and/or at Mx/US scheduled for biopsy were studied. Ten min after i.v. injection of 740 MBq of 99mTc‐tetrofosmin, MBI was acquired using a high resolution (1.6 mm spatial resolution) semiconductor (CZT) DBC mounted on a mammography unit that allowed similar projections than Mx and mild breast compression during acquisition. A definitive histological diagnosis was obtained in all cases after MBI whose additional value in respect of Mx was calculated. Results: At histology, 299/343 patients had a primary BC (multifocal/multicentric in 39 cases and bilateral in 4) and 44/343 patients a benign disease; there was a total of 416 breast lesions: 366 carcinomas (332 invasive and 34 in situ) and 50 benign lesions. MBI was positive in 96.6% of BC patients, revealing multifocal/multicentric disease in 87.2% of cases and bilateral disease in 100% of cases. MBI detected 95.3% overall tumor foci, including 96% invasive carcinomas and 91.2% carcinomas in situ. Sensitivity values were 89.2% in ≤10 mm carcinomas and 98.6% in >10 mm carcinomas, the smallest carcinoma measuring 1.8 mm. MBI was true negative in 88.6% of patients with benign disease and in 88% of the lesions. MBI was more accurate than Mx in 123/343 cases (35.9%), ascertaining invasive carcinomas missed at Mx in 21 patients with dense breast, carcinomas in situ occult at Mx in 6 patients and additional tumor foci, all <10 mm, in 16 of the 39 patients with multifocal/multicentric disease changing the surgical management in 8 of these; moreover, MBI modified the local staging in further 47 patients in whom it identified the intraductal component around invasive cancers missed at Mx and correctly characterized benign disease in 33 patients with inconclusive or suspicious findings at Mx. Conclusions: 99mTc‐tetrofosmin MBI with high resolution DBC proved a highly accurate diagnostic tool in breast cancer patients. In our series, MBI increased Mx sensitivity and
specificity and also defined better local tumor extension, thus guiding the surgeon to a more appropriate surgical treatment. A larger employment of MBI as a complementary tool to Mx in the work‐up of patients with breast lesions is thus suggested.
P831 Imaging strategies for the therapeutical innovation in lung cancer S. Pesnel1, P. Reverdiau2, S. Iochmann2, N. Heuzé-Vourc'h2, A. Belenkov3, S. Lerondel1, A. Le Pape1; 1TAAM-UPS 44, CIPA-CNRS, Orléans, FRANCE, 2 INSERM U618, Tours, FRANCE, 3Visen Medical, Woburn, MA, UNITED STATES. Aim: For experimental oncology with orthotopic models of lung tumor in mice, imaging is the only resource to assess both tumor progression and activity of anticancer agents, but equally to optimize tumor induction procedures via interventional imaging. In addition, we validated quantitation in Fluorescent Molecular Tomography (FMT) in order to use this technique as an alternative to radioisotopic imaging to reduce exposure of tumors. Materials & Methods: In Balb/c nude mice, NCI‐H209‐Luc cells traced by 99mTc were implanted to a given bronchial location in the right lung under the control of interventional X‐ray and planar scintigraphy imaging. 2D or 3D bioluminescent imaging is performed weekly to assess the tumor growth. The expression of VEGFr was assessed with fluorescence imaging using AlexaFluor 680 labeled Cetuximab®. One month after implantation, mice were treated with anti‐EGFR mAb Cetuximab® by endotracheal nebulization, the quality of the administration being controlled by SPECT imaging. CT with respiratory gating was performed before then after treatment for tumor sizing determination. To validate the quantitation in FMT, inclusions containing different concentrations of AlexaFluor 680 were surgically implanted behind the liver. The mice were then imaged both with FMT2500 and high resolution CT to further precise the localization of inclusions. After 3D reconstruction, the signal was quantitated and compared with actual AF680 inclusions concentrations and the images coming from CT and FMT2500 were fused. Results: From the scintigraphy, the focus cell deposit is checked and the equivalent number of tumor cells actually deposited in bronchus for each mouse is calculated from the radioactivity. The CT evidenced a partial tumor regression with Cetuximab® treatment. A good linear correlation was obtained between the fluorescent signals acquired in FMT and the actual AF680 inclusions concentrations. Fusion coming from CT and FMT2500 resulted satisfactory co‐localization. Conclusion: Imaging is a resource of great value to control the different steps of a study led on orthotopic models of lung cancer. In some case, the quantitative FMT can be used as an alternative to nuclear imaging, in order to limit the dosimetry to tumors for multimodal imaging.
P832 Study on biodistribution and imaging of radioiodinated arginine-arginine-leucine peptide in nude mice bearing human prostate carcinoma R. Wang, M. Yu, C. Zhang, P. Yan, Y. Cui, H. Liu, M. Liu, L. Kang; Department of Nuclear Medicine, Peking University First Hospital, Beijing, CHINA. Objective: To investigate the biodistribution and imaging of 131I labeled arginine‐arginine‐leucine (RRL) peptide in human prostate carcinoma bearing nude mice. Methods: The 10‐mer cyclic peptide contained the RRL sequence was synthesized (YCGGRRLGGC) by the solid phase method. Disulfide bonds between the cysteines maintain the cyclic structure. Radioiodination of the RRL peptide was performed by the chloramine‐T method. 131I labeled peptides were injected into the nude mice bearing human prostate carcinoma via tail vein. Biodistribution and imaging results in vivo were obtained. Results: The 131I labeling rate of RRL peptide was about 60%. The radiochemical purity was 96.5%. The radiochemical purity of the labeled compound remains 90.3% at 24h in human blood serum at 37ºC. In the biodistribution studies, radiolabeled RRL peptide probe accumulated in the tumor to a level of approximately 2.52% and 0.65% injected dose per gram of tissue at 6h and 24h after administration. The datas for the 131I labeled control peptide were 0.73% and 0.06% ID/g at 6h and 24h after administration. The ratio of radioactivity in tumors to radioactivity in blood at 1, 6, and 24 h after injection were about 0.32, 1.12, 1.30 for RRL peptide and 0.30, 0.37, 0.22 for control peptide. The ratio of radioactivity in tumors to radioactivity in muscle at 1, 6, 24 h after injection were about 1.40, 3.94, 9.08 for RRL peptide and 1.98, 2.89, 1.78 for control peptide. At 24h after administration,the SPECT imaging obtained clearly showed a contrasting tumor on the right armpit of the mouse with high concentrations of radioactivity and the surrounding background was very low. Conclusion: The results suggest that radioiodination of RRL peptide is feasible and the labeled compound is stable in human blood serum at 37 ºC at 24h. The 131I labeled RRL peptide shows high tumor uptake and good tumor‐to‐ 131 organ ratios that allow noninvasive visualization of tumors. The I labeled compound is valuable to detected tumors as molecular probe. Key words: peptide; tumor; biodistribution; image
P833 Study on cell uptake kinetics and specific gene expression effect of antisense molecular probe in vitro R. Wang, M. Liu, P. Yan, C. Zhang, M. Yu; Department of Nuclear Medicine, Peking University First Hospital, Beijing, CHINA. Objective: The aim of present study was to observe the cell uptake kinetics and specific gene expression effect of antisense molecular probe in vitro. Methods: Antisense molecular probes targeting human telomerase reverse transcriptase(Htert) mRNA was radiolabeled with technetium‐99m. The uptake kinetics of molecular probes mediated by liposome or not in hTERT‐ expressing cells was examined in vitro. RT‐PCR (reverse transcriptase polymerase chain reaction) method was performed to assay the mRNA level after proliferating cells had been incubated with the molecular probes. All data were analyzed by the statistic software of SPSS12.0. Results: The labeling efficiencies of molecular probe reached 76%±5% (n=5), the specific activity was up to 1,850 kBq/μg, and the radiochemical purity was above 96% after purification. The result of cellular uptake kinetics demonstrated that radioactivity accumulated to a higher concentration in hTERT‐expressing cells with antisense molecular probe than with sense molecular control (P < 0.05). The absolute accumulation of 99mTc, whether on antisense or sense molecular probe, was
Poster Presentation
labelling of commercial MAG3. Average labelling efficiencies of 50‐60% were achieved within 15 min at room temperature, with a specific activity of 70 µCi/µg. Beta Imager analysis of radiolabelled slices shows peripheral tumour tracer uptake with F3B whereas non‐specific control aptamer does not show any specific area but only non specific labelling. And there is no binding with radiolabelled MAG3 alone. 4. Discussion/Conclusion Our preliminary results showed that 99m Tc‐ MAG3‐ F3B aptamer seems to bind specifically to the MMP9 protein in tumour sample. Whereas a non‐ specific control aptamer does not bind to this protein. These results strongly suggest that this tracer allows imaging of matrix metalloproteinases involved in tumour genesis. The first results are encouraging for the development of a novel specific radiotracer of MMP9, with usefulness in tumour molecular imaging. Further studies are in progress to confirm our first results.
S472 clearly higher with liposome‐mediated than without liposome‐mediated (P < 0.05). Furthermore, liposome advanced the peak time of cellular uptake of antisense molecular probe, with the highest accumulation occurring at 2hr, and remaining at the same level till 3hr. In comparison with sense molecular probe, antisense molecular probe preserved the capacity to bind living hTERT‐expressing cells specifically and inhibit the expression of hTERT mRNA significantly as well as ASON. Conclusion: Antisense molecular probe accumulated in the targeting cells much higher than sense molecular probe did. Liposome‐mediated method could increase cell uptake of molecular probes in vitro. Antisense molecular probe preserved the capacity to inhibit the expression of targeting mRNA specifically. All results provided the basis for the in vivo study in the near future. Key words Molecular probe; Liposome; Cell uptake; HepG2 cells; hTERT; Antisense
P90 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Molecular imaging: molecular biology
P834 In vitro Tumor-targeted radionuclide Therapy using the human sodium-iodide symporter driven by telomerase reverse transcriptase promoter Z. L. Liu, Y. Z. Shi, H. Huang, J. Tang; The Second Affiliated Hospital of Soochow University, Department of Nuclear Medicine, Suzhou, CHINA. Objectives: Human telomerase reverse transcriptase(hTERT) is highly active in most cancer cells and,thus,could be used for tumor targeting. The human sodium iodide symporter(hNIS) gene is being actively researched as a potential radioiodine gene therapy.We investigated the possibility of using the hNIS gene driven by the hTERT promoter for radioiodine gene therapy. Methods: The hTERT core promoter was amplified from genomic DNA of Hepatoma cells(HepG2) by PCR.The Recombinant adenovirus containing hNIS gene driven by hTERT promoter(Ad‐hTERT‐ hNIS) was constructed by AdEasy system.The positive control of adenovirus Ad‐CMV‐hNIS containing the CMV promoter followed with hNIS gene and the negative control of adenovirus Ad‐CMV not containing hNIS gene were also created by Adeasy system.The cell‐specific transcriptional activity of hTERT was examined by RT‐PCR in transiently transfected A549 cell lines.Iodide uptake assays were used to confirm hNIS expression and function. Toxic effects of 131I on tumor cells were studied by in vitro clonogenic assay. Results: The results revealed a 23‐fold and 31‐fold iodide uptake increase in Ad‐hTERT‐hNIS and Ad‐CMV‐hNIS infected A549 cells, respectively. No significant iodide uptake increase was detected in cells infected with the negative control virus.In vitro clonogenic assay revealed approximately 70% of Ad‐hTERT‐hNIS and 80% of Ad‐CMV‐hNIS transfected A549 cells were killed by exposure to iodide‐131, respectively,while only about 10% of NIS‐negative control cells were killed. Conclusions: This study represents a promising first step investigating the potential for NIS‐mediated radioiodide therapy of tumors.
P835 Clinical Implication of Activin A, Inhibin A, and Their Receptors mRNA Expression in Thyroid Papillary and Follicular Carcinomas L. Glavas-Obrovac1, I. Vladika2, M. Stefanic1, M. Suver3, I. Mihaljevic1; University Hospital Osijek, Clinical Dept. of Nucelar Medicine and Radiation Protection and School of Medicine Osijek, Osijek, CROATIA, 2Clinical Hospital Center Zagreb, Dept. of Otorhinolaryngology, Head and Neck Surgery, Zagreb, CROATIA, 3University Hospital Osijek, Scientific Unit for Clinical-Medical Research, Osijek, CROATIA. 1
Aim: To determine clinical implications of activin A (ActA), inhibin A (InhA), and their receptors ActRI and ActRIIB mRNA expression profile testing in papillary (PTC) and follicular (FTC) thyroid carcinoma. Methods: Tissue samples were divided in 6 groups: 27 PTC, 21 FTC, 11 Hürthle cell carcinomas (HC), 16 follicular adenomas (FA), 15 Hürthle cell adenomas (HA) and 26 euthyroid multinodular goiters (MNG). RNA was isolated from 10‐μm paraffin tissue sections. Gene expression was studied using reverse transcription‐polymerase chain reaction (RT‐PCR). An internal control gene was HPRT1. ImageQuantTL program was used for relative quantification of RT‐PCR bands. Data, expressed as medians (interquartile ranges), were processed using Kruskall‐ Wallis test with Schaich‐Hamerle post‐hoc analysis. Results: InhA, ActA and ActRI, but not ActRIIB mRNA, were expressed in the majority of tissue samples. InhA mRNA was over‐expressed in HA relative to FA (P=0.00044), FTC (P=10‐3) and PTC (P=2.9x10‐5). HC were indistinguishable from HA, as well as FTC from FA. In contrast, InhA mRNA was consistently overexpressed in Hürthle cell neoplasms when compared to follicular variants [181 (142‐205) vs. 89 (70‐112), HA vs. FA, P=5.5x10‐5 and 164 (115‐176) vs. 98 (81‐107), % HPRT1 mRNA, HC vs. FTC, P=7.9x10‐5]. Moreover, InhA mRNA was over‐expressed in metastatic PTC (n=10) relative to non‐metastatic forms [99 (92‐117) vs. 84 (76‐88), % HPRT1 mRNA, pN1+ vs. pN0, P=0.007]; no other differences were observed between PTC, FTC and MNG. Additionally, ActRI mRNA expression was down‐regulated in FA, FTC and PTC relative to MNG (P=1.8x10‐5, 6.8x10‐4 and 3.3x10‐4), whereas ActA mRNA was under‐expressed in PTC relative to FA and, marginally, HC (P=2.3x10‐3and 8.6x10‐3). Neither pT stage, nor age was related to mRNA expression in cancerous tissue specimens. Conclusion: Activin system is involved in the maintenance of homeostasis in normal and transformed thyrocytes: InhA, ActA and the activin signaling pathway are differentially affected by cell transformation over a broad spectrum of neoplastic phenotypes and may play role in thyroid tumorigenesis. Here, we implicate InhA mRNA expression as a possible marker of PTC aggressiveness, metastatic potential and progression.
P836 The detection of BRAFT1799A mutation on fine needle aspiration biopsies reduces in 30% the rate of false negative papillary carcinomas
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 M. Cañadas Garre, E. Cabrera Cazorla, P. Becerra Massaré, M. A. Muros de Fuentes, M. López de la Torre Casares, M. Á. López Nevot, J. Villar del Moral, Á. Concha López, F. Garrido Torres-Puchol, A. Ferrón Orihuela, J. M. Llamas Elvira; Hospital Universitario Virgen de las Nieves, Granada, SPAIN. The prevalence of thyroid nodules ranges from 4‐25%, although only 5‐10% are estimated to be malignant, mainly papillary thyroid cancer (PTC). Although the diagnosis of PTC by fine‐needle aspiration biopsy (FNAB) is reliable and accurate, the rate of malignancy in the indeterminate (follicular neoplasm), negative and inadequate categories of FNAB samples ranges between 10‐ 42%, 1‐18% and 5‐28%, respectively. BRAFT1799A mutation is the most common genetic alteration in thyroid cancers, occurring in 30‐80% of PTC; its detection on FNAB specimens is robust and low‐cost. AIM Assess the increment of preoperative diagnosis of PTC on FNAB by using the BRAFT1799A mutation status on the FNAB sample as a complementary tool to the cytopahological diagnosis. MATERIALS AND METHODS 693 FNAB smears from 642 patients considered for thyroid surgery (475 negative for malignancy, 167 inadequate, 45 indeterminate, 6 PTC) were analyzed for the presence of the BRAFT1799A mutation by genomic DNA extraction, polymerase chain reaction (PCR)‐restriction fragment polymorphism analysis and DNA sequencing in positive samples. RESULTS 130 out of 642 patients underwent thyroidectomy; 25 were diagnosed of PTC. BRAFT1799A was positive in 12 patients (12/25; 48,0%). BRAFT1799A was positive in 3 out of 475 patients with negative for malignancy FNAB and in 1 out of 167 patients with an inadequate FNAB. These four patients were referred to thyroid surgery and histopathology confirmed the diagnosis of PTC. 91 patients with a negative for malignancy or inadequate FNAB underwent surgery, with 13 patients diagnosed as PTC and a rate of malignancy of 14,3% in these categories. 4 out of these 13 PTC patients (30,8%) were diagnosed preoperatively and solely by BRAFT1799A. The presence of BRAFT1799A rescued these false negative PTC patients from the pool of negative citologies. 3 out of 45 patients with an indeterminate FNAB were positive for BRAFT1799A. The rate of malignancy in this category was 18,2% (6 cases of PTC out of 33 operated patients). The BRAFT1799A confirmed the 50,0% of these PTC cases (3/6). 5 out of 6 patients (83,3%) cytologically diagnosed as PTC were positive for BRAFT1799A. CONCLUSION The determination of BRAFT1799A mutation on FNAB predicts the diagnosis of PTC in specimens not detected by cytopathology. Nearly half of patients with PTC (48,0%) can be diagnosed solely based on BRAFT1799A mutation analysis on FNAB (50,0% in indeterminate; 30,8% in negative samples), establishing BRAFT1799A mutation as a reliable method in the preoperative protocol to assess the malignant nature of a thyroid nodule.
P837 Establishment of Sodium Iodide Symporter (NIS) gene transfected adipose-derived murine stem cell for cell tracking imaging Y. Lee1, J. Kang1, G. Cheon1, S. Lim1, S. Lee2, J. Yoo2, B. Ahn2, J. Ha2, J. Lee2; 1Kirams, Seoul, REPUBLIC OF KOREA, 2School of Medicine, Kyungpook National University, Daegu, REPUBLIC OF KOREA. Purpose: To develop a non‐invasive combined imaging method of gamma camera and PET imaging to assess adipose‐derived murine stem cell, we generated to retrovirus containing to hNIS gene, and transfected to adipose‐derived murine stem cell using retrovirus and monitored hNIS gene expression in vitro and in vivo. Methods: Adipose‐derived murine stem cells (SC) were prepared from the subcutaneous fat of anterior abdominal wall in SD rat. Retrovirus containing human NIS gene driven by CMV promoter was transfected to stem cells (SC‐N). After 48hrs, transfected cells underwent RT‐PCR, radioiodine uptake and radioiodine efflux. SC and SC‐N cells were injected to 2 flank sites in nude mouse (Balb/c‐nu/nu). Scintigraphic image was performed at 2h and 1day after intraperitoneal injection of Tc‐99m. Results: The expression of hNIS gene in SC‐N cells was confirmed by RT‐PCR. In iodide uptake, SC‐N cells accumulated 217.4±49.9, 725.8±58 and 922.1±190.8 pmol/ mg protein at 5, 30 and 60 min, respectively. But SC cell did not uptake iodide. The half lives of radioiodine in SC‐N cells were about 6 min by efflux study. Scintigraphy showed increased uptake of Tc‐99m in SC‐N than in SC cell in animal body.Conclusion: The NIS gene transfected into adipose‐drived murine stem cell using retrovirus was found to increase the accumulation of radioiodine in vitro and in vivo. These results suggest that NIS gene has an excellent feasibility as a molecular reporter gene, and it can be used to monitors cell trafficking.
P838 In vitro screening of PET radiotracers transport by human Pglycoprotein and Breast Cancer Resistance Protein N. Tournier1, J. M. Scherrmann2, M. Bottlaender1; 1CEA, Orsay, FRANCE, 2 Inserm U705; CNRS UMR7157, Paris, FRANCE. It was recently shown that P‐glycoprotein (P‐gp, MDR1, ABCB1) and Breast Cancer Resistance Protein (BCRP, ABCG2) are the main efflux transporters at the human blood‐brain barrier. These transporters are able to modulate a wide range of compounds access to the brain and could also dramatically influence PET tracers disposition. Interspecies variability and complex protocol developed to assess substrate properties of radiotracers in vivo justify the interest in developing a high‐throughput screening assay that is specific of human isoforms and adapted to β+‐emitting radiotracers. An in vitro model, based on previously described assay, was adapted to radiotracers study. Two epithelial cell lines (MDCKII) stably transfected with human MDR1 or BCRP genes are seed and cultured to reach confluence on Transwell® inserts. After 30 min pre‐incubation with or without specific inhibitor (PSC833 5 µM for P‐gp and Fumitremorgin C 10 µM for BCRP), compartments are filled with transport medium containing radiotracer to test at ~1 MBq/mL, with or without inhibitor (n=3). Plates are then incubated at 37°C under humidified atmosphere to allow optimal transporters activity. Samples are collected and counted in each apical and basolateral compartment at selected times. At the end of the experiment, monolayer integrity is controlled by measuring trans‐epithelial electrical resistance (TEER) on every well. Radiotracer is considered as a transporter substrate if (i) concentration in apical compartment is significantly higher than in basolateral one at the end of incubation, showing evidence of a polarised transport through the monolayer and (ii) polarised transport is abolished when inhibitor is co‐ incubated, that ensures specificity of the result. The dual P‐gp and BCRP substrate [3H]‐prazosin is added to the radiotracer solution as an internal positive control and tritium is counted the day after the experiment. Model revealed a significant and time dependant polarised transport of [3H]‐prazosin on both P‐gp and BCRP cells, which was totally inhibited by respective inhibitors.
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P839 Thyroid Autoantibodies and Vitamin D Receptor Gene 3'Haplotypes in Graves' Disease and Hashimoto's Thyroiditis M. Stefanic1, L. Glavas-Obrovac1, S. Tokic1, M. Suver2, I. Karner1, I. Mihaljevic1; 1University Hospital Osijek, Clin. Dept. of Nuclear Medicine and Radiation Protection, Osijek, CROATIA, 2University Hospital Osijek, Scientific Unit for Clinical-Medical Research, Osijek, CROATIA. Background: Vitamin D receptor (VDR) signaling exerts potent B, Treg, Th1 and Th17 immunomodulatory activity. Aim: to test whether particular VDR gene 3’‐restriction haplotypes (baT/BAt), previously associated with allelic expression imbalance and differences in total VDR mRNA expression, are implicated in thyroid peroxidase (TPOAb) and thyrotropin receptor antibody (TRAb) production in Graves’ disease (GD) and Hashimoto’s thyroiditis (HT). Methods: rs1544410 (BsmI), rs7975232 (ApaI) and rs731236 (TaqI) polymorphisms were genotyped by polymerase chain reaction‐restriction fragment length polymorphism (RFLP) method in 138 unrelated Caucasian GD individuals (18 male, mean age at diagnosis 41±11.6 years) and 108 geographically‐matched HT cases (8 male, 45±13.8 years). Two decisions were modeled: the probability to develop antibodies above the threshold level and the level of TAb once they occur. Left‐censored, covariate‐adjusted Box‐Cox Tobit regression that minimizes Pagan‐Vella conditional moment test was applied and compared to semiparametric, robust Powell’s censored least absolute deviation (CLAD) and symmetrically trimmed least squares estimators. Age (GD, 4 HT) and Box‐Cox transformed thyrotropin values (HT) were used as covariates; 10 direct bootstrap replicates were generated to empirically estimate standard errors. The threshold effect and the change effect were derived by McDonald‐Moffitt’s decomposition. Haplotype phases were assigned using Stephens‐Donnelly coalescent‐based Bayesian method. Pretreatment TPOAb and TRAb‐IgG were measured by enzyme‐linked immunoassay and radioreceptor assays, respectively, calibrated against WHO and MRC reference standards. Results: In GD group, TPOAb were positive in 75% of cases, with significantly higher median (IQR) levels detected in the HT group [897 (477‐2407) vs 246 (47‐948) mIU/L, P(exact)=7.8x10‐5]. All TPOAb‐negative GD cases were TRAb‐positive. All genotype frequencies were in Hardy‐Weinberg equilibrium. No genotype associations between any of the polymorphisms and TPOAb/TRAb levels were observed in either condition. In contrast, when compared to non‐carriers (‐/‐), BsmI‐TaqI Bt and BsmI‐ApaI‐TaqI BAt haplotype homozygosity, but not heterozygosity, was consistently and positively associated with latent TPOAb variable in GD, but not HT cases [βCLAD=2814±995, PCLAD=0.0047, βTobit=11.28±4.1, P=0.006, (Bt/Bt) vs (‐/‐); βCLAD=2826±986, PCLAD=0.0042, βTobit=11.42±4.09, P=0.0053, (BAt/BAt) vs (‐/‐), R2a/CLAD~8.4%, Box‐Cox λ=0.09, change effect scalar=0.639, threshold effect scalar=0.26]. For TRAb, no effect was observed whatsoever. Conclusion: no consistent evidence for association of two major VDR gene 3’‐haplotypes with TAb status in AITD were obtained. Although background/disease‐specific effects may exist, interpretation is complicated by the potential confounding effects of the vitamin D status, tagging properties of the 3’‐RFLPs, imperfect correlation between intrathyroidal synthesis and serum titers of thyroid autoantibodies, data transformations, variable serum clearance rates and sample selection procedures.
P840 Radioiodination, Biodistribution and Imaging in vivo of Antihuman Tumor-derived IgG Light Chain Antibody (4E9) in Nude Mice Bearing Tumor P. Yan, R. Wang, C. Zhang, M. Yu, L. Kang, Y. Cui; Department of Nuclear Medicine, Peking University First Hospital, Beijing, CHINA. Objective Human cancers of epithelial origin produce IgG. It contributes in cancer initiation in the precancerous stage when the epithelial cells are actively proliferating. Tumor‐derived IgG light chain genes have the identical sequence and highly express in many cancer cells. The study is to radioiodinate antihuman tumor‐derived IgG light chain antibody (4E9), and study on biodistribution and imaging in vivo in nude mice bearing tumor for researching the potentiality of radioimmunoimaging and targeted raodioimmunotherapy of human cancers. Methods 4E9 was labeled with 131I by the Chloramine‐T method and purified through Sephadex G‐25 column. 131 BALB/c nude mice were inoculate with HeLa MR cells in the right hind leg. I‐4E9 was injected intravenously in nude mice bearing tumor for biodistribution study and SPECT imaging at 3hr, 6hr, 24hr, 48hr, 72hr. IgG2b and mIgG were used as a contrast. All data were analyzed by the statistic software of SPSS12.0. Results The labeling efficiencies of 131I‐4E9 reached 89.9%±4.72% (n=4), the specific activity was up to 1.26MBq/μg, and the radiochemical purity was 98.1%±1.24% (n=4) and >90% after 72hr when stored 4°C refrigerator or 37°C of human serum. At different time phase postinjection 131I‐4E9, 131I‐ IgG2b or 131I‐ mIgG, it accumulated mostly in liver and kidney. 131I‐ IgG2b and 131I‐ mIgG removed from blood more slowly than 131I‐4E9 (P<0.05). In comparison with the T/NT ratio of 131I‐4E9 and 131I‐ IgG2b were closely, and that of 131I‐4E9 and 131 I‐ mIgG were significant difference (P<0.05). The ratio of T/M and T/B reached 8.94±4.86 (n=3)and 1.25±0.432 (n=3). As for imaging in vivo, 131I‐4E9 was more clearly imaged at 24hr till 72hr than 131I‐ IgG2b and 131I‐ mIgG. Conclusion This study provided the evidence that antihuman tumor‐derived IgG light chain antibody (4E9) could be used as a new radiopharmaceutical for cancer targeted therapy. Key works Antihuman tumor‐derived IgG light chain antibody (4E9); Radioiodination; Human cancers of epithelial origin; radioimmunoimaging; raodioimmunotherapy
P841 An experimental study on targeted therapy of radioiodinated cyclic cRGD peptide on melanoma bearing mice
R. Wang, Y. Cui, C. Zhang, P. Yan, M. Yu, H. Liu, Z. Fu, F. Guo, Y. Zhao, M. Liu, L. Kang, Y. Ding; Department of Nuclear Medicine, Peking University First Hospital, Beijing, CHINA. Objective Ectogenic RGD peptide can bind to integrin αvβ3 receptor on tumor cells surface and neovasculature endothelial cells .It can prevent tumor growing and metastasizing. The research discuss the double inhibitory effect of radioiodinated cyclic cRGD peptide on the melanoma bearing mice. Methods cRGD peptide was labeled with 131I by Ch T method under the optimum labeling conditions. Twenty mice were randomly divided into four groups: experimental group (131I‐cRGD), cRGD control group, 131I‐cGGG control group and PBS control group. Five mice per group. All mice were injected through tail vein. Tumor volume and weight of each mouse were observed. All groups were compared by one‐way ANOVA. Results The labeling efficiency and the radiochemical purity of 131I‐cRGD peptide reached respectively (89.14±4.57)% and (99.14±0.72)%.Compared with the PBS group at 21st day, the tumor inhibitory rate of each group was respectively 64.92% (131I‐cRGD group), 37.70% (cRGD group) and 24.78% (131I‐cGGG group). The mice were sacrificed at 28th day and the tumor weight was respectively 6.48±5.19g (131I‐ cRGD group), 10.81±6.25g (cRGD group), 14.21±5.91g (131I‐cGGG group), 18.88±7.59g (PBS group) (F=3.479 P=0.041<0.05). Date were analyzed by one‐way ANOVA and there was significant difference between 131I‐cRGD group and PBS group(P<0.05).There was no significant difference between the other groups(P>0.05). Compared with the PBS group at the end of treatment, the tumor inhibitory rate of each group was respectively 65.72% (131I‐cRGD group), 42.76%(cRGD group) and 24.77% (131I‐cGGG group). The net weight of the mice (net weight = weight ‐ the weight of the tumor) were respectively 29.12±8.66g (131I‐cRGD group), 25.89±6.49g (cRGD group), 24.29±2.97g (131I‐cGGG group), 20.92±5.95g (PBS group) and there was no significant difference(F=1.444 P=0.267>0.05). Conclusion Tumor growth was apparently inhibited by 131I‐ 131 cRGD in melanoma bearing mice. The results of the study show that I‐cRGD appears to be a broad application foreground in treating melanoma. Key words RGD; Tumor; Therapy; Radionuclide; αvβ3 receptor
P91 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Molecular imaging: imaging with PET and SPECT
P842
18
125
Comparison molecular imaging of F-FDG and I-anti-EGFR human Fab in different EGFR expressing level tumor model R. Zhang1, N. Xu2, G. Cai1, W. Ye1, B. Cao2, H. Huang1, Y. Zhou1, M. Jiang1, B. Zhang1, X. Gu1; 1Jiangsu Institute of Nuclear Medicine, Wuxi, CHINA, 2 Key Laboratory of Antibody Technology of Ministry of Health, Nanjing Medical University, Nanjing, CHINA. Aim: To evaluate the ability of 125I‐anti‐EGFR human Fab (125I‐Fab) as an EGFR expressing level diagnosis imaging agent. Methods: 125I‐Fab was prepared by the Ch‐T methods, purified with PD‐ 10 column. The radiochemistry purity was measured with TCA precipitation method, and the immunoreactivity was analysized with ELISA methods. Cell uptakes of 125I‐Fab were performed with A431, NIH3T3 and U118 cells in vitro. Different EGFR‐expressing level tumor models were established by inoculating different EGFR‐expressing level tumor cells into right forelimbs of athymic nude (nu/nu) mice. Imaging of 125I‐Fab and ROI analysis were performed with SPECT in different EGFR‐expressing level tumor models at different times after injecting 0.2ml 3μg 11.1MBq 125I‐Fab per mouse. These tumor mice were anesthetized with isoflurane, injected 3.7MBq 18F‐FDG per mouse, imaged and analysized ROI with MicroPET at different times. Results: The radiolabeling efficiency of 125I‐Fab was about 75%, and the radiochemical purity was above 95%. ELISA and cell uptake of 125I‐Fab showed that the process of radioiodination didn’t affect the immunoreactivity of Fab severely and 125I‐Fab did recognize EGFR specifically, the binding rates of 125 I‐Fab with cell increased with the EGFR‐expressing levels of different cells. 125I‐Fab imaging 18 have significant difference in EGFR‐expressing level tumor models, but F‐FDG imaging have no significant difference. Conculsions: 125I‐Fab may be a potential tumor EGFR‐expressing level imaging agent. Keywords: EGFR 125I‐Fab 18F‐FDG
P843
11
6-Bromo-7-[ C]methylpurine is a Specific Probe for the ABC Transporter Mrp1, but not for Mrp2, Pgp, and Bcrp T. Okamura, T. Kikuchi, M. Okada, H. Wakizaka, K. Fukushi, T. Irie; National Institute of Radiological Sciences, Chiba, JAPAN. Aim: Multidrug resistance‐associated protein 1 (MRP1), an ABC efflux transporter, at the blood‐ brain barrier (BBB) serves as defense mechanisms limiting tissue accumulation of naturally occurring toxins, xenobiotics, and drugs. Based on the concept of Metabolite Extrusion Method, 6‐bromo‐7‐[11C]methylpurine (I) has been developed as a probe to assess the function of MRP1 in the brain. The probe readily enters the brain after intravenous injection and is efficiently converted to a MRP1 substrate of a glutathione (GSH) conjugate (II) in situ. The GSH conjugate was rapidly cleared from the brain of wild type (WT) mice; it was mostly trapped in that of Mrp1 knockout (KO) mice. However, we cannot still exclude the possibility that other ABC transporters such as MRP2, P‐glycoprotein (Pgp), and breast cancer resistance protein (BCRP) at the BBB contribute to the efflux transport of the GSH conjugate. In this study, we examined the involvement of these transporters in the efflux transport of the GSH conjugate from the brain. Materials and Methods: The compound I was synthesized by the reaction of 6‐bromopurine with 11 CH3I. Brain kinetics of I was evaluated using Mdr1a/b‐Bcrp triple, Mrp1, and Mrp2 KO mice. Anesthetized mice were dynamically scanned for 60 min following intravenous injection of I. ROIs were placed on a summed PET image and transferred to all of the frames of images to produce time‐sequential radioactivity concentration. The efflux rate of the GSH conjugate was determined from the time‐radioactivity after the complete conversion of I to II. Results: For all KO and WT mice, the radioactivity reached maximum level 1.5 min after injection, and subsequently it was rapidly cleared from the brain except for Mrp1 KO mice. The semilogarithmic plot of brain radioactivity exhibited excellent linearity to provide the first‐order efflux rate with high precision: 0.15 h‐1 for Mrp1 KO and 1.4 h‐1 for other KO and WT mice. Conclusion: Main ABC efflux transporters at the BBB, MRP2, Pgp, and BCRP, did not contribute to the efflux transport of II out
Poster Presentation
Several PET radiotracers were tested on the model. As an example, [18F]‐F‐A‐85380, [18F]‐DPA‐ 714 and [18F]‐fallypride did not exhibit any carrier mediated transport. P‐gp and BCRP transport is a major concern and has to be documented, as PET radioligands are often co‐administered to potent inhibitors during pharmacological and clinical protocols. Furthermore, this model can be performed to screen new substrates that could be developed to study P‐gp and BCRP activity in Man using PET imaging.
S474 of the brain. These results firmly suggested that I would be a specific probe to quantitatively assess Mrp1 function in the living brain.
P844 Radionuclide reporter gene imaging of mouse xenograft model of human colon cancer cell lines stably expressing human sodium-iodide symporter (hNIS) C. Murai1, M. Inubushi1, H. Hata2, Y. Jin1, M. Shidahara1, C. Sogawa1, A. Tsuji1, M. Koizumi1, Y. Kitagawa2, T. Saga1; 1National Institute of Radiological Sciences, Chiba, JAPAN, 2Graduate School of Dental Medicine, Hokkaido University, Sapporo, JAPAN. Aim: The purposes of this study were to establish cancer cell lines stably expressing human sodium‐iodide symporter (hNIS), and to investigate characteristics of their relevant xenograft models in nude mice by SPECT/CT imaging. Materials & Methods: A recombinant plasmid containing hNIS (pcDNA3‐hNIS) was transfected into a human colon cancer cell line HCT116 by the calcium phosphate coprecipitation method, and 5 stably transformed cell lines (A, B, C, D, E) were isolated by G418 selection. Their functional hNIS expression was confirmed by 99mTcO4‐ uptake tests in vitro. Three lines (A, B, E) of them and negative control HCT116 (N) were subcutaneously injected into four regions of 16 nude mice. The rate and time of tumor formation (≥ 8 mm) were observed, and the tumor diameter was measured every 2 to 3 days. When the 99m tumor diameter was between 8 and 13 mm, TcO4‐ SPECT imaging was performed using a dedicated small animal SPECT system FX(SPECT/CT) (Gamma Medica‐Ideas, CA) to estimate tumor 99mTcO4‐ uptake in percent injection dose per gram (%ID/g). Results: The 16 mice formed 11 tumors of cell line A (69%), 10 of line B (63%), 14 of line E (94%), and 14 of control N (88%) (p=NS). The time of tumor formation was 36±9 (mean±SD) days in line A, 24±8 days in line B, 26±12 days in line E, and 18±12 days in control N (p<0.05 for A vs N; otherwise p=NS). The SPECT image quality was good, and all the tumors of cell lines A, B and E were well visualized. The average of tumor 99mTcO4‐ uptake in %ID/g was 25.7±8.3 to line A tumors, 35.9±12.3 to line B tumors, 11.6±6.4 to line E tumors, and 2.4±0.9 to control N tumors (p<0.001 for A vs N and for B vs N; p<0.01 for B vs E; otherwise p=NS). These results indicate the cell line B has the best characteristics of preserved rapid growth rate and the highest 99mTcO4‐ uptake for SPECT imaging. Conclusion: We established the cancer cell line stably expressing hNIS (HCT116‐hNIS line B), and succeeded in imaging the mouse xenograft model by 99mTcO4‐ SPECT. In the future, this model will provide a tool to track tumor metastasis in vivo in mice so that the molecular mechanism involved in metastatic cascade will be elucidated.
