Unilateral Versus Bilateral Prostatic Arterial Embolization for Lower Urinary Tract Symptoms in Patients with Prostate Enlargement

Purpose

This study was designed to compare baseline data and clinical outcome between patients with prostate enlargement/benign prostatic hyperplasia (PE/BPH) who underwent unilateral and bilateral prostatic arterial embolization (PAE) for the relief of lower urinary tract symptoms (LUTS).

Methods

This single-center, ambispective cohort study compared 122 consecutive patients (mean age 66.7 years) with unilateral versus bilateral PAE from March 2009 to December 2011. Selective PAE was performed with 100- and 200-μm nonspherical polyvinyl alcohol (PVA) particles by a unilateral femoral approach.

Results

Bilateral PAE was performed in 103 (84.4 %) patients (group A). The remaining 19 (15.6 %) patients underwent unilateral PAE (group B). Mean follow-up time was 6.7 months in group A and 7.3 months in group B. Mean prostate volume, PSA, International prostate symptom score/quality of life (IPSS/QoL) and post-void residual volume (PVR) reduction, and peak flow rate (Qmax) improvement were 19.4 mL, 1.68 ng/mL, 11.8/2.0 points, 32.9 mL, and 3.9 mL/s in group A and 11.5 mL, 1.98 ng/mL, 8.9/1.4 points, 53.8 mL, and 4.58 mL/s in group B. Poor clinical outcome was observed in 24.3 % of patients from group A and 47.4 % from group B (p = 0.04).

Conclusions

PAE is a safe and effective technique that can induce 48 % improvement in the IPSS score and a prostate volume reduction of 19 %, with good clinical outcome in up to 75 % of treated patients. Bilateral PAE seems to lead to better clinical results; however, up to 50 % of patients after unilateral PAE may have a good clinical outcome.     

Intra-vesical Prostatic Protrusion (IPP) Can Be Reduced by Prostatic Artery Embolization

Background

Prostate artery embolization (PAE) is a new approach to improve lower urinary tract symptoms (LUTS) related to benign prostatic hyperplasia. PAE results in global reduction of prostate volume (PV). There are no data available on the efficacy of PAE in reducing intra-vesical prostatic protrusion (IPP), an anatomic feature that is clinically related with bladder outlet obstruction and LUTS.

Objective

To assess the results of PAE in patients with significant IPP due to median lobe hyperplasia and to compare the IPSS decrease and IPP change.

Material and Methods

Prospective analysis of 18 consecutive patients with significant IPP (>5 mm) related to median lobe hyperplasia undergoing PAE using 30–500-μm-calibrated trisacryl microspheres. We measured IPP on sagittal T2-weighted images before and 3 months after PAE. IPSS and clinical results were also evaluated at 3 months.

Results

PAE resulted in significant IPP reduction (1.57 cm ± 0.55 before PAE and 1.30 cm ± 0.46 after PAE, p = 0.0005) (Fig. 1) with no complication. IPSS, quality of life (QoL), total prostate-specific antigen (PSA) level, and PV showed significant reduction after PAE, and maximum urinary flow rate (Q _max) showed significant increase after PAE. No significant change of International Index of Erectile Function (IIEF) for clinical evaluation after PAE. A significant correlation was found between the IPP change and the IPSS change (r = 0.636, p = 0.0045).

Conclusion

Patients had significant IPP reduction as well as significant symptomatic improvement after PAE, and these improvements were positively correlated.

     

Clinical, Laboratorial, and Urodynamic Findings of Prostatic Artery Embolization for the Treatment of Urinary Retention Related to Benign Prostatic Hyperplasia. A Prospective Single-Center Pilot Study

Purpose

This study was designed to describe the clinical, laboratorial, and urodynamic findings of prostatic artery embolization (PAE) in patients with urinary retention due to benign prostatic hyperplasia (BPH).

Methods

A prospective study of 11 patients with urinary retention due to BPH was conducted. Patients underwent physical examination, prostate specific antigen (PSA) measurement, transrectal ultrasound, and magnetic resonance imaging. International prostate symptom score (IPSS), quality of life (QoL), and urodynamic testing were used to assess the outcome before and after 1 year.

Results

Clinical success was 91 % (10/11 patients) with a mean follow-up of 22.3 months (range, 12–41 months). At the first year follow-up, the mean IPSS score was 2.8 points (p = 0.04), mean QoL was 0.4 points (p = 0.001), mean PSA decreased from 10.1 to 4.3 ng/mL (p = 0.003), maximum urinary flow (Qmax) improved from 4.2 to 10.8 mL/sec (p = 0.009), and detrusor pressure (Pdet) decreased from 85.7 to 51.5 cm H₂O (p = 0.007). Before PAE, Bladder Outlet Obstruction Index (BOOI) showed values >40 in 100 % of patients. After PAE, 30 % of patients were >40 (obstructed), 40 % were between 20 and 40 (undetermined), and 30 % were <20 (unobstructed). Patients with a BOOI <20 had higher PSA values at 1-day after PAE.