P845 Dynamic studies of the receptor metabolism of rats with HiSPECT A. Wirrwar, S. Nikolaus, A. Azmoudeh, S. Viehöver, H. W. Müller; University of Duesseldorf, Duesseldorf, GERMANY. Aim Dynamic visualization of the Uptake behaviour of the receptor ligand 123‐I‐IBZM in the Striatum of a rat using HiSPECT. Material& Methods The HiSPECT technology uses clinical SPECT cameras in combination with multipinhole apertures. HiSPECT allows spatial resolutions of less than 1 mm FWHM with sensitivity values up to 2000cps/MBq. For this pilot study both detector heads of a clinical gamma camera (PRISM 2000 S) has been equipped with a 20‐pinhole aperture with medium resolution (1.5 mm FWHM). This configuration promises a temporal resolved visualization of the receptor metabolism in the rat brain. An anesthetised 3 months old Wistar rat was injected 25 MBq of I‐123 labelled IBZM into the tail vein. The total measurement time of 100 mins was initially divided in steps of 20 seconds/projection and 8 projections per frame; the frames after 10mins p.i. had a length of 10 mins and were divided into 14 projections. The data were reconstructed with a dedicated MLEM algorithm (HiSPECT, Scivis GmbH, Göttingen, Germany) and evaluated with the AMIDE 0.9.1. Results Due to the movement of the camera head between the first (0°) to the second projection with 90° and back the minimum measurement time per frame is mechanically limited to 100sec. As a result of the grown sensitivity of the HiSPECT even with 20sec/projection and 25MBq I‐123‐IBZM sufficient counts/pixels had been collected to reconstruct a regionally evaluable image quality with a pixel size of 0.7mm. The first three frames show a high IBZM uptake in the heart and lungs. Later frames display a clearly definable accumulation in the striatum which is characterized by a high D2 receptor density, as well as nonspecific enrichments in the Harderian and the salivary glands. Conclusions HiSPECT permits tomographic dynamic studies of small animals. In this study the uptake behaviour of the receptor ligand IBZM was measured quantitatively with a temporal resolution of 2 minutes. Thus, HiSPECT seems to be a good nuclear‐medical alternative to small animal PET, in particular for longitudinal protocols.
P846 Longitudinal in Vivo Pinhole SPECT Measurements of Colorectal Liver Metastasis in Nude Mice using NIS as Reporter P. R. Franken, R. Marsault, J. Guglielmi, B. Karimdjee-Sohili, A. SchmidAlliana, H. Schmid-Automarchi, M. Koulibaly, T. Pourcher, J. Darcourt; Faculté de Médecine, Nice, FRANCE. The purpose of this work was to characterize longitudinal tumor progression in a murine orthotopic model of colorectal liver metastasis using NIS as reporter and SPECT with Tc99m pertechnetate as imaging modality. Materials and methods. Human colorectal carcinoma cells (HT29) were transfected with the sodium iodide symporter gene (mNIS). NIS expression was 125 controlled using in vitro I uptake and immunocytology. Cell lines stably expressing NIS were surgically transplanted into the liver of 24 nude mice. Imaging was performed under isoflurane gas anesthesia, 20 min after intraperitoneal injection of 200 MBq of Tc99m pertechnetate using a clinical gamma camera equipped with a 1 mm pinhole. Images were reconstructed using an iterative algorithm incorporating the pinhole geometry, the collimator response and the angular variation of the pinhole sensitivity allowing a 1 mm spatial resolution (Defrise, IEEE 2008). Tracer uptake was quantified using AMIDE program. Results. In a first group, imaging followed by sacrifice was obtained at days 9 (n=2), 16 (n=2), 20 (n=2), 26 (n=2) and 35 (n=2) after intra‐
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 hepatic injection of 5x106 HT29‐mNIS cells in 0.1 ml PBS. Regions with increased tracer uptake were clearly identified in the liver in all animals as early as 9 days after transplantation and correlated well with histopathological analysis. Despite standardized surgical procedure however, there was a large variability in the number and location of metastases which were also disseminated in the abdominal cavity in 9 of 10 animals. In a second group (n=14) only 2x106 HT29‐mNIS cells were injected in the liver and care was taken to wash properly the abdominal cavity to avoid peritoneal dissemination. The animals were imaged sequentially every 2 weeks up to 60 days after transplantation. Single intra‐hepatic tumor was clearly identified in 7 mice. Tumor size increased progressively averaging 50 mm3 at the end of the experiment (range 6 to 101 mm3). Tracer uptake correlated well with tumor size (R2 = 0.92). Conclusion. Tc99m pinhole SPECT imaging using NIS as reporter can be used to easily detect and longitudinally monitor colorectal liver metastasis in vivo. The technique showed a large variability in the number and location of metastases despite standardized procedures and can therefore be used to make homogeneous groups to evaluate therapeutic interventions.
P847 A comparative FDG activation PET study on electrical and light stimulations in the photoreceptor degeneration rabbit model S. Kim1, J. Lee1, J. Park2, J. Seo3, S. Kim3, H. Chung2, D. Lee1; 1Department of Nuclear Medicine, Seoul National Univ. Col. of Medicine, Seoul, REPUBLIC OF KOREA, 2Department of Ophthalmology, Seoul National Univ. Col. of Medicine, Seoul, REPUBLIC OF KOREA, 3School of Electrical Engineering and Computer Science, Seoul National Univ., Seoul, REPUBLIC OF KOREA. Objectives Artificial vision systems based on retinal electrical stimulation have been developed to electrically stimulate neurons along the visual pathway. The previous study of our group showed increased metabolism of the same cortical area on light and electrical stimulation of the rabbit retina on 18F‐FDG PET. In this study, the cortical areas activated by same stimuli were evaluated in photoreceptor degeneration rabbit model. Methods Three static PET over 40 min after injecting FDG (37 MBq) were acquired in each four rabbits using a microPET Focus 120 scanner. Photoreceptors of the retinae were destructed by intravenous injection of sodium iodate (50mg/kg). For the light stimulation, repetitive flash light (103.6cd, 1 Hz, 6 min total) was applied on one eye 1 min prior to FDG injection. For the electrical stimulation, repetitive electrical retinal stimulation (250μA, 1 Hz, 6 min total) was applied on the same eye. PET images were spatially normalized to the study specific template. Differences between rest and stimulus groups were analyzed by voxel‐wise two sample t‐tests. Results The visual cortex was not increased by light stimulation. However, it was increased by electrical stimulation. The activated cortical area was coincided with the area activated by the light and electrical retinal stimulation in normal rabbit. Conclusions This study showed that the electrical retinal stimulation evokes the increase glucose metabolism at the specific cortical area in the normal and the photoreceptor degeneration rabbit model, which suggests that electrical stimulation of the retina can induce visual perception in the rabbit.
P848 Biological differences between squamous cell carcinomas and adenocarcinomas of the lung demonstrated by tissuearrays. Interest for for 18F-FDG-PET. M. Pombo, P. Arce-Calisaya, I. Abdulkader, F. Gude, L. Leon, S. Argibay, V. Pubul, A. Ruibal; Hospital Clinico Santiago, Santiago de Compostela, SPAIN. In order to study the possible biological differences between squamous cell carcinomas and adenocarcinomas of the lung, we have analyzed in139 cases (54 adenocarcinomas and 85 squamous cell carcinomas) the inmunohistochemical expression of bcl‐2, cyclins A, B1, D1, D2, D3, ciclooxigenase 2 (COX‐2), HIF1a, HIF2a, p16, p21, p27, p53, p63, MIB1, and EFGR by means of tissue‐arrays. In relation to the clinical stage, the patients were classified as follows: ADENOCARCINOMAS: 17 I, 2 II, 22 III, 13 IV; SQUAMOUS: 21 I, 16 II, 33 III and 15 IV. The squamous cell carcinomas were less frequent in women (2/85 vs 8/54; p: 0,016) and they showed higher expression of bcl‐2 (38/85 vs 14/54; p:0,0257), cyclin A (66/85 vs 21/54; p:0,0000), cyclin B1 (74/85 vs 36/54; p:0,0039), cyclin D2 (68/85 vs 20/54; p:0,0000), p21 (82/85 vs 30/54; p:0,0000), p53 (61/85 vs 27/54; p:0,009), p63 (75/85 vs 5/54; p:0,0000), MIB1 (79/85 vs 42/54; p:0,009) and EGFR (56/85 vs 26/54; p:0,030). On the other hand, adenocarcinomas were more frequently COX‐2 positive (16/85 vs 20/54; p:0.017). There were no differences in the rest of the parameters measured. These differences (MIB1, EGFR, cyclin B1 and COX‐2) might support the idea that the squamous cell carcinomas show higher values of maxSUV concordant with the results described in the literature. We did the follow up of 81 patients during a period of time between 1 and 80 months (median 21) and after multivariate analysis we could observe that only the clinical stage (I‐II vs III‐IV; p:0,009; HR: 2,45) was an independent outcome factor. These results we get to the following conclusions: 1) the squamous cell carcinomas of the lung have a biological profile different from that of the adenocarcinomas, with higher expression of several parameters, some of them could have any influence in the maxSUV of the 18F FDG PET such us MIB‐1 and EGFR; 2) The clinical stage was the only outcome prognostic factor.
P849 MaxSUV-18F-FDG PET in non small cell lung cancer (NSCLC). Correlation with different biological parameters A. Ruibal, A. Sanchez-Salmon, A. B. Ciobotaru, M. Garrido, I. Abdulkader, F. Gude, L. Leon, J. Cortes; Hospital Clinico Santiago, Santiago de Compostela, SPAIN. In order to study which biological factors could relate to the values max SUV‐18F‐FDG‐PET in NSCLC patients, we have determined by means of tissue‐arrays, the inmunohistochemical expression of bcl‐2, cycline A, D1, D3, HER‐2/Herceptest, HIF2a, p27, p53, p63, PDEGF, VEGFR1 and MIB1. The group of study included 60 patients, 41 of them were squamous cell carcinoma
S475
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
P850 In vivo imaging of apoptosis with 1
99m
Tc-(CO)3-HIS-AnnexinV
2
M. De Saint-Hubert , K. Prinsen , K. Vunckx1, L. Zhou1, H. Wang3, J. Li3, Y. Ni3, J. Nuyts1, C. Reutelingsperger4, L. Mortelmans1, A. Verbruggen5, F. M. Mottaghy1; 1Division of Nuclear Medicine, Kul, Leuven, BELGIUM, 2 Laboratory for Radiopharmacy, KUL, Leuven, BELGIUM, 3Department of Radiology, Kul, Leuven, BELGIUM, 4Laboratory of Biochemistry, UM, Maastricht, NETHERLANDS, 5Laboratory of Radiopharmacy, Kul, Leuven, BELGIUM. Introduction Molecular imaging of apoptosis has gained much interest in cardiology for the detection of the area at risk in acute myocardial infarction (AMI) and in oncology for the early assessment of tumor response after therapy [1]. To improve the target‐to‐background ratio of apoptosis imaging with 99mTc‐labeled AnxV, a site‐specific labeling outside the binding region of the protein was performed [2]. HIS‐tagged AnxV was successfully labeled with 99mTc‐(CO)3 and showed better results compared to 99mTc‐HYNIC AnxV [3]. This study evaluated 99mTc‐(CO)3‐HIS‐ AnnexinV (99mTc‐hAnxV) in clinically relevant models. Methods First the affinity of 99mTc‐hAnxV was evaluated in rats with reperfused hepatic infarction (1) and ethanol induced cell death in muscle (2). Then an AMI rat model (3) (LAD artery occlusion 3h before 99mTc‐hAnxV administration) was used to image apoptosis in the area at risk of AMI. Finally therapy response was assessed in rhabdomyosarcoma rats treated with CombretastatinA4 (CA4P, 10 mg/kg 3h before 99mTc‐hAnxV administration) and local radiotherapy (2x10Gy, 24h and 2h before 99mTc‐ hAnxV administration) (4). µSPECT images were acquired and activity ratios of injured or treated to viable tissue were quantified by autoradiography. The results were correlated to histological analysis for apoptosis (TUNEL or caspase‐3). Results 99mTc‐hAnxV activity ratios of infarct to viable liver tissue ranged from 4 to 15 (1) and injured to viable muscle ranged from 14 to 30 (2), depending on the time post injection of the tracer (1‐5h p.i.). The increased uptake was visualized in vivo (µSPECT 4h p.i.) and correlated well with the histological evidence for apoptosis. µSPECT images (6‐8h p.i.) of (3) show apical 99mTc‐hAnxV uptake matching the perfusion defect area (NH3‐µPET). Autoradiography images show a 15‐fold increased uptake in the infarct area corresponding to apoptosis. Therapy induced apoptosis in tumors (4) was visualized in vivo (µSPECT 4h p.i.) and showed a heterogeneous uptake in the tumor corresponding to a heterogeneous distribution of apoptosis. Autoradiography showed a 2‐fold increased overall 99m uptake of Tc‐hAnxV in treated tumors compared to non‐treated tumors. Conclusion This study evaluated different applications of 99mTc‐hAnxV. 99mTc‐hAnxV imaging of rescuable myocytes proceeding in apoptosis would enable monitoring of therapy strategies inhibiting apoptosis. Finally the early response assessment in tumors with 99mTc‐hAnxV could be an important tool for individualized treatment management in oncology. References: [1] Boersma HH, et al. J Nucl Med 2005;46:2035‐2050. [2] Fonge H, et al. Bioorg Med Chem Lett 2008; 3794‐3798. [3] De Saint‐ Hubert M, et al. J Nucl Med (submitted).
P851 Radioimmuno PET imaging of vascular endothelial growth factor in colon cancer B. Paudyal, P. Paudyal, H. Hanaoka, Y. Iida, T. Hideyuki, H. Yoshioka, S. Yamamoto, N. Oriuchi, K. Endo; Gunma University, Maebashi, JAPAN. Background: Vascular endothelial growth factor (VEGF) is a key mediator of angiogenesis, the formation of new blood vessels. Angiogenesis is essential for cancer development and growth. Development of humanized monoclonal antibody against VEGF, bevacizumab (Avastin) in combination with chemotherapeutic agents have been successful in blocking VEGF induced tumor angiogenesis. The aim of the present study is to develop 64Cu labeled bevacizumab for the non‐invasive imaging of VEGF in colon cancer. Methods: Bevacizumab was radiolabeled with 64 Cu, a positron emitter through DOTA chelator, and injected intravenously in the nude mice bearing HT29 colorectal cancer. Whole body images were obtained immediately, at 24h, and 48h post injection with small animal PET. Animals were sacrificed after PET imaging, radioactivity was measured with gamma counter. The tumor sections were collected for immunohistochemical analysis of CD31 and VEGF A. Results: PET imaging revealed the accumulation of 64Cu‐DOTA‐ bevacizumab in the tumor region after 24 hours postinjection. Quantitative ex vivo analysis also revealed higher tumor activity (18.00±1.04% injected dose/g) at 24 hours post injection. The tumor to blood ratio was 2.15±0.74. Radiation dosimetry revealed that liver (2.35mGy/MBq) is the primary and spleen (1.20mGy/MBq) is secondary critical organ based on the animal data. Immunohistochemical analysis showed the strong expression of VEGF A and CD 31, which might 64 have led to the increased uptake of Cu‐DOTA‐bevacizumab in the tumor. Conclusion: The present study demonstrated the qualitative and quantitative analysis of 64Cu‐DOTA‐bevacizumab as a PET tracer for non‐invasive imaging of VEGF expression.
P852 SPECT-CT imaging nanoparticles
of
99m
Tc
labeled
ligand-tagged
P. Areses1, M. Agüeros2, G. Quincoces3, M. Collantes4, E. Prieto1, M. Ecay4, L. López-Sánchez1, J. Richter1, J. Irache2, I. Peñuelas3; 1Department of Nuclear Medicine, University Clinic of Navarra, Pamplona, SPAIN, 2 Pharmacy and Pharmaceutical Technology Department, University of Navarra, Pamplona, SPAIN, 3Radiopharmacy Unit, Department of Nuclear Medicine, University Clinic of Navarra, Pamplona, SPAIN, 4Small Animal Imaging Research Unit. CIMA-CUN, Pamplona, SPAIN. Aim Poly‐(anhydride) nanoparticles (NP) are useful drug delivery system for oral administration due to their potential to develop adhesive interactions with the gut mucosa. NP tagging with different ligands can increase the residence time and consequently the bioavailability of drugs. We herein compare the ability of conventional and cyclodextrin‐tagged NP (CD‐NP) to develop bioadhesive interactions within the gut by labelling with 99mTc and studying their in vivo biodistribution. Methods NP were labelled with 99mTcO4‐ by reduction with SnCl2. A double‐ solvent ITLC system was used to measure radiochemical purity. Absence of colloids was confirmed by size and polydispersion measurement of the technetium‐labelled NP in a Zetamaster analyser system. Biodistribution studies were performed in Wistar rats. A solution with 99mTc‐NP or 99mTc‐CD‐NP (1mCi, 10 mg) was administered orally. Images were acquired in a SPECT‐CT every 30 minutes for 8 hours under continuous isofluorane anesthesia. Images were converted into a dynamic set and in all frames regions of interest were drawn and evaluated to get the time‐course evolution of the biodistribution of the labelled NP. Animals were euthanized 8 hours after 99mTc‐NP administration; blood, urine and organs (liver, kidney, intestine, and stomach), were obtained weighed, carefully washed, and radioactivity measured in a gamma counter. Results Both NP and CD‐NP were radiolabelled with 99mTc with high efficiency as demonstrated both by ITLC and Zetamaster results. SPECT‐CT images with conventional and CD‐ NP showed similar results, with no distribution to other organs different that the gut. However, quantitative studies showed that CD‐NP were adhered to the stomach longer than conventional NP. t(m 60 in) NP
90
120 150 180 210 240 270 300 330 360 390 420 450 480
82.8 76.2 69.8 55.4 41.1 28.4 19.5 14.7 9.1± 6.6± 4.6± 3.7± 2.9± 2.9± 2.9± ±6.8 ±6.4 ±6.8 ±5.4 ±4.7 ±5.6 ±4.9 ±5.4 1.2 0.7 0.5 0.9 1.0 0.9 0.9
CD‐ 93.0 86.9 80.2 72.5 65.6 57.3 52.2 40.1 32.8 22.1 19.8 16.1 15.7 12.9 11.6 NP ±5.8 ±7.9 ±6.4 ±3.0 ±2.7 ±6.4 ±7.5 ±9.7 ±9.7 ±7.9 ±5.7 ±4.1 ±4.7 ±2.6 ±2.0 Table 1: Percentage±SD of stomach uptake values at different times with conventional NP and CD‐NP (n=3 for each case) Activity measurement of organs proved that NP remained in the gastrointestinal track at 8 hours, confirming that CD‐NP showed higher adhesion to the stomach and proximal regions of the small intestine. Only residual activity was found in the liver and the urine after 8h. Conclusion 99mTc‐labeling of nanoparticles permits in vivo imaging biodistribution studies, localization of NP tagged with different ligands and quantitative evaluation of their bioadhesive properties.
P853 Sorafenib efficacy on pre-clinical models of lymphoma V. Ambrosini1, C. Quarta1, P. Zinzani2, C. Nanni1, M. Fini3, P. Torricelli3, G. Giavaresi3, A. D'Errico-Grigioni4, D. Malvi5, F. Ceci1, R. Franchi1, S. Fanti1; 1 Nuclear Medicine, Azienda Ospedaliero-Universitaria di Bologna, S.OrsolaMalpighi University Hospital, Bologna, ITALY, 2Haematology, Azienda Ospedaliero-Universitaria di Bologna, S.Orsola-Malpighi University Hospital, Bologna, ITALY, 3Laboratory of Preclinical Surgical Studies, Istituti Ortopedici Rizzoli, Bologna, ITALY, 4Pathology, Azienda OspedalieroUniversitaria di Bologna, S.Orsola-Malpighi, Bologna, ITALY, 5Pathology, Azienda Ospedaliero-Universitaria di Bologna, S.Orsola-Malpighi University Hospital, Bologna, ITALY. Background: Sorafenib showed good results for treatment of advanced renal carcinoma and unresectable hepatocellular carcinoma while on‐going clinical trials (melanoma, small cells lung cancer) and preclinical studies (renal cells carcinoma, breast cancer, colon carcinoma and melanoma) are assessing its efficacy in other solid tumours. Aim: to evaluate the efficacy of Sorafenib in murine models of human lymphoma. Methods: Sorafenib citotoxicity was assessed in vitro on human cell culture of anaplastic Large Cells Lymphoma (Karpass299) and Hodgkin Lymphoma (L428). Studies on cells cultures were performed seeding cells in 24‐well plates (density of 5 x 104 cells/ml) and each line was treated with increasing drug concentration 24 hours later and calculating the IC50. For the measure of apoptosis, cells of three random wells of each groups were collected, lysated, and frozen at ‐80°C and assayed for Caspase‐3 at a later time. Xenografts models of human lymphoma were obtained by subcutaneous injection of both cell lines (107cells/mouse) in NOD/SCID mice. 18F‐FDG Small Animal PET and small animal CT were used to monitor tumour growth over time. Tumour bearing animals were randomly selected to either receive daily treatment with Sorafenib (80mg/kg) by gavage or no treatment (negative controls). Pathology was carried out in all cases at the end of the experiments. Results Sorafenib showed a strong effect in vitro on both cells proliferation and apoptosis in both ALCL and HD. IC50 for L428 was approximately 10 folds lower than Karpas‐299 (0.0343 mg/L vs 0.319mg/L). Caspase‐3 production showed a dose‐depended trend reaching significantly higher values for 0.046mg/L and 0.465mg/L drug concentrations in both cell lines. Small animal PET identified the engraftment before macroscopic evaluation (at 4 days in Karpass299 and at 7 days in L428 mice) and selected animals candidate to treatment (true positive PET in 6/7 Karpass299 and in 7/10 L428 mice). Negative PET results were confirmed by pathology carried out at the end of experiment. Small animal PET and CT were used to assess the efficacy of Sorafenib in vivo. In both animal models, tumour lesions showed a progressive increase of tumour metabolism and volume regardless treatment. Conlcusions: Although Sorafenib showed a good citotoxic effect in vitro, especially on human HD, these findings were not confirmed in‐vivo. Several factors might have influenced the discrepancy between in vitro and in vivo results: Sorafenib biodistribution
Poster Presentation
and 19 wer adenocarcinoma. The ages ranged between 41 and 86 years (64 +/‐12; median 67), and according to the clinical stage, the distribution was as follows: IA: 3; IB: 11; IIA: 1; IIB: 8; IIIA: 11; IIIB: the 14 and IVth: 12. PET was performed in an Advanced. (GE) system, with adquisión 2D. In the patients with squamous cell carcinoma, SUVmax's values ranged between 4,0 and 32,1 (17,3 +/‐6,3) and did not differ statistically with the values obtained in adenocarcinomas (i: 1,6‐ 47; 15,1 +/‐9,8). SUVmax's values did not differ statistically in function or not of the positivity for bcl‐2 (‐: 16,4 +/‐9,0 vs +: 16,0 +/‐5,6); cycline A (‐: 14,9 +/‐5,3 vs +: 17,5 +/‐8,8), cycline D1 (‐: 14,9 +/‐5,6 vs +: 16,9 +/‐9,4), cycline D3 (‐: 17,7 +/‐8,8 vs +: 13,7 +/‐4,7), HER‐2/HERCEPTEST (‐: 16,7 +/‐5,2 vs +: 21,1 +/‐14,5), p27 (‐: 14,0 +/‐5,4 vs +: 15,7 +/, 6), p53 (‐: 17,4 +/‐7,2 vs +: 16,8 +/‐8,4), p63 (‐: 17,4 +/‐11,0 vs +: 15,7 +/‐5,7), VEGFR1 (‐: 16,0 +/‐6,3 vs +: 16,4 +/‐9,5), HIF2a (‐: 15,4 +/‐ 7,0 vs +: 14,1 +/‐6,0) and PDEGF (‐: 16,8 +/‐8,9 vs +: 14,4 +/‐5,6) The SUVmax values associated postively with the expression of MIB1 (+ / ++: 14,0 +/‐5,4 vs +++: 18,8 +/‐8,8), near to the statistical significance (p:0,099), HIF1alfa (‐/+:10,3 +/‐4,4; vs ++ / +++:17,5 +/‐8,2; p:0.033), EGFR (‐: 9,4 +/‐5,4; +: 13,9 +/‐6,3; ++: 16,5 +/‐3,9; +++: 19,6 +/‐9,7; p:0.034) and negatively with p16 (‐: 17,3 +/‐8,3; +: 15,3 +/‐4,0; ++: 8,0 +/‐3,9; p:0,039). The positivity of HIF1a and EGFR did not modify significantly the SUV values considering the positivity of each one of the parameters. There were differences when considered: HIF1a +/p16 + 13,3 +/‐5,7 vs HIF1a +/p165:18,8 +/‐9,1; p:0,081) and between the EGFR +/p16 + 16,6 +/‐3,7 vs EGFR +/p16:19,3 +/‐9,3; p:0,025). EGFR had more statistical significance than p16. The previous results suggest us that the maxSUV values are positively influenced by the expressions of HIF1a, EGFR, MIB1 (cellular proliferation) and negatively by p16 expression
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and metabolism in NOD/SCID mice, drug availability at tumour site or differences in the downstream pathways.
P854 Development of a New Selective Agent Designed for PET Imaging of Melanoma D. Denoyer1, I. Greguric2, A. Katsifis2, P. Roselt1, O. C. Neels1, D. Dorow1, R. J. Hicks1; 1Centre for Molecular Imaging, Peter MacCallum Cancer Center, East Melbourne, AUSTRALIA, 2Radiopharmaceuticals Research Institute, Australian Nuclear Science and Technology Organisation, Sydney, AUSTRALIA. Melanoma is one of the most highly metastatic cancers and its incidence is increasing in many countries. Despite the development of new therapies and improvement of existing treatments, the most effective therapy for melanoma metastases remains surgical excision. Therefore, early detection of metastatic spread is important for prognostic stratification and identification of patients suitable for surgery, or, failing this, evaluation of response to systemic treatment of unresectable disease. Benzamide (BZA) radiopharmaceuticals that selectively concentrate in melanoma due to a high affinity binding to melanin have recently shown promise as imaging agents. However, the sensitivity of several of these has been compromised by significant hepatobiliary clearance, limiting detection of abdominal disease. A nicotinamide analogue, MEL50, which is suitable for labeling with [18F]fluorine has been designed to provide primarily renal clearance. The aim of the current study was to evaluate the melanoma imaging potential of 18 [ F]MEL50 using PET imaging and high‐resolution autoradiography in various murine models of melanoma. The high specificity of [18F]MEL50 for melanin was studied by comparing its accumulation in pigmented B16‐F0 allograft model with that of human amelanotic A375 xenograft model. To test the ability of [18F]MEL50 to assess the metastatic spread of melanoma cells, we used a model of lung metastasis by injecting B16‐F0 cells via the tail vein of C57Bl/6 mice. In pigmented B16‐F0 grafts, PET images revealed a significant accumulation of [18F]MEL50 with a tumour to background ratio of >50:1 at 2 and 3 hours post tracer injection. Unlike pigmented tumours, no tumour uptake was observed in the mice bearing amelanotic melanoma. Intense tumour uptake of [18F]MEL50 has also been observed in metastatic lesions in the lungs of B16F0 tumour bearing mice. The PET findings were confirmed by high‐resolution autoradiographic images of the lung metastasis. Conclusions: [18F]MEL50 showed a rapid and high tumour uptake with a high specificity for melanin suggesting that this selective agent can be used to non‐invasively evaluate the metastatic spread of melanoma in the clinic. Therefore, [18F]MEL50 has a great potential as an imaging agent to evaluate efficacy of novel therapeutic strategies for metastatic melanoma.
P855 Dynamic and static imaging using micro-SPECT in Rats to monitor Renal Function after a Therapeutic Dose of Lu-177labelled Octreotate M. Melis1, R. Valkema1, S. C. Berndsen1, M. de Visser1, J. de Swart1, E. P. Krenning1, O. C. Boerman2, M. de Jong1; 1Erasmus MC, dept. of Nuclear Medicine, Rotterdam, NETHERLANDS, 2UMCN St.Radboud, Dept. of Nuclear Medicine, Nijmegen, NETHERLANDS. Aim: Peptide receptor radionuclide therapy (PRRT) in patients with somatostatin receptor overexpressing tumours using radiolabelled somatostatin analogues like octreotate, shows beneficial results. However, partial reabsorption of the radiopeptides in the kidneys may lead to long‐term nephrotoxic effects. Nowadays co‐infusion of lysine/arginine is a protective measure in the clinic during PRRT. In rats 460 MBq Lu‐177‐DOTA‐octreotate results in complete tumour response, but delivers 60 Gy to the kidneys, which can be reduced with 40% when lysine (Lys) is co‐administered. Beyond 90 days after therapy, increased urinary protein and serum creatinine/urea values indicate renal damage. In this study dynamic imaging of In‐111‐DTPA and Tc‐99m‐MAG3 and static Tc‐99m‐DMSA imaging were performed to monitor glomerular filtration, tubular secretion and reabsorption resp. after PRRT, using a small animal SPECT/CT camera. Materials and methods: Rats were scanned using the multi‐pinhole NanoSPECT/CT camera (BioScan). Three groups of male Lewis rats were imaged, (1) control rats, (2+3) rats >90 days post therapy (p.t.) with 460 MBq/15 microgram of Lu‐177‐DOTA‐octreotate, with (3) or without (2) 400 mg/kg Lys co‐injection (n=4 per group). Dynamic dual isotope studies were performed between at 100‐120 days p.t. using 50 MBq In‐111‐DTPA and 50 MBq Tc‐99m‐MAG3 simultaneously. 20 scans of approximately 2 min each were acquired. Separately, static Tc‐99m‐ DMSA scans were acquired 2 h after i.v. administration of 25 MBq 90 and 140 days p.t. After reconstruction radioactivity was quantified and expressed as percentage of injected dose (%ID). Results: In‐111‐DTPA and Tc‐99m‐MAG3 studies revealed the same time‐activity pattern as in humans with a peak 2‐6 min. after administration, followed by a decline of renal radioactivity. A clear correlation was found between scintigraphic results and biochemical parameters. All parameters tested indicated renal damage in the PRRT group. The PRRT + Lys group had minor biochemical signs of renal damage, no differences vs. controls with In‐111‐DTPA or Tc‐99m‐ DMSA, but Tc‐99m‐MAG3 peak activity was significantly reduced. Conclusion: Dynamic dual isotope and static imaging with In‐111‐DTPA, Tc‐99m‐MAG3 and Tc‐99m‐DMSA in rats is feasible using the NanoSPECT/CT, enabling monitoring of renal function over time. Glomerular and tubular functions were affected beyond 90d after PRRT with 460 MBq Lu‐177‐DOTA‐octreotate. Lysine co‐administration preserved kidney function as monitored by In‐111‐DTPA and Tc‐99m‐ DMSA. Tc‐99m‐MAG3 renography seems to be a more sensitive marker of tubular function after PRRT than Tc‐99m‐DMSA imaging, serum urea or urinary protein content. This study was funded by KWF/NKB (Dutch Cancer Foundation), grant no. EMCR 2007‐3758 (peak) %ID/kidney
Control PRRT
In‐111‐DTPA
4.7 ± 1.0 2.1 ± 1.4 4.4 ± 0.6
PRRT + Lys
Tc‐99m‐MAG3 13.1 ± 2.6 4.3 ± 1.5 8.5 ± 1.6 Tc‐99m‐DMSA 13.7 ± 1.4 6.4 ± 2.4 12.5 ± 1.2
P856 MicroPET/CT of mice bearing αvβ3-expressing tumors by a 18F-labeled bifunctional chimeric RGD peptide A. Zannetti1, F. Iommelli1, M. Panico1, A. Del Gatto1, L. Zaccaro1, M. Saviano1, C. Pedone1, M. Salvatore2, S. Del Vecchio2; 1Institute of Biostructures and Bioimages, National Research Council, Naples, ITALY, 2 Department of Biomorphological and Functional Sciences, University of Naples “Federico II”, Naples, ITALY. In a previous study, we designed and synthesized a novel bifunctional chimeric RGD peptide including a cyclic RGD pentapeptide covalently linked by a spacer to an echistatin domain (RGDechi) that showed a high selectivity for αvβ3 integrin and lack of cross‐reactivity with αvβ5 (Del Gatto A. et al. 2006; J. Med. Chem. 29: 3416‐3420). Aim To test the ability of this chimeric peptide to discriminate in vivo αvβ3 from αvβ5 and to differentially modulate the function of the two integrins. Materials and Methods The chimeric peptide was preliminarily tested for inhibition of αvβ3‐dependent cell adhesion and competition of 125I‐echistatin binding to membrane of stably transfected K562 cells expressing αvβ3 (Kαvβ3) or αvβ5 (Kαvβ5) integrin. The full‐length chimeric peptide and a truncated derivative, lacking the last five C‐terminal aminoacids, were then labeled with 18F using a one‐step procedure and used for PET imaging. Briefly, nude mice bearing tumors from U87MG human glioblastoma and A431 human epidermoid cells were injected with 200 μCi of 18F‐labeled peptides in presence or absence of a large excess of cold ligand and then subjected to microPET/CT (eXplore Vista PET/CT, GE Healthcare).Results Adhesion and competitive binding assays showed that the novel chimeric peptide selectively binds to αvβ3 integrin and does not cross‐react with αvβ5. In agreement with in vitro findings, PET/CT imaging studies showed that the radiolabeled chimeric peptide selectively localizes in tumor xenografts expressing αvβ3 and fails to accumulate in those expressing αvβ5 integrin. When 18F‐labeled truncated derivative was used for PET imaging, both αvβ3 and αvβ5 expressing tumors were visualized indicating that the five C‐terminal aminoacids are required to differentially bind the two integrins. In vivo competition experiments showed the specificity of binding of both peptides. Conclusion Our findings indicate that the novel chimeric RGD peptide, having no cross‐reaction with αvβ5 integrin, allows highly selective αvβ3 expression imaging and monitoring.
P857 Imaging of Bcl-2/Bcl-xL dysregulated apoptotic program in NSCLC cells resistant to EGFR tyrosine kinase inhibitors A. Zannetti1, F. Iommelli1, R. Fonti1, A. Lettieri1, G. Pirozzi2, R. Bianco3, G. Tortora3, M. Salvatore4, S. Del Vecchio4; 1Institute of Biostructures and Bioimages, National Research Council, Naples, ITALY, 2Department of Experimental Oncology, National Cancer Institute, Naples, ITALY, 3 Department of Endocrinology and Molecular and Clinical Oncology, University of Naples “Federico II”, Naples, ITALY, 4Department of Biomorphological and Functional Sciences, University of Naples “Federico II", Naples, ITALY. Non small cell lung cancers (NSCLC) expressing epidermal growth factor receptor (EGFR) mutants were reported to be highly sensitive to EGFR tyrosine kinase inhibitors (TKIs) such as erlotinib and gefitinib. However, acquired resistance to TKIs invariably emerges over time, in part due to secondary mutations or alternative mechanisms that may affect key downstream mediators of the TKIs‐induced apoptotic program. Aim To test the role of Bcl‐2/Bcl‐xL in the development of resistant phenotype in NSCLC cells and whether such TKI resistance can be identified in vivo by non‐invasive imaging. Materials and Methods NSCLC cells with EGFR mutations showing a large spectrum of sensitivity to TKIs were analyzed for levels of EGFR, P‐EGFR, Bcl‐2, Bcl‐xL, Bad and Bim. Sensitivity of lung cancer cells to erlotinib treatment was assessed by cell viability and apoptosis assay. Based on our previous study in breast cancer cells (Zannetti A. et al. 2008, Clin. 2+ Cancer Res. 14: 5209‐5219) we tested the effect of increasing concentrations of erlotinib on Ca release from endoplasmic reticulum through inositol trisphosphate receptor type 3 (IP3R3) modulated by Bcl‐2/Bcl‐xL and on 99mTc‐Sestamibi uptake. Cytosolic and mitochondrial Ca2+ levels were assessed by FACS analysis using fluorescent dyes. The expression of IP3R3 was suppressed by transfecting resistant tumor cells with targeted siRNA. Nude mice bearing non small cell lung carcinomas were subjected to microSPECT with 99mTc‐Sestamibi before and after erlotinib treatment. Results We found that resistant NSCLC cells, expressing relative high levels of Bcl‐2/Bcl‐xL or failing to upregulate Bim in response to erlotinib, show an increased 99mTc‐ Sestamibi uptake at TKI concentrations achievable in plasma. A relative increase of cytosolic and mitochondrial calcium levels also occurred in resistant cells thus mimicking tracer uptake. Suppression of IP3R3 expression by siRNA completely abolished TKI‐dependent enhancement of tracer uptake. Post‐treatment imaging studies in nude mice bearing lung cancer xenografts showed a high tumor uptake of the tracer in erlotinib resistant tumors whereas baseline studies failed to visualize both sensitive and resistant tumors. Conclusion Overexpression or unopposed action of Bcl‐2/Bcl‐xL may cause resistance to erlotinib in NSCLC through modulation of IP3R3 and such resistance can be detected in vivo using SPECT and 99mTc‐Sestamibi.
P858 The Value of Fluorodeoxyglucose PET/CT in Managing Patients with Large Vessel Vasculitis - Referring Clinician’s Perspective T. Koc, N. Brejt, M. Peters, K. Davies, I. Haq, S. Dizdarevic; Royal Sussex County Hospital, Brighton, UNITED KINGDOM. AIM: To our knowledge, there are no studies investigating the value of 18F‐FDG PET/CT in the management of patients with large vessel vasculitis from the referring clinician’s point of view. We aim to assess the impact of 18F‐FDG PET/CT and its evolving role in the management of large vessel vasculitis. MATERIALS & METHODS: Between December 2005 and December 2008, 24 FDG PET/CT scans were performed to investigate the presence of large vessel vasculitis, 10 of which specifically requested investigation of Takayasu's arteritis. Retrospectively, a questionnaire was sent to the referring physicians to assess impact on patient management. RESULTS: All 24 scans
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P859 Imaging of regional red blood cell mass in the rat brain using NanoSPECT/CT D. Mathe1, I. Portoro2, G. Nemeth1, A. Eke2; 1Mediso Ltd., Budapest, HUNGARY, 2Inst. Human Physiology and Clinical Experimental Research, Semmelweis University, Budapest, HUNGARY. Introduction: Regional oxygen supply by red blood cells (RBCs) within the regional cerebral blood volume (rCBV) has a major impact on brain functions. Hence, our motivation ‐ by using a NanoSPECT/CT small animal imaging system with its proprietary Multiplexed‐Multipinhole Collimation for in vivo quantitative SPECT ‐ was to develop a method for imaging RBC mass in the brain. As a test, rCBV was decreased by increasing the vascular tone via the NO/cGMP pathway by L‐NAME. Material and Methods: Male Wistar rats (n=4) were anesthetized by a 1:1 mixture of Ketamine‐Xylasine solutions (100 mg/mL and 5 mg/mL, respectively) given i.p. in a dose of 2.5 mL/kg bdw for induction, followed by an hourly maintaining dose of 1.5 mL/kg bdw. Catheters were inserted into the femoral artery and vein. RBCs were labeled with 99mTc using stannous pyrophosphate as reducing agent (20 μg Sn (II)/kg bdw,i.v.). Thirty minutes later, 1 mL of pre‐ treated arterial blood was withdrawn and gently mixed with 1 mL of 99mTc‐pertechnetate solution of ~ 200 MBq activity, and allowed to stand for 10 minutes prior to re‐injection. Labeled RBCs were re‐injected (in 0.7 mL with approximate activity of 70 MBq) for mapping RBCs 5 minutes post‐injection. Two animals were treated by L‐NAME (100 mg/kg bdw, i.v.). Scans were acquired for control and at 44 minutes following the L‐NAME injection. Animals were sacrificed by saline infusion (a total of 100 mL) given via the arterial line with concomitant drainage via the venous line in order to remove blood from the brain's parenchyma. Cerebral RBC mass (CRBCM) was characterized by activities normalized by the brain's volume. Results: No activities were found in the thyroids and in the stomach, the sites where free 99mTc pertechnetate in blood accumulates if present; an evidence of a larger then 95% purity of radiolabeling. Hot spots in the brain were detected at sites of venous sinuses and the circus of Willis. CRBCM decreased in the L‐NAME treated animals, as anticipated, while 99mTc‐activity became about a magnitude smaller (0.03 mBq/cm3) after saline infusion demonstrating the specificity of the 99mTc‐radiolabeling for RBCs. Conclusions: Quantitative NanoSPECT technology is efficient to assess regional RBC mass in the rodent and the technique can be further used in studies of mechanisms affecting the pathways of vascular regulation and its regional and organ differences. Acknowledgements: NKTH, Hungary Grant 2008ALAP1‐01569/2008 and EMIL FP6 NoE EC
P860 Application of measurements of tumor size and perfusion as NanoSPECT/CT biomarkers in mice D. Mathe1, G. Nemeth2, J. Tovari3, E. Raso3, L. Balogh4, G. Janoki5; National Institute of Radiobiology and Radiohygiene and Mediso Ltd., Budapest, HUNGARY, 2Mediso Ltd., Budapest, HUNGARY, 3National Institute of Oncology, Budapest, HUNGARY, 4National Institute of Radiobiology and Radiohygiene, Budapest, HUNGARY, 5Medi-Radiopharma Ltd, Erd, HUNGARY. 1
Introduction. We investigated the possibilities of treatment biomarker determination in mouse hepatocellular carcinoma and metastatic melanoma models using measurements with the multiplexed multipinhole NanoSPECT/CT technology. Tumor size and perfusion estimates were chosen as biomarkers. We quantified radiopharmaceutical uptake in a given time period using SPECT in the tumors. Material and Methods. For intrahepatic and intraabdominal studies, mice were implanted with a liver‐spleen metastatic hepatoma cell line (HepG3) four weeks before. 10 MBq of 99mTc‐labelled nanosized protein colloid (Nano‐AlbumonTM) has been injected iv. into 6 SCID mice. For CT studies we injected the eXiaTM mouse contrast agent i.v. 3 h before the scan. 6 Subcutaneous model studies were performed in 3x5 Nude mice implanted with 10 B‐16 melanoma cells 3 weeks before. Treatments were performed using erythropoietin (E), Avastin (A) and a combination of erythropoietin and Avastin (E+A). A hepatomas were treated with Avastin. 5 mice served as untreated control. SPECT was performed using 99mTc‐labelled human serum albumin (30 MBq/animal) as blood plasma labeling agent. Size of the tumor was measured using the CT reconstructions. Tumor perfusion was estimated by quantifying the tumor Volume of Interest activity content versus the activity content of a predefined aortic VOI in the same animal. Results. In all animals multiplex liver lesions were visualized as cold spots in SPECT. There was no statistically significant difference between the control and the treated group. In the subcutaneous studies there was no significant difference found between the A, E and E+A groups but both tumor size and perfusion estimates were slightly but significantly different from treated control. Discussion. Biomarker measurement thus therapeutic efficiency studies are both effectively feasible using multiplex multipinhole SPECT/CT. The method of perfusion estimation described here could be used for screening purposes in drug discovery/efficiency studies as well.
P861 MicroSPECT/CT and MicroPET Imaging of Human Breast Cancer Xenografts Expressing HER2 in Athymic Mice using 111 64 In- and Cu-DOTA-Trastuzumab Fab
C. Chan, D. A. Scollard, K. McLarty, S. Smith, R. M. Reilly; Departments of Pharmaceutical Sciences and Medical Imaging, University of Toronto and Toronto General Research Institute, Toronto, ON, CANADA. Purpose: Our aim was to compare microSPECT/CT and microPET imaging of human breast cancer (BC) xenografts in athymic mice expressing HER2 using 111In or 64Cu‐trastuzumab (Herceptin) Fab fragments. Methods: DOTA‐derivatized Fab of trastuzumab and rituximab were labeled with 111 In‐ or 64Cu‐acetate. Radiochemical purity (RCP) was measured by HPLC and immunoreactivity by saturation binding to SK‐Br‐3 cells. Athymic mice with s.c. MDA‐MB‐231 (HER2 0+), BT‐20 (1+) and two sizes (6‐8mm or 12‐15mm) of MDA‐MB‐361 (2+) BC xenografts were injected i.v. with 111 In‐ or 64Cu‐trastuzumab Fab and images acquired at 24h p.i using Bioscan nanoSPECT/CT (100K counts/projection) or Siemens MicroPET Focus‐220 (>5x106 total counts). ROI counts were expressed as %ID/voxel. Tumour‐to‐blood or background (T/B) ratios were calculated. Biodistribution studies were performed following imaging. The specificity of tumour uptake of trastuzumab Fab was examined with 111In‐ or 64Cu‐rituximab Fab (anti‐CD20). Results: RCP of 111 In‐ or 64Cu‐trastuzumab Fab substituted with 3.7 ± 0.2 DOTA was >98%. 111In‐ or 64Cu‐ trastuzumab Fab showed specific binding to HER2 on SK‐Br‐3 cells (Kd = 41 ± 3 nM); there was no binding of rituximab Fab. Uptake of 111In‐ and 64Cu‐trastuzumab Fab into small MDA‐MB‐361 tumours was 4.4 ± 0.6 vs. 5.0 ± 1.2% i.d./g; p>0.05. Blood radioactivity was greater for 111In‐ and 64 Cu‐rituximab Fab than for trastuzumab Fab (2.1 ± 0.7 and 2.8 ± 0.3% i.d./g vs. 0.4 ± 0.1 and 1.4 ± 0.2% i.d./g). This caused 3.1‐ and 2.4‐fold higher T/B ratios (p=0.01) for 111In‐ and 64Cu‐ trastuzumab Fab than for rituximab Fab (10.7 ± 1.9 and 3.6 ± 0.6 vs. 3.4 ± 1.5 and 1.5 ± 0.1), suggested non‐specific tumour uptake of 111In‐ and 64Cu‐rituximab Fab (6.5 ± 0.8 and 4.3 ± 0.8% i.d./g). ROI analysis correlated well with biodistribution data. T/B ratios were greater for 111In‐ and 64Cu‐trastuzumab Fab in MDA‐MB‐361 tumours than in BT‐20 or MDA‐MB‐231 tumours. 111 64 Tumour uptake of In‐ or Cu‐trastuzumab Fab in larger MDA‐MB‐361 tumours was 6.1 ± 0.8 and 7.1 ± 1.7% i.d./g and T/B ratios were 12.3 ± 0.8 and 3.9 ± 1.3. MDA‐MB‐361 xenografts overexpressing HER2 were imaged by microSPECT or microPET, whereas MDA‐MB‐231 and BT‐20 tumours were less clearly visualized. Conclusions: Human BC xenografts in athymic mice overexpressing HER2 (2+) were imaged at 24h p.i. of 111In or 64Cu‐trastuzumab Fab by microSPECT/CT or microPET. Supported by the Ontario Institute of Cancer Research.
P862 Applicability of Hypoxic Tracers the Imaging on Infection Rat
99m
Tc-HL91 and Derivative for
C. Hsia1, L. Shen1, H. Wang2; 1Institute of Nuclear Energy Research, TauYen, TAIWAN, 2Institute of Biomedical Imaging and Radiological Science, National Yang-Ming University, Taipei, TAIWAN. Purpose: Detection and localization of infectious and noninfectious foci in soft tissues were of primary importance for the management of patients with presumed or established inflammatory and septic diseases. When recruited to tissue foci of inflammation or infection, they encountered a declining oxygen gradient which increased cellular hypoxia‐inducible factor (HIF)‐1α levels. This study represented the diagnostic efficacy from hypoxic tracers on the infected rats’ model. Material and method: The infection studies were performed with male Sprague‐Dawley rats. Animals, 6‐ to 8‐wk old and 100‐120 g in weight, were inoculated with Escherichia coli or/ and Staphylococcus aureus on the right or/and left thighs. After 24 h inoculation of the bacteria, rats were injected intravenously with 99mTc‐HL91 or 99mTc‐HL91‐NI, then dynamic imaged by microSPECT for 2 hours. Results: The T/NT ratio of or 99mTc‐HL91‐NI at the highest uptake was 1.44±0.28 or 1.78±0.37, respectively. The E. coli infected thigh had higher 99mTc‐HL91 uptake than S. aureus. But it’s almost the same uptake by the image with 99mTc‐HL91‐NI. Conclusion: Our results indicated that both hypoxic tracers, 99mTc‐HL91 and 99mTc‐HL91‐NI, had higher uptake on the infected thigh and the latter seemed better than the former. Different infected bacteria also had different effect on the hypoxic tracer’s diagnostic efficacy. This study provided the applicability on the imaging of infection by hypoxic tracer.
P863
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Invitro and in vivo evaluation of [ Cu-DODAT-ior/R3] targeting vector for PET imaging of EGF receptor expressing cancer P. P. Hazari, S. Singh, N. Kumar, L. Singh, A. K. Tiwari, A. K. Mishra, A. K. Mishra*; Inmas, Delhi, INDIA. Receptor‐specific Antibody conjugates containing cyclam chelators have shown promise for production of 64Cu‐labeled targeting vectors to be used in site‐directed positron‐emission tomography (PET) and radiotherapy. The addition of pendant carboxylic acid groups further increases stability, forming six‐coordinate copper(II) complexes where two of the pendant arms are coordinated to the metal centre. The chelate 6‐(4‐isothiocyanatobenzyl)‐5, 7‐dioxo‐1, 11‐ (carboxymethyl)‐1, 4, 8, 11 ‐ tetraazacyclotridecane (DODAT) has an isothyocyanatobenzyl functional group which allows mAb binding and free amide and COOH coordination centre for 64 Cu‐labeling. METHODS: We have developed a method for the efficient production of high specific activity 64Cu utilizing the 64Ni(p,n)64Cu nuclear reaction. Nickel has been electroplated successfully at thicknesses of 20‐300 mm and bombarded with proton current of 25μA. Conjugation of EGFr monoclonal antibody was performed by adding 25 µL of 20 mM of chelate solution was added to 300 µL of a solution containing 1 mg of antibodies in 0.1 M sodium phosphate buffer, pH 7.4. Saturated trisodium phosphate solution (40 µL) was added to make the pH to approximately 8.5‐9.0. The reaction mixture was incubated at 37°C for 1h. 64CuCl 2 (2 mCi) was added to 0.1 M ammonium citrate buffer, pH 5.5. 64 Cu‐citrate was added to DODAT‐ior/R3 in 0.1 M ammonium citrate, pH 5.5, and incubated for 30 minutes at room temperature.The Antibody chelate mixture was then subjected to centrifuged G‐50 Sephadex column gel chromatography. RESULTS: The radiotracer was synthesized with a high specific activity (11100 GBq/mmol [300 Ci/mmol]). The immunohistochemical study showed the antibody conjugated with the chelate maintained reactivity with ior egf/R3 antibody.Uptake of conjugate in tumor was 5.58 ± 0.72% ID/g at 1 h and accumulation of radioactivity in liver tissue (3.58± 0.49% ID/ g, 1 h p.i.) is indicative of rapid renal‐urinary excretion and suggests very high in vivo kinetic stability of 64 Cu‐DODAT‐ior/R3 with little or no in vivo dissociation of 64Cu from the DODAT chelator. Kidney accumulation at 1 h p.i. was 7.79± 2.39% ID/ g. PET imaging studies in EGFr expressing tumor in Balb/c mice produced high‐contrast,high‐quality PET images.
Poster Presentation
contributed to patient care: 10 (42%, 95% CI 24%‐61%) confirmed the proposed management; 14 (58%, 95% CI 39%‐76%) led to management change, especially in regards to changes in therapy (p<0.001) compared to investigations (p<0.01). Of these, 5 resulted in the addition of a new drug; one resulted in change of drug dose; 2 resulted in an additional investigation and addition of a new drug; one resulted in cancellation of a proposed investigation and an addition of a new drug; one resulted in a request for additional investigation and addition of a new drug; 3 resulted in requests for additional investigation; 2 resulted in the withdrawal of a drug and one resulted in cancellation of a planned investigation. 7/24 (29%, 95% CI 15 ‐ 49%) scans showed active inflammation. The presence or absence of active inflammation was not related to likelihood of management change (p=0.60). CONCLUSION: PET/CT is helpful in the management of large vessel vasculitis with respect to both investigation and therapy, irrespective of the presence of active inflammation.
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P864 Pharmakokinetic study of C-11 donepezil in rats by means of positron planar imaging system J. Hatazawa, E. Shimosegawa, Y. Kanai, M. Imaizumi, H. Kato; Osaka University Graduate School of Medicine, Suita, JAPAN. The US FDA (2006), European (2004), and Japanese (2008) regulatory authorities recommended a new approach for drug development known as microdosing with PET. We tested pharmakokinetics of Donepezil (DNP) in rats by means of planar positron imaging system (PPIS) (Hasegawa Y, et al. Ann Nucl Med 22; 301‐307:2008). Methods: C‐11 DNP (74MBq or less, 2microgram) was injected to tail vein in six male Wister rats (8 weeks old weighed 200~250g) under 0.4% isoflurane anesthesia. Image acquisition started immediately after injection and continued for 40 min. During the initial 20 min, 120 1 sec‐ scan, 80 6 sec‐scan, 50 12 sec‐scan were performed for whole body. Relative Uptake Value (RUV, %), defined as regional counts divided by whole body counts multiplied by 100 for initial 20min, was measured for brain, heart, liver, intestine, kidney, and urinary bladder. Results: C‐11 DNP accumukated predominantly in liver and was excreted to biliary tract and small intestine within 40min. During the first 20min the RUV for brain was 1.50±0.08%. Conclusion: Pharmacokinetics of Donepezil can be quantitatively visualized by means of the present PPIS and its C‐11 labeled compound.
P92 ‐ Tuesday, October 13, 2009, 16:00 ‐ 16:30, Poster Exh. Hall
Molecular imaging: imaging with optical method or other modalities.
P865 Dendritic Cell Labelling with Paramagnetic Nanoparticles, 111 In-Oxine and PKH26 for In Vivo Magnetic Resonance, SPECT and Optical Imaging of their Migration 1
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Introduction To improve PRRT for liver metastases of neuroendocrine tumours, new approaches such as locoregional administration are being tested in preclinical tumour models. To monitor tumour size intrahepatically after PRRT in a liver metastases model in a sensitive and quantitative way, we aimed to apply bioluminescence imaging (BLI) in combination with SPECT/CT imaging. Somatostatin receptor 2 (sst‐2)‐positive rat pancreatic tumour cells of acinar origin (CA20948) were stably transfected with a GFP/Luciferase plasmid construct and characterized by BLI and SPECT/CT imaging using 111In‐DTPA‐octreotide in mouse and rat. Methods: CA20948 cells were transfected with a GFP/Luciferase plasmid using lipofectamin. GFP‐positive clones were isolated and clones with high luciferase expression were selected and characterized in vitro for expression of sst‐2 receptor expression. Cells were inoculated subcutaneous in the shoulder of nude mice; non‐transfected cells in the left shoulder, transfected cells in the right shoulder. BLI (IVIS, Xenogen) was performed 10 days when the tumours reached a size of 7‐12 mm. SPECT/CT imaging was performed with the NanoSPECT/CT (Bioscan) in the same anesthetized mice 4 h after i.v. injection of 111In‐octreotide (30 MBq/animal). Biodistribution analysis and ex vivo autoradiography of the tumours was performed 24 hours after injection. Transfected cells were inoculated subcapsulary in the liver of a Lewis rat. Intrahepatic tumor was visualized by BLI and SPECT/CT imaging. Results: After transfection GFP positive cells were observed and cloned. In vitro internalisation experiments showed similar binding and uptake of radiolabeled octreotide as the control non‐transfected cells. GFP/luciferase‐transfected tumours could be clearly visualized by BLI. Tumour growth could be quantified by BLI measurements in time (total flux/time). SPECT/CT images after injection of 111In‐octreotide showed accumulation of high levels of radioactivity in both control and transfected tumours. Biodistribution data confirmed comparable uptake levels of 111In‐octreotide in transfected and control tumours. Subcapsulary inoculation of the transfected CA20948 tumour cells in rat liver resulted in an intrahepatic tumour, which could be visualized by both SPECT/CT and BLI. Conclusion: Luciferase‐transfected and non‐transfected CA20948 tumours show comparable sst2 receptor expression and 111In‐octreotide uptake in vitro and in vivo. Transfection of CA20948 tumour cells did not alter the properties of the cell line for its use as preclinical model for PRRT. Transfected tumours could be clearly visualized by BLI and SPECT/CT imaging in mouse and rat. The transfected tumor cell line is a promising and new preclinical model for tumour monitoring in studies aiming at further optimizing PRRT for neuro‐ endocrine tumours.
TECHNOLGISTS POSTER PRESENTATIONS
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C. Martelli , L. Ottobrini , M. Borelli , V. Rainone , M. Lecchi , M. Clerici , D. Trabattoni7, G. Lucignani8; 1Dept of Biomedical Sciences and Technologies, University of Milan. Supported by the Doctorate School of Molecular Medicine, University of Milan, Milano, ITALY, 2Dept of Biomedical Sciences and Technologies, Centre of Molecular and Cellular Imaging - IMAGO, University of Milan, Milano, ITALY, 3Dept of Preclinical Sciences, University of Milan. Supported by the Doctorate School of Molecular Medicine, University of Milan, Milano, ITALY, 4Dept of Preclinical Sciences , University of Milan. Supported by the Doctorate School of Molecular Medicine, University of Milan, Milano, ITALY, 5Dept of Biomedical Sciences and Technologies, University of Milan, Milano, ITALY, 6Dept of Biomedical Sciences and Technologies, University of Milan - Don Gnocchi Foundation IRCCS, Milan, Milano, ITALY, 7Dept of Preclinical Sciences, University of Milan, Milano, ITALY, 8Dept of Biomedical Sciences and Technologies, University of Milan. Centre of Molecular and Cellular Imaging – IMAGO, University of Milan. This work is supported by the FP6 funded Hi-CAM project (LSHC-CT-2006-037737)., Milano, ITALY. Aim: The aim of this study is the development and the evaluation of a tumour‐specific DC vaccine in a transgenic murine model of breast cancer (MMTV‐v‐Ha‐Ras). DC labelling with commercial paramagnetic nanoparticles (MNPs, Endorem®), 111In‐Oxine or PKH26 will permit to study their distribution and migration to local lymph‐nodes by MRI, SPECT or optical imaging, respectively. Methods: Total bone marrow cells were extracted from wt mice. DC differentiation was studied th 111 by flow cytometry; at the 6 day of culture DCs were labelled with commercial MNPs, In‐Oxine or PKH26. Dose response and kinetic of labelling studies were performed. Labelling efficiency was evaluated. iDCs were loaded with tumour antigens and maturation was monitored by flow cytometry. Stimulatory activity of antigen‐loaded DCs was evaluated by T‐cell proliferation and IFN‐γ production by T cells; DC migration was evaluated in the presence of 6Ckine, MIP‐3β, MIP‐ 1α and MIP‐1β. MNP‐labelled DCs, loaded with tumour antigens were injected into the footpad of transgenic tumour bearing mice. Perl’s staining of the draining lymph nodes was carried out to evaluate DC migration. Results: FACS analyses identified the best time point to perform DC labelling. Results showed that labelling efficiency with MNPs was proportional to the medium iron content and to the incubation time (ideal conditions 200 μg Fe/ml, for 16h with 85% efficiency) as confirmed by relaxometric assay. Labelling with MNPs did not affect DC immune‐ phenotype or functionality as demonstrated by CD86 and CD83 expression levels, and by LPS induction of labelled DC maturation. Labelling with 30 and 60 μCi of 111In‐Oxine resulted in a 75% and 72% efficiency, respectively. Concurrent DC labelling with PKH26 and 30 μCi of 111In‐Oxine did not impair labelling efficiency. DC vitality was not highly affected by all the labelling procedures. Antigen‐loaded DCs induced T‐cell proliferation and INF‐γ production. Migration assays showed that antigen‐loaded DCs were able to migrate in the presence of stimulatory chemokines (6Ckine and MIP3β). Perl’s staining of lymph node sections after in vivo injection of labelled DCs loaded with the antigens, showed the presence of iron within the node, indicating that mature and labelled DCs migrate in vivo from the site of injection to the draining lymph node. Conclusions: Cell labelling with different probes for multimodal imaging of DCs will permit to overcome the limitation of the single imaging techniques and to in vivo visualise their migration and limph‐node localisation, shedding light on the fundamental parameters responsible for the anti‐neoplasic efficacy.
P866 Multimodality imaging of somatostatin receptor positive tumours with nuclear and bioluminescence imaging S. E. Pool, W. Breeman, A. Eggermont, C. Van Eijck, E. Krenning, T. Ten Hagen, G. Koning, M. de Jong; ErasmusMC, Rotterdam, NETHERLANDS.
TP1 ‐ Tuesday, October 13, 2009, 08:00 ‐ 09:30, Hall 117
Technologists Poster Session 1
TP001 Myocardial Gated SPECT in the Evaluation of Septal Wall Perfusion Defect in Patients with Left Bundle Branch Block H. H. Salman, G. Biswas, M. Massoud, M. Sayed; Chest Diseases Hospital, Kuwait-City, KUWAIT. Background &Aim: In routine stress myocardial SPECT studies,reversible perfusion defects may occur in patients( pts) with left bundle branch block(LBBB).Decreased coronary flow reserve,a shortened diastolic filling time and a thinned septum as seen in LBBB,can mimick exercise induced ischemia even in pts with normal coronary arteries.These false positive findings may be avoided by using Gated myocardial perfusion SPECT(G SPECT) which allows simultaneous assessment of perfusion and function.Our aim is to show how GSPECT quantitative studies can enhance the accuracy in reporting perfusion defects in pts with LBBB. Methods:36 consecutive pts (mean age 52 years) underwent a 2 day stress/rest dipyridamole GSPECT,using Tc 99m tetrofosmin and a dual head gamma camera.All 36 pts were referred for evaluation of chest pain.Unstable angina or uncontrolled hypertension were not enrolled.First, visual analysis of the slice images,then revised assessment of the gated studies were done on endsystolic(ES) enddiastolic(ED) images and on the regional wall motion and wall thickness to evaluate the perfusion of the septum. Results:Visual analysis of stress/rest images revealed: reversible septal hypoperfusion was seen in 25 pts(group A), fixed septal defects in 7 pts(group B) and 4 pts had a normal septal perfusion(group C) . After quantitative analysis of the gated studies: out of the 25 pts of group A, 19 pts had normal findings and the other 6 pts showed reversible septal hypoperfusion. The 7 pts of group B (previously reported as fixed septal defects) were found to have a normal septal perfusion on the Gated SPECT images. Conclusion:the use of Gated SPECT myocardial perfusion scintigraphy,particularly the enddiastolic images,can help in the evaluation of septal perfusion, wall motion, wall thickness and hence differentiate between true perfusion defects from false patterns in pts with LBBB.
TP002 Examination of the absorption correction for the 3D MR-PET Imaging M. YAMADA1, M. Yamagishi1, M. Hirano1, S. Watanabe1, D. Kikuta1, K. Ito1, A. Seto1, E. Imabayashi1, I. Kuji1, K. Ito2, H. Matsuda1; 1Saitama Medical University, Hidaka, JAPAN, 2Kamishirane Hospital, Yokohama, JAPAN. [Introduction] Most of the new PET system uses the segmented attenuation correction1) method for calculating PET images using the X‐ray CT image data2) sets. The aim of this present study is to examine the procedure that calculates it using the magnetic resonance imaging (MRI) 3D data3) sets by modified J‐ADNI(Japanese Alzheimer's Disease Neuroimaging Initiative)'s MP‐RAGE ( Magnetization Prepared Rapid Gradient Echo ) pulse sequence. [Materials and Methods] To make of Imaging and measurement emission scan (ES) by the Biograph 16 ( Siemens co.). Scan parameter of ES scan was 2 min/bed, matrix size was 168 pixel, FWHM was 6.0 mm ( Gauss Filter ), reconstruction method was using the OSEM4), iterration number was three, subset number was eight. Our PET system does the CT based positron emission CT absorption correction that causes it to the data for absorption correction calculated by using X‐ray CT image data and be calculating the positron emission CT image. We did the examination of the MRI based absorption correction method that we do absorption correction using the image data of the MRI data by modified J‐ ADNI's MP‐RAGE pulse sequence. This pulse sequence can make a 3D image data with high
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TP003 Interobserver Variation in estimating Thyroid Volume. W. Heegaard, P. Holdgaard; Vejle Hospital, Vejle, DENMARK. Aim: To determine interobserver variation among technologists of estimated thyroid volumes calculated at pertechnetate thyroid scintigraphy. Materials and methods: Thirteen technologists independently created ROIs in 31 different pertechnetate thyroid scintigraphies. The study was made with a view to evaluate the crude and daily variation, i.e. the technologists did not undergo any specific training as to standardization of the delineations of ROIs. The thyroid examinations were, however, chosen so that thyroids differed in size, type, and tracer uptake. The scintigrams were made with an ADAC Thyrus gamma camera using a pinhole collimator. Thyroid size was estimated with an ellipsoid model for multiple two‐dimensional measurements. The source of variation in the algorithm for calculating the volume is the size of the ROI. Statistical analysis was performed using ANOVA after logarithmic transformation to assess the interobserver variation between the technologists by calculating the coefficient of variation, and confidence intervals. Results: The interobserver coefficient of variation was 18 % which is of the same magnitude as reported in the literature both for scintigraphy and ultrasound. The largest variation was found in patients either with low pertechnetate uptake or large thyroid volumes. The confidence interval (CI) increased with thyroid size. For a normal sized thyroid of 20 ml the CI is 15‐28 ml and for moderat goitre of 50 ml it is 36‐69 ml. We observed systematic differences between technologists. Some tended to obtain large volumes and others had a trend towards low volumes. Excluding patients with very low uptakes from volume estimation and introducing a more standardized / uniform method would probably decrease interobserver variation. Conclusion: The interobserver variation of estimating thyroid volumes was acceptable, and in line with earlier reported results achieved with similar and other techniques such as ultrasound. However, since we found systematic tendencies of different technologists in creation of ROIs there is no doubt that training and standardization of performance will decrease the interobserver variation of thyroid volume estimates.
TP004 Development and clinical effect of the artifactual improvement software
We have developed a form called Radioactive Decay Calculator which computes radioactive decay for a databank containing 43 radioisotopes. With a combo box the user can select an isotope from the list, but if the desired isotope is not on the list, the user can enter the isotope half‐life and its time unit in the text boxes at the top of the form. Useful for calculating today’s activity for any radioactive isotope. You may also back decay sources to find out the original activity (or for any date), knowing the current activity. We also have developed a form for calculating dose‐volume of radiopharmaceuticals, according the isotope, time, initial activity and initial volume. This form also calculates the remaining activity and volume at any time and relies on a database to store, manage and retrieve the data. Calendar pickers are included for date entry convenience. These forms are included in a software called Nucleolab, which is freely available at http://serfa.radiofarmacia.org/?m=27 Conclusion: The two forms we have developed have an easy‐to‐use interface that makes the calculation complexity of radioactive decay, and other parameters about dispensation of radiopharmaceuticals, completely hidden for the users, saving you the time that you previously spent on these laborious calculations and reducing the risk of error.
TP006 Imaging of gastrointestinal bleeding with Tc-99m-HYNIC-IGG imaging B. Bosveld; Radboud University Nijmegen Medical Centre, Nijmegen, NETHERLANDS. Purpose: In our hospital, imaging of gastrointestinal bleeding is routinely performed with Tc‐99m labeled autologous erythrocytes. As labeling of red blood cells of a male patient suffering of persistent gastrointestinal bleeding and melaena proved impossible, we decided to use Tc‐99m labeled hydrazinonicotinamide‐derivatized human nonspecific immunoglobulin G (Tc‐99m‐ HYNIC‐IgG) as an alternative. We describe the use of this radiopharmaceutical and discuss our findings in relation to conventional tracers. Methods: Human nonspecific immunoglobulin G (IgG) was labeled with Tc‐99m using hydrazinonicotinamide (HYNIC) as a linker. The patient was intravenously injected with 740 MBq of Tc‐99m‐HYNIC‐IgG and anterior planar dynamic images (120 frames of one minute) of the abdomen and pelvis were obtained using a standard gamma camera (Siemens Symbia). Results: The scintigrafic images showed normal physiological distribution of Tc‐99m‐HYNIC‐IgG in heart, blood vessels, red marrow, liver, spleen and bladder. Fourty minutes after injection we observed progressive accumulation of activity in the left side of the abdomen which was interpreted as an active bleeding in the left hemicolon. The quality of the obtained images was at least equivalent compared to the conventional technique with autologous erythrocytes. Discussion: Compared to commonly used tracers, such as Tc‐99m labeled autologous erythrocytes and Tc‐99m‐sulphur colloid, Tc‐99m‐HYNIC‐IgG showed the advantages of the other two agents. Similar to sulphur colloid, Tc‐99m‐HYNIC‐IgG can be prepared easily and quickly from a kit without chances of labeling difficulties. Like autologous erythrocytes, the slow blood clearance allows a continuous monitoring of the whole gastrointestinal tract for a prolonged period of time (24 hours), which is advantageous in relation to the generally intermittent nature of gastrointestinal bleeding. Furthermore, Tc‐99m‐HYNIC‐IgG shows only slight uptake in liver, kidneys and bone marrow, there is no rapid excretion to the bladder and no accumulation of free pertechnetate in stomach, facilitating interpretation of the images. Conclusion: Tc‐99m‐HYNIC‐IgG seems to be a promising radiopharmaceutical in the imaging of gastrointestinal hemorrhage which deserves further investigation.
R. Tanaka1, K. Yoshioka2, K. Seino1, J. Tajima3; 1Kushiro City Medical Association Hospital, Hokkaido, JAPAN, 2Fujifilm RI Phama Co.LTD, Tokyo, JAPAN, 3Nagoya City University, Nagoya, JAPAN.
TP007
The generally used filtered back projection (FBP) method is likely to be influenced by high accumulation, especially in the liver and biliary system, and it is often difficult to reduce the waiting time for imaging with a 99mTc‐myocardial perfusion tracer. In this study, reduction of artifacts using the artifactual improvement software (RDM) was studied. Method: The myocardial locus in raw data commonly deviates from a center of rotation. Therefore, drift generates it in reciprocal relationship information on the data when we perform a mask processing in an individual image when we perform a mask processing of the data. A program to perform three steps in sequentially was devised to maintain mutual information on the data. 1. Displacement of the myocardial rotation center 2. Mask batch processing 3. The correction of the mask peripheral zone Results: In phantom, a reconstruction of model A (non‐artifact), model B (with artifact) and RDM (model B+RDM processing) was performed. The count was compared using circumferential profile curve in the same profile of the Short‐axis image. The average and the variance of model A, model B and RDM were 83.91±54.67, 69.61±131.18, 82.68±94.35, respectively. As for myocardial % Uptake, the change was not observed in model A and RDM, but, as for model B, a mean decreased by artifactual influence, and the variance increased. Also, non‐ RDM and RDM were used for 11 clinical cases to show a streak artifact, and it was reconstituted. The average of the variance of non‐RDM and RDM was 21.05 and 3.95, respectively, and a significant difference was observed (P <0.05). Conclusion: As for the developed artifactual improvement software, it is thought as a method removing a streak artifact effectively.
H. Park, J. Kim, M. Park, S. Lee, C. Kang, C. Lee, J. Lee; Severance Hospital, Yonsei University Health System, Seoul, REPUBLIC OF KOREA.
TP005 A software for automatic calculation of radioactive decay and dispensation of radiopharmaceuticals J. L. Gómez-Perales1, A. García-Mendoza2, C. Téllez Llanzón1, J. A. Furest Pérez1; 1Nuclear Medicine Service, Hospital Universitario Puerta del Mar, Cádiz, SPAIN, 2Nuclear Medicine Service, Hospital Universitario “San Cecilio”, Granada, SPAIN. Introduction: The radioactive concentration of radiopharmaceuticals decreases according to radioactive decay law, so for a certain activity the volume needed increases in time. In the day‐ to‐day practice of nuclear medicine services and radiopharmacies it is necessary to calculate radioactive decay, activity and volume of radiopharmaceuticals. These calculations are not very complex but annoying and time‐consuming. Objective: The aim of this project is to develop a software for automatic calculation of radioactive decay, activity and volume of radiopharmaceuticals at every time. Materials and methods: For developing a software incorporating this calculations we have used Visual Basic 6.0 and Visual Studio Installer. Results:
A phantom study to obtain the reliability of the SUV in PET/CT images
As the number of domestic medical institutions installing PET/CT is increasing rapidly. The transfer of PET/CT images among medical institutions is also increasing. Thus, it is necessary to collect the co mparative SUV data from several medical institutions’ PET/CT systems through a phantom study, which semi‐quantitatively compares the SUV on one bed, the change scale of the SUV on the slices, and the time of measuring. The research to find differences among the SUVs from various PET/CT offers the opportunity to obtain the reliability of the SUV in PET/CT images. The six PET/CT systems (A Discovery ST, 2 Discovery STe, 2 Biograph Duo, and a Biograph TurePoint 40) from the medical institutions in Korea were used. The internal structures of NEMA PET phantom TM were removed and Six thousand milliliters of distilled water which has 1mCi of F‐ 18 FDG was put into the phantom. The water was properly integrated with F‐18 FDG. The images were acquired at 60, 70, 80, 90, 100, 110 and 120‐minutes for 3 minute each. Two hundred square centimeters of region of interests were placed and analyzed. The coefficient of variability of the SUV from ‐11.0 to 9.90 % fell into the range of international standards(±10%) along with the SUV on a bed, the change scale of the SUV on the slices, and the time of measuring, except one PET/CT system. Using data of the differences among the SUVs, we came to withdraw a correction chart ranging from 0.803 to 1.246. Although studies have been made on the variation of the SUV, there is little attention on the standardization of the SUV. Based on this study of the quantitatively comparable data about the SUV accommodating the correction chart, it would help to have more corrective diagnosis.
TP008 Power spectrum analysis for estimating the optimal iteration number of OSEM in PET A. Kimura1, N. Kubo2, N. Kudo1, C. Katoh2; 1Teine Keijinkai Hospital, Sapporo, JAPAN, 2Hokkaido University, Sapporo, JAPAN. Aim: Filtered back‐projection (FBP) and ordered‐subset expectation maximization (OSEM) algorithms are both used for image reconstruction. Although OSEM has increasingly been applied to positron emission tomography (PET), no algorithms have been developed for determining the optimal number of OSEM iterations. Instead, the number of iterations employed for clinical data is determined empirically. The purpose of this study was therefore to estimate the optimal number of OSEM iterations using power spectrum analysis. Materials & Methods: 11C‐ methionine PET images of a brain tumor were reconstructed by FBP and OSEM (subsets: 8;
Poster Presentation
resolution. All images were acquired on the Trio 3T MRI system ( Siemens co. ) and a standard PA ( Phase Array ) coil. Typical scan parameters for MP‐RAGE were as follows‐ 256x192 matrix, 160 slices 5 mm thickness, 50 cm FOV, TE/TR 3.61ms/2s, TI 1000msec, FA ( Flip Angle ) 8, scan time is about 4 min. Next, we make reconstruct the magnetic resonance imaging data sets again with the slice similar to PET image data sets and implement segmentation processing to this data and calculated absorption correction data by exchanging table data that were segmented different two echo time sequence data image sets. Finaly, we could get the PET image data sets from this absorption correction data sets. [Results and Conclusion] We were able to obtain the PET image data by MRI based absorption correction by using MRI image data, although less than 6% error is included quantitatively in comparison with CT based attenuation correction method.But,these method is good for the PET medical examination center without CT examination image data. [Reference]1) Phys. Med. Biol. 47 (2002) 1143‐1160. 2) Med Phys. 25 (1998) 2046 ‐2053. 3) SNM 53rd Annual Meeting pp. 217(2006). 4) Proceedings Fully 3D Meeting and HPIR Workshop. (2007) 37‐40
S480 number of iterations: between 1 and 10). We wrote a Visual C++ program to calculate the radial power spectra of reconstructed images. The power spectra amplitudes of the images reconstructed using OSEM were then compared with those of the image generated by FBP. Results: Images generated using four or more OSEM iterations had larger power spectra amplitudes than the image generated by FBP in a spatial bandwidth of 0.012‐0.018 cycles/mm, which contained the object signal. The image generated using three OSEM iterations had lower power spectrum amplitudes than the image generated by FBP in a spatial bandwidth of 0.012‐ 0.018 cycles/mm, exclusive of the point at 0.014 cycles/mm. Similarly, the power spectra amplitudes of images generated using only one or two OSEM iterations were less than those of the image generated by FBP in the spatial bandwidth of 0.012‐0.018 cycles/mm occupied by the object signals. We therefore considered the optimal number of iterations to be four in the case of a PET image of a brain tumor. Conclusion: Power spectrum analysis can thus be applied to any image because it permits comparison with an image generated by FBP. We propose using this method to determine the optimal number of iterations for OSEM.
TP009 Time optimized protocol for a plenar and spect-acquisition A. Godswill, S. Schrei, C. Harris, A. Muellner, P. Knoll, M. Rodrigues, S. Mirzaei; Wilhelminenspital, Vienna, AUSTRIA. Planar and SPECT scintigraphy are standard imaging techniques in conventional Nuclear Medicine. The recommended protocols are based on clinical studies aimed at obtaining optimum image resolution. Aim To evaluate the effect of a time optimized protocol with reduction of acquisition time for whole body and SPECT imaging on the image quality. Materials and Methods 12 patients (7m, 5f, age range 56 ‐ 73 years) with different malignancies who were referred to our department for bone scintigraphy were examined both by standard protocol (13 cm/min, LEHR collimator) and time optimized protocol (25 cm/min, LEHR collimator) using a dual head gammacamera (Siemens, Symbia T6). The data acquired with time optimized protocol was processed using Oncoflash processing software. Results The whole body bone scintigraphy acquired with a standard protocol gives a comparable image quality after processing to that of time optimized protocol. Bone SPECT with reduced acquisition time showed also good image quality comparable to the standard protocol without alteration of the images. Conclusions Time optimized protocol allows shorter acquisition times for both planar and SPECT imaging without alteration on image quality and without loss of diagnostic accuracy. Furthermore, motion artifacts due to prolonged imaging time could be reduced with this protocol.
TP010 Usefulness of SLN Lymphoscintigraphy in Obese Patients among Breast Cancer’s Patients at Day-Before-Surgery H. Nam-Koong, H. Park, S. Lee, J. Kim, C. Lee; Severance Hospital, Yonsei University Health System, Seoul, REPUBLIC OF KOREA. PURPOSE: Generally, most of patients underwent surgery of breast cancer dissect axillary lymph node as well as tumor of breast. 99mTc‐Phytate was performed subcutaneous injection areola between tumor and nipple, and this radiopharmaceutical goes up with lymphatic duct, then the first hot spot is detected. This hot spot means Sentinel lymph node (SLN). At this time, this examination progress immediately before surgery at day‐of‐surgery. In normal weighted patients, sentinel lymph node is directly ascertained after subcutaneous injection of 99mTc‐Phytate, however, because obese patients have thick layer of fats, migrate time of the radiopharmaceutical is delayed, and the ascertainment of sentinel lymph node is difficult. It is this purpose of study that obese patients of determined surgery of breast are performed lymphoscintigraphy of breast on day‐before‐surgery, and that migrate time of radiopharmaceutical is assigned sufficiently. That is, this method will be helpful in accurate localization of sentinel lymph node and to prevent inconvenient of patients from occurrence. MATERIALS AND METHODS: Normal weighted 25 patients and obese 25 patients were chose 99m according to BMI (Body Mass Index). The radiopharmaceutical arranged to Tc‐Phytate 0.5 mCi by 0.5 cc volumes and after performed subcutaneous injection to it, acquired to images. Patients that sentinel lymph node (SLN) was ascertained immediately finished a scanning and patients that SLN wasn’t ascertain immediately performed delayed scanning. RESULTS AND CONSIDERATION: Both normal weight 23 patients and obese 4 patients were ascertained SLN immediately, both normal weighted 2 patients and obese 21 patients weren’t ascertained SLN immediately. Obese 21 patients that unconfirmed SLN immediately were ascertained faintly after four hours. And image qualities were remarkably lower than images of confirmed SLN patients immediately. In alternative about this problem, obese 10 patients performed subcutaneous injection with 99mTc‐Phytate 2.5 mCi by 0.5 cc volume at day‐before‐surgery lately and images were acquired before surgery at next day. Resultantly, SLN had marked exactly and acquired images had been distinct CONCLUSION: As we can see, in some of all obese patients, Sentinel lymph node was ascertained immediately, and in the others, not. It has a limitation that we didn’t include all obese patients who had surgery of breast in YUHS (Yonsei university health system). In this study, we willing to show effect of day‐before‐surgery improved various problems, comparing to same‐day‐surgery. Therefore, we consider that obese patient’s lymphoscintigraphy of breast on day‐before‐surgery is useful.
TP011 Is gold thrown onto the street? (A study on residual activity of 18 F-FDG in syringes with different volume) K. J. Birch, A. Larsen, M. Lonsdale; Bipsebjerg Hospital, København NV, DENMARK. Aim The use of SUV in 18F‐FDG‐PET diagnostics depends critically on the exact knowledge of the amount of tracer injected into the patient. To assure the correct dose, the syringes are measured 18 before and after injection. We observed that the residual activity of F‐FDG in the syringes decreased during the day. This was probably due to a larger dose volume. The aim of this study was find out if it is possible to optimize the dose given to the patient by increasing the volume of the dose. Material and Methods In the hot lab the dose given to the patient is adjusted to 400 MBq at the injection time, allowing for a 10% variation. The dose is brought to the patient and the syringe is measured again just before administered to the patient. The study was performed in two parts. In part one syringes for 48 consecutive patients were measured before and after
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 injection, after injection both with and without needle. The needle was only used as a cap and not for injection. In part two to test if increased dose volume had an effect on residual activity, 2 ml saline was added to the syringes, if the dose volume was less than 3 ml. This was done in 19 patients. All the syringes were measured in a dose calibrator (Capitec CRC‐ULTRA®). Results Residual activity of 18F‐FDG in syringes with needle Study Volume N Max./Average/Median (MBq) 1
2ml
40 41.7/17.3/18.7
1
5ml
7 19.4/12.5/15.5
2
5ml
19 47.9/13.1/10.6
Average difference between measurements with and without needle was 9.5 MBq (excluding the 1ml syringe). We measured 1 1ml syringes with an average residual activity on 177 MBq 18F‐ FDG with the needle on and an average residual activity on 1.1 MBq 18F‐FDG measured without the needle. On behalf of this measurement we excluded the 1ml syringes from the study. Diluting 18 F‐FDG doses less than 3ml resulted in a significantly lower residual activity. Conclusion The result shows that by increasing the injection volume, the residual activity in the syringes with and without the needle will decrease. Resulting that the patient will get a dose closer to the prescribed dose and thereby reduce the waste of tracers.
TP012 Efficacy of Automatic Dispensing/Injection System to Reduce Radiation Exposure of Nuclear Medicine Workers During FDG PET I. Moon, J. Lee, H. Kim, D. Lee; Seoul National University Hospital, Seoul, REPUBLIC OF KOREA. Objective: With prevalent use of PET, the radiation exposure of nuclear medicine workers (NMW) are increasing. In this study we assessed the efficacy of an automatic dispensing/injection system (ADIS) to reduce the radiation exposure of NMW during FDG PET. Methods: In dispensing FDG, NMW were classified into 2 groups, one of which used conventional manual method and the other used an ADIS (UG‐05, Universal Giken, Japan). The radiation dose of finger and whole body were measured using personal dosimter for 1 mo. The radiation dose during injection were also measured in both groups, with another set of experiment (n = 30, respectively) Results: In dispensing step, ADIS imposed significantly less radiation dose than conventional method, both to finger (0.09 ± 0.02 vs. 21 ± 8 μSv, P < 0.001) and to whole body (0.09 ± 0.02 vs. 0.36 ± 0.08 μSv, P < 0.001) of NMW. In injection step, ADIS also imposed significantly less dose to finger (0.5 ± 0.1 vs. 9.2 ± 3.1 μSv, P < 0.001), while the dose of whole body was somewhat larger in ADIS than in conventional method (0.5 ± 0.1 vs 0.38 ± 0.1 μSv, P < 0.001). Conclusion: Using ADIS, the radiation exposure of NMW during dispensing was markedly reduced. Also, the exposure of finger during injection was markedly reduced, although exposure of whole body was mildly increased. The results of this study suggest that overall radiation exposure of NMW during FDG PET can be reduced with use of ADIS. Key Words: Radiation exposure, ADIS, FDG PET
TP013 Comparison of Radiation Exposure During Delivery of FDG between A Manual Delivery System and An Air-Shooter System H. Lee; Seoul National University Hospital, Seoul, REPUBLIC OF KOREA. Objective: In most PET centers, injection rooms are apart from radiochemistry or dispensing facilities, and radiopharmaceuticals should be delivered between them. In this study, we calculated the radiation exposure according to the methods of delivery. Methods: A conventional manual delivery system with a lead container (MDS) and an air‐shooter system with a tungsten container (ASS) were compared by simulation. For simulation, radiation doses were calculated at the surface (for simulation of finger) and 30‐cm distance (for simulation of body) of containers with an assumption of 370 MBq FDG in each container. Afterward, the radiation doses were also measured actually using a surveymeter. It was assumed that 400 cases were managed in a month. Results: The radiation dose was much lower in ASS than in MDS, for both the finger (464 vs. 32.0 mSv/mo) and the whole body (0.512 vs. 0.036 mSv/mo), using the calculated values. Surveymeter‐measured values also resulted in lower dose in ASS than in MDS (4.64 vs. 0.328 mSv/mo for the finger, 0.155 vs. 0.014 mSv/mo for the whole body). Conclusion: Radiation dose in ASS during delivery of FDG was less than a tenth of that in MDS. Therefore, ASS is effective to reduce the operators' radiation exposure during delivery of radiopharmaceuticals. Key Words: Radiation exposure, air shooter system, FDG, PET
TP014 Split glomerular filtration as an adjunct to renal perfusion scintigraphy M. Wakenhut, M. Schlotter, B. Krankenhaus, Hagen, GERMANY.
Thoms,
T.
Reuter;
Allgemeines
Glomerular scintigraphy may be added to renal perfusion imaging without additional radionuclide application. Unfortunately, background subtraction based on an extra‐renal ROI is not reliable because the peri‐renal blood pool is much smaller than the renal one. Therefore we placed the extra‐renal ROI in an extra‐renal region with high blood pool activity, i.e. the spleen. This requires the spleenic count rates of the blood pool phase and the filtration phase to be normalized to the renal blood pool activity. Methods Eight renal perfusion studies with 600 MBq 99m‐Tc‐DTPA were analysed. A dynamic study consisted of 100 images of 3 seconds. Data analysis was done by means of a PIXIE makro program. ROI where applied to the spleen and to one of the kidneys and total counts where registered during the blood pool phase: BP‐S and BP‐K (45 to 75 sec p.i.) and the filtration phase: GF‐S and GF‐K (120 ‐ 180 sec p.i.). By this, we obtained three variables needed for the calculation of the “total counts”: TC‐BP‐S (spleen), TC‐GF‐S (spleen) and TC‐BP‐K (kidney). TC‐GF‐K (kidney) represents the total renal activity during the filtration phase, it equals the sum of renal blood pool activity (TC‐BF) and renal filtered activity (TC‐A) during the filtration phase. Renal blood pool (TC‐BF) during filtration equals: TC‐BF = TC‐ BP‐K x TC‐GF‐S / TC‐BP‐S. Renal filtered activity; (TC‐A) is obtained by subtraction of renal blood
S481
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TP015 Quality assurance S. L. Kristiansen, A. K. E. Nielsen; Aalborg Hospital, Aalborg, DENMARK. AIM: The implementation of a quality assurance programme in the Nuclear Medicine Department at Aalborg Hospital over the last decade. There is an important need for standardisation of work as our department is undergoing rapid growth in not only the number of staff employees but also the number of examinations performed. Accreditation has become a key concept for health care. It involves systems that provide continuous learning and quality development and as the department prepares for the upcoming accreditation it comes into the main focus. We continuously focus on organization, responsibilities, training, development of guidelines and instructions and implement them. MATERIALS AND METHODS: Since the department started it has continuously developed guidelines and instructions. In line with developments in nuclear medicine and the ever‐growing staff, it is useful to "standardise" the way work is done, so patient studies are independent of who performs it and ensure that staff training is a specific standard template. Within recent years the department has had larger focus on drafting and implementing appropriate guidelines as well as maintaining and updating the guidelines already in effect. Relevant guidelines and instructions are transferred to a document management system ,which is part of the upcoming accreditation system. Acting on patient safety has been part of this work. In Denmark, an accidental incident is analyzed at the department where the incident occurred and then reported to the Danish Patient Safety Database to eliminate repetition of the incident for the benefit of the patient. The department has two trained risk advisors who manage this. All staff are instructed to report adverse events and may do so anonymously if they wish. Good hygiene practices are also a focus. We work closely with hospital hygiene team to develop local instructions and participate in the audit of good hygiene. Hygiene rules are reviewed with all the new recruits and new hygiene guidelines are being implemented in the department. RESULTS: All regulations and instructions are updated. Reporting of adverse events has become a natural part of the work. The increase in reviews is caused by more awareness. For all staff with patient contact, good hygiene is a natural part of everyday life and is regularly discussed and updated. CONCLUSION: It has created a positive working culture of the department, where all employees are aware of and take part in risk management and thereby create a better and more consistent safer patient environment.
TP016 A technique for reducing the influence of scattered rays from surrounding organs to the heart during Gated cardiac blood pool scan J. Kim, H. Park; Severans Hospital, Seoul, REPUBLIC OF KOREA. Objectives: There are few reports regarding the influence of scattered rays from surrounding organs to the heart. Thus, in this study, we are to minimize the overestimate of left ventricular ejection fraction (LVEF) by modified body position to reduce the influence of scattered rays in the background region of interest (ROI). Methods: Gated cardiac blood pool scan using in vivo 99mTc‐red blood cell was carried out in 20 patients (mean 44.8±8.6 y) with chemotherapy for a breast carcinoma. Data acquisition requires about 600 seconds and 24 frames of one heart cycle by the multigated acquisition mode, Synchronization deteriorates toward the end of the cycle and with the distance from the trigger signal by electrocardiogram gating. It was studied with conventional method and compared with modified method (left lateral flexion position with 360 mL of drinking water). Results: The ROI counts of modified scan method were lower than left ventricle conventional method (1429±251 versus 1853±243, <0.01). And LVEF of modified method was also decrease compared with conventional method (58.3±5.6% versus 65.3±6.1%, <0.01). Imaging analysis indicated that stomach was expanded because of water and spleen position was changed to lateral inferior compared with conventional method. Conclusions: This study shows that the modified method reduce the influence of scattered rays from surrounding organs. Because after change the body position to left lateral flexion and drinking water, the location of spleen, left lobe of liver and stomach had changed and they could escaped from background ROI. Therefore, modified method could help to minimize the overestimate LVEF.
TP017
18
Usefulness of F-Fluoride PET/CT in Bone Metastasis of Prostate Cancer M. Park, J. Kim, H. Park, C. Kang, H. Lim, J. Kim, C. Lee; Severans Hospital, Seoul, REPUBLIC OF KOREA. Purpose: Today, Prostate cancer has been gradually increasing, according to the change of internal incidence rate of cancer. Generally, prostate cancer has lead to dead over 90%, in case of metastasis of lymph node and bone. So, innovative development of new radiopharmaceutical and imaging modality is progressed for detection of that metastasis, in nuclear medicine, now. Therefore, this study shows the usefulness of 18F‐Fluoride PET/CT improved diagnosability on bone metastasis of prostate cancer. Materials and Methods: In this study, 33 male patients with prostate cancer were examined (The mean age: 67.8±10.2 years old). Every patient was done each whole body bone scan (WBBS) and 18F‐Fluoride positron emission tomography/computed tomography (18F‐Fluoride PET/CT). And then, using Receiver Operating Characteristic Curve (ROC curve), each sensitivity and specificity of two modalities was measured and compared with. Results: In 22 patients (66.6%) of all, bone metastasis was detected. And, in WBBS, sensitivity 18 was 63.6%, specificity, 81.8%; in F‐Fluoride PET/CT, sensitivity was 100% and specificity was 90.9%. As a result of ROC curve, AUROC (The Area under an ROC) of WBBS was 0.778, and that of 18 F‐Fluoride PET/CT, 0.942. Conclusion: 18F‐Fluoride PET/CT was higher both sensitivity and specificity than WBBS, and it was valuable to detect bone metastasis of prostate cancer more
definitely, with 3D imaging realization. Also, in 18F‐Fluoride PET/CT, physiological images were acquired in more short time than WBBS, so, it was possible to reduce patient’s waiting time and complaint. Therefore, it is considered that 18F‐Fluoride PET/CT is able to improve diagnosability by offering more accurate images, as cuts in a share of high cost.
TP018 Multimodality Imaging. Registration And Basic Fusion Of Images Using Standardized Formats And Shared Storage Systems M. Rial, J. Pou, M. Álvarez, F. Loira, A. Serena, J. Barandela, L. Campos; Hospital Do Meixoeiro (CHUVI), Vigo, SPAIN. INTRODUCTION: Digital medical images and standardized common formats, mainly DICOM, allow the exchange and the images fusion of different modalities (conventional X‐rays, CT, MRI, conventional nuclear medicine, SPECT and PET) even without availability for hybrid equipment. The archive and management systems (PACs) open the possibility to this multimodal approach within the same center or Hospital Complex, or even among distant net‐integrated hospitals. Even with basic register systems, using only rigid transformations, inter and intramodal image fusion can be done making the diagnosis easier or more accurate. MATERIALS AND METHODS: Our University Hospital Complex (three hospitals) has available 50 conventional radiology stations, 5 CT scanners, 4 MRI systems, two tomo‐gamma‐cameras and two hybrid equipments: SPECT‐CT and PET‐CT of several vendors; the images in DICOM format are stored in a PAC (Udiat). The electronic medical record (IANUS) allows the access to reports and images from other Hospital or Health Complex (6) of our area. In our workstations (E.Soft; Xeleris; Advance) we can retrieve and fusion images from different modalities after simple registration and manual adjustment using anatomic references. RESULTS: We present different examples of fusion between planar and tomographic inter and intramodal images: Osteoarticular: Osteomelytis (planar intermodal: simple X‐Ray/99mTc‐DPD). Hip prosthesis infection (Planar intermodal: 99mTc‐DPD/67Ga). Localization of exact focus of infection. Infection/ Inflammation: Aortic prosthesis infection (Intermodal Tomography: Thoracic CT/SPECT 99mTc leukocytes) Bowel inflammatory disease (Planar intermodal: X‐ray Intestinal transit/99mTc leukocytes), leukocytes accumulation in retracted intestinal loop. Oncology: Lymphoma (intermodal tomography: CT/ SPECT 67Ga). Accuracy in visceral (Gastric lymphoma) or extravisceral localization (Adenopathies in the gastrohepatic ligament). Cervical paraganglion (CT/SPECT111In‐Octreoscan) Relation with cervical structures. Others: Gorham’s Syndrome (CT/ SPECT 99mTc‐DPD): Localization of active osteolysis areas. Accessory spleen (CT/SPECT 99mTc‐heat‐denaturalized erythrocytes) Spleenectomy history and ferropenic anemia. Evidence of an accessory splenic tissue. CONCLUSION: The use of standarized DICOM format, PACS and hospital network systems, allow accomplishing image fusion, making easier the diagnosis. The careful and ruled positioning, the use of external references and more complex algorithms (elastic, affine, etc) could improve the results, but are not essential in the routine care. The systems with rigid transformations require a manual adjustment and a thorough supervision of the results. The pathologies that take place of mobile organs, e.g: Bowel, involve a difficulty.
TP019 Measurement of splenic function with heat-damaged red blood cells R. Schmitz, E. Hemayat, A. Lammers, A. de Porto, J. de Jong, R. Bennink; AMC, Amsterdam, NETHERLANDS. Patients with asplenic function are more at risk to develop a severe sepsis, known as post splenectomy sepsis (PSS). This condition can be prevented with vaccines and antibiotics. There is a larger population of hyposplenic patients that are at risk to develop PSS as well, and should get vaccines and antibiotics. Quantifying the splenic function is difficult and a gold standard is missing. Measurements of splenic function with heat‐damaged red blood cells (RBC’s) have been described but need alteration for the use in routine clinical setting. Therefore, the aim of this investigation was to assess the optimal labelling and imaging technique of heat‐damaged RBC’s for the assessment of splenic function. Methods: RBC’s of healthy volunteers were isolated before and 15 min after the i.v. injection of 3.9 mg of pyrophosphate. Two methods of labelling RBC’s with pyrophosphate were compared, the in‐vivo and the in‐vitro method. To obtain good heat‐damaged RBC’s, 3 heating conditions were compared: heating in plasma, saline and as packed cells. Alteration of the RBC’s was measured with a filter that blocks heat‐damaged RBC’s. To minimise the amount of free pertechnetate in the plasma an additional washing step was evaluated. 40 volunteers (healthy volunteers, functional hyposplenic, asplenic and splenectomized patients) were injected with 80 MBq of heat‐damaged RBC’s. 30 min dual‐head dynamic scintigraphy was performed immediately after injection. Subsequently, a SPECT‐(low‐ dose)CT acquisition was made. During acquisition blood samples were drawn to determine blood clearance of labeled heat damaged RBC’s. Results: There was no statistical significant difference in labelling efficiency between the in‐vitro or in‐vivo method. Heating RBC’s in saline showed less damaging compared to heating in packed cells. Damaging assessment of RBC’s heated in plasma showed false positive results caused by obstruction of the filter. The additional washing step showed no improvement. Measurement of splenic function using dual‐head dynamic scintigraphy is feasible and enables assessment of splenic function. Visual correlation helps interpretation as compared to blood clearance values which largely depends on liver uptake in patients with reduced or absence of splenic function. Additional SPECT may be helpful in determination of splenic functional volume, which is a parameter requiring further investigation. Conclusion: Isolation and heat damaging of the RBC’s seems optimal with in‐vivo or in‐vitro pyrophosphate labeling and heat damaging as packed cells. The damaging of RBC’s in plasma could not be evaluated. Splenic function scintigraphy is accurate in healthy and patients with reduced splenic function.
TP020 Realisation of a service centre for nuclear medicine in 4 local hospitals H. Pronk1, W. Wassen1, P. Zwaal2, J. Aalderink1, J. A. C. van Osch1, H. Stevens1; 1Sazinon, Meppel, NETHERLANDS, 2Medical Phit, Utrecht, NETHERLANDS.
Poster Presentation
pool activity (TC‐BF) from the total activity during the filtration phase (TC‐GF‐K). Split renal glomerular uptake (SRGU) was compared with split renal perfusion (SRP). The eight studies were analysed independently by two technologists and a physician. The percentage of the left kidney was calculated by each person independently. Results: The two technologists calculated a percentage of 36.4 % and 42.1% respectively. The doctor achieved 39.8%. Conclusion: Calculation of split glomerular filtration should be done routinely in renal perfusion studies as an additive. To improve inter‐observer variance, plain ROI definition should be replaced by application of binary masks to the matrix before drawing the borders of the ROI.
S482 In four different small community hospitals in the northern part of the Netherlands nuclear medicine is provided by one group of nuclear medicine physicians and technologists. Until now only the nuclear medicine department was partially digitalized. The aim of the project was to create one central appointment system for the four hospitals, PACS archive and the ability for reporting in each hospital for each hospital. So far we know this will be the first completely digitalized service centre for nuclear medicine in the Netherlands. Simultaneously dual head cameras replaced the old single head cameras. For making the appointments at one central location the Centricity RIS (GE Healthcare) was installed. Patient characteristics are retrieved from each hospital using HL7‐ADT. The secretary of the central department plans the nuclear program. DICOM Working list is sent to the GE Infinia Gammacamera at each location by HL7 DICOM connection. Processing is performed using Xeleris processing system. Pictures are stored at one location using the Centricity PACS, with archive server and a Centerra for long term storage. In each hospital a workstation is installed for reporting by the nuclear medicine physician. Reports are produced using speech recognition and RA600 PACS working station with Xeleris floating license plug in. Using this plug in the nuclear medicine physician can perform additional processing or use a 3D viewing application that is installed on the PACS. Since a central PACS and RIS is used reports can be made at each hospital for each hospital. The reports are distributed in each hospital in the EPD,the pictures are distributed in the EPD using a URL connection with a webviewer.
TP021 Implementation of a new image reconstruction method for clinical purpose. E. Abrahamsson, M. Federspiel, A. Loft, F. Andersen, T. Klausen; Rigshospitalet,Copenhagen University Hospital, Copenhagen, DENMARK. Aim: Implementation of TrueX in the daily work in a clinical setting. While installing a new scanner unit in our PET department, we decided to implement a new image software option, True X, a Point Spread Function Reconstruction method, to improve the PET image quality. As TrueX is computational time consuming, this turned out to have impact on the daily routine. Materials and Methods: The image modality is a Siemens Biograph 40, TruePoint PETCT scanner. During the upstart period we used our conventional reconstruction methods for corrected reconstruction; Reconstruction method: Iterative, Iterations: 4, Subsets: 8, Image size: 256, Zoom: 1.0, Filter: Gaussian, 4.0 mm FWHM. The True X reconstruction method for clinical purposes was implemented using the following protocol: Recon method: True X, Iterations: 21, subsets: 3, Image size: 336, zoom: 1.0, Filter: Gaussian, 2.0 mm FWHM. Scanning acquisition time was 2.5min/bed and the injected dose of 18F‐FDG was 400MBq. Results: We examined some clinical cases and found that those small lesions are easier to detect with TrueX than with the standard iterative reconstruction method. Furthermore the images appear less noisy and the hot spots are sharper and betterdefined. The scanning procedure with this new scanner type, with four rings, is very fast, about 11‐13 minutes for a whole body scan. However, the True X reconstruction is much more time consuming. We use 6.40min/bed in reconstruction time on average leading to a build‐up patient data in the reconstruction queue. As we validate the images before the patient leaves the scanner, this leads to logistic problems. Therefore, we use a quick iterative reconstruction method with an image matrix size of 168x168 pixels to decide if the scanning is adequate and the patient may leave. This reconstruction is finished within a few minutes after end of scan. The TrueX reconstructions are then queued and reconstructed over night, ready for clinical evaluation the following morning. This can be a problem if an acute scan interpretation is needed. Conclusion: The good results have meant, that the TrueX reconstruction method is now adapted as a standard procedure in the clinic along with an extra image reconstruction for image quality evaluation immediately after the scan. This makes it possible to maintain a fast patient throughput. The longer reconstruction time means that the reconstructions often will be done late in the afternoon, after finishing all patients, and the scans will first be evaluated the next day.
TP022 A software for automatic calculation of red cell survival J. L. Gómez-Perales1, A. García-Mendoza2, R. Rodríguez Aguilar1, J. A. Furest Pérez1; 1Nuclear Medicine Service, Hospital Universitario Puerta del Mar, Cádiz, SPAIN, 2Nuclear Medicine Service, Hospital Universitario San Cecilio, Granada, SPAIN. Introduction: Red cell survival studies are performed in large number in hospitals throughout the world. The object of red cell survival studies is to obtain estimates of the rates of red cell production and destruction. The calculation of the time taken for half the label to leave the circulation (T1/2) and the percentage of red cell destroyed a day, are not very complex but annoying and time‐consuming. Objective: The goal of this project is to develop a computing facility to automatically calculate the parameters of red cell survival studies. Materials and methods: Cr‐51 is eluted at a rate which significantly affects estimates of mean red‐cell lifespan. The average rate of chromium elution is of the order of 1% per day, which is of the same magnitude as the normal rate of red‐cell destruction. Accordingly, variations in the rate of elution in different individuals may seriously affect the accuracy of estimates of mean red‐cell lifespan when survival is normal or only slightly reduced. Elution is fairly constant in normal subjects and an appropriate correction factor f can be applied, which can be calculated by f = 0.0125 t + 1.0178 if t in days or f = 0.0005 t + 1.0178 if t in hours. For developing a software incorporating the calculations of f, T1/2 and the percentage of red cell destroyed a day, we have used Visual Basic 6.0 and Visual Studio Installer. Results: We have developed a form which allows an easy calculation of red cell survival studies. This form relies on a database to store, manage and retrieve the data of red cell survival studies. Moreover the form offers the possibility of printing a detailed report of each study. This form is included in a software called Nucleolab, which is freely available at http://serfa.radiofarmacia.org/?m=27 Conclusion: The software we have developed has an easy‐to‐use interface, that makes the calculation complexity of erytrokinetic studies completely hidden for the user, saving you the time that you previously spent on these laborious calculations and reducing the risk of error.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 S. Nowak1, T. Herrler2, P. Bartenstein1, M. Hacker1; 1University of Munich, Department of Nuclear Medicine, Munich, GERMANY, 2University of Munich, Department of Surgery, Munich, GERMANY. Objectives: The aim of the present study was to establish a method suitable for serial studies of renal perfusion in acute kidney injury (AKI) mice, with eventual application for testing stem‐cell therapy. Methods: 37 Mbq [99m Tc]‐MAG3 were injected into a tail vein of Balb/C nu/nu mice. Upon injection, whole body images were acquired by the dynamic planar technique, using a triple‐headed gamma camera. Each detector head was equipped with a LEHR collimator, only one head was used. Multiple image acquisitions were performed varying of the following aspects of data acquisition and reconstruction parameters: pinhole or LEHR collimator, number of frames, time per frame, image matrix and zoom factor. Results: Optimal image quality was achieved using a LEHR collimator, a 64 x 64 matrix with a pixel size of 1.78 mm, zoom factor of 4, and 240 frames of 5 seconds each, resulting in a total acquisition time of 20 min. Applying these parameters, it was possible to collect perfusion data from each animal on 3 occasions: pre AKI, day 2 and 18 post AKI. Data were analysed using Hermes dynamic analysis software V 4.1. Regions of interest (ROI) were drawn for the left and right kidneys, their adjacent background ROIs, whole body, bladder and site of injection. Data were exported to Microsoft Excel for calculation of renal perfusion in units of percentage injected dose ( %ID). Conclusions: We obtained good quality dynamic images of renal perfusion and function in mice using a conventional gamma camera equipped with a LEHR collimator. This approach permitted non‐ invasive serial measurements of renal perfusion and function, applicable for treatment monitoring in AKI stem cell based therapy.
TP024 Kurchatovio Program. Patient safety and quality assurance. Devised and utilized by the Nuclear Medicine Unit of San Cecilio Universitary Hospital in Granada (Spain) E. Pérez Maldonado, R. Nieto-Serrano, L. Martín-Navas, E. GarcíaPeinado, C. Rubiols-Maluenda, M. Marín-Melgarejo, C. Sánchez-García; Hospital Universitario San Cecilio, Granada, SPAIN. The aim of this work is to present the program Kurchatovio, devised by our Unit and developed in collaboration with the Informatics Department of our Hospital, which provides Quality Assurance and safety of the patient attended in our Nuclear Medicine Unit. It is based on Real Decreto 1841/1997, by means of which quality standards in nuclear medicine are set. The first version of the program came out in January 1998, and has undergone several updates from then on, in order to adapt it to the quality and safety standards of our Unit. Also, it is integrated with the Patient Appointment Software and with the Electronic Medical Record of the patients, where our records and images are stored. Kurchatovio accurately records and displays the attention provided to the patient in our Unit, since their arrival for a diagnostic test until the moment they leave, when the Electronical report of the examination is given. This is made in a comprehensive and integrated way, with the participation of doctors, nursing personnel and imaging technicians. Briefly, this process consists of: ‐ Patient appointment. ‐ Consent or Non‐consent, on the part of the doctor in charge of examining the patient, in view of the referral from the consultant (indicating examination, radiopharmaceuticals to be administered, radiation dose, administration route, date and time of the administration, date when the images were taken, etc.). Motivations for non‐consent are also stated. ‐ Displaying of the list of patients that have been confirmed in our radiopharmacy, in order to prepare monodoses, dispensed with the patient’s personal details, radioactive pharmaceutical and its activity. ‐ Outpatient admission at our Unit (nurse in charge of the patient, time of arrival, information provided, basic history…). ‐ Administration of radiopharmaceuticals (nurse in charge of patient, radiopharmaceutical administered, dose, route of administration, noting of incidents...). ‐ Data acquisition from images (nurse and/or technician responsible, incidents...). ‐ Record output (date, time, doctor…). ‐ Exploitation of the application.
TP025 Evaluation of brain SUV in WB studies performed with PET/CT - levels definitions according to age group D. Calado, D. Ferreira, P. Saragoca, C. Ovidio, M. T. Rezio, C. Loewenthal, M. R. Vieira; Hospital da Luz, SA, Lisboa, PORTUGAL. AIM: The objective of this study was to investigate cerebral FDG distribution patterns and to perform a statistical evaluation of average SUVs (Standardized Uptake Values) in three different age groups. The patients included had no known brain disease and were performing PET/CT for other reasons. We evaluated uptake in different brain regions: frontal lobes (right and left), temporal lobes (right and left), and parietal lobes (right and left). METHOD: We studied 27 subjects who performed FDG PET/CT for reasons other than cerebral disease. Group I ‐ subjects born between 1930‐1940; Group II ‐ subjects born between 1950‐60; Group III ‐ subjects born between 1961 ‐ 1970. All subjects underwent FDG PET/CT scan in 3D WB conditions and all were euglycemic (glycemia < 120mg/dL). Whole body 3D PET/CT scans were performed on a Biograph 16 Siemens tomograph. Imaging was obtained approx. 60 minutes after IV injection of 3.7 MBq/Kg of the radiopharmaceutical (18F‐FDG).The department physicians oriented the drawing of the ROI´s used to obtain the SUV values for the various brain regions. The results of FDG uptake were studied using a region of interest (ROI) based analysis. We used three reference regions: (1) ROIs in frontal lobe, left and right, (2) ROIs in temporal lobe, left and right and (3) ROIs in parietal lobes, left and right. RESULTS: We analysed the data performing the Qui‐square test value in different lobes within the same group, and among the different groups. The results were ≅ 1; Within the same lobe, we calculated the average and standard deviation, between different groups: Lobes
Average
Standard Deviation
Right frontal lobe
6,051481
1,318221
Left frontal lobe
6,009259
1,448317
Right parietal lobe 6,58444444 1,42351227
TP023
Left parietal lobe
Renal perfusion and function imaging in mice using [99mTc]MAG3 scintigraphy
Right temporal lobe 6,51703704 1,4894935
6,632963
1,370061
Left temporal lobe 6,45185185 1,43354868
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TP2 ‐ Tuesday, October 13, 2009, 08:00 ‐ 09:30, Hall 117
Technologists Poster Session 2
TP026 How to Solve Loss of Scheduled Patient & Study Identification on Image Modality J. Bartl; Masaryk Memorial Cancer Institute, Brno, CZECH REPUBLIC. Purpose: 1) Loss of scheduled patient from DICOM Modality Work List (DMWL) on some SPECT image modalities in case of an In‐111 or Ga‐67 examination. 2) Default setting of image fusion creates loss of the study identification on some PET or PET/CT image modalities. Aim: 1) Automatic rescheduling of patient examination for the SPECT Picker workstation (WS) Odyssey. 2) Archiving rejection of wrong fused images from the PET or PET/CT Siemens WS Syngo. Material: OS Linux, SW Virtualbox OSE, DCMTK. Method: 1) Scheduling of a patient examination is usually done on a day of radioisotope application. Because most of DMWL can see only a scheduled patient for the current and following day(s) the scheduled patient is lost in the time of examination (24h or more after In‐111 or Ga‐67 application) from DMWL. Manual patient data pre‐loading from DMWL in the time of radioisotope application for an examination in next day(s) is very depended on human factor. A simple possible solution is by daemon to resend the opened record from DMWL server for previous day(s) to the scheduled modality. 2) Initial modality for an image fusion with PT is default CT or MR and fused images have always “Accession Number” and “Study ID” of the initial modality. CT or MR images from another than the current study create that way loss of the study identification. A possible solution is to start a fusion with PT images and after validation of this fusion rule on temporary (TMP) PACS then resend fused images to target PACS. Results: Proposed solutions allow to obtain backwards automatically the scheduled patient data for an unfinished examination on the WS Odyssey and presentation of all patient image data from PACS for given examination after the query from HIS. Archiving of wrong fused images is rejected with immediate notice to the WS Syngo. All presented solutions have been realized with SW DCMTK (daemon, TMP PACS) and are running under OS Linux on a virtual (SW Virtualbox OSE) intranet server. Conclusion: Patient rescheduling is ordinarily done by a RIS but in case e.g. of one SPECT modality and relatively a few of In‐111 or Ga‐67 examinations is it very expensive solution. Solutions using free SW tools may not be always easy but in some cases are the cheapest. Supported: This project is a part of the research program MZ0MOU2005 “Functional Cancer Diagnostic”.
TP027 99m
99m
Tc-Leukoscan/ TcNanocolloids Marrow Imaging Protocol: Diagnosing infection in lower extremity joint arthroplasties
M. Oliveira, I. Amorim, F. Fontes, A. Silva, C. Sousa, J. Nery, R. Castro; Centro Hospitalar do Porto, Porto, PORTUGAL. INTRODUCTION AND OBJECTIVES: The diagnosis of prosthetic joint infection still remains a clinical problem since the symptomatology is similar to aseptic unsealed prosthesis. Infection of internal structures is difficult to localize without the aid of imaging procedures. Radionuclide imaging is an important diagnostic tool for the evaluation of patho‐physiological processes of infection in prosthetic joints. A spectrum of radiopharmaceuticals and a number of imaging protocols have been used in clinical practice. However every method differs in its potential to gather information at the cellular e molecular level. Literature refers to ImunoScintigraphy/ Bone Marrow Scintigraphy method as a protocol with height sensitivity and specificity (100% and 97% respectively). PET scan is also a possible option but with less sensitivity and specificity. The aim of 99m 99m this study is to make obvious the advantages of Tc‐LeukoScan/ Tc‐Nanocolloids Marrow Imaging protocol in patients with failed lower extremity prosthetic joint for the differential diagnosis between infection and aseptic unsealed prosthesis. The results will change treatment protocols and the actuation method, conducting to eradication of infection. MATERIAL AND METHODS: 14 patients were involved in the study. Diagnosis was made by the physician. The cases were conducted for Radionuclide studies after analyse of laboratory parameters, so they have height probability for infection. Results were positive for unsealed aseptic prosthesis if 99m Tc‐LeukoScan and 99mTc‐Nanocolloids Marrow images have coincident locals of increased activity. Results were positive for infection if 99mTc‐LeukoScan has a local of increased activity that doesn’t have correspondence in 99mTc‐Nanocolloids Marrow scan. Patients with abnormal findings in 99mTc‐LeukoScan/99mTc‐Nanocolloids Marrow Imaging were submitted to surgery with posterior microbiologic examination and leukocyte count of the tissue. RESULTS: 3 studies were positive to prosthetic joint infection and remaining 11 were negative. 85,7% of the patients have prosthetic joint of the knee and 14,3% have prosthetic joint of the hip. Sensitivity and specificity of 99mTc‐LeukoScan/99mTc‐Nanocolloids Marrow Imaging were 100% and 91%, respectively. CONCLUSIONS: 99mTc‐LeukoScan/99mTc‐Nanocolloids Marrow Imaging is a non invasive and easy to apply technique, diagnostically definitive in all patients with low extremity failed joint replacement in the detection of the sites of infection, thus, it can be considered an appropriate imaging procedure in this type of population. It can change treatment protocols, because diagnose of infection in many cases was until now made after surgery.
TP028 Image Quality of Myocardial Perfusion Gated Studies: effect of fat chocolate, low fat chocolate and a glass of water to reduce extra-myocardial abdominal signal.
L. Vieira1, D. Faria2, J. Patrina2, P. Almeida3, D. C. Costa2; 1ESTeSL FCUL/IBEB, Lisboa, PORTUGAL, 2HPP Medicina Molecular, SA, Porto, PORTUGAL, 3FCUL/IBEB, Lisboa, PORTUGAL. Introduction: stomach, liver and bowel radioactive signal intensity is known to interfere with visual and quantitative evaluation of the infero‐septal region of the myocardium during 99mTc‐ tetrofosmin Myocardial Perfusion Gated Single Photon Emission Computed Tomography (MP‐ Gated‐SPECT) studies. Aim: to evaluate the effect of different foods in extra‐myocardial radioactivity signal reduction to improve image quality of MP‐Gated‐SPECT. Material and methods: eighty seven consecutive patients referred for MP‐Gated‐SPECT underwent a one‐day imaging protocol subdivided in three groups: A (FC) ‐ 30 patients had fat chocolate (13,4 g of lipids) after stress and resting injections; B (LFC) ‐ 30 patients had low fat chocolate (8,7 g of lipids) after stress and resting injections; C (W) ‐ 27 patients drank 400ml of water after stress and resting injections. Anterior and posterior thoraco‐abdominal static views were acquired on each occasion approximately 60 minutes post‐injection. Regular regions of interest (ROI) were drawn over right lung (RL), left lung (LL), heart (H), liver (L) and stomach (S) and then relative uptake indices (UI) of RL/H, LL/H, L/H and S/H, were calculated. Kruskall‐Wallis, Wilcoxen and Mann‐Whitney‐Wilcoxen tests were used for statistical anaçysis. Results: comparisons made between the UI of RL/H, LL/H, L/H and S/H, in the different studies according to the ingested food [A (FC), B (LFC) and C (W)] and type of study (stress and rest) revealed consistently significant differences at the 5% level (p<0,05) only for L/H when using fatty chocolate ‐ A (FC). Conclusion: our data reveals that fatty chocolate administered after stress and resting radiopharmaceutical injections reduces the amount of liver radioactive signal in MP‐Gated‐SPECT. This could be due to increased secretion of cholecystokinin enhancing biliary excretion and might improve image quality in some patients.
TP029 Can whole body bone SPECT (MIP) with shorter waiting time (90 minutes) replace conventional whole body bone scan without losing lesion detectability? K. Saito1, T. Higuchi2, Y. Takahashi1, H. Otake3, H. Shimada3, Y. Arisaka2, N. Oriuchi2, K. Endo2; 1Gunma Prefectural College of Health Sciences, Maebashi, JAPAN, 2Gunma University Graduate School of Medicine, Maebashi, JAPAN, 3Gunma University Hospital, Maebashi, JAPAN. Purpose: Bone scan is widely used as a screening tool for bone metastasis. However, the 180 to 240 minutes (min) waiting time after intravenous (i.v.) injection of tracer is both long and tiresome. To solve these shortcomings, bone scan with shorter waiting time is expected. In this study, we developed new bone scan method with 90 min whole body bone SPECT (MIP : maximum intensity projection) and evaluated its diagnostic ability comparing with conventional bone scan. Methods: In phantom study, hot gels of 99mTc‐HMDP (φ= 4,6,8,10,12,13,15,16,19 mm, 2.5 times radioisotope counts than background) were set on the bone phantom. In healthy volunteers, SPECT images were obtained from chest to abdomen at 30, 60, 90, 120 and 180 min after 99mTc‐HMDP injection. Then, MIP images were reconstructed. Whole body image was also obtained at 200 min, and the image quality was compared. In 20 patients with breast cancer, the delectability of uptake regions (metastases) was compared visually. A 740MBq of 99mTc‐HMDP were used in human studies. Acquisition parameters were a matrix size of 128×128 and 4 min/rotation (bed) with continuous scanning mode (5 beds = 20 min in total). At SPECT image reconstruction, scatter correction was performed using the triple‐energy window (TEW) method. Results: In phantom study, the SPECT (MIP) image depicted a 4 mm hot lesion. In healthy volunteers, the image quality at 90 min SPECT (MIP) was comparable to that of 240 min planar image. In 20 clinical cases, all hot lesions detected with 240 min planar scan were concordantly depicted with 90 min SPECT (MIP). Conclusion: Although a 4 mm size hot gel (2.5 times of B.G) was difficult to depict on the conventional SPECT, the MIP imaging could recognize it clearly. The MIP reconstruction with scatter correction could improve S/N of the hot lesion. In conclusion, it is suggested that 90 min whole body SPECT imaging can reduce waiting time and keep comparative diagnosis power with conventional bone scan.
TP030 The Disposal Procedure of Radioactive Wastes M. Park, S. Jung, H. Park, K. Oh, J. Kim, C. Lee; Severance Hospital, Seoul, REPUBLIC OF KOREA. Purpose : Radioiodine (I‐131) therapy has been known as the one of the methods treating hyperthyroidism or thyroid tumor, facilitating a separated ward. Since this technique was used, its clinical efficacy has been proven for decades. Its demands would increase continuously because of the increasing number of the patients with thyroid cancer. However, various kinds of wastes generate from a procedure of radioiodine therapy. Therefore, this study proposes that the safety in using radiation has to be secured through the effective and safe disposal procedure. Materials and Methods : In our hospital, each waste generated from radioiodine therapy was classified into general and radioactive one, each of them, then, was collected and disposed in accordance with the procedure plans of our hospital’s own disposal system approved by the Ministry of Science and Technology. At this time, textile export and garbage (leftover food) were collected in separated storages, and the rest of the solid was kept together in other storages. Then, additional label was attached, the rule of attenuation term for each type was set up, and finally disposed at the point when radioactivity was below 100Bq/g. Results : The general one of all wastes was discarded immediately as infectious wastes. On the other hand, radioactive wastes were classified through the labeling in order to separate storages piece by piece. And, improvement in plan for garbage and the rest of the solid raised efficiency, and maintained disposal spaces more cleanly. Finally, it was disposed, only when its radioactivity was below permissible level (4Bq/cm2). Conclusion : In the past, radioactive wastes were disposed by designating relevant corporations and paying a consignment fee to them. . However, since each hospital’s own disposal system was continuously corporated and approved by the notice of the Ministry of Science and Technology (1997), it has been possible to manage them easily and securely. Therefore, in our hospital, since the disposal procedure of them was set up, it makes the control more efficiently, decreases individuals’ exposure to radioactive and leads the effect of costs reduction as well.
Poster Presentation
CONCLUSION: We analyzed the data performing the chi‐square test and assuming the null hypothesis as no existing significant differences between the data. With the p values obtained we can assume that the compared data are from the same population (p>0.10). By the average and standard deviation values, we can also say that there is no significant difference between the different groups and the different lobes. In our department, this data will serve as a preliminary database of brain uptake in patients without brain disease and further interpretation of brain disease.
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TP031 Resting Technetium-99m Sestamibi Myocardial Washout in Patients with Ischemic Heart Disease H. Tsueda1, Y. Nakazawa1, T. Nakamura1, I. Moriwaki1, Y. Shiomura2, N. Okamoto2; 1Saiseikai Gotsu General Hospital, Gotsu City, JAPAN, 2 FUJIFILM RI Pharma Co.Ltd., Tokyo, JAPAN. Aim: Previous study have suggested that Tc‐99m sestamibi(MIBI) shows very slow myocardial washout after its initial uptake, which is related to mitochondrial function. The purpose of this study was to clarify global and regional myocardial MIBI washout in patients with ischemic heart disease. Some investigators have reported that reverse redistribution(regional washout) of MIBI was observed in patients with AMI after direct PTCA, indicating that the ability of myocardium to retain the tracer may be impaired. However, the clinical usefulness of MIBI washout is not established yet. Materials and Methods: This study was performed on 21 patients( 6 female and 15 male, mean age 75±8 yrs) with ischemic heart disease. An intravenous injection of 600 MBq of MIBI was given. All patients underwent resting MIBI SPECT imaging with initial(1 hour) and delayed(4 and 6 hours) acquisition. Myocardial MIBI washout rates(WR) were calculated from the initial and delayed images{ WR‐1:initial‐delayed(4 hours), WR‐2:initial‐delayed(6 hours)}. For regional evaluation of myocardial MIBI washout, the left ventricule was divided into 5 segments on polar map(anterior, lateral, septal, inferior, and apex). Results: Global MIBI WR‐2(34.4±7.6%) were significant higher than MIBI WR‐1 (22.6±9.3%)(p<0.0001)in all patients. The myocardial MIBI‐WR was significant higher in ischemic region(34.7±7.3%) compared to normal region(30.5±6.6%) (p=0.001). The washout of MIBI from the heart increased approximately in a linear manner. Conclusion: The myocardial MIBI WR is considered to be a good marker for evaluating the myocardial viability. Furthermore, it potentially provides the severity of myocardial ischemia.
TP032 A Strategy for Regional Analysis using Clinical Amyloid Ligand [11C]-PiB PET Scanning in Dementia C. S. Knudsen, A. Ljunggren, B. Dall, S. Hasselbalch, I. Law; Copenhagen University Hospital, Copenhagen, DENMARK. Background and aim: The positron emission tomography (PET) 11C‐labeled radiotracer Pittsburgh Compound‐B ([11C]PIB) binds with high affinity and specificity to the amyloid structures in the brain and can provide important supplementary information in the diagnosis of dementia subtypes. Present image analysis techniques rely on the export to supplementary software. This, however, is inconvenient and time consuming in the application of [11C]PIB PET into a routine clinical work flow. Therefore, our aim was to develop and test a strategy that could be confined within supplied standard clinical software (Siemens Syngo, TrueD), and be performed by Nuclear Technologists. Material and Methods: Ten subjects were included (4 Alzheimer's disease [AD], 4 mild cognitive impairment [MCI], 2 Indeterminate Dementia). A 30 min emission scan was performed 40 min after mean injection of 334 (172‐387) MBq [11C]PIB using a GE‐Advance PET scanner. PET scans were co‐registered to T1 weighted magnetic resonance images (MRI). Six types of cortical ROI’s were drawn covering grey (GM) or grey and white matter (WM) within a 3D or 2D Ellipse, or a 2D Rectangle. Thus, the ROI’s varied in complexity, in total volume and in volume of grey matter, and were located in the frontal lobe, posterior parietal cortex and cerebellum. Activity uptake ratio’s relative to the cerebellar ROI’s were calculated in each group of ROI’s. Results: Activity uptake ratio’s (UR) relative to cerebellum in the posterior cingulate gyrus ROI
Vol (ml) AD UR MCI UR
Complexity Location
N = 10 N = 4 N = 3 N = 1 N = 1 N = 1
Other UR
PIB + PIB ‐ PIB + PIB ‐
High
3D GM Ellipse
20,0
2,40
2,01 1,10 2,27 1,00
3D GM & WM Ellipse
51,7
2,14
1,79 1,19 2,02 0,99
Moderate 2D GM Ellipse
0,8
2,40
1,94 1,10 2,50 0,97
2D GM & WM Ellipse
2,2
2,06
1,76 1,16 2,33 1,00
Low
2D GM Rectangle
0,6
2,62
1,99 1,15 2,53 0,93
2D GM & WM Rectangle 1,4
2,25
1,92 1,25 2,32 0,95
Conclusion: The unspecific binding in the white matter will generally tend to decrease the UR’s in PIB positive patients and increase the UR’s in PIB negative patients, however, with only limited clinical impact. Thus, clinical [11C]PIB PET need in most cases only be supplemented with UR’s using the low complexity strategy, that can probably be placed with the aid of CT alone.
TP033
18
Ovarian and Endometrial F-FDG uptake during the menstrual cycle in normal premenopausal patients : Evaluation by PET/CT Y. Bahn, H. Park, H. Nam-Koong, S. Kim, H. Lim, C. Lee; Severance Hospital, Yonsei University Health System, Seoul, REPUBLIC OF KOREA. Purpose : The menstrual cycle of normal premenopausal patients was divide into menstrual flow phase, proliferative phase, ovulatory phase, secretory phase. The aim of this study was to ovarian and endometrial 18F‐FDG uptake during the menstrual cycle in normal premenopausal patients. Methods : We identified 200 incidental 18F‐FDG uptake in the ovary. The patient fasted at least 6 18 hours before receiving an intravenous injection of 370‐592 MBq (10‐16mCi) of F‐FDG. Scanning from the base of the skull though the mid thigh was performed using the Discovery Ste PET/CT system (GE Healthcare, Milwaukee, WI, USA). Ovarian and endometrial 18F‐FDG uptake (expressed as standardized uptake value) was measured on PET/CT image. Results : Two peaks of 18 increased endometrial F‐FDG uptake were identified during the menstrual cycle. The SUVavg and SUVmax was 2.89±1.04 g/ml and 3.17±1.59 g/ml in menstruating patients, 2.4±0.88 g/ml and 2.98±1.14 g/ml in proliferative phase patients, 3.59±1.76 g/ml and 3.17±1.67 g/ml in ovulatory phase patients, 2.58±1.39 g/ml and 3.1±1.8 g/ml in secretory phase patients. Conclusion :
Increased ovarian and endometrial 18F‐FDG uptake could be found the time of menstrual flow and ovulatory phase of menstrual cycle. Increased uptake in endometrium adjacent to a cervical tumor does not necessarily reflect endometrial tumor invasion. Since increased uptake was dependent on the menstrual cycle, it can be avoided by scheduling PET/CT just after menstruation. Non‐menstrual‐related endometrial uptake may be instrumental in establishing a diagnosis in a premenopaual patient.
TP034 Radiation exposure to the staff with an automatic18F-FDG dose injector C. W. Skøtt, S. Holmboe, L. Skads; Herlev Hospital, Copenhagen, Herlev, DENMARK. AIM: The aim was to measure the radiation exposure to the staff when using an automatically dose injector and compare it to manual administration and injection. Automated injection machinery may diminish the exposure to the staff due to better shielding from the radioactivity. Methods: We measured the radiation to the staff during both manually and automatically administration. 100 patients were examined in each group. In 15 cases in both groups the radiation from a single patient in the injection room was measured. 370 MBq18F‐FDG was administrated to each patient for the PET scanning. RADOS, RAD‐60S personal dosimeter was used to measure the whole body radiation to the staff. One experienced technologist performed 90% of the injections in both groups. A) The radioactive dose to the patient was drawn into a syringe and measured manually in a laboratory geographically away from the patient area. The tracer was transported to the patient in a lead box on a small trolley. The tracer was given manually to the patient through an existing intravenous access. B) Medrad`s Intego™ PET infusion system is a new equipment dedicated for automatic injection of 18F‐FDG in patients. The FDG is placed in a tungsten‐shielded multi‐dose vial, which is placed in the Intego™. Prior the infusion, the Intego™ measures the dose of 18F‐FDG along with a salina flush. Patient data is filled in on the screen, and the tracer is then ready for injection through the intravenous access. The staff can observe the infusion in a safe distance. Results: The measured average radiation dose to the staff per patient was A) Using the manual administration of 18F‐FDG: 2.53 µSv ± 0.61µSv (mean ± SD) with several patients in the room and 2.21 µSv ±0.67 µSv with a single patient in the room. B) Using the Intego™ system: 0.64 µSv ± 0.46µSv with several patients in the room and 0.25 µSv ± 0.47µSv with a single patient in the room. Thus, a significantly lower radiation dose to the staff was found when using automated injection (p<0.00001, Student’s t‐ test) Conclusion: The benefit of automated injection is a three to ten‐fold reduction in radiation dose depending on the number of already injected patients present in the injection room. An added benefit we experienced was time‐saving and a quick response to schedule changes and delays.
TP035 A Prospective Evaluation of Hepatobiliary Scintigraphy both decubitus position in bile leakage patients Y. Bahn, D. Roh, C. Kang, J. Kim, C. Lee; Severance Hospital, Yonsei University Health System, Seoul, REPUBLIC OF KOREA. Purpose : Hepatobiliary scan of biliary leakage diagnosis was separated determine to biliary leakage and bowl drainage bile‐juice. We prospectively evaluated Hepatobiliary Scintigraphy both decubitus position in bile leakage patients. Methods : 31 patients (male 14, Female 17), 51.1±14.4 years. Dynamic scan acquisition 60 frame for 60 minute on supine position. And delay scan was 2 hrs, 4 hrs, 24 hrs for 5 minute on supine, both decubitus position. Both decubitus position scan was kept for 5 minutes. The overall sensitivities of biliary leakage was evaluated density and size of ROI. The density was evaluated average of ROI (region of interest)/BKG(background) uptake (counts/pixel) ratio and the size was evaluated average No. pixels of ROI. Results : Anatomical leakage location was supine position very well, but both decubitus position was separated bile leakage and moving bile‐juice in bowl. Also, average of ROI/BKG uptake (counts/pixel) ratio was supine 5.02, left decubitus 2.08, right decubitus 2.68. Average No. pixels of ROI counted supine 538.83 pixels, left decubitus 575.5 pixels, right decubitus 569 pixels. It was compared ROI/BKG ratio and ROI No. pixels of supine, both decubitus. There was significant difference in this study. No. pixels of supine position was 19% larger than left decubitus, 5% larger than right decubitus, And density was 60%, 50% lower than left decubitus, right decubitus. Conclusions : If Hepatobiliary Scintigraphy was additional both decubitus position scan in bile leakage patients, this study will be more valuable in diagnosis of bile leakage to a change condition in each position.
TP036 Setting up a treatment scheme for 177-Lutetium-Dotatate. T. Heiberg, T. L. Klausen, J. Mortensen; Dept.of Clin.Phys & Nucl.Med., Rigshospitalet, Copenhagen, DENMARK. Introduction: The aim of this poster is to describe the set‐up of a treatment scheme for radionuclide treatment of neuroendocrine tumours utilizing the beta emitter 177‐Lutetium‐ Dotatate at the Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Rigshospitalet Denmark. Material and methods: Introducing a new treatment scheme at a nuclear medicine department is a circular process which involves the processes of handling a new isotope, adapting the necessary treatment facilities, introducing the treatment to relevant personnel inside and outside the department and deciding upon the scanning and testing procedures. Results: Due to practical considerations, such as the opening hours of the department of Nuclear Medicine, it was decided that the patients should stay in the department during the administration of the 177‐Lutetium‐Dotatate and scanning only. During the remainder of the time the patients should be in the care of the clinical ward. The required facilities were adapted in both departments and the necessary calibrations of dose calibrators, well counters and gamma cameras was performed. Lead canisters were constructed for the isotope for transportation and administration inside the department. Informational materials for the patients and various personnel were authored and the relevant personnel were instructed in managing the patients undergoing this form of treatment, including information about cleaning and decontamination of a beta emitter. Decisions were made to scan the initial patients on day 0, 1, 4 and 7 and also extracting blood samples for dosimetric testing. Discussion and conclusion:
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 The process of introducing a new treatment into a department is an interdisciplinary process including everyone working in the department, counting among others physicians, physicists, secretaries and lab technicians, as well as experience from other institutions. Each group had their responsibilities, and the progress was discussed at frequent interdisciplinary meetings. As the first patients pass through the department and the mistakes and shortcomings become apparent one must be open for the possibility of adapting the procedures. Because of these finding the everyday evaluation becomes more evident and conspicuous.As a result the Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Rigshospitalet Denmark, is now treating patients suffering from neuroendocrine tumours with 177‐Lutetium‐Dotatate.
TP037 Comparison of three chromatographic methods for the 99m Tc-nanocolloid. determination of radiochemical purity of M. Molina, L. Ruiz, R. Iglesias, A. Bonilla, A. Fernández, J. Castro; H.U.Virgen Macarena, Sevilla, SPAIN. Aim:To compare a chromatography method with those recommended by the manufacturer for the determination of radiochemical purity of 99mTc‐nanocolloid. Material and Methods:According to manufacturer’s instructions, 12 vials of labeled 99mTc‐nanocolloid were included (NANOCOLL ©‐GE Healthcare). Each preparation passed three controls, two of them included in the Technical Leaflet and a third in‐house control, such as follows: Reference controls recommended by the manufacturer: Method 1:Whatman‐1 as the stationary phase and methanol:water (85:15 v/v) as the mobile phase. Freen technetium ascends to the front of the strip. Method 2: ITLC‐SG as the stationary phase and the solvent above described. Free techenetium ascends to the front of the strip. The proposed in‐house method: Alternative method:Whatman‐31 as the stationary phase and ClNa 0,9% as the mobile phase. Free technetium ascend to the front of the strip. Strips were analysed in a radiochromatography instrument (Mini‐gitas©, Raytes, Isotoponpenmebgeräte GMBH). Results: Method
% Radiochemical Purity % Radiochemical Purity % Radiochemical Purity (recommended method 1) (recommended method 2) (alternative method)
Mean
99,26%
98,03%
98,44%
Standard Deviation
0,22%
0,94%
0,35%
Coefficient of 0,22% variatión
0,96%
0,36%
Comparative study of conventional lung scan versus ventilation spect and perfusion CT-spect for the diagnosis of pulmonary thromboembolism (PTE)
Comparison of two chromatographic methods for assaying 99m Tc-HMDP the radiochemical purity of A. De Bonilla, J. Romero, R. Iglesias, M. Molina, A. Fernández, J. Castro; H.U.V. Macarena, Seville, SPAIN. Aim: To compare chromatography with the recommended method for assaying the radiochemical purity of 99mTc‐HMDP. Material and methods: According to manufacturer’s instructions, 19 vials of 99mTc‐HMDP were included (OSTEOCIS©, CIS bio international). Each preparation passed two controls, a reference and an alternative control such as follows: The recommended reference control, using: Whatman‐17 as the stationary phase and ClNa 0,9% as the mobile phase, which separates reduced‐hydrolyzed technetium. Whatman‐17 as the stationary phase and methanol:acetone (85:15), which separates free technetium. The proposed method, using: ITLC‐SG (Gelman) as stationary phase and water as mobile phase, which separates reduced‐hydrolyzed technetium. Whatman 3‐MM and acetone as mobile phase, which separates free technetium. Strips were analysed in a radiochromatography instrument (Mini‐gitas©, Raytes, Isotoponpenmebgeräte GMBH). Results: Method
% Radiochemical purity (recommended % Radiochemical purity (alternative method) method)
Mean
97,01%
97,02%
Standard Deviation
0,41%
0,65%
Coefficient of variatión
0,42%
0,67%
Introduction: The main technique used in Nuclear Medicine for the diagnosis of Pulmonary Thromboembolism (PTE) is Ventilation/Perfusion (V/Q) planar lung scan. A study protocol to validate the tomographic technique versus the planar technique was decided upon the introduction of hybrid CT‐SPECT equipment that allows for tomographic V/Q imaging and the fusion of these images with CT‐acquired scans. Aim of the study: To assess the viability of exploring patients whit this method and to compare the advantages and inconveniencies of its application in assistance practice. Method: A prospective study was carried on 34 patients (18 female and 16 male, age 56±18) submitted to the Nuclear Medicine Service with a clinical suspicion of PTE. The study was performed with a double‐headed gamma camera (GE Hawkaye) incorporating non‐diagnostic CT, using a LEHR collimator. Conventional V/Q lung scan was made on all patients, adding a ventilation SPECT and a perfusion CT‐SPECT (128² matrix, 10 sec image every 3º) immediately after planar V/Q imaging. Results: For several reasons (decubitus intolerance by dyspnea, claustrophobia, dementia, technical difficulties), the V/Q tomographic study could not be performed in four patients. Ventilation SPECT plus CT‐SPECT is a methodology that consumes less time (20 min.) than planar V/Q (25 min.), reducing time to 12 min. if only perfusion CT‐SPECT is used. The pulmonar dosimetry added to the perfusion study, using aerosol ventilation is 139,3 mGy, while the used CT adds 1596 mGy (274mGy.cm). In 2 patients, the ventilation tomographic study did not reach minimum quality for diagnosis, because these patients did not perform a correct ventilation. Conclusión: V/Q SPECT is a methodology applicable to most patients suspect of PTE. The use of perfusion CT‐SPECT shortens exploratory time, does not significantly increments dosage to the patients and does not require for their collaboration if compared to the ventilation study.
TP041 Scheme of health care in nuclear medicine Y. Garcia-Rivero, M. Moriana-Porras, M. Lopez-Gomez, A. Nuñez-Navarro, M. Ruiz-Caballero, A. Garcia-Rodriguez, E. Maldonado-Prieto, M. MartínezSanchez; Hospital Universitario Virgen De La Nieves, Granada, SPAIN. Introduction Different authors have been studied the importance of supply basic needs for patients and their caretaker. Traditionally, this issue has been unattended by Nuclear Medicine research units. This raises the issue that as these patients attended in Nuclear Medicine units have similar needs than those others attended by other medicine units, it is desirable that they enjoy the same basic cares. AIM: The aim of this abstract is to expose our experience in the implementation of an scheme of health care in our Nuclear Medicine Department. DATA AND
In all cases, the quality control was considered valid as the minimum required (95%) was passed. Conclusions: Radiochemical purity approaches 100% when using the proposed alternative method, showing a higher deviation than the recommended by the manufacturer. Although a higher variability and a lower precision were observed. The proposed method is faster than the recommended method.
TP039 Application of Tc-99m-HYNIC-IgG for Monitoring Systemic Leakage during Regional Chemotherapy 2
E. P. Mijnheere , W. J. M. van den Broek , J. J. Bonenkamp , W. J. G. Oyen1; 1Department of Nuclear Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, NETHERLANDS, 2Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, NETHERLANDS.
METHODS: ‐ Elaboration of the scheme of task distribution, nursery register adapted to patient needs (following Henderson model used in the Hospital) and implementation of nursery cares. ‐ Administration of radiopharmaceuticals. ‐ To obtain the patient Informed Consent for authorisation of diagnoses tests. ‐ Advices for Radioprotection. ‐ Nursery register. ‐ To discard pregnancy in fertile women RESULTS Alter implementation of current scheme without any increase of material means or staff, it has been possible to conduct a higher number of explorations, increasing the quality of assistance and level of user satisfaction, checked through telephone interview by the Quality Commission at Hospital on a 60‐case random sample among patients who were attended at our unit, showing a percentage of satisfaction of 93%. DISCUSSION The implementation of a care program is basic in the development of daily work, giving raise to a high level of satisfaction for both the health staff and users as much as a high level of performance to the medical unit.
Poster Presentation
TP038
1
TP040
A. Macia-Macia, J. Barbeta-Sánchez, C. Gutiérrez-Gómez, T. TermensLlargues, C. Segura-Melero, M. Negre-Busó, F. Dellepiane-Clarke, J. Castell-Conesa; Hospital Universitari Vall d'Hebron, Barcelona, SPAIN.
In all cases, the quality control was considered valid as the minimum required (95%) was passed. Conclusions: The results obtained with the first method recommended by the manufacturer are closer to 100% while mean and data variability of the proposed alternative method are intermediate values. In conclusion, the proposed method is faster than the recommended by the manufacturer, showing values within the accepted limits
1
Purpose: Hyperthermic isolated limb perfusion (ILP) and isolated limb infusion (ILI) with high doses of cytotoxic drugs like Melphalan and TNF‐α is used in the treatment of patients with malignant melanoma of the limbs. Monitoring leakage from the isolated limb into the central part of the body is essential due to the high toxicity of these agents. We describe the use of Tc‐ 99m‐HYNIC‐IgG for continuous external measurement as a monitoring system for systemic leakage. Method: A collimated NaI crystal connected with an appropriate counting system was fixed above the heart region of the patient. A standardized dose of 7.4 MBq Tc‐99m‐HYNIC‐IgG (10% of dose injected in the isolated limb), was injected intravenously into the blood pool of the patient and continuous measurement (counts/10 sec.) of the radioactivity above the heart region is started. When a plateau is reached a calculation was made to determine the counts/10 sec . representing 1% of the systemic leakage. After about 5 minutes a standardized dose of 74 MBq Tc‐99m‐HYNIC‐IgG was injected into the system of the ILP/ILI. When a balance, measured by radioactivity above the heart region, was reached the Melphalan and/or TNF‐α perfusion was started (time of treatment 1‐1.5 hours). Continuous monitoring of the radioactivity above the heart region during the ILP/ILI directly registered the percentage of systemic leakage. Results: Twenty‐two patients were treated with Melphalan and/or TNF‐α during ILP/ILI. In 20 patients there was a measured mean systemic leakage of 2.4% (range 0‐9.6%) of the dose injected in the limb, which means that the treatment could be completed. As a maximum systemic leakage of 10% by Melphalan and 5% by TNF‐α is considered to be acceptable, treatment could not be completed in 1 patient because 27 minutes after Melphalan treatment the radioactivity above the heart region rapidly increased to a maximum of 13.8% of the injected dose of the limb. Treatment was immediately interrupted to avoid toxicity. In 1 patient no treatment with Melphalan was started because no stable baseline could be obtained from the Tc‐99m‐HYNIC‐IgG dose injected in the limb. Conclusion: Continuous monitoring of system leakage during ILP/ILI with high doses of Melphalan and/or TNF‐α is of vital importance. Tc‐99m‐HYNIC‐IgG is cleared very slowly from the blood and does not accumulate in the body of the patient. It is therefore a good alternative for commonly used tracers such as Tc‐99m‐autologous erythrocytes or I‐131‐ HSA for monitoring of isolated limb chemotherapy.
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TP042 Modified chloroform extraction method for the radiochemical purity test of 99mTc-HMPAO C. LOPEZ, M. SABATE, G. PLA, E. MOYA, M. QUERA, B. SORIANO; HOSPITAL UNIVERSITARI VALL D'HEBRON, BARCELONA, SPAIN. Aim The aim of the project was to improve the visual separation of the two layers formed by chloroform and 0.9% sodium chloride in the chloroform extraction method. Materials and methods In order to improve the visual separation of the two layers, 0.9% sodium chloride was dyed with a drop of Trypan Blue. Test tubes where filled with 3 mL of chloroform and 3 mL of dyed saline. Radiochemical purity tests of 99mTc‐HMPAO (0.1 mL from the same batch) were performed with either dyed and not dyed saline. Two different technitians performed both tests. After extraction activities were measured in a dose calibrator (Capintec Radioisotope Calibrator ® CRC‐7). The radiochemical purity of 99mTc‐HMPAO was calculated as the percentage of activity in the chloroform layer from the total activity in both layers. Results 99m
Technitian A
Tc‐HMPAO
Technitian B
With Trypan Blue Without With Trypan Blue Without
Radiochemical purity (%)
82.1
81.7
84.2
82.4
n determinations
10
10
10
10
0.04
0.06
0.04
CV (Coefficient of Variation) 0.06
Conclusion Results showed that both methods had similar reproducibility. Although Trypan Blue increases variability it facilitates the operation.
TP043 A comparative study of the Standard Uptake Values of the PET reconstruction methods; Using Contrast Enhanced CT and Non Contrast enhanced CT S. Lee, H. Park, S. Ahn, S. Oh, H. Nam-Koong, H. Lim, J. Kim, C. Lee; Yonsei University Health System, Seoul, REPUBLIC OF KOREA. Purpose: At the beginning of PET/CT, CT was mainly used only for Attenuation Correction (AC). As the performance of CT has been increase, it gives improved diagnostic information with Contrast Media. However, it was controversial that Contrast Media could affect AC on PET/CT scan. Some submitted thesis shows Contrast Media could overestimate when it is for AC data processing. On the contrary, there has been the opinion The overestimated AC data processing does not have a definite effect on the diagnosis. Thus, the affection of Contrast Media on AC was investigated in this study. Methods: Patient inclusion criteria required a history of a malignancy and performance of an integrated PET/CT scan and contrast‐enhanced CT scan within a 1‐day period. Thirty oncologic patients who had PET/CT scan from December 2007 to June 2008 underwent staging evaluation and met these criteria. All patients had a whole body PET/CT performed without IV contrast media followed by a contrast‐enhanced CT on the Discovery STe PET/CT scanner. CT data were used for AC and PET images came out after AC. The ROI was set along with them and compared to SUV. A paired t‐test of these results was performed to assess the significance of the difference between the SUV obtained from the two attenuation corrected PET images. Results: The mean and maximum SUV for different regions averaged over all Patients. Comparing before using Contrast Media and after using, Most of ROIs have the increased SUV when it did Contrast Enhanced CT (CECT) compare to Non‐Contrast enhanced CT (NCCT). All regions have increased SUV and also their p value was under 0.05 except the meanSUV of the Heart region. Conclusion: In this regard, the effect on SUV measurements that occurs when a contrast‐enhanced CT is used for attenuation correction could have significant clinical ramifications. But some submitted thesis insisted that the percentage change in SUV that can determine or modify clinical management of oncology patients is small. Because there was not much difference that could be discovered by interpreter. But obviously the numerical change was occurred and on the stage finding primary region, small change would be base line, such as the region of liver which has greater change than the other regions needs more attention. Mean and Maximum SUV for Different Regions Regions
Non Contrast enhanced Contrast Enhanced Computed Computed Tomography Tomography(Mean±SD) (Mean±SD)
Increase of SUV (p value)
Liver max SUV Liver mean SUV
2.48±0.59 1.99±0.41
2.97±0.59 2.13±0.41
16.5% (0.01) 6.5% (0.01)
Lung max SUV Lung max SUV
0.52±0.10 0.42±0.09
0.58±0.13 0.46±0.11
10.3% (0.01) 8.7% (0.04)
Heart max SUV Heart mean SUV
2.11±0.39 1.61±0.32
2.41±0.42 1.76±0.53
12.4% (0.01) 8.5% (0.23)
TP044 Comparison of Glucose metabolism measured by FDGPET/CT and Cellularity obtained from MRI for malignancy evaluation of pancreatic tumor K. Tanimoto1, K. Yoshikawa1, T. Obata1, S. Toubaru1, S. Ohashi1, M. Hasebe1, T. Shiraishi1, K. Watanabe1, T. Saga1, H. Ikehira1, J. Mizoe1, T. Kamada1, H. Tsujii1, A. Kato2, M. Miyazaki2; 1National Institute of Radiological Sciences, Chiba, JAPAN, 2Chiba University, Chiba, JAPAN. Objectives FDG‐PET provides quantitative information about tumor glucose utilization witch is useful for clinical diagnosis of tumor diseases. Standardized Uptake Value (SUV) is most commonly used for evaluation of tumor glucose utilization. But, SUV is affected by many factors that cannot be controlled or even taken into account. In that respect, brain reference index (BRI: ROI of tumor / ROI of cerebellum) is one of the novel quantitative approaches to eliminating the variety of factors that affect SUV. Meanwhile, a MRI pulse sequence could reveal the information about tissue cellularity. This information is useful to evaluate tumor nature. It suggests that it can
be useful in the evaluation of malignancy in the lesions. We compared the role of glucose metabolism and cellularity for detection of pancreatic tumor malignancy. Materials and Methods PET/CT: Toshiba Aquiduo, LSO crystals, 3D acquisition mode: 3min, OS‐EM Iteration: 4, Subset: 14, Gaussian post filter: 8.0mm 16 Multidetector‐row CT, 120kV, Automatic exposure control (160 effective mAs), Helical pitch: 15mm/rot. MRI: GE healthcare Signa HDx 3T Pre‐surgery patients with primary pancreatic tumor underwent a whole body FDG‐PET/CT and 3Tesla MRI. The malignancy or benignancy of excised specimens was pathologically confirmed in all cases. Tumor glucose utilization was evaluated with SUV and BRI in FDG‐PET/CT study, and tumor cellularity was determined with MRI factors, apparent diffusion coefficient (ADC), T2 value and tumor to non‐tumor ratio of proton density (TNRPD) in MRI study. l ADC were measured with a diffusion weighted image (DWI) using a spin‐echo echo‐planar sequence (TR=10s; TE=80ms; b factor=0, 400, 800,1200s/mm2). l T2 value and proton density were measured with a spin‐echo sequence (TR=3s; TE=40, 60, 80, 100ms). l We calculated TNRPD from proton density values of tumor and normal pancreas. We compared these results with pathological findings. Results FDG uptake tended to be higher in malignant tumor than benign tumor. BRI seemed to distinguish malignant lesions from benign lesions more clearly than SUV alone. ADC was lower in malignant tumor than benign tumor. Malignant tumors showed higher TNRPD than benign tumors. Conclusions The tumor that shows high SUV, high BRI, low ADC, high TNRPD, high T2WI and high DWI indicate a high probability of pancreatic tumor malignancy. FDG‐PET/CT in combination with MRI was superior to each modality alone for evaluating tumor malignant nature.
TP045 Usefulness of applying Macro for SPM Processing in Brain SPECT&PET K. Gye Hwan, L. Hong Jae, K. Jin Eui, L. Hyeon Joo; Seoul National University Hospital, Seoul, REPUBLIC OF KOREA. Purpose : Diagnostic and functional imaging softwares in Nuclear Medicine have been developed significantly. but, there are some limitations which like take a lot of time. In this article, We introduced that the basic concept of macro to help understanding macro and its application to NM computer processing. We adopted macro software to SPM and PACS verify processing of Brain SPECT&PET. Material and Method : In Brain SPECT&PET, we choose SPM and PACS verify works which have large portion of a work. We made SPM process & PACS verify process to be more simple by using macro program. and, We compared time for making result by hand with making result by macro program. Finally, we got results by applying times to number of studies in 2007&2008. Results : In 2007&2008, the number of SPM studies were 1075 and the number of PACS studies were 1610 according to Diamox study. It was taken 10 to 15 minutes for SPM work by hand according to expertness and 5 minutes and a half was uniformly needed using Macro. After applying needed time to the number of studies, we calculated an average time per a year. When using SPM work by hand according to expertness, 179 to 268 hours were needed and 98 hourswere needed for using Macro. When using PACS work by hand, 2 to 3 minutes were needed and for using Macro, 45 seconds were needed. After applying theses time to the number of studies, when working by hand, 53~80 hours were needed and for using Macro, 20 hours were needed. Following by these results, it was shown that 33 to 60 hours were saved. Therefore, we could save 45 to 63% for SPM, 62 to 75% for PACS work and 55 to 70% for total Brain SPECT&PET processing in 2007&2008. Conclusion : On the basis of the number of studies, there was significant time saved when we applied Macro program to brain SPECT&PET processing and also it was shown that even though work is taken a little time, there is a possibility to save lots of time according to the number of studies. It gives time on technologist's side which makes radiological technologist more concentrate for patients and reduce probability of mistake. Appling Macro to brain SPECT&PET processing helps for both of radiological technologists and patients and contribute to improve quality of hospital service.
TP046 Dual time-point 18F-Choline PET/CT imaging for improved diagnostic image quality M. de Bloeme, J. Trinckauf, T. F. Hany, T. Berthold, S. Knöfel, D. Beutel, S. Epp; University Hospital Zürich, Zürich, SWITZERLAND. Aim: The aim of this retrospective study was to evaluate the role of dual time‐point imaging in 18F‐Choline (FCH) PET/CT (DT‐FCH‐PET/CT) regarding A) diagnostic image quality and B) diagnostic accuracy in patients with proven local recurrence. Material and methods: In this retrospective study, dual‐time point FCH PET/CT of 20 patients (mean age 62.5, 51‐74) with a proven local recurrence of prostate cancer (PCA) after radical surgery was evaluated regarding the detectability of the local recurrence and the FCH‐uptake in normal lymph nodes. Dual time‐ point FCH‐PET/CT using a standard dose of 200 MBq F‐18 Choline was performed on a 16‐ or 64 slice PET/CT system (Discovery STE/RX, GE Healthcare) following: 1) low‐dose CT from the pelvic floor to the head, 2) 2 minutes after intravenous FCH injection, PET emission data 2 minutes/bed‐ position starting at the pelvic floor to the head (6 bed‐positions = 12 minutes) 3) Subsequently, repetition of PET data acquisition starting again at the pelvic floor. Total imaging time = 24 minutes. Subjective and objective PET/CT image data analysis of the early and late scan were evaluated on a dedicated soft‐ware (AW workstation, GE Healthcare). Standard‐uptake values (SUV) in the local recurrence and possible uptake in regional lymph nodes were measured. Further, bladder contamination in the early and late scan were described. Results: In none of the 20 patients, uptake in the bladder was seen in the early scan, on the other hand, in all late scans, this was present. In all patients, the local recurrence was visible on the early scan, however in 5 of 20 patients (25% false negative), the local recurrence in the late scan was not discernible from bladder activity in the late scan. In 13 of these 15 with visible uptake in the recurrence, SUV increased form average 2.9 to 4.3. Overall, 36 lymph nodes were visible in 19 patients which demonstrated a reduction of SUV in 88% of patients (average SUV initial: 2.2, average SUV late: 1.4). Conclusion: Dual phase FCH‐PET/CT imaging for recurrent PCA is easily performed, early scanning after 2 minutes improves detectability of the local recurrence by reduction of false negative findings related to physiological accumulation of FCH in the bladder. Further, cancer tissue does typically demonstrate increased FCH uptake in the late phase compared to early phase, contrary to uptake in non‐malignant probably inflammatory lymph nodes.
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Technologist management of radiopharmaceutical laboratory according with new Italian roules. F. Buffoni; Fondazione IRCCS Ospedale Mangiagalli, Regina Elena, Milano, ITALY.
Maggiore
-
Policlinico.
INTRODUCTION:At July 31st 2005 the Italian government approved the supplement of the XI Edition of the Italian Official Pharmacopeia. This includes a chapter about the rules for a good preparation of the radiopharmaceuticals in Nuclear Medicine (RGPR‐NM), where the requested specific criterions for manipulation of the radiopharmaceuticals can be found. AIM:To point out the economic and procedural impact that new rules will have in nuclear medicine departments in the observance of the rules in force on the matter of safety and radioprotection of the patient and the worker (D.Lgs n.187/00 and D.Lgs n.241/00) and safety of the working places (L. n.626/94). METHODS:First phase: analysis of: ‐ compliance of premises and equipment in use; ‐ hotlab workflow organization and supply of the services. Second: constitution working team composed by a NM director, a Nuclear Medicine physician, a physicistwith higth competence in radiation protection, a radiochemist, radiologist technician. Third: periodic meetings. RESULTS: Fulfilment of feasibility studies, estimates, financial coverage, contracts and traceableness of new premises (the classification of the new premises and equipment considered in the rules needs dedicated spaces). Presentation to the medical facility direction a project for the structural improvements needed for the updating of the premises. CONCLUSIONS: Although the laws‐ making of the RGPR‐NM took place in 2005, we have to consider the time required for the setting of these measures. The operations that must be done are economically onerous and difficult for the functionality because the execution needs an important period. During this time the dept. will work at a low speed or only for the emergency cases. On the programmatic matter, the ideal period for these interventions could be the month of August which is already a month of low‐ demand of services. This would make possible to interrupt the activity on the expiry term of the validity of the decree and to reopen to the public with the structures adequate to the laws.
TP048
offers the possibility of printing a detailed report of each study. These forms are included in a software called Nucleolab, which is freely available at http://serfa.radiofarmacia.org/?m=27 Conclusion: The software we have developed has an easy‐to‐use interface, that makes the calculation complexity of red cell volume and plasma volume completely hidden for the user, saving you the time that you previously spent on these laborious calculations and reducing the risk of error.
TP050 A phantom study evaluating the cut off threshold in SUV calculating process H. Park, S. Lee, J. Kim, H. Lim, J. Kim, C. Lee, J. Lee; Severance Hospital, Yonsei University Health System, Seoul, REPUBLIC OF KOREA. This study would like to obtain the cut off threshold which has high reproducibility of the tumor volumes and the differences of the tumor volumes in terms of the changes in cut off threshold. PET‐CT Phantom TM (10, 13, 17, 22 and 28mm: 5 sphere) was used. F‐18 FDG was mixed with water. The radioisotope was put into the spheres whose concentrations range from 2, 4, 6, 8, 10 times more intensive, respectively. The difference of the tumor volume from each set of cut off threshold was compared with the sphere’s actual size and the size of the reproduced image. The SUV of the each sphere’s hot regions were taken from whole images. When both the SUV and the diameter of tumor were increasing, the SUV was increasing and the size of tumor was expanding. When the diameter of tumor was decreasing, the size of tumor was expanding. When both the SUV and the diameter of tumor were decreasing, the size of tumor was reducing. When the SUV was decreasing and the diameter of tumor was increasing, the size of tumor was reducing. The cut off threshold was obtained from quadrant correction table considering the image of tumor size and the SUV. In terms of the set of the SUV in PET/CT system, if data of the difference of tumor volume applied to clinic, it would help to have more corrective diagnosis. And this will stimulate the further study that provides more correct tumor volume.
Usefulness of the Determination of the Early Radioiodine Thyroid Uptake Test in Prediction of Outcome of GravesBasedow Hyperthyroidism during Antithyroid Drugs Treatment
TP3 ‐ Tuesday, October 13, 2009, 08:00 ‐ 09:30, Hall 117
T. Topuzovic, N. Topuzovic, J. Smoje, I. Mihaljevic; Clinical Hospital Osijek, Osijek, CROATIA.
Ga-68-DOTATOC PET/CT - Potential Pitfalls in the Volume of the Upper Abdomen
Introduction: Antithyroid drugs may be proposed as the first line therapy for hyperthyroidism due to Graves‐Basedow disease. But, as the response to antithyroid drugs treatment for Graves‐ Basedow disease is unpredictable, it would be useful to have test that could predict outcome during treatment and, therefore, to initiate the most appropriate form of therapy in individual patients. Aim: To evaluate the usefulness of the determination of the early radioiodine thyroid uptake test in predicting both persisting hyperthyroidism and the onset of remission during antithyroid drugs therapy of hyperthyroidism. Patients and Methods: We performed a retrospective survey of 67 patients (58 women and 9 men; mean age 36 years), from our thyroid clinic database, presenting with a first episode of Graves‐Basedow disease. Graves‐Basedow disease was defined as the presence of biochemical hyperthyroidism (raised serum free T4 and T3 concentration and undetectable TSH) together with the diffuse goiter and significant titer of thyroid peroxidase and/or thyroglobulin autoantibodies. Our policy over the period of the study was to offer a course of an antithyroid drug (carbimazole or propylthiouracil) combined with L‐ thyroxine for 12 ‐ 18 months in the hope of achieving remission. Early thyroid uptake test (TST) was performed 10 minutes after intravenously injected 370 KBq (10 µCi) Iodine‐131. TST was estimated every 6‐8 weeks together with thyroid hormone during combined therapy with antithyroid drugs and L‐thyroxine. Remission was defined when TST reached value below 4% together with suppressed TSH and normalized FT4 and FT3. Results: By using a cut‐off limit of 4% TST outcome of Graves’ hyperthyroidism after a course of antithyroid drugs was 1) successful (euthyroid for at least 6 months after withdrawal of thionamide treatment) in 50 patients, and 2) failed (persistent or relapsed disease after a full course of thionamide treatment) in 17 patients. In 7 of them radioiodine therapy was considered, in 4 younger patients surgery was advised and in 6 patients antithyroid drugs treatment was continued. Conclusion: Determination of the early radioiodine thyroid uptake test can be a useful guide to management of Graves‐Basedow hyperthyrodism by promptly identifying patients likely to benefit from antithyroid drugs treatment from those with permanent hyperthyroidism who need further radical (radioiodine or surgery) therapy.
A. Winter, R. A. Bundschuh, A. Al-Ibraheem, A. Buck, M. Schwaiger, K. Scheidhauer; Klinikum rechts der Isar der TU München, München, GERMANY.
TP049
Comparison of irregular manual adjusted and regular elliptic regions of interests for the calculation of relative renal function in Renal Scintigraphy with 99mTc-DMSA
A software for automatic calculation of red cell volume and plasma volume by isotopic diluiton method J. L. Gómez-Perales1, A. García-Mendoza2, R. Rodríguez Aguilar1, A. García-Curiel1; 1Nuclear Medicine Service, Hospital Universitario Puerta del Mar, Cádiz, SPAIN, 2Nuclear Medicine Service, Hospital Universitario San Cecilio, Granada, SPAIN. Introduction: A nuclear medicine study is the gold standard for blood volume measurement. Blood volume studies using the indicator dilution technique and radioactive tracers have been performed in nuclear medicine departments for over 50 years. The calculation of red cell volume and plasma volume are not very complex but annoying and time‐consuming. Objective: The aim of this study is to develop a computing facility to automatically calculate the red cell volume and plasma volume. Materials and methods: the equations used in the calculations are RCV = S R Vs Hv / B PV = BV ‐ RCV BV = RCV / (f Hv) VP = S R VS / P0 BV = PV / (1 ‐ Hb) RCV = BV ‐ PV Predicted mean normal red cell volume and plasma volume by The Espert Panel of Radionuclides of the International Council for Standardization in Haematology ( ICSH): For males: RCV = (1486 x S) ‐ 2 825 PV = 1578 x S For females: RCV = (1.06 x age) + (822 x S) PV = 1395 x S S = surface area (m ) S = h0.425 x w0.725 x 0.007184 For developing a software incorporating these calculations we have used Visual Basic 6.0 and Visual Studio Installer. Results: We have developed two forms for easy calculation of red cell volume and plasma volume. This forms relie on a database to store, manage and retrieve the data of red cell volume and plasma volume studies. Moreover the form
Technologists Poster Session 3
TP051
Objectives: Ga‐68 DOTATOC PET/CT recently became an important tool for diagnosis, staging and therapy control of neuroendocrine tumors expressing somatostatin receptors. In the area of the upper abdomen a severe problem is the hepato‐biliar excretion of the tracer, which can lead to focal uptake in the pancreas head and the duodenum in later time frames. Additionally, respiratory movement can lead to smearing artefacts and misalignment between PET and CT images and hence to a wrong attenuation correction. Methods: 47 consecutive Ga‐68‐DOTATOC studies (acquisition start 20‐30 minutes after injection of 100‐130 MBq of the tracer) were analyzed. For quantification of misalignment in the upper abdomen the distance between the liver dome in PET and CT images was measured in sagittal slices. Images were analyzed for focal uptake in the upper abdomen. Results: In 27 patients (57 %) misalignment was more than 1 cm and considered as influencing the diagnostic accuracy. In these patients the misalignment ranged from 1.1 to 5.7 cm (mean 2.5 cm). Therefore, misalignment was corrected by manual shifting of the image sets (PET vs. CT). In 17 (36 %) of the patients focal uptake was found in the area of the pancreas. Only in 3 patients, a malignant process of the pancreas was histopathological proven. The other findings were either found to be duodenal uptake or interpreted as physiological uptake due to hepato‐biliar excretion, as there was no tumor correlate in the clinical follow up of at least 6 month. Conclusions: Using Ga‐68‐DOTATOC demands good correlation between PET and CT data in the upper abdomen, therefore breathing commands and careful instruction of the patient is important. Additionally analysis of potential misalignment and consistent correction of the data is substantial. Acquisition timing has to be early to reduce false positive findings in the area of the pancreas head due to physiological processes.
TP052
A. Duarte, P. Santos, S. Chin, A. Santos, M. Filipe; Hospital Garcia de Orta, Almada, PORTUGAL. Introduction: Acute pyelonephritis is a frequent disease in the pediatric age with urinary tract infections. Which can lead to renal scars, with eventual progression to chronic renal failure. Renal scintigraphy with 99mTc‐DMSA is a sensitive and specific method for detection and localization of renal cortex anomalies associated with urinary tract infections and is also the “gold standard” for differential renal function. Renal scintigraphy with 99mTc‐DMSA, also allows the calculation of relative renal function. Aim: The aim of this study is to compare the irregular adjusted to renal region of interest normally used for the calculation of renal function and regular elliptic ROI's in order to reduce possible errors through a simple method. Method: We conducted a 99m retrospective analysis of 100 renal scintigraphy acquired 3 hours after de injection of Tc‐DMSA (111 MBq. Adapted according to body weight), in posterior view, with 300kcts or 10minutes, matrix 256x256, low energy high resolution collimator, in children’s weighing less than 40kg. Of the total cases we had 46 cases with a difference between the two kidneys superior to 5% and 25 cases with a difference superior to 10% (average=10.36). All the cases were processed initially with the usual irregular ROI adjusted to renal region and afterwards with regular elliptic ROI. The results obtained were subjected to linear correlation analysis. Results: We obtained a 0,99 correlation between irregular adjusted and regular elliptic, right and left ROI’s. Of the 100 cases
Poster Presentation
TP047
S488 examined, only 23 showed a difference superior to 1% (average= 0.76). Conclusion: We conclude that the use of regular elliptic regions of interest is a reliable, easy and inexpensive method to calculate relative renal function with renal scintigraphy with 99mTc‐DMSA. Keywords: ROI’s, relative renal function, calculation, DMSA, scintigraphy
TP053 f-18 fdg pet in children: do we have enough counts? p. R. R. Demuynck, H. Ham, A. Dobbeleir, J. Keppens, I. Goethals, Y. D'Asseler, C. Van De Wiele; Uz Gent University Hospital, Gent, BELGIUM. Aim: Based on guidelines, the range of the recommended F‐18 FDG dose is quite large, ranging from 3.0 MBq up to 7.5 MBq/kg of body weight, and it is not clear whether the use of the lower dose is associated with images of sub‐optimal quality or the higher dose implies unnecessary radiation burden. The aim of the study was twofold: first to find out whether by following the guidelines the number of counts were sufficiently high to guarantee optimal image quality. Second, to determine the optimal time per bed position once a given dose was determined. Material and method: In our institution, children are routinely injected with a dose of 6.5 MBq (175µCi) of F‐18 FDG per kg body weight. Acquisition is started between 45 to 60 minutes after the tracer administration with a duration of 3 minutes per bed position and reconstructed in a matrix of 4 mm3 voxel size. A Jaszczak phantom of 6,64 l was filled with 16 mCi of F‐18, providing an initial concentration of 2,4 µCi/ml, about 10 times higher than the concentration in patients. Emission data were acquired for increasing scan duration in order to obtain scans with 500, 1000, 2000, 3000, 5000, 7000 and 9000 counts per voxel in the phantom. Additionally every hour during 10 hours the same scans with increasing counts were obtained with decreasing concentrations due to decay of F‐18. The final concentration was about 0,05 µCi/ml, about 2 or 3 times less than patient scans. Results: In children, a wide range of regional count density per 4 mm3‐voxel was observed, the highest was noted at the cerebellum (up to 10.000). Beside the cerebellum and the Waldeyer ring, the counts per voxel were usually lower than 2500 counts. Using phantom data we found that up to a certain level, higher count was associated with higher image quality. After that level, a higher dose induced unfavorable randoms to trues ratio resulting contradictorily in degradation of image quality. In patients following the official guidelines, the counts per voxel observed in patients were lower than the minimal required to produce optimal quality images. Conclusion: To improve the total count, hence the resolution of our clinical image, an increase in acquisition time seems to be more advantage than increasing the administered activity.
TP054 Will direct measurements of radiation absorbed dose in vivo be possible? - use of large-area thermoluminescent detectors (TLD) in nuclear medicine, initial report. M. Tomaszuk1, M. Klosowski2, B. Glowa1, A. Sowa-Staszczak1, P. Olko2, A. Hubalewska-Dydejczyk1; 1Nuclear Medicine Unit Endocrinology Department, Jagiellonian University, Medical College, Krakow, POLAND, 2Institute of Nuclear Physics PAN, Krakow, POLAND. Aim of the study: The aim of this study was to present the initial experience with large‐area thermoluminescent detectors (TLD), used on the patient undergoing peptide receptor radiotherapy (PRRT) with 90Y‐labelled compound. Materials & Methods: Thermoluminescent detectors in form of small pellets are well‐known in nuclear medicine. They are commonly used for measuring individual or finger doses for the staff handling labeled compounds for diagnosis and therapy. At the Institute of Nuclear Physics in Cracow large‐area 2D TL detectors based on CaSO4:Dy mixed with high temperature polymer were developed. Dimensions of standard TL detector is 400cm2 (20cm x 20cm) and thickness is 0,3 mm. A special 2D CCD TL reader was built 60 to read them and Co source is used for their calibration. The light output might be correlated with the absorbed dose, like in standard pellets. The aim of these detectors in nuclear medicine is as follows: the detectors attached to the skin of a patient undergoing treatment with 90Y might permit the assessment of the critical organs absorbed dose. First, 2D TL detectors were tested. 99m 90 Conventional 10ml vials with different activity of Tc and Y were surrounded with detectors for 24h to verify their sensitivity and linear response to photon and beta particles, generally used in nuclear medicine. Secondly, the special phantom made from PMMA polymer (plexiglass) (density 1,17 g/cm3) was used for measuring the range of 90Y‐beta particles. Thirdly, two detectors (~10cm2) were stuck to a patient’s skin for 24h in line with the kidneys ‐ critical organs for PRRT therapy (confirmed in USG). The patient with GEP‐NET was undergoing PRRT with 3,7GBq of 90Y‐DOTATATE. Results: Measurements with 10ml vials confirmed detectors sensitivity and linear response to photon and beta particles. The range of 90Y‐beta particle measured with plexiglass phantom by means of 2D detectors was 9mm. Detectors stuck to patients confirmed that the measurements in vivo were possible. Conclusion: In future large‐area thermoluminescent detectors TLD will be still tested in the Department and they are hoped to be used for estimating the dose absorbed by critical organs (especially by kidneys) in an individual patient undergoing PRRT and perhaps for the optimisation of the administered therapeutic activity.
TP055 Advantage of LMEGP collimator in the brain SPECT image acquisition with I-123 labeled radiopharmaceutical; Preliminary evaluation of the image quality using one day rest and rest method. H. Shimada1, H. Otake1, N. Oriuchi2, T. Higuchi2, Y. Arisaka2, Y. Kawamura3, M. Hirai4, T. Numajiri4, K. Endo2; 1Dept. Radiology, Gunma University Hospital, Maebashi, JAPAN, 2Dept.Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, Maebashi, JAPAN, 3Dept. Radiology, Jichi Medical University Hospital, Shimotsuke, Tochigi, JAPAN, 4Dept. Radiology, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, JAPAN.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 [Purpose] Various type of collimator is used in the nuclear medicine study using I‐1 23 labeled compounds. As a quality assurance of 1 day protocol (Rest and Acetazolamide Stress study) of I‐ 123 IMP (N‐isopropyl P(123I)‐ iodoamphetamine ; IMP)brain SPECT, 2 acquisition data obtained using LMEGP and LEHR collimator under 1 day protocol (Both under resting condition) were preliminarily compared each other. [Materials and Methods] Five minutes SPECT data acquisition were started 5 minutes after injection of IMP (111 MBq) and repeated for 4 times (Rest1). At 25 minutes after first injection of IMP, secondary dose of IMP (111MBq) was injected and same acquisition protocol was repeatedly performed. Following to these acquisition study, SPECT count value was calculated and first SPECT data was compared with corrected second image data (true_Rest2). [Results] As a result supporting the accuracy of brain distribution estimation metho d, measured and estimated SPECT values showed significant correlation (R2=0.998). True rest 2/Rest 1 values of LMEGP (n=14) and LEHR (n=9) were 1.018[[Unsupported Character ‐ ア]]0.074 and 1.082[[Unsupported Character ‐ ア]]0.049, respectively. Furthermore, background ratio of projection data for LMEGP and LEHR were 1.866[[Unsupported Character ‐ ア]]0.074 and 1.987[[Unsupported Character ‐ ア]]0.056, respectively. (Rest 2 was calculated by the sum of first and second measured IMP SPECT counts.) [Conclusion] Since scattered fraction is known to increase the count from second I‐123 IMP SPECT, appropriate selection of collimator is important in the I‐123 IMP brain SPECT study. Although our final goal is the application of this method to the clinical evaluation of vascular response by 1 day rest and ACZ stress protocol, various problems such as scattered gamma ray and penetration still remained and therefore, accurate quantification is difficult in nuclear medicine study. However, we can expect some improvement of quantification by understanding the individual character of each SPECT machine.
TP056 Implementation of an acquisition protocol for PET/CT 4D scans R. Mei, M. Fiorenza, M. Ferrari, G. Paganelli; European Institute of Oncology, Milano, ITALY. Objectives: PET/CT 4D scan is a new technological development to follow the organ and lesion motions during the PET and CT acquisitions. Real‐time Position Management (RPM) respiratory gating is one of the available techniques for the respiratory tracking, but it utilizes a bi‐ dimensional system monitoring. Aim of this work was to set up and test a new 3D system of respiratory tracking based on a set of opto/electronic marker. Material and methods: 20 patients affected by hepatic and pulmonary lesions underwent PET/CT 4D using RPM respiratory gating. Studies were performed with a Discovery ST HP60 with Dimension 3D console (GE). The patients were injected with 250 ± 38 MBq of 18F‐FDG and started acquisition 50 minutes after the injection. CT scans were acquired in cine mode with 120 kVp, 90mAs, detector configuration 8 * 2.5 (mm) slice thickness, 0.5 sec gantry rotation and 70cm FOV of acquisition. PET scans were acquired with 9 ‐ 12 minutes time per AFOV. At the beginning of the scan the patient were instructed to breath normally and the zone of maximum extension (thorax or abdomen) was chosen by placing a marker block on the skin of patient. After, the tracking camera was adjusted: the pair of passive reflective markers on the marker block must be in the centre of the camera. Start the acquisition the respiratory gating and control the regularity of patient’s breathing. The PET image was reconstructed with 4D Gated Vip protocol. When the exam was finish all the images and all RPM information sent to Advantage Windows 4.4 (GE), where the match of the different information acquired was possible. RPM respiratory gating system is a breathing scanning method bi‐dimensional, the new system set‐up consist of different (7‐8) skin marker for a complete 3D mode gating acquisition. In an other group of patient the two systems of respiratory tracking were used simultaneously, both the RPM and the multi‐opto electronic marker. With the 3D system the images were reconstructed, different operator checked the differences in the two set of images obtained with the two distinct systems. Results and conclusion: A multiple configuration of marker allowed a better correlation between internal and external structure of the patient, improving PET‐CT 4D RPM image modality.In addition the use of more marker on the abdomen‐thorax region consent to better personalise the breathing motion of each patient, allowing a reduction of the image’s artefact.
TP057 The Usefulness of OsiriX in PET/CT Image Fusion and Maximum Intensity Projection (MIP) H. Choi; National Cancer Center, Goyang-si, Gyeonggi-do, REPUBLIC OF KOREA. Purpose: Recently, the efficiency of PET/CT image processing become more important due to the increasing number of cases of PET/CT. The aim of our study was to assess the benefits of OsiriX which is an open source software for medical images in PET/CT image fusion and MIP. Subjects and Methods: 20 patients Biograph (Siemens) were analyzed after being examined in the nuclear medicine department of the National Cancer Center. After examining the 20 patients, we measured the transfer time of data to Osirix (ver. 3.3.2 32‐bit), the required time of image fusion and MIP in OsiriX and the transfer time of data to PACS in OsiriX. As a standard of estimation, we measured the required time to do image fusion and MIP and the transfer time of data to PACS with workstation (ICS, Siemens). Results: 1) The required time of PET/CT image fusion by workstation (ICS, Siemens) was 410±7sec and the transfer time of fusion images to PACS was 245±4.7sec. 2) The required time of image fusion and MIP in OsiriX was 68.5±1.7sec. 3) The transfer time to PACS from OsiriX was 271.8±6.2sec. Conclusion: We can work more quickly for PET/CT image fusion and MIP by OsiriX. Since OsiriX is able to receive and send images more easily, it is transferred by DICOM communication protocol from any PET/CT equipment. In addition, OsiriX is an Open Source application, which means we'll spend a lot less for the imaging viewer. We believe that the use of OsiriX for supporting existing systems is effective in PET/CT image fusion and MIP Key Words: OsiriX, fusion and MIP, PACS
TP058 The significance of SPECT/CT in the diagnosis of parathyroid adenomas
S489
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
The aim of our study was to determin the role of 99mTc‐ pertechnetat and 99mTc‐MIBI scintigraphy using planar, subtracted, SPECT and SPECT/CT scans in the diagnosis and localisation of parathyroid adenomas. Patients and methodes: 50 hyperparathyroid patients (33 female and 17 male) were observed, in 7 cases because of recurrent disease. Fifteen and 120 minutes after the injection of 370 MBq 99mTc‐MIBI planar scans of the neck and mediastinum were performed, with substraction (99mTc‐MIBI/99mTc‐pertechnetat) in both phases, and 90 minutes after the injection with the completion of SPECT/CT examination. Results: In 22 cases planar, subtracted, SPECT and SPECT/CT scans were positive. In 10 patients parathyroid adenomas were successful extracted and proved by histology. In 1 patient it was a recurrent disease. Nineteen cases were negtive in all examinations. Even so, 1 patient was operated and the histology did not find parathyroid tissue. Besides the negativity of planar and subtracted scans, SPECT and SPECT/CT examinations were positive in 5 cases. One patient with recurrent disease was operated succsessful. In 1 case SPECT image was positive besides the negativity of planar and subtracted scans, but SPECT/CT did not show adenoma in the location of increased cumulation. In 2 patients, on the base of suspect planar and subtracted scans, SPECT and SPECT/CT and succsessful operation confirmed the diagnosis in 1 case, but in the other one SPECT and SPECT/CT did not support that. In 1 case besides the positivity of planar and subtracted scans SPECT and SPECT/CT were negative. Conclusions: In addition to planar and subtracted scans SPECT image increases the specificity and sensitivity of the method but the key to the successful operation is the accurate localisation, insured by SPECT/CT.
TP059 Lung SPECT : Potential interpretation pitfall due to respiratory lung excursions M. Hudournik, M. Kac, B. Poharc, G. Smid, D. Hrastnik, M. Milcinski; Department of Nuclear Medicine, General Hospital Celje, SLOVENIA. Background. When evaluating SPECT V/P scintigrams, different length of lungs was noted during comparison of reconstructed ventilation and perfusion scans, and the reason for this phenomenon was searched for. Aim of our study was to assess the influence of lung diaphragmatic respiratory excursions on lung SPECT scintigrams. Material and methods: lung model was constructed from two sponges, soaked with technetium, approximately 200 MBq per lung lobe. Respiratory movement was simulated moving the model for 2 cm, 3 cm, 4 cm, respectively, in respiratory rate of 20/minute. Tomographic acquisition was performed in both 64 and 128 matrix, two head gamma camera (Siemens‐ e.cam), 180 degrees each, 6 sec per frame, LEHR collimator, acquisition time 6 min. Data were reconstructed using Flash 3D (4 subsets, 8 iterations). Rotating raw images and reconstructed images were evaluated visually for lung base motion. Results: 6 lung scans were processed using routine processing software. Respiratory movement was noted in all matrix size on rotating scan quality control, while after processed tomographic rotating images movement was seen on all others scans except on 128 matrix with movement excursion of 2 cm. Conclusion: care has to be taken during interpretation of V/P lung tomographic images due to possible reconstruction artefacts resulting from movement of lung base in patients with diaphragmatic respiratory excursions more than 2 cm.
TP060 Reproducibility of split renal function on MAG3 dinamic renal scintigraphy M. Hudournik, M. Kac, B. Poharc, G. Smid, D. Hrastnik, M. Milcinski; Department of Nuclear Medicine, General Hospital Celje, SLOVENIA. Aim of our study was to assess reproducibility of kidney function evaluation on dynamic renal scintigraphy in our institution. Materials and methods: consecutive studies of 28 patients (16 adult and 12 children) from archives were included. 99m ‐Tc‐MAG3 dynamic renography was acquired using 128x128 matrix, 10 sec/frame, 192 frames, zoom 1,23 and LEHR collimator. Average applied dose was 120 MBq (dose for children was calculated for age and weight). Studies were processed using commercial renal protocol MAG3 (without samples) with manual ROI delineation. Split renal function was calculated in 1,0‐2,0 min without any correction. All studies were evaluated twice by four technologists. Only renal function was used for this evaluation. Inter‐ and intra‐observer reproducibility analysis was performed. Results: of analysis of the each technologist are presented in table. Table: Results of difference in split renal function for separate technologist, 2 analyses each
A1:A2 B1:B2 C1:C2 D1:D2
MAX
10,1 9,1
4,4
7,3
MIN
0,0
0,0
0,0
0,0
AVERAGE 1,7
2,1
1,5
2,0
The mean differences between the technologists were from 0 to 19,9%, average 2,7 %. Conclusion: Reproducibility of split renal function calculation in repeated analysis for each technologist is good and better than the inter‐tecnologist reproducibility; however, difference can be quite high even when using standardized analysis without influence on time‐range for renal function calculation.
TP061 Abnormal finding on bone scintigraphy S. Martinali-Couwenberg, R. J. Kooistra, Westfriesgasthuis, Hoorn, NETHERLANDS.
G.
M.
M.
Gommans;
The aim The aim of this case report is to demonstrate an abnormal finding on bone scintigraphy. Methods A 51 year old female with proven breast cancer was presented to the department of Nuclear Medicine. Bone scintigraphy was performed to evaluate the presence of metastases. At examination time no further clinical history except normal X‐ray of chest, lumbal spine, pelvis was available. Scintigraphy was performed 2 hours after administration of 550 MBq 99mTc HDP. Results Scintigraphy showed no focal uptake of metastasis. An unexpected finding of
considerably soft tissue uptake and extremly pulmonary uptake was seen. To exclude a possible failure on labelling of 99mTc HDP or to exclude an incorrect administration of the radiopharmaceutical, bone scintigraphy was repeated five days later. Both scintigraphies showed the same abnormality. To further check out patient medical history, research was performed in three different hospitals. History found: in 1998 the patient underwent in hospital 1 a kidney transplant because of renal failure and in hospital 2 a parathyroidectomy. Retrospectively at time of bonescintigraphy the blood values of the patient showed an abnormal value of creatinine (395 micromol/l), a normal value of calcium (217 mmol/l) and an abnormal parathyroid hormone value (30.4 pmol/l). A recently performed ultrasound of the abdomen reported some micro calcifications in the liver. Conclusion In spite of normal chest X‐ray and no prove of microcalcifications in lungs, abnormality of diffuse lung activity and soft tissue uptake as seen on the bone scintigraphy were due to chronic renal failure.
TP062 Intra-acquisition variation during PET/CT: a factor to take into account for radiotherapy treatment planning. B. Verhoeven, E. van Mierlo, N. Marmouk, A. van Dijk, A. Arens, M. van de Pol; Institute Verbeeten, Tilburg, NETHERLANDS. Purpose Evaluation of the intra‐acquisition variability during PET/CT in lung cancer patients. Background The target for radiotherapy includes the visible tumor plus a margin for subclinical disease. This volume is expanded to allow for uncertainties in planning or treatment delivery. One of these factors is patient movement during image acquisition for radiotherapy planning. Displacement of skin marks is proven to be a useful surrogate for patient motion during both image acquisition and radiation treatment. We evaluated the patient motion, so called intra‐ acquisition variability, during both whole body and thoracic range PET/CT scans in lung cancer patients. Material and Methods For the PET/CT scan (Gemini ‐ Philips Medical Systems), 10 patients were immobilized were immobilized in supine, treatment position using arm and leg support and a flat table top. Patients were aligned by in‐room lasers and six skin marks were placed prior to the scanning procedure. Subsequently a whole body PET/CT scan was acquired (median bed positions: 10, median acquisition time 30 minutes). The position of the skin marks after the acquisitions was localized using the in‐room laser system. After completing the whole body acquisition, a thoracic range PET/CT was acquired in 9 patients (median bed positions: 2; median acquisition time 7 minutes) Again, localization of the skin markers was repeated. The differences between the position of the skin marks before and after both whole body en thoracic range PET/CT were calculated. Displacements of less than 2mm in mediolateral and craniocaudal direction and 5mm in ventrodorsal direction were considered to be acceptable for PET/CT scans used for target definition. Results During the whole body acquisition, the mediolateral displacement in 4 out of 10 patients and the craniocaudal displacement in 3 patients exceeded the 2mm. The ventrodorsal displacement was in 5 patients more than 5mm. Based on the above‐ mentioned criteria, the patient‐movement during only 2 out of 10 whole body acquisitions was appropriate for target volume definition. The displacements during the thoracic range scans were significantly less disturbing. Seven out of 9 scans were eligible for radiotherapy planning. Conclusion We described a practical method with minimal workload to analyze the intra‐ acquisition variability, an underestimated factor in setup‐uncertainties for lengthy acquisition procedures such as PET/CT. Based on our series, we advocate the use of this method to ensure that the intra‐acquisition variability is small enough and moreover we recommend using the thoracic range PET/CT for radiotherapy planning in lung cancer.
TP063 Influence of a carbohydrate restricted diet on the myocardial 18 uptake of F-FDG I. Strijbosch, I. M. de Bruin-Hakkert; St. Antonius Hospital, Nieuwegein, NETHERLANDS. Aim 18F‐FDG PET might be useful in detecting inflammatory processes in the heart. However, 18 there is a physiologic uptake of F‐FDG in the myocardium. To increase the sensitivity of PET in detecting inflammatory lesions in the heart, the physiological 18F‐FDG uptake in the myocardium needs to be suppressed. This physiologic uptake might be reduced by the use of a carbohydrate restricted diet. The aim of this study is to analyze the effect of a carbohydrate restricted diet on myocardial 18F‐FDG uptake. Material & methods One hundred patients without a cardiac history, undergoing 18F‐FDG PET, were prospectively analysed. Patients were randomised to follow a carbohydrate restricted diet on the day before imaging (Group I) or no specific dietary instructions were given before imaging (Group II). All patients filled out a questionnaire to verify their meals. Myocardial uptake of both groups was evaluated by measuring the maximum standardized uptake value (SUVmax) over the left and right ventricle. Data were expressed as mean ± SD. Results The average SUVmax for Group I was 2.9 ± 1.6 (n = 48) and 4.8 ± 2.9 for Group II (n = 52), (p < 0.001). Conclusion Using a carbohydrate restricted diet resulted in a significantly lower myocardial 18F‐FDG uptake. This could facilitate the detection of inflammatory processes in the endocardium, myocardium and epicardium. These findings are important because the carbohydrate restricted diet might increase the sensitivity of 18F‐FDG PET in cardiac inflammation such as endocarditis, cardiac sarcoidosis and pericarditis.
TP064 Action protocol of the technician in the sentinel limph node biopsy L. Roque Caballero, A. I. Saiz Guadalajara, J. I. Rodriguez Melcón, M. D. Guerrero Trujillo, J. Montavez Sánchez, A. Pais García, J. Moreno González, I. Martín Soto, M. J. Pereira Rodriguez, A. Cantón Serrano, L. M. Martín Curto; Hospital Universitario La Paz, Madrid, SPAIN. AIM To determine the technician nuclear medicine protocol action in the realization of the sentinel lymph node biopsy after incorporation of the SPECT/CT in our service. MATERIAL AND METHODS We have created a new protocol in our service since the SPECT/CT installation in July 2008. The material used for the study is: 1‐ Cold kit nanocolloid albumin with a minor or equal diameter to 80nm. 2‐ One head gamma camera Siemens orbiter. 3‐ SPECT/CT GE Infinia Hawkeye 4. 4‐ Gamma probe: Europrobe. The cold kit must be labelled firstly with 99mTc and incubate at
Poster Presentation
E. Schmidt1, Z. Szabó1, K. Dérczy2, C. Weninger2, S. Szekeres1, M. Sarkadi1, K. Zámbó1; 1University of Pecs Dept. of Nuclear Medicine, Pecs, HUNGARY, 2University of Pecs Dept. of Radiology, Pecs, HUNGARY.
S490 room temperature during 40 minutes. Acquisition images of breast cancer patients are made 30 min postinjection. During this time, patients must massage themselves the injection point. The study begins with planar images acquisition in lateral and antero projections, using a matrix 256X256, zoom: 1, time and number of counts changes depending on the obtained images. It is necessary to cover the injection point using a shielding. Using a pointer, the patient contour must be drawn in order to mark the lymph node location in the skin. For melanoma patients, the radiopharmaceutical injection is realized on gamma camera, obtaining dynamic images of 10 images of 10 seconds with a matrix of 64X64 and zoom of 1. As in breast cancer planar images must be obtained. Once static images acquisition is finished, the SPECT/CT study of the zone where lymph nodes have been located is done in both cases, placing the patient in supine position and arms down. The acquisition parameters are: 1‐ SPECT: Zoom: 1, matrix 128X128, angle of 360 º, with 120 images, 25 seconds for image. 2‐ Axial CT: slice width 5 mm, 140Kv, 2.5 mA We obtain SPECT /CT low dose CT images, tomography emission images of nuclear medicine and fusion images. This procedure allows a more lymph node anatomical location. Once images acquisition is finished the physician will use the probe in order to locate the highest count point in the skin that corresponds with the sentinel lymph node. CONCLUSION Thanks to the introduction of SPECT/CT and implement of this protocol we have improved the anatomical sentinel lymph node location.
TP065 Is monitoring of ejection fraction necessary in patients treated with cardiotoxic drugs for multiple sclerosis? G. Nehme, M. H. B. Frederiksen, B. Hesse, P. S. Oturai; Rigshospitalet, Copenhagen, DENMARK. Background: Mitoxantrone (MIT), an immuno‐suppressive agent, is useful in the treatment of subgroups of patients with multiple sclerosis (MS), but MIT has also been associated with development of irreversible cardiomyopathy. Repeated examinations with radionuclide MultiGated Acquisition (MUGA) or echocardiography for determination of left ventricular ejection fraction (LVEF) is therefore recommended. However, little systematic evidence is available showing the frequency of heart failure development or the prophylactic value of LVEF monitoring. The aim of this study was to evaluate the outcome of LVEF monitoring by MUGA in our hospital (Rigshospitalet, Denmark). Material and methods: In 2004‐2008 131 MS‐patients (59 male, 72 female) were referred to MUGA because of MIT‐treatment. Mean age at first MUGA was 43 years (SD=9.9). After iv. injection of 600 MBq 99mTc‐labelled human serum albumin (Vasculosis®) an acquistion over 15 minutes with the camera in a 30‐45o LAO was made on a ADAC‐Thyrus or Mediso‐45 gammacamera. LVEF was calculated on an eNTEGRA workstation using an automated EF‐processing program. Normal value for LVEF is ≥0.50 in our department, and a change in LVEF by ≥0.10 is considered significant. Most patients (n=96) had only one examination performed (=baseline LVEF before start of MIT treatment). 20 patients underwent MUGA twice, 12 patients 3‐4 times, and 3 patients ≥ five times. The number of MUGA scans cancelled due to the patient not turning up was compared to cancer patients in treatment with other cardiotoxic chemotherapy. Results: Median LVEF at baseline was 0.64, ranges 0.49‐0.77. In the 35 patients undergoing 2 studies or more median LVEF changed from 0.64 to 0.62 at second MUGA (p<0,05). Only one patient obtained a subnormal LVEF at the second study, but the decrease was only from 0.50 to 0.48. 11 patients experienced a decline in LVEF of ≥0.10 during the examinationperiod. For comparison only 2 patients had a rise in LVEF of ≥0.10. 18% of planned MUGA scans were cancelled because patients failed to be present, compared to 5% among the oncologic patients. Conclusion: The significant reduction (≥0.10) of LVEF in nearly one third of the patients undergoing repeated MUGA scans confirms earlier observations of a cardiotoxic effect of MIT. But the clinical importance of cardiac monitoring is still uncertain in relation to the absence of subnormal LVEF as observed in our patients. Together with almost 20% cancellations it emphasizes the need for a systematic evaluation of the cardiotoxic risk and cost‐ effectiveness in MS‐patients treated with mitoxantrone.
TP066 Development of attenuation correction for a combined PET/SPECT/CT scanner K. Matsumoto1, Y. Magata2, Y. Wada3, H. Yamaguchi2, K. Murase4, T. Mukai1, Y. Watanabe3; 1Kyoto College of Medical Science, Kyoto, JAPAN, 2 Hamamatsu University School of Medicine, Hamamatsu, JAPAN, 3RIKEN, Kobe, JAPAN, 4Graduate School of Medicine, Osaka University, Suita, JAPAN. Aim: For quantitative small animal PET/SPECT information, correction of tissue photon attenuation is mandatory. Generally in conventional small animal PET/SPECT, the attenuation map is obtained from a transmission scan, which uses a rotating radionuclide source. However, in the case of PET/SPECT/CT scanners developed in recent years, the attenuation map can be calculated from the X‐ray CT image instead. The purpose of this study was to develop the X‐ray CT attenuation correction in the small animal PET/SPECT scanner. Methods: A PET/SPECT/CT scanner, Gamma Medica‐Ideas FX system, was used to scan images two type animal, a rat and rabbit. The X‐ray CT pixel values in Hounsfield units were transformed into linear attenuation coefficients in cm‐1, using a conversion formula for a lookup‐table from phantom experiments. The phantom experiment used three kinds of phantoms with a different diameter. Measured activity concentrations from identical regions of interest in representative normal organs and in pathologic foci uptake were evaluated. Also, quality of the reconstructed images was assessed using the profile curves brain and thoracic regions. Results: In the rabbit for the PET scan, the activity concentration of X‐ray CT‐corrected images was approximately two times higher than the without X‐ray CT‐corrected images. As for the phantom experiments, the profile curve of the X‐ ray CT‐corrected image was flat curve. Conclusions: This method allows reliable X‐ray CT‐based attenuation correction for small animal PET/SPECT scans. Further work is necessary to validate the method for different animal imaging.
TP067 Scintigraphic detection of Extramedullary Hematopoiesis in CT findings
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 B. Ferreira, A. Fonseca, L. Pereira, I. Paula, T. Coutinho, I. Ruiz, H. Duarte, A. Lima Bastos; Nuclear Medicine Department, Instituto Português de Oncologia Francisco Gentil Porto, Oporto, PORTUGAL. Aim: Extramedullary hematopoiesis is defined as the recurrence after birth of normal marrow outside the skeleton. It occurs in chronic hemolytic states, ineffective erythropoiesis, myelophtisic conditions and in myeloproliferative disorders as an attempt to compensate for the anemia. Most frequently, the extraskeletal marrow is present in liver and spleen. With this work we pretended to evaluate the use of 99mTc‐nanocolloid scintigraphy in the differential diagnosis of masses previously detected by CT in order to confirm the presence of suspicious extramedullary hematopoiesis. Materials and Methods: We describe a case of a 65 years old female patient, with history of spherocytosis, anemia, who had performed an abdominal CT, which revealed the existence of paravertebral masses. To relate the existence of extramedullary tissue with the CT findings, a 99mTc‐Nanocolloid scintigraphy was executed. In order to do this study, wholebody image acquisition was performed 10 minutes after iv injection of 296 MBq 99mTc‐Nanocolloids (Dual Head SIEMENS E‐CAM, 256x1024 matrix, scan speed 7 cm/min, LEHR collimators). For a better identification of this suspicious extramedullary tissue, we also performed a SPECT (128x128 matrix, 128 frames, 40 sec/frame) and CT (SIEMENS PET‐CT Biograph 6, 130kV, 94 mA, slice 5mm) acquisitions which were fused to provide anatomic location of the masses and thus a more accurate diagnosis. Since SPECT and CT images were acquired separately in different devices patient position was carefully handled in order to achieve a good image co‐registration. Results and Conclusion: We observed nanocolloids uptake in paravertebral masses at D9‐D11 level, which were related to the presence of extramedullary hematopoietic tissue. The fusion between SPECT and CT images enabled us to locate the activity in the paraspinal region corresponding to the masses seen on CT, and by doing so, proving that they were indeed extramedullary hematopoietic tissue. 99mTc‐Nanocolloids Scintigraphy is a suitable, sensitive and noninvasive method to establish the presence of extramedullary marrow, providing functional information which could not be retrieved by the CT scan. SPECT and CT images fusion improved study accuracy, allowing the correct identification of extramedullary hematopoietic tissue.
TP068 Measurement of cellular amino acid uptake iodine/astatine-labeled L-phenylalanine derivates
using
Z. Korkmaz, T. Petrich, D. Krull, G. J. Meyer, W. H. Knapp; Medizinische Hochschule, Hannover, GERMANY. Aim Brain tumors often demonstrate increased protein metabolism and amino acid uptake. Therefore, radiolabeled amino acids like phenylalanine (Phe) are interesting tracers for metabolic imaging and therapy of these tumors. Compared to beta‐emitting radionuclides, alpha‐emitters are known to exert substantial biological toxicity due to their high ionization capacity. To develop an experimental radionuclide based therapy concept for brain tumors, we labeled Phe with the alpha‐emitter astatine (At‐211). We compared the uptake mechanism of various astatinated derivates with that of iodine‐labeled Phe in a glioma cell line in vitro. Material and Methods At‐ 211 was produced in the MHH‐cyclotron unit following the Bi‐209(α,2n)At‐211 reaction and trapped in methanol. We labeled o/p‐bromo‐L‐phenylalanine with I‐131 (o/p‐I‐131‐Phe) and p‐ iodo‐L‐phenylalanine with At‐211 (p‐At‐211‐Phe) using non‐isotopic/isotopic Cu+ assisted exchange. The specific activity of o‐I‐131‐Phe was 4.1 MBq/µmol and that of p‐I‐131‐Phe was 9.1 MBq/µmol. The specific activity of p‐At‐211‐Phe was 5.4 MBq/µmol and 7.4 MBq/µmol. The human glioma cell line DBTRG‐05MG was grown at 37°C with 5% CO2 in RPMI1640 medium in 24‐ well plates (1x105 cells/well) over 24h. For measurement of cellular uptake kinetics, glioma cells were incubated with 20‐640kBq (0.2‐8x106cpm) I‐131‐ or At‐211‐labeled L‐Phe over 30min. After the cells were washed with ice‐cold bHBSS buffer, 1ml ethanol was added to extract intracellular labeled Phe and gamma counting was performed. As a control, intracellular transport inhibition was measured using unlabeled L‐Phe in concentrations ranging from 50‐2000nmol/ml. Results In our kinetic experiments, we demonstrated a specific uptake of radiolabeled Phe into glioma cells. The uptake depended on the specific activity of the tracers: higher specific activities led to higher cellular uptake. No major differences in uptake were observed among the different labeled Phe‐ derivates (o‐I‐131‐Phe, p‐I‐131‐Phe and p‐At‐211‐Phe). The intracellular transport of all derivates was 80‐95% blocked by unlabeled Phe, depending on the concentration of the inhibitor. After higher concentrations of labeled Phe, a saturation of cellular uptake appeared. Conclusions We successfully labeled Phe with I‐131 and At‐211 and demonstrated specific cellular transport of the labeled amino acid into glioma cells. Thereby, we conclude that different astatinated and iodinated Phe derivates potentially can be used as therapeutic and diagnostic agents. Further experimental therapy studies should be performed in cell culture and animal models.
TP069 Gastrointestinal hemorrhage Scintigraphy localization using SPECT/CT images
-
improved
A. Fonseca, L. Pereira, B. Ferreira, I. Paula, T. Coutinho, I. Ruiz, H. Duarte, A. Lima Bastos; Nuclear Medicine Department, Instituto Português de Oncologia Francisco Gentil Porto, Oporto, PORTUGAL. Aim: Effective and prompt therapy for acute gastro intestinal bleeding depends on the accurate localization of the site of hemorrhage, which can take place along any part of the gastrointestinal tract. The aim of this study is to prove the usefulness of SPECT CT image fusion in study interpretation, allowing the precise detection of active gastro intestinal bleeding foci. Material and Methods: We describe a case of a 75 years old female patient, with history of carcinoma of the endometrium, who presented active gastro intestinal bleeding and anemia. Abdominal arteriography was inconclusive in accessing bleeding site. 99mTc‐labeled erythrocyte (modified in vivo/in vitro method, 740 MBq activity) scan was performed (Dual Head E‐Cam Siemens) by acquiring dynamic images (128x128 matrix; Phase1: 60 frames, 2 sec/fr; Phase2: 28 frames, 60 sec/fr) followed by sequential static images every 60 minutes (256x256 matrix, 1200kc) until bleeding was confirmed. Due to the difficult anatomic localization of focus, we performed SPECT images (128x128 matrix, 128 frames, 30sec/fr) which were fused with CT images (performed on a PET‐CT Siemens Biograph 6, 130 kV, 127 mA, 5 mm slice). Since SPECT and CT images were acquired separately in different devices patient positioning was carefully handled in order to achieve a good image co‐registration. Results and Conclusion: 99mTc‐labeled erythrocyte study showed hemorrhagic foci in the ileo. Due to scintigraphic limitations in accessing anatomic
S491
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
TP070 Histiocytosis assessment by 18F-FDG PET/CT vs other imaging modalities - a case report L. Pereira, A. Fonseca, B. Ferreira, I. Paula, T. Coutinho, I. Ruiz, H. Duarte, A. Lima Bastos; Nuclear Medicine Department, Instituto Português de Oncologia Francisco Gentil Porto, Oporto, PORTUGAL. Aim: Histiocytosis encompasses a group of diverse disorders with the common primary event of the accumulation and infiltration of monocytes, macrophages, and dendritic cells in the affected tissues. This disease may not inflict significant morphological changes in bone tissue, thus some lesions cannot be detected with MR, CT ore conventional radiographs, complicating disease staging. Bone scintigraphy is also used to identify osseous lesions in histiocytosis, but lacks specificity for disease activity. With this case we pretend to demonstrate the effectiveness of FDG‐PET scans in identifying sites of active disease in opposite to other image modalities that often fail in this disease staging, or can only detect it in an advanced stage. Material and Methods: We describe a case of a 28 years old female patient, with history of histiocytosis who had performed several imaging modalities including CT, MR and bone scintigraphy with 99mTc‐ HDP, which couldn’t reveal any sign of disease. Only two days after bone scintigraphy, it was performed a 18F‐FDG PET‐CT study (PET‐CT Siemens Biograph 6). PET‐CT whole body scan was performed 60 minutes after i.v. injection of 370 MBq 18F‐FDG, using 3 min/bed; 130 kV, 127 mA, 5 mm slice. Images were visually analyzed and were compared with other image modalities findings. Results and Conclusion: In this case of histiocytosis, 18F‐FDG PET‐CT study was the only who provided disease assessment, since other imaging modalities failed doing so. PET images showed an increase of 18F‐FDG uptake in lymphatic nodules at celiac trunk, splenic hilum, hepatic, lombo‐aortic, spleen, left parietal bone, vertebral spine, mandible, clavicle, scapula, sternum, ribs, humerus, right radius, femurs, tibias and fibulas, which were related to histiocytosis. Whole body FDG‐PET scans can detect histiocytosis activity with greater accuracy than other imaging modalities in patients with histiocytosis lesions in the bones and soft tissues. Whole‐body 18F‐FDG‐PET scanning is an important informative study in the diagnosis and disease follow up of patients with histiocytosis.
TP071 Sentinel lymph node scanning of prostate cancer - planar acquisition or SPECT/CT? K. Koetz, S. Cords, C. von Forstner, U. Luetzen, E. Henze; University Hospital of Schleswig-Holstein, Kiel, GERMANY. Aim: Sentinel lymph node (SLN) scanning is used to delineate the first draining lymph node of a tumour prior to surgery. This technique can be employed in different tumour entities (e. g. breast cancer, malignant melanoma) to avoid radical lymph node resection. The aim of this study is to find out advantages and disadvantages of SPECT/CT in comparison with the established planar technique. Methods: Thirty patients were examined 1‐2 hours after injection of 150 MBq Tc‐99m nanocolloid. We acquired planar scans in anterior, left and right lateral projections for 5 mins each. A flood source (Co‐57) was used for indirect body contouring. Immediately afterwards a SPECT and low‐dose CT was acquired using a Siemens Symbia T using the following parameters: H mode, 128x128 matrix, 90 projections of 8‐12 s each with continuous rotation; CT 130 kV, 17 mAs with CareDose. The additional radiation exposure to the technologist generated by using the flood source was measured with an electronic dosimeter. Results: Indirect body contouring facilitates diagnostic interpretation by providing an approximated anatomical location and caused only a marginal extra radiation dose to the technologist (about 1‐2 microsieverts). The acquisition time for planar imaging is comparable to SPECT/CT (12‐18 mins). The additional CT radiation dose to the patient of 1‐4 mSv (1) is outweighed by additional anatomical information from SPECT/CT co‐registration which is of particular benefit in the pelvic area. SPECT/CT detected more SLN than planar imaging in 7/30 patients (24%). This is in agreement with other studies (1), which found a benefit from SPECT/CT particularly for SLN close to the injection site (2) and in patients with a high BMI (3). Conclusions: Low‐dose SPECT/CT leads to a more precise anatomical localisation of SLN with the potential benefits of less radical surgery and more individualised radiotherapy planning. The patient receives a moderate additional radiation dose, but indirect body contouring which leads to a dose to the technologist is no longer necessary. Acquisition times for both techniques are comparable. SPECT/CT should be preferred to planar scans for SLN imaging. References: (1) Buck et al., J Nucl Med 49:1305(2008); (2) Lerman et al., Eur J Nucl Med 33:329(2006); (3) Lerman et al., J Nucl Med 48:201(2007)
TP072 Myocardial scintigraphy using I-131 metaiodobenzylguanidine (MIBG)in patients with suspected Pankinson's disease T. Mikulic, B. Oresic, T. Samardzic, D. Dodig; University Hospital Zagreb, Zagreb, CROATIA. Parkinson's disease is only one of many possible differential diagnosis in patients with movement disorders. It has been observed that only patients with idiopathic Parkinson's disease (IPD) show evidence of diminished sympathetic cardiac innervation. From 2008. our department is using I‐ 131 MIBG scintigraphy to differentiate patients with IPD from patients with other kinds of movement disorders. We are using 20 MBq of I‐131 MIBG and acquiring scintigrams of thoracic region after 15 min, 2, 3, 4 and 24 hours after i.v administration. In order to quantify postganglionic sympathetic cardiac innervation, regions of interest are placed over the cardiac and mediastinal region. We examined twenty patients and found the method to be very simple and patient friendly.
TP073 Pros and cons of insulin downregulation in hyperglaemic patients performing FDG-PET scans. M. Van Roy; Da Vinci, Wilrijk, BELGIUM. It is well known that a high glycaemia in patiënts results in lesser sensitivity of FDG‐PET scans due to competitive inhibition of FDG uptake. We found that the uptake of FDG in tumours diminished when the glycaemia reached 150 mg% (EANM 2005). However, the overall aspect of the scan remained unchanged. Down regulation with insulin results often in undesirable side effects. Muscle uptake is observed frequently, as well as diffuse uptake throughout the scan, and bowel uptake. There is a strong relation between the degree of glycaemia decrease and the muscle uptake. Conclusion:We propose to postpone FDG‐PET scans when patiënt glycaemia levels are above 150 mg% or, if this is not feasible, to administer a small amount of insulin to lower the glycaemia to just around 150 mg% before administration of FDG .
TP074 A software for automatic calculation of glomerular filtration 51 rate with Cr-EDTA J. L. Gómez-Perales1, A. García-Mendoza2, P. Valderas Montes1, J. A. Furest Pérez1; 1Nuclear Medicine Service, Hospital Universitario Puerta del Mar, Cádiz, SPAIN, 2Nuclear Medicine Service, Hospital Universitario San Cecilio, Granada, SPAIN. Introduction: glomerular filtration rate (GFR) studies with 51Cr‐EDTA are performed in large number in hospitals throughout the world. There are three important methods to determinate GFR: the method of Ham and Piepsz (Ham HR, Piepsz A. “Estimation of glomerular filtration rate in infants and children using a single plasma sample method”. J Nucl Med 1991; 32: 1294.), the method of Mistry (Mistry R. Manual of Nuclear Medicine Procedures, Cap 2 Chapman and Hall Ltd, 1988.) and the bicompartmental model proposed by Sapirstein (Truniger B, Donath A, Kappeler M. “Simplified clearance techniques”. Helv. Med. Acta, 34: 116‐119, 1968). The calculation of GFR using any of these methods is not very complex, but tedious and time‐ consuming. Objective: The goal of this project is to develop a computing facility to automatically calculate GFR. Materials and methods: Briefly, the equations used in the calculations are Method of Ham and Piepsz: GFR = 2.602 x V120 ‐ 0.273 V120 = Dose /A120 A120 = A(t) x e (0.008)(t‐120) Method of Mistry: GFR = Dose x 0.693 x 0.87 x1000 / (A0 x 1000 x T1/2) Bicompartmental model of Sapirstein: GFR = I λ a λ b / (A λ a + B λ b) = I ln2 / (A T1/2a + B T1/2b) At = A e ‐ λ a t (fast exponential) and Bt = B e ‐ λ b t (slow exponential) I = doses in cpm λ = ln2 / T1/2 For developing a software incorporating these calculations we have used Visual Basic 6.0 and Visual Studio Installer. Results: We have developed three forms for automatic calculation of GFR by means of three methods: the method of Ham and Piepsz, the method of Mistry and the bicompartmental model proposed by Sapirstein. Each form relies on a database to store, manage and retrieve the data of GFR studies. Moreover these forms offer the possibility of printing a detailed report of each GFR study. These forms are included in a software called Nucleolab, which is freely available at http://serfa.radiofarmacia.org/?m=27 Conclusion: The software we have developed has an easy‐ to‐use interface, that makes the calculation complexity of GFR studies completely hidden for the user, saving you the time that you previously spent on these laborious calculations and reducing the risk of error.
TP075 A software for automatic calculation of effective renal plasma 131 flow with I-Hipuran J. L. Gómez-Perales1, A. García-Mendoza2, P. Valderas Montes1, J. A. Furest Pérez1; 1Nuclear Medicine Service, Hospital Universitario Puerta del Mar, Cádiz, SPAIN, 2Nuclear Medicine Service, Hospital Universitario San Cecilio, Granada, SPAIN. Introduction: effective renal plasma flow (ERPF) studies with 131I‐Hipurán are performed in large number in hospitals throughout the world. The calculation of the ERPF using the bicompartmental model proposed by Sapirstein is not very complex, but tedious and time‐ consuming. Objective: The goal of this work is to develop a computing facility to automatically calculate ERPF, using the bicompartmental model proposed by Sapirstein. Materials and methods: The equations used in the calculations are FPRE = I λa λb / (A λa + B λb) = I ln2 / (A T1/2a + B T1/2b) where At = A e ‐λa t (fast exponential) Bt = B e ‐λb t (slow exponential) I = doses in cpm λ = ln2 / T1/2 For developing a software incorporating these calculations we have used Visual Basic 6.0 and Visual Studio Installer. Results: We have developed a form for automatic calculation of ERPF. This form relies on a database to store, manage and retrieve the data of ERPF studies. Moreover, the form offers the possibility of printing a detailed report of each study. This form is included in a software called Nucleolab, which is freely available at http://serfa.radiofarmacia.org/?m=27 Conclusion: The software we have developed has an easy‐ to‐use interface, that makes the calculation complexity of ERPF studies completely hidden for the user, saving you the time that you previously spent on these laborious calculations and reducing the risk of error.
TP4 ‐ Tuesday, October 13, 2009, 08:00 ‐ 09:30, Hall 117
Technologists Poster Session 4
TP076 Is dose reduction in PET/CT study is possible without loosing clinical detail? A phantom study. S. Kumar; Aiims, New Delhi, INDIA. The presence of image noise can alter the information content of a scan and makes the scan interpretation difficult. Image noise is inversely related to the dose delivered to the patient. We
Poster Presentation
information we complemented this study with CT images which allowed a precise anatomical localization of hemorrhagic focus and improved the accuracy of this study. Scintigraphy was superior to angiography in locating bleeding, and patient underwent segmental ileocolectomy due to hemorrhage. 99mTc‐labeled erythrocyte SPECT‐CT scintigraphy provides a reliable and directed localization of GI bleeding and offers carefully guidance to segmental resection, and should be the primary tool used in the diagnosis of patients with active lower gastrointestinal bleeding, improving patient prognosis.
S492 have conducted a phantom study to find optimum protocol which reduces the patient dose without loosing clinical detail. We filled the Jaszack phantom with 4mCi (148 MBq) to 12 mCi (444MBq) at an interval of 2mCi(74MBq) of 18F‐FDG. We scanned the phantom at seven different values of tube currents in one setting. We have noted the weighted CTDI value in each scan. The difference between first scan (50 mAs) and last scan (16 mAs) was 45 min. Region of interest (ROI’s) of size 2.5 cm2 were drawn on homogeneous area of CT and PET slices to estimate noise value. Two nuclear medicine physician experts in reporting PET/CT scan evaluated the scans for clinical detail. The mean ± standard deviation (Noise) of CT number (in 8 mCi phantom) at 50,45,40,35,30,25 and 16 mAs were ‐0.56 ±8.10,0.12 ±8.70, ‐0.06±8.78,0.42 ±9.60, 0.12±11.72,0.62±11.34 and 0.00±14.44 respectively. The mean ± standard deviation (Noise) of SUV values in PET scans (of 8 mCi phantom) were 8.06±0.18, 7.64±0.20, 6.00±0.16, 7.32±0.16, 6.84±0.10, 6.7±0.10 and 6.48±0.22 respectively. The weighted CTDI value in these scan were 5.41, 4.9, 4.32, 3.8, 3.28, 2.71 and1.73 mGy at 50, 45.40,35,30,25 and16 mAs tube current respectively. Nuclear medicine physician find no difference in these scan as far as clinical details are concerned although images were noisier towards lower mAs. The present study confirms that a dose reduction (approximately 68%) is possible without losing clinical detail only by modulating the tube current.
TP077 Correlation between estimated Glomerular Filtration Rate (eGFR) using camera-based Gates method and Schwartz formula in pediatric oncology patients S. Sajid, S. Ahmed, T. A. Shahbaz, M. K. Nawaz, M. U. Khan; Department of Nuclear Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, PAKISTAN. Introduction & Aim: Estimation of Glomerular Filtration Rate (GFR) plays a significant role in assessment of renal function especially in paediatric oncology patients undergoing nephrotoxic chemotherapy. Estimation of GFR with Tc‐99m‐DTPA is a common norm. According to the NKDEP (National Kidney Disease Education Program) currently the best equation for GFR estimation in children from serum creatinine is the Schwartz equation. This study aimed at assessing the correlation between eGFR using camera‐based Gates method and Schwartz formula in paediatric oncology patients undergoing baseline renograms prior to chemotherapy. Material & Methods: 50 consecutive patients who were referred to the Nuclear Medicine department from February 2008 onwards for renal scintigraphy and GFR estimation were included. 40‐males & 10‐females [Age Range: 1‐15years; Mean: 5.3years]; [Height Range: 56‐179cm; Mean 106.3cm]; [Weight Range: 6‐56kg; Mean: 18.3kg] with normal or low serum creatinine levels (mg/dl) underwent Tc‐ 99m‐DTPA Renogram (Mean dose 46.8MBq). Imaging performed on dual head Gamma camera. LEHR collimator, matrix size 64x64 and a zoom of 1.14 was used. Study duration was 25min (1sec/fr for 1‐min, 96fr of 15sec each & counts from empty syringe and inject site taken) with injection frusemide given at 15min post injection. Processing was done using Xeleris‐1 workstation, with ROI’s drawn on kidneys, for background and aorta. Time Activity Curves generated and GFR estimated using camera‐based Gates method. Patients characteristics of serum creatinine, height, weight etc were put into the Schwartz equation and GFR value derived. Both eGFR values were correlated for concordance/discordance. Results: eGFR derived from camera‐based Gates method ranged from 42.6mls/min to 147.1mls/min (Mean eGFR=95.6mls/min). NKDEP presently recommends reporting eGFR values greater than or equal to 75mls/min/1.73m2. All patients had eGFR values derived from the equation as >75mls/min. There was concordance observed in 45(90%) patients while in 5(10%) the eGFR value was lower. 3/5 of these patients had a poor injection bolus. Conclusion: Our experience shows that there is a good correlation that exists between the two methods of estimating GFR values in paediatric oncology patients.
TP078 Clinical communication skills in performing renal cortical scintigraphy in children-how do we do it and how ti improve it H. Medvedec, B. Oresic, T. Mikulic, M. Poropat, D. Dodig; Clinical Hospital Centre Zagreb, Zagreb, CROATIA. Aim:The main idea for this work is to improve technologist daily interaction with juvenile patients and their parents by investigating and measuring quality at a local level ‐ starting with our first contact with patient by telephone until the point when they leave the investigation room on the day when DMSA scintigraphy is performed. Materials and methods: Since we do not give written instructions to patients parents, we tried to explore the most confusing factors for them at the time of arrival to the NM department as well as the possible reasons for misunderstandings and fear. Usually we perform around 65 DMSA renal pediatric scans per month.We use low energy all purpose collimator, matrix size is 128x128, acquisition time 300 sec. per frame or 400.000 counts. Scans are taken 2‐3 post injection. Dose application is done by well trained technologists with fine butterfly needle G 25. The majority of our little patients are under 7 years old, mostly less then 1 year. Drug sedation has never been used in our department. All patients are scheduled at 8.00 a.m. and parents are asked to give information and clinical history about previous imaging or renal abnormalities to our physician for review. Then the procedure is explained separately to patient and parents/accompanying person by 2 technologists who then are in charge of transforming patient role into a partner role.From patient perspective well informed person receives better treatment and care. Since we live and work in a web based world, we here from patients on weekly basis, how they search more information, advices or looking for some answers by searching the Internet. Unfortunately in most cases the got even more worried and concerned, then before the search, since most of answers they find, are those collected from forums, parent societies, etc.Of, course, they find medical articles about indications, or general procedure gudelines, but not practical details related to scintigraphy as it is. Conclusion:We have decided that there is a need and a possibility, since we have a technologist society web site, to create special heading ,,Info for patients in Nuclear Medicine“. The conent would be sent for approval to physician society, but would only be explained from technologists point of view, in line with our compentencies. Our first title by the end of this year will be ,,Renal scintigraphy in children ‐ most important tips“.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
TP079 Impact of contamination from scatter phantom in National Electrical Manufacturers Association NU 2-2007 standards on image quality. K. Shimizu1, K. Matsumoto2, H. Fukukita3, M. Hayashi4, K. Suzuki5, H. Kitamura6, H. Daisaki7, M. Abe8, M. Sakurai9, K. Murakami5, M. Senda1; 1 Institute of Biomedical Research and Innovation, Kobe, JAPAN, 2Kyoto College of Medical Science, Kyoto, JAPAN, 3Kohnodai Hospital, International Medical Center of Japan, Ichikawa, JAPAN, 4Osaka Medical College Hospital, Takatsuki, JAPAN, 5Dokkyo Medical University, Tochigi, JAPAN, 6National Cancer Center Hospital East, Kashiwa, JAPAN, 7National Cancer Center, Tokyo, JAPAN, 8Nakatsu Hospital, Osaka, JAPAN, 9Nippon Medical School Hospital, Tokyo, JAPAN. Aim: This study evaluated effects of scatter phantom in National Electrical Manufacturers Association (NEMA) NU 2‐2007 standards on image quality.Materials and Methods: Image quality evaluated in two PET scanners, including ECAT EXACT HR+ (CTI‐Siemens) and Discovery‐ST (GE Healthcare). The NEMA body phantom for evaluating image quality and 70cm scatter phantom for counting rate were also used. The background in the body phantom was filled with water containing an F‐18 solution (5.3 kBq/ml). 10mm of the sphere was filled with F‐18 at 4 times the background activity, and the other 5 spheres (13, 17, 22, 28, 37 mm) were filled with background activity. The scatter phantom was filled with 116MBq of F‐18 to yield an effective activity “concentration” equal to the background activity concentration. The body phantom was positioned at the center, together with the scatter phantom placed in contact at the edge in the same arrangement as NEMA NU 2‐2007 protocol. Data acquisition was 3D mode. We made reconstitution image from 1 minute to 10minutes. The same body phantom scan performed without scatter phantom too. Additionally, the same data acquisition performed at radionuclide half‐life decayed (background activity was 2.65 kBq/ml). These data were corrected for attenuation and scatter and reconstructed with Ordered Subset Expectation Maximization. Evaluating method was visual assessment, contrast, background variability and noise equivalent count rate (NEC). Results: In both PET scanners, there is little change in visual assessment between with and without scatter phantom. There is a trend that NEC without scatter phantom was higher than with scatter phantom. The difference is 5.3 kBq/ml more than 2.65 kBq/ml. In Discovery‐ST scanner, background variability was not affected by scatter phantom. It is very well corrected scatter correction. The contrast in 5.3 kBq/ml background activity was affected by scatter phantom more than 2.65 kBq/ml. In ECAT EXACT HR+ scanner, background variability and contrast in 2.65 kBq/ml were affected by scatter phantom more than 5.3 kBq/ml. Conclusion: In quantitative value with scatter phantom, there was a difference in NEC, contrast and background variability as compared with no scatter phantom. The data of this study have suggested that impact of scattered events and random events from scatter phantom on image quality depend on type of PET scanner in NEMA NU 2‐2007 protocol.
TP080 A simplified method for FDG-PET kinetic analysis W. Hui, H. Gang, S. Shao-li; Dept. of Nuclear Med, Renji hospital, School of Medicine, Shanghai JiaoTong University, Shanghai, CHINA. Objective: Establishment a simplified method to avoid arterial blood sampling and to reduce the total time of dynamic PET imaging. Methods: 15 rabbits VX2 tumor model were performed dynamic FDG PET imaging. Arterial blood samples were collected for measured input function calculation. Time Activity Curve (TAC) from left ventricle region of interest (ROI) was used as noninvasive input function. 1000 sets of simulated data with various noise and spillover effects , and 15 sets of rabbit data were used to validate noninvasive input function’s validity. Then, a algorithm using curve fitting and Numerical Solution of Differential Equation to reduce the total time of dynamic PET imaging was presented. The full kinetic analysis results of several different dynamic PET samples were compared. Result: (1) Comparison of LCMRGlc values obtained with the measured and the fitted input curves showed that both procedures gave consistent results, with a maximal relative error in mean LCMRGlc of 5% when using the Patlak method(R=0.9913,P<0.001) and 15% using Nonlinear least squares (NLS) methods(R=0.9824,P<0.001);(2) In the low or middle noise lever condition, computer simulation result reveals 25 minutes dynamic PET sampling is feasible for FDG‐PET full kinetic analysis. The result of animal tumor model shows ki60 =0.9127*ki25‐0.0013(ki60 is short for ki of 60 dynamic PET sampling, ki25 is similar) (R=0.9182,p<0.001). Conclusion: For rabbit model or bigger animal models, heart ROI TAC can be using as noninvasive input function. With the algorithm in this paper, the total time of dynamic PET imaging can be reduced.
TP081 Effects of reconstruction parameters on standard uptake value calculation S. Tastan, K. KIR, Ö. Küçük, S. Tunca; Ankara University, Ankara, TURKEY. As semi‐quantitative parameters Standard Uptake Values (SUV) can lead the clinician in tumor staging and monitoring therapy response. However, it is a well known fact that these values are affected by factors like glucose level, length of the uptake period and body composition and body weight [2]. The aim of this study is to evaluate image reconstruction parameters (Filtered Back‐ Projection (FBP), iterative reconstruction (OSEM) on calculated SUVs and to calculate contrasts in cold and hot spheres. The evaluation was done on the GE Discovery ST PET/CT system. Method; The evaluation was done using NEMA IQ phantom with sphere to background activity concentration 4:1 and 8:1. This activity concentration corresponds to 370 MBq (10 mCi), typical injected dose for total body studies [1].The cold lesions were filled with water containing no radioactivity. To simulate body activity from outside of the scanner FOV, the scatter phantom used. It was positioned at one edge of the phantom. For this imaging, line source of the external phantom was filled with the activity of F‐18 [1]. Studies were acquired in 2D and 3D modes. Data were corrected for random coincidences, geometry, normalization, dead‐time losses, scatter and attenuation. 2D reconstruction parameters: FBP and OSEM number of subset 15, 21, 30, 42 and number of iteration 2 and 4. 3D reconstruction parameters: FBP, reproject and FORE‐ITERATIVE
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 number of subsets 12, 32, 64 and number of iteration 5 and 7. Contrasts were calculated using ROIs placed in the center of the structure of interest. The accuracy of attenuation and scatter correction were calculated as the residual error in lung region. So an ROI was drawn on the central cylindrical insert for all the slices. SUVs were calculated as SUV (body weight), SUV (lean body mass), SUV uptake and SUV (body surface area). Results; Quantitatively evaluated slices with high contrast reconstructed in subset 30 iteration 4 for 2D and subset 64 iteration 7 for 3D modes were also qualitatively evaluated. Regarding all the slices reconstructed, lesions in slice images done according to reconstruction parameters were observed to have differences in between SUV. It is given in Table I. One has to be careful in using SUVs as a parameter in follow up studies and in making the distinction between benign and malign disease due to the variation in calculated values using reconstruction parameters and parameters related to the patient. HOT 1 (%) HOT 2 (%) HOT 3 (%) HOT 4 (%) COLD 1 (%) COLD 2 (%)
2D 1/4 94,7
105,7
47,9
34,1
53,1
61,7
2D 1/8 107,3
142,2
88,0
63,0
62,1
57,7
3D 1/4 65,3
82,5
75,7
46,1
73,5
40
3D 1/8 91,41
97,7
97,5
62,61
48,6
34,5
Mean ± SD Min ‐ Max
Syringe before injection
344.1±47.3 239.6 ‐ 444.1
Syringe after injection
9.2±7.4
Swabs
0.54±0.97 0 ‐ 4.36
Venous catheter
0.18±0.61 0.02 ‐ 5.21
0.14 ‐ 41.3
SUV error due to residual activity in catheter and swabs (%) 0.12 ± 0.26 0.00 ‐ 1.33 All the activities are reported at the time of injection. We could observe that the residual activity in the catheter is higher when the activity was applied through the direct venous line 0.58 ± 1.17 MBq than through the anti‐reflux valve 0.13 ± 0.32 MBq (p = 0.04). The residual activity in the intravenous catheter showed no significant correlation with the intravenous catheter size (p = 0.9). Conclusion The residual activity in the catheter was correlated with the injection technique but not with the size of the catheter. With standardised injection procedures the error due to residual activity in catheters and swabs is too small to be relevant for SUV determination.
Table I. Differences in between max and min SUVs
TP085
TP082 To confirm the validity of SUV after well counter correction P. y. Bai1, W. P. Lu2, C. S. Wu1; 1Chi Mei Medical Center, Liouying, Tainan County, TAIWAN, 2General Electric Healthcare, Taiwan, Taipei, TAIWAN. Aim: The standard uptake value (SUV) is very important data in diagnosis of benign or malignancy of the lesion. Normalization of SUV with body weight, body surface and body lean mass had been evaluated for the accuracy of SUV in the literature. To confirm the validity of SUV after well counter correction is an important key in stability of SUV during a long period of machine running. How to confirm this, to our knowledge, is not reported in the literature and is the purpose of this article. Materials and methods: We perform the well counter correction by using two phantoms with standard operating procedure. For the revelation of the data difference, one phantom contents a 1.62 mCi 18F‐FDG and the other contents a 0.81 mCi 18F‐FDG (default data). Both results are accepted by machine following standard operating procedure. We use a patient’s data to apply the individual phantom data to see the difference. Result: At same slice and location of a patient’s lesion, the maximal SUV standardized with body weight is 6.600 g/ml at the corrected data using the 1.62 mCi 18F‐FDG and is 6.026 g/ml at the corrected data using the 0.81 mCi 18F‐FDG. After drawing ROI (region of interest) of whole phantom in one slice, the mean SUV is 1.097 g/ml at phantom with 1.62 mCi 18F‐FDG and is 0.992 g/ml at phantom with 0.81 mCi 18F‐FDG. Both data reveal minimal difference. Conclusion: To confirm the validity of SUV, except for strictly standing to the standard operating procedure in well counter correction, the mean SUV of ROI of whole phantom is recorded every time. It also needs to compare with every previous record to know the validity and difference.
TP083 Ventilation lung scintigraphy using "Techegas" generator B. V. Oresic, T. Mikulic, D. Dodig; University Hospital Zagreb, Zagreb, CROATIA. Aerosol generator "Technegas" is being used in Department of Nuclear Medicine and Radiation Protection since 2003. The generator produces particles by heating graphite core to 2550° C in argon gas flow and labelling them with 99mTc‐pertechnenate, using high specific activity(80mCi 99mTc in 1 mL). Ten respiratory cycles are usually sufficient to successfully visualize lungs, but first two are the most important, which enables the test to be performed in patients with shortness of breath. Our new device, which we are using for two the last two years, additionally has Ambu bag, so that ventilation lung scanning is possible even in comatose patients. This device generates particles much smaller when compared to ultrasound aerosol generators, which makes lung visualization superior, because smaller particles can penetrate small bronchial branches more easily. Better scans are also accounted to less deposit artefacts in mouth and windpipe, but at the same time high count rate on ventilation scans disables lung perfusion scanning to be performed the same day. For this reason, it is our practice to perform ventilation scanning after perfusion scan, only if necessary.
TP084 Effect of the injection technique on Standardized Uptake Value in F-18-FDG PET M. Rochat1, J. Curtet1, M. Recordon2, J. Prior2, G. Allenbach2, Delaloye2, J. A. Pires Jorge1; 1HECVSanté-Filière TRM, University of Applied Sciences Western Switzerland, SWITZERLAND, 2Department of Nuclear Medicine, Centre Universitaire Vaudois and University of Lausanne, SWITZERLAND.
Activity (MBq)
A. Bischof Lausanne, Lausanne, Hospitalier Lausanne,
Aim Accurate measurement of standardized uptake value (SUV) in F‐18‐FDG PET is mandatory for patient follow‐up. The injected activity needs to be known precisely. Our aim was to investigate the influence of variations of the injection technique and residual activity in the intravenous catheter after injection in the SUV values. Method In clinical routine we inject F18‐FDG through a venous catheter (22G and 20G optiva®2 I.V. catheter) and flush directly after with 20ml of saline. Blood glucose concentration is checked before injection. The acquisition starts 1 hour after injection. The residual activity in the syringe is measured in a dose calibrator and subtracted from the activity measured in the syringe before injection to obtain the injected activity used for SUV calculation. To avoid time errors, PET console and injection room clocks are synchronized to the laboratory’s clock each week. Some variations in flush volume or injection way (through the anti‐ reflux valve or through the direct venous line) are possible. In 80 consecutive patients referred for oncological FDG‐PET, we removed the intravenous catheter used for injection and measured it, as well as the swabs. Different parameters were recorded, either specific to each patient (blood glucose concentration), or specific to the technique (injection method, injection time,
Impact of SPECT coupled with tomodensitometry (SPECT-CT) in the daily practice of the bone scintigraphy. F. Netter, J. Mayer, S. Grandpierre, B. Meneroux, P. Olivier, G. Karcher; Chu Brabois, Nancy, FRANCE. The purpose of our study was to assess the impact of SPECT coupled with tomodensitometry (SPECT‐CT) in our daily practice of the bone scintigraphy. SPECT‐CT obtained as a complement to the planar bone scintigraphy in 39 patients were retrospectively studied. Each examination was reread by two differents observers. A nuclear medicine physician interpreted planar bone scintigraphy, the second one interpreted SPECT‐CT without having access to the planar bone scintigraphy. In this population of patients, 17 patients had a cancer or a history of cancer. The 22 other patients were addressed for indeterminated pain without neoplasic context. In 13 % of the cases, SPECT‐CT specified the precise location of an hyperfixation seen on planar bone scintigraphy. In 38 % of cases, SPECT‐CT confirmed a diagnosis suspected by the planar bone scintigraphy. In 10 % of cases, SPECT‐CT established a diagnosis that was indeterminated by the planar bone scintigraphy. In 26 % of cases, SPECT‐TDM brought no additional information. Finally in 3 % of cases, SPECT‐CT proved to be more sensitive than planar images. Our study highlights the utility of SPECT CT in the daily practice of bone scintigraphy, this complementary imaging study benefited to 74 % of our patients.
TP086 99mTc-Mertiatide Renal Scintigraphy in Unfused Crossed Renal Ectopia J. Rodrigues, R. Silva, G. Costa, J. Lima; Hospitais da Universidade de Coimbra, Coimbra, PORTUGAL. Introduction: Unfused crossed renal ectopia (UCRE) is a very rare congenital anomaly consisting in a transposition of a kidney to the side opposite its normal position. The associated ureter normally crosses the midline to insert in its normal position in the bladder. In this case the patient is a female with 61 years old. Has a UCRE, with the left kidney in inferior middle line of the right kidney and pelvic anterior localization. She had been diagnosed in 1990, while being treated to lithiasic uropathy in the right kidney, but only in March of 2009 she came to our department to perform a 99mTc‐mertiatide renal scintigraphy. This clinical procedure was made to assess the differential function and possible obstructive pattern after lithotripsy. Objective: The objective of this work is to show how we proceeded technically to obtain the differential renal function and renographic curves with a 99mTc‐mertiatide renal scintigraphy, in a very rare clinical abnormality. Material/Methods: The 99mTc‐mertiatide renal scintigraphy was performed in a dual head gama‐camera, by using our routine protocol acquisition. The renographic curves of the kidneys were obtained separately, using the anterior projection for the ectopic kidney and posterior projection for the right kidney. To study the differential renal function we adapted the DMSA processing protocol. We added the images from the 2‐3 minutes of the study to a single one, to obtain an anterior and posterior planar image, to use them as input data. In this protocol we use the mean geometric method for differential renal function. Results: We obtained a differential renal function to the right kidney of 59% and the ectopic kidney of 41%. The renographic curves show a slow elimination in the right kidney, which solves with diuretic administration. The ectopic kidney has a similar behaviour to the right kidney. Conclusion/Discussion: This method allowed us to calculate the differential function, despites the ectopic localization of the left kidney.
TP087
99m
FASTERAS Tc-Venticol a new lung ventilation aerosol: a preliminary evaluation of contamination levels during patient administration F. Zito, M. Bardo, R. Leo, M. Schiavini, V. Longari, C. Canzi, F. Voltini, P. Gerundini; Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milano, ITALY. Aim: To study the contamination levels of the area (air and surfaces) surrounding the apparatus and of the staff during patient administration with FASTERAS (Medical Product Research ‐ Italy), a 99m Tc labeled aerosol, recently proposed for lung ventilation scintigraphy. Materials and Methods: Contamination measurements were performed during 12 patient administrations. For lung scintigraphy , 500 MBq of 99mTc‐Venticol (nanocolloid albumin) were gasified with medical oxygen gas flux and delivered to the patient under the assistance of a technologist (TSRM) in the administration room for 10‐20 s via a mouth tube. To assess surface contaminations, 8 test points (100 cm2) respectively 3 on the shielded FASTERAS box and 5 on the floor around the administration positioning were smeared with glass fiber disks, soon after aerosol delivering. Air
Poster Presentation
SUV
injected activity, residual syringe activity, activity in the intravenous catheter and the swabs, NaCl flush volume, time of PET acquisition). Results The mean concentration of glucose in the blood of the 80 patients was 5.74 ± 1.00. The PET‐CT was acquired 69±9 minutes after injection.
S494 concentration measurements were performed by drawing 2000 l of air with a pump through glass fiber and carbon filters, placed one upon another. For TSRM, clothe contaminations (disposable apron, hat, mouth‐nose mask and gloves) and potential internal exposure via urine sample, were checked. Bq/cm2 for surfaces and clothes, Bq/m3 for air and Bq/ml for urine were measured with a calibrated NaI well counter, corrected for physical decay to administration time and for background. Estimation of the potential intake dose for the assistant technologist from the air concentration was also assessed assuming 30 min permanence, 1.2 m3/h breathing and 2.9‐11 Sv/Bq factor. Results: In the administration room: floor smear test ranged from 0.5 to 10 Bq/cm2 and air radioactivity varied from 20 to 6000 Bq/m3. From this airbone radioactivity for technologist a potential intake dose from 0.3 to 111 nSv should be derived. No urine contamination was detected for TSRM. The highest contamination levels correspond to the worst pulmonary functional status of the patient and the highest gas flux. Conclusion: In this preliminary evaluation, over 12 patients, lung ventilation with FASTERAS showed small contamination levels for surface and air and no internal exposure for the assistant personnel.
TP088 Optimization of scan time in PET/CT-scans C. Baun, K. F. Braas, H. Petersen, M. J. Nielsen, O. Gerke; Department of Nuclear Medicine, Odense University Hospital, Odense, DENMARK. Aim: The majority of departments performing PET/CT‐scans administer a dose of 370‐400 MBq 18 F‐FDG intravenously, and use a scan time of 2½ to 3 min per bed position. We wanted to investigate the possibility of decreasing the scan time in the emission scan without diminishing the quality of the images. Materials and methods: 60 patients scheduled for PET/CT‐scan were included. After a fast of at least 6 hours, patients were given 4 MBq/kg 18F‐FDG intravenously. All patients were scanned 60‐75 min after injection. CT‐scan was followed immediately by a PET‐ scan acquired in listmode with an acquisition time of 3 min per bed position. Data was histogrammed in to acquisition times of ½, 1, 1½, 2, 2½ and 3 min and reconstructed using 3D OSEM. For each patient images were reviewed randomly and independently by two physicians. SUV max and SUV mean were measured in regions from liver and spleen and where possible, SUV max was measured for a malignant process. The equivalence of SUV max/mean at any time point in comparison to the reference value at 2½ min was evaluated. Results: The images were scored 1 to 5, with 1 designated a high observer confidence in the diagnostic quality of the images and 5 designated a low observer confidence. Images reconstructed using 2½ min scan time was used as gold standard. Scan times of 2, 2½ and 3 min resulted in images with a score of 1 or 2. However 90% of images with scan time of 1½ min, 11% of images with scan time of 1 min and none from the ½‐minute‐group scored 1 or 2. The SUV max at time points 1½ min, 2 min, and 3 min were equivalent in comparison with the reference value for both liver, spleen and malignant processes. At 1 min, only the measurements for malignant process were equivalent to the reference value. Regarding SUV mean, ½ min, 1 min, 1½ min, 2 min, and 3 min were equivalent to the reference measurement for liver and spleen. There was no data available for malignant processes at any time point. Conclusion: Measurements for SUV max and SUV mean indicate a possibility of decreasing scan time to 1½ min per bed position. However based on observer confidence it was only possible to decrease scan time to 2 min per bed position in order to sustain the diagnostic quality.
TP089 Sample characterization and risk work attitudes in the professional group of Portuguese Nuclear Medicine Technologists D. M. P. S. Neves, F. F. Vale, A. Pascoal; Faculty of Engineering, Catholic University of Portugal, Sintra, PORTUGAL. Objectives: Occupational medical radiation exposure is rising in Portugal. A 30% increase in the collective dose (man.Sv) in the professional group of nuclear medicine technologists has been reported between 1999 and 2003. To our knowledge, no Portuguese epidemiological data is available to investigate potential associations between occupational exposure and detrimental effects on staff health condition. The proposed work aims to provide a contribution to the existing knowledge on the subject by implementing a case‐control epidemiological study. It proposes collecting evidence on: practices in use within the Portuguese nuclear medicine technologists, individual exposure, and health records, Methods: An epidemiologic questionnaire was designed and disseminated to a population of 100 cases and 100 controls, matched by age, sex, and residence postal code. The cases were identified from a cohort of nuclear medicine technologists involved in similar routine activities, with (at least) one year of individual dose records. The questionnaire was applied at a national level, attempting a total coverage of nuclear medicine centers. The questionnaire was the main tool to gather information on work practices and personal health records. Data collection is ongoing, and so far, 40 questionnaires were analyzed using descriptive statistics. Results: Preliminary results revealed a majority (70%) of female cases, with an average age of 35,1 (SD 11,1) years old. Collected data included 37,5% cases living and working in the Lisbon area. The majority (80%) had a graduate degree and, on average 12,7 (SD 11,4), years of work experience. Participants were employed in public healthcare providers (50%), private practices (25%) or both (25%). All cases were involved in radiopharmaceutical preparation procedures and the vast majority (65%) performed intra‐ venous administrations, mainly, using syringe protection and dose recipient (96%). 45,7% performed PET scans. The use of lead apron, lead gloves, and protection glasses was not common practice (12,5%). Periodic (monthly) individual dose record values ranged between 0,20 and 0,50 mSv for 45% of the inquired. No cases of overexposure were identified. Conclusion: The study has been triggering the attention of the target population that has been cooperating actively. A significant number (40%) of expected answers was collected so far and is likely to increase, representing significant coverage of the nuclear medicine technologists population in Portugal (estimated 200). Preliminary data analysis provided an insight into the work practices and suggests their variation regarding daily routine activities and radiation protection measures. Detailed data analysis and future work developments will be presented.
TP090 Microbiological contamination during the reconstitution of cold kits in a radiopharmacy unit.
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496 J. L. Martinez Soler1, A. Laut Martinez1, M. E. Bellon Guardia2, A. Valades Miranda1, Y. Said Criado1, J. M. Llamas Elvira2; 1Radiopharnacy unit, Hospital Virgen de las Nieves. Granada, SPAIN, 2Nuclear Medicine Department, Hospital Virgen de las Nieves. Granada, SPAIN. AIM: The aim of our study was to evaluate the potencial risk of microbiological contamination of radiopharmaceutical (RP) cold kits during their reconstitution with 99mTc generador eulate vials and to assess the sterility of the procedure in a radiopharmacy unit. METHODS: 73 samples were selected randomly from all the RP preparations for diagnostic use in our radiopharmacy unit over a period of 73 weeks (one each week). All of them were stored until the activity reached background. We tested each sample twice with three different kind of commercial microbiological test (TIOGLIC/RESAZ; TRYPC/SOYA and SABOURAUD). We used saline solution as negative control. They were incubated for two weeks. We considered a positive result if there was evidence of mocrobiological growth by visual inspection in both assays. RESULTS: Despite the 73 sample were negative for microbiological testing, two of them (2.7%) showed the presence of microbiological grows in one of the two assay performed for each sample. CONCLUSION: These results suggest that microbiological contamination in conventional manipulation and reconstitution of cold kits in our radiopharmacy unit is nearly absent and we can confirm the validity of our departamental protocol for radiopharmaceutical preparations.
TP091 Implementation and validation of a OSEM reference database for myocardial perfusion szintigraphy using iterative reconstruction K. Krommes, G. Barth, J. Holzmannhofer, T. Seifen, C. Pirich; Salzburger Landeskliniken, Salzburg, AUSTRIA. Aim : Iterative reconstruction using ordered subsets expectation maximisation (OSEM) may improve image quality and diagnostic accuracy in Tc99m myocardial perfusion szintigraphy (MPS). However reference perfusion polar maps based on the ordered subsets expectation maximisation (OSEM) reconstruction have not been available yet. We report about the implementation and validation of a OSEM reference database for MPS. Methods and patients : 1) Creating the OSEM reference database 59 subjects (30 males and 29 females) with excluded coronary artery disease were included into a male/female OSEM reference database for stress/rest MPS using 8MBq/kg body weight Tc99m tetrofosmin according to manufacturer`s recommendations for creating a normal database in 4DM SPECT. For OSEM reconstruction we used an 3D iterative reconstruction with 12 iterations and 4 subsets with a Gauss filter 8.40 mm. 2) Validation of the OSEM reference database For validation 59 patients (30 male and 29 female) with suspected coronary artery disease with a mean age of 67 were investigated of whom 22 underwent coronary angiography. Imaging was performed 10 minutes after injection using a dual head Siemens gamma‐camera according to the EANM guidelines for MPS (Hesse B., et.al.;EJNMMI (2005) 32:855‐897). Projection data were reconstructed using both OSEM and filtered back projection (FBP). OSEM reconstruction‐deviced perfusion polar maps were compared with data from FBP, supplied by the manufacturer. For FBP reconstruction we used an Butterworth filter 0,4/6. Myocardial perfusion analysis was performed using a 17‐segment model with 4 DM SPECT software providing the summed stress score (SSS), summed rest score (SRS) and summed difference score (SDS), respectively. Median SSS, SRS and SDS were calculated. Non‐ parametric statistical tests (McNemar and Wilcoxon) were used to analyse for differences between the OSEM and FBP perfusion scorings, respectively. Results: Overall polar map analysis revealed complete concordance in 75% of all segments analysed. In the subgroup of patients with documented coronary artery disease polar maps showed concordance in 95 % of all segments analysed. Median SSS, median SRS and median SDS were 12, 3, 8 using OSEM and 13, 5, 6 using FBP respectively. Conclusion: Implementation of a database using OSEM reconstruction is feasible and clinically comparable to the 4DM SPECT reference database delivered by the manufacturer.
TP092 Combined DaT-Scan and Test of Olfactory Function for Differential Diagnosis of Movement Disorders - a Longitudinal Study K. Knudsen, A. Düsterdich, A. Eskild-Jensen, P. Borghammer; Aarhus University Hospitals, Aarhus, DENMARK. Aim: Olfactory dysfunction is present in patients with Parkinson’s disease (PD), often preceding debut of motor symptoms. Thus, tests of olfactory function may become an important screening device for diagnosing patients with very early PD, once effective neuroprotective pharmacological agents become available. Furthermore, PD patients cannot be reliably differentiated from patients with atypical parkinsonian disorders (aPD) on the basis of a DaT‐ Scan. However, the olfactory function of aPD patients is mostly normal. The specific aims of the present study are: (1) characterize the relationship between striatal FP‐CIT values and olfactory function, as measured by a validated smell test; (2) evaluate whether combined DaT‐scan/smell test can contribute to differentiating aPD patients from idiopathic PD. Here, we present preliminary data from the initial 6 months of recruitment. Methods: All patients referred to the department for DaT‐Scan is offered participation in the study. We aim to include 150 patients (20 aPD) over a 2 year time period. All patients are examined with DaT‐SPECT and the 10‐item Tabert smell test. Olfactory function normal reference data is available from an independently examined group of healthy age‐matched controls. Blinded clinical follow‐up will be performed on all individual subjects by movement disorder experts at least two years after participation in the study. So far, 33 study patients (14 females) were included. Results: A total of 23 pathological DaT‐scans were identified. Sixteen patients displayed severely decreased olfactory function (>2 SD below control mean). A further ten subjects displayed moderately decreased olfactory function (>1 SD below control mean). Four subjects displayed intact olfactory function and pathological DaT‐scan (potential aPD patients). In general, decreased olfactory scores correlated with decreased DaT values (R2=0.25, p=0.003). This correlation was more outspoken in females (R2=0.54, p=0.002), and not quite significant in males (R2=0.13, p=0.13). Conclusion: In these preliminary data, we detected significant correlation between decreased olfactory function and loss of striatal dopaminergic innervation, particularly in female patients. Four patients with
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Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
TP093
Radiation protection problem in the case of death of patients treated by therapeutic activity
get the activity to be administered easily according the latest EAMN paediatric dosage recommendation. In addition, the introduction of minimum activities guarantees a minimum standard of image quality throughout Europe, thus avoiding a variety of administered activities in children of the same weight in different countries, which was the case when using the previous EANM dosage card.
Z. Pašková1, J. Zimák2, D. Valachová2, J. Sabol2, P. Vlček2; 1State Office for Nuclear Safety, Praha 1, CZECH REPUBLIC, 2Faculty Hospital Motol, Praha 5 , CZECH REPUBLIC.
TP096
The death of a patient treated by radionuclides of therapeutic activity is a rare occurrence. Therefore, there are no special rules reflecting radiation protection viewpoints in the case of death of patients who underwent such treatment neither in the Atomic Act nor in relevant Decrees in the Czech Republic. Moreover, previous sanitary regulations on burials of internally contaminated patients are no longer valid. Lack of such procedures has a direct impact on departments of hospitals specialised in the cancer treatment characterized by high activities of radiopharmaceuticals administrated to patients. At present, seven nuclear medicine departments perform thyroid cancer treatments by 131I and most of 44 departments apply 89Sr, 153Sm or 186Re palliative therapy in the Czech Republic. It is recommended that in order to solve the problem, these nuclear medicine departments, in co‐operation with the State Office for Nuclear Safety, develop adequate internal procedures. Therefore, instructions for the case of death of patient treated by radionuclides shall be worked out summarising procedures and duties of workers of the department of nuclear medicine and department of pathological anatomy. In addition, recommendations for funeral undertakers and relatives during the real event shall be prepared. A case of a patient treated for carcinoma by 131I and who died shortly after the treatment has been described. In order to assess radiation protection conditions, two radiation protection officers observed all procedures connected with the cremation. Digital survey monitor was used for measurements of radiation levels. It can be concluded that, based on the results of these measurements and taking into account the time spent by any person with the corp during the manipation and cremation, the resulting exposure was so low that the annual limits for population were not exceeded. In line with the Atomic Act and in accordance with the Decree on Radiation Protection, it is recommended to follow the relevant clearence levels as a general rule for radioactive discharges into the enviroment.
H. Nam-Koong, H. Park, Y. Ban, H. Lim, C. Lee; Severance Hospital, Yonsei University Health System, Seoul, REPUBLIC OF KOREA.
TP094 A software for automatic calculation of 1
99m
Tc-MAA dosage
2
J. L. Gómez-Perales , A. García-Mendoza , C. Téllez Llanzón1, J. A. Furest Pérez1; 1Nuclear Medicine Service, Hospital Universitario Puerta del Mar, Cádiz, SPAIN, 2Nuclear Medicine Service, Hospital Universitario San Cecilio, Granada, SPAIN. Introduction: In the day‐to‐day practice of a radiopharmacy it is necessary to calculate the number of particles and the activity in a dose of 99mTc‐MAA, because the concentration of particles is constant in time but the radioactive concentration decrease. The calculation of these parameters is not too complex, but it is annoying and time‐consuming. Objective: The goal of this project is to develop a form to calculate number of particles in a dose of 99mTc‐MAA and other parameters in the labelling of MAA. Materials and methods: For developing a form incorporating these calculations we have used Visual Basic 6.0 and Visual Studio Installer. Results: We have developed a form for automatic calculation of number of particles, volume and activity of doses, labelling volume and labelling activity in 99mTc‐MAA preparations. This form is included in a software called Nucleolab, which is freely available at http://serfa.radiofarmacia.org/?m=27 Conclusion: This new software have an easy‐to‐use interface that makes the calculation complexity of 99mTc‐MAA preparations completely hidden for the user, saving you the time that you previously spent on these laborious calculations and reducing the risk of error.
TP095 A software for automatic calculation of EAMN paediatric dosage card J. L. Gómez-Perales1, A. García-Mendoza2, C. Téllez Llanzón1, A. Furest Pérez1; 1Nuclear Medicine Service, Hospital Universitario Puerta del Mar, Cádiz, SPAIN, 2Nuclear Medicine Service, Hospital Universitario San Cecilio, Granada, SPAIN. Introduction: Jacobs et al. proposed the use of three tracer‐dependent dosage cards for paediatric nuclear medicine (Optimised tracer‐dependent dosage cards to obtain weight‐ independent effective doses. Eur J Nucl Med Mol Imaging 2005;32:581‐8). Based upon this work, the EANM dosimetry and paediatrics committees introduced a condensed and revised version of this dosage card (Eur J Nucl Med Mol Imaging 2007;34:796‐798) for major nuclear medicine paediatric diagnostic procedures, replacing the previous card by Piepsz et al. and including a set of minimum activities. The disadvantage of this approach is an increased complexity concerning the activity calculations. Objective: To overcome the complexity of the new EAMN paediatric dosage card by developing a software, where the user could enter the patient weight and the radiopharmaceutical for automatic calculation of paediatric dosage of radiopharmaceuticals, according to EAMN 2007 paediatric dosage card. Materials and methods: Briefly, the new EAMN dosage card calculates the administered activity by multiplying a baseline activity by different multiples for the three clusters A, B and C (the recommended radiopharmaceutical class): A[MBq]Administered = Baseline Activity × Multiple; where A[MBq]Administered denotes the activity to be administered (in MBq), and Baseline Activity and Multiple are weight‐ and radiopharmaceutical‐dependent factors to be used for the calculation of the activity to administered. The baseline activity equals the activity to be administered to a child weighing 3 kg. If the resulting calculated activity is smaller than the minimal recommended activity, the minimum activity should be administered. For developing a software incorporating the features of this new EANM paediatric dosage card we have used Visual Basic 6.0. Results: We have developed a new software to calculate paediatric dosage of radiopharmaceuticals according to latest EAMN paediatric dosage card, with an easy‐to‐use interface that makes the calculation complexity completely hidden for the user, saving you the time that you previously spent on these laborious calculations and reducing the risk of error. This software is freely available at http://serfa.radiofarmacia.org/?m=4. Conclusion: As a result of this new software, the user will
A Study of Influence of Filgrastim (G-CSF) on PET-CT in Diffuse Large B cell Lymphoma
Purpose: It has been known that PET‐CT is very valuable in follow‐up study of diffuse large B cell lymphoma (DLBCL). Generally, in DLBCL, radiotherapy and chemotherapy has been progressed, because the lesion hasn’t been limited to one site. And, it has lead to the decrease of leukocyte like neutropenia, due to myelosuppression of chemotherapy. So, in that case, administration of Filgrastim (Granulocyte colony‐stimulating factor; G‐CSF) is universal. However, in short time after administration, PET‐CT has limitation to offer accurate images, through the uptake of 18F‐ FDG is increased in the region that is activated bone marrow by hematopoietic growth. Therefore, the aim of this study is that PET‐CT in a certain period of time after administration of 18 Filgrastim (G‐CSF) is able to show normal degree of F‐FDG uptake. Materials and Methods: 10 patients under follow‐up study of diffuse large B cell lymphoma were examined in this study from January, 2007 to January, 2009 (Male: 4 persons; Female: 6 persons; The mean age: 53.8 years old; The mean weight: 57.3Kg). Using PET‐CT (Discovery STe; GE Healthcare, Milwaukee, WI, USA), whole body images were acquired in 1 hour after 18F‐FDG injection. For image analysis, each ROI (120mm2) was drawn on C6 (the sixth C‐spine), L4 (the forth L‐spine), liver, spleen, and lung, then SUV (Standard Uptake Value)s were measured. We compared with each uptake between in 1‐day and 5~7 days after administration of Filgrastim (G‐CSF) at same patient, so confirmed significance about these by SPSS version 12. Results: In case of C6, L4, spleen, every SUV of 1‐day later was remarkably higher than that of 5~7 days later, but liver and lung were similar. Also, the images acquired after 5~7 days distinct remarkably and show normal degree of 18 F‐FDG uptake, because uptake of bone was almost disappeared. Conclusion: In this study, each SUV was prominent difference as a period of time after Filgrastim (G‐CSF)’s administration. And Filgrastim (G‐CSF) makes concentrate uptake of 18F‐FDG in bone, but, after 5~7 days, bone’s uptake was greatly decreased. Therefore, we are able to infer a certain period of time that shows normal degree of uptake, by numerical value proven. Also, we consider that this study contribute to advanced study about the other agent like Pegfilgrastim, Lenograstim besides Filgrastim, afterwards.
TP097 Heating unit for radiochemical syntheses in cleanroom environment P. Saipa, T. Viljanen, E. Kokkomäki, T. Saarinen, S. Vauhkala, O. Solin; Turku PET Centre, University of Turku, Turku, FINLAND. Aim: The aim of this study was to develop an easily controlled heating method for radiochemical syntheses in a cleanroom environment. For this purpose a heating unit for reaction vessel which doesn’t need water or oil was developed. Materials & Methods: The heating unit consists of a double wound heating coil insulated with glass wool and tinfoil. This is placed into a stainless steel cover. A connection for compressed airflow is also included. The reaction vessel is placed into the coil. The heating unit is controlled by a special PID (proportional‐integral‐derivate) controller. The heating unit and PID software were tested for suitability with regard to temperature and power for radiochemical syntheses. In this test series 1 ml 60 % CH3CN (aq) was evaporated. Different temperatures and evaporation times were tested. Results: The heating unit evaporates 1 ml 60 % CH3CN (aq) as efficiently as a heating unit with water or oil when 260 °C and low compressed airflow is used. The airflow distributes the heat evenly on the reaction vessel and also cools down the cover. Conclusion: The heating unit is easily controlled and works efficiently without need for liquid to transfer the heat. The heating unit is convenient for cleanroom use.
TP098 Evaluation of effective dose in patients performing WB studies with 18F-FDG PET/CT D. Calado, D. Ferreira, P. Saragoça, C. Ovidio, M. T. Rezio, C. Loewenthal, M. R. Vieira; Hospital da Luz, SA, Lisboa, PORTUGAL. AIM: The aim of this study was to evaluate whole‐body effective dose and brain dose in patients performing whole body (WB) studies. In this work we calculate the effective dose from PET and the effective dose from CT. METHOD: The whole body 3D PET/CT scans were performed in a Biograph 16 Siemens Tomograph. The images were obtained 40 ‐ 50 minutes after IV injection with 3.7 MBq/kg of the radiopharmaceutical (18F‐FDG) The CT component is acquired with the following parameters: 80 kvp, 50 ‐ 120 mAs, colimator thickness of 1,5 mm, pitch of 1,0, slices between 4 ‐ 5 mm and a rotation of 0,5 seconds. The reconstruction method is OSEM‐2D. With the DLP (dose length product) we can determine the brain dose and the WB dose, from the CT and with the injected activity we can calculate the PET dose. RESULTS: We analyzed 27 patients. The effective dose from, both, PET and CT is represented in table 1.
Poster Presentation
potential atypical parkinsonism were included so far. Pending the two‐year clinical follow‐up, sensitivity and specificity of the combined DaT‐Scan/olfaction test can be calculated.
S496
Eur J Nucl Med Mol Imaging (2009) 36 (Suppl 2):S281–S496
nº Patient
DLP
CT Brain CT WB Injected dose Effective activity (mGy) dose (mSv) (MBq)
PET Brain dose (mGy)
PET WB Total WB Effective Effective dose dose (mSv) (PET/CT) (mSv)
1
361
0,10
5,19
202,76
5,68
3,85
9,04
2
402
0,11
5,78
388,5
10,88
7,38
13,16
3
402
0,11
5,78
377,4
10,57
7,17
12,95
4
361
0,10
5,19
333
9,32
6,33
11,52
5
402
0,11
5,78
347,8
9,74
6,61
12,39
6
402
0,11
5,78
333
9,32
6,33
12,11
7
402
0,11
5,78
296
8,29
5,62
11,40
8
361
0,10
5,19
314,5
8,81
5,98
11,17
9
361
0,10
5,19
259
7,25
4,92
10,11
10
402
0,11
5,78
386,65
10,83
7,35
13,13
11
401
0,11
5,76
262,7
7,36
4,99
10,76
12
361
0,10
5,19
292,3
8,18
5,55
10,74
13
361
0,10
5,19
288,6
8,08
5,48
10,67
14
402
0,11
5,78
292,3
8,18
5,55
11,33
15
402
0,11
5,78
292,3
8,18
5,55
11,33
16
361
0,10
5,19
222
6,22
4,22
9,41
17
361
0,10
5,19
233,1
6,53
4,43
9,62
18
402
0,11
5,78
336,7
9,43
6,40
12,18
19
361
0,10
5,19
202,76
5,68
3,85
9,04
20
402
0,11
5,78
203,5
5,70
3,87
9,65
21
321
0,09
4,61
303,4
8,50
5,76
10,38
22
402
0,11
5,78
355,2
9,95
6,75
12,53
23
402
0,11
5,78
299,7
8,39
5,69
11,47
24
361
0,10
5,19
257,15
7,20
4,89
10,08
25
402
0,11
5,78
310,8
8,70
5,91
11,68
26
402
0,11
5,78
277,5
7,77
5,27
11,05
27
361
0,10
5,19
224,96
6,30
4,27
9,46
Patient nº
DLP
CT Brain CT WB Injected dose Effective activity (mGy) dose (mSv) (MBq)
PET Brain dose (mGy)
PET WB Total WB Effective Effective dose dose (mSv) (PET/CT) (mSv)
Average
382,26 0,10
5,50
292,35
8,19
5,55
11,05
Standard Desviation
23,64 0,01
0,34
55,16
1,54
1,05
1,24
Table 1. The medium effective dose/patient who performed a PET/CT WB scan was 11,05 (mSv). CONCLUSION: With these results, we can conclude that the effective dose levels of WB 18F‐FDG PET/CT studies are performed in accordance with the accepted standards for best practice.
TP099 Technetium-99m labeled Mebendazole and Biodistribution in experimentally Trichinella spiralis-infected rats T. Inceboz1, F. Yurt Lambrecht2, O. Yilmaz3, G. Capa Kaya4, E. Kolatan3, K. Durkan2, A. Bagriyanik5, A. Uner6; 1Dokuz Eylul University School of Medicine Department of Parasitology, Izmir, TURKEY, 2Ege University, Institute of Nuclear Sciences Department of Nuclear Applications, Izmir, TURKEY, 3Dokuz Eylul University School of Medicine Department of Laboratory Animal Science, Izmir, TURKEY, 4Dokuz Eylul University School of Medicine Department of Nuclear Medicine, Izmir, TURKEY, 5Dokuz Eylul University School of Medicine Department of Histology, Izmir, TURKEY, 6 Ege University, School of Medicine, Department of Microbiology and Clinical Microbiology Department of Parasitology, Izmir, TURKEY. Aim: To localize Trichinella spiralis infection is very important clinically and life saving processes. Scintigraphic methods used in infection/inflammation imaging may help to determine the sites of infection. The aim of this study was to investigate Technetium‐99m mebendazole biodistribution in Trichinella spiralis‐infected rats. Materials: Mebendazole was labeled with Tc‐99m described previously. Labeling efficiency using RTLC‐SG was % 84±2. Tc‐99m mebendazole was given at the doses of 23‐46 MBq/μmol/rat via intravenous (IV) and oral gastric catheter in two groups; Trichinella spiralis infected group and control group, to examine the localization of Tc‐99m mebendazole in normal rat muscle and inflamed muscle with trichinellosis. The rats were sacrificed 1 hour after Tc‐99m mebendazole was given via intravenously and 2 hours after Tc‐ 99m mebendazole was given via oral gastric catheter. Tc‐99m mebendazole retention organs and muscles were investigated using Cd (Te) detector. The results were expressed as the percent uptake of injected dose per gram of organs and muscles (%ID/g). Results: The counts obtained with Cd (Te) detector was higher in IV‐administrated‐rats (0.10%ID/g) than in rats administered via oral gastric catheter (0.03%ID/g). Uptake in diaphragm was higher five times and uptake in musculus massetter was higher three times than control group in IV‐administrated rats. Conclusion: Because high counts obtained in tissues infected with Trichinella spiralis larvaes using Tc‐99m mebendazole, this agent may be used as an imaging agent in Trichinella spiralis infection.
TP100 The Clinical Nurse Specialist in Radionuclide Therapy L. Causer; The Royal Marsden NHS Hospitals Trust, London, UNITED KINGDOM. Abstract for EANM October 2009 Title The Oncology Clinical Nurse Specialist as a coordinator in Radionuclide Therapy. Introduction Radionuclide therapy is a complex procedure in nuclear medicine, requiring good communication and it is vital that the multidisciplinary team works together to deliver this service. The clinical nurse specialist, however, can be pivotal to a successful administration. Over the last 10 ‐15 years there has been a slow expansion of Radionuclide therapy services in the UK. The resource implications are high and this could be the reason for the slow progress. At the same time there have also been many debates on how care should be provided for patients within the health service and many policy statements and national guidance documents for example the National Cancer Plan that have required more staff to be available to meet targets and therefore working at an advanced level has been required. Nursing probably has paved the way with many advanced roles being assumed by nursing staff and the development of the Clinical nurse specialist role (CNS) has ensured that patients have access to best practice. The CNS role within nuclear medicine therapy is: To provide / coordinate care within the multidisciplinary team. To be available from referral for information on specific treatments. To perform telephone assessment pre treatment and obtain a history. Act as information resource for patients and other healthcare professionals Act as patient advocate Facilitate informed consent and all aspects of information relating to radiation protection Coordinate treatment and other professionals in the nuclear medicine team eg ordering radiopharmaceuticals, imaging, physics, radiation protection issues Act as Operator on the administration day ensuring safe administration of therapy Provide telephone advice and assessment post treatment to patients their families and other healthcare professionals. Good coordination and communication ensures that the patient receives a high quality service from referral to on going treatment. The CNS creates a collaborative holistic approach that improves the patients pathway through their treatment and ongoing care. We owe it to patients that attend nuclear medicine to have this highly specialised service available.