Conclusions

Clinical and urodynamic parameters improved significantly after PAE in patients with acute urinary retention due to BPH. Total PSA at day 1 after PAE was higher in patients with unobstructed values in pressure flow studies.     

Efficacy of preoperative transcatheter arterial chemoembolization combined with systemic chemotherapy for treatment of unresectable hepatoblastoma in children

Purpose

The purpose of this study was to evaluate, retrospectively, the clinical efficacy of preoperative transcatheter arterial chemoembolization (TACE) combined with systemic chemotherapy for unresectable hepatoblastoma.

Materials and methods

Five boys and three girls (mean age 15.2 months) were treated with preoperative TACE combined with systemic chemotherapy for unresectable hepatoblastomas. Mean tumor diameter and mean alfa-fetoprotein (AFP) level were 11.8 cm and 549,386 ng/mL, respectively. Pretreatment, the extent of disease (PRETEXT) was: II, 1; III, 6; IV, 1. For all patients, preoperative systemic chemotherapy was administered before TACE. At each TACE, carboplatin and adriamycin mixed with iodized oil were infused into the feeding arteries. Tumor response and prognosis after treatment were evaluated.

Results

TACE resulted in few Grade 1 adverse effects (AEs), without G3 or more AEs, according to CTACAE 3.0. Mean tumor shrinkage was 60.9 %, and the mean AFP decrease from initial levels was 94.8 %. In all cases TACE combined with systemic chemotherapy enabled subsequent safe and complete surgical resection. After a mean follow-up of 59 months, tumor-free survival was 75 %.

Conclusion

Preoperative TACE combined with systemic chemotherapy was effective in inducing surgical resectability of unresectable hepatoblastoma.     

Risk Factors for Rebleeding and Prognostic Factors for Postoperative Survival in Patients with Balloon-Occluded Retrograde Transvenous Obliteration of Acute Gastric Variceal Rupture

Purpose

Balloon-occluded retrograde transvenous obliteration (B-RTO) has shown great potential in controlling acute gastric variceal hemorrhage, although rebleeding related to the procedure may occur in a small percentage of patients. The purpose of this study was to identify risk factors of perioperative rebleeding and prognostic factors of postoperative survival in B-RTO performed for acute episodes of gastric variceal hemorrhage.

Methods

We retrospectively analyzed 39 consecutive patients who underwent B-RTO for gastric variceal rupture at our hospital between June 2003 and May 2011. Uni- and multi-variate analyses were performed to assess risk factors for perioperative rebleeding and prognostic factors for postoperative survival.

Results

Surgical success and complete eradication of varices were achieved in 36 cases (92.3 %) and 35 cases (89.7 %), respectively. Six patients experienced rebleeding either intraoperatively (n = 3) or within 1 h after B-RTO (n = 3). Child-Pugh class C was identified as a risk factor for rebleeding on univariate (P = 0.018) and multivariate analyses (odds ratio, 6.003; P = 0.014). With a median follow-up of 23 months (range 0–106.6 months), overall survival rates at 1, 3, and 5 years were 91.7, 74.7, and 67.2 %, respectively. Multivariate analyses revealed Child-Pugh class C as a prognostic factor for survival (relative risk, 4.014; P = 0.023).

Conclusion

Although B-RTO is generally effective in the treatment of acute gastric variceal rupture, patients classified as Child-Pugh class C have a higher risk of perioperative rebleeding and shorter survival.     

Ruptured brain arteriovenous malformations associated with aneurysms: safety and efficacy of selective embolization in the acute phase of hemorrhage

Introduction

The impact of targeted embolization of ruptured cerebral arteriovenous malformation (AVM)-associated arterial aneurysms in the acute phase of bleeding is not well known. The objective of our study was to analyze the safety and efficacy of this treatment strategy with special emphasis on its protective effect against rebleeding.

Methods

From a prospective database, all patients presenting between December 2005 and March 2012 with a ruptured cerebral AVM associated with arterial aneurysms contiguous to the hemorrhage were selected. Hemorrhagic stroke severity and clinical outcome were measured using, respectively, Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS) scores.

Results

Twenty-five patients with ruptured cerebral AVMs associated with 31 arterial aneurysms contiguous with the hemorrhage were included. In the first group of 17 patients, the mean time to treatment was 30.1 h, while in the second group with 1 patient in poor initial clinical conditions and 7 admitted 7 to 28 days after bleeding, it was 17 days. All arterial aneurysms were totally occluded. Four patients presented rebleeding before treatment (mean interval 9.6 days) and four had rebleeding after treatment (mean interval 8.25 months). At a mean follow-up of 56 months, 21 patients were alive (19 mRS?≤?2, 2 mRS?>?2). Three patients died 2 days, 9 days, and 2 months after bleeding and another died of rebleeding of her residual AVM 19 months after treatment. Treatment-related morbidity and mortality were, respectively, 4 and 0 %.

Conclusion

Selective embolization of arterial aneurysms associated with ruptured AVMs is a safe procedure and could lower the immediate risk of rebleeding.     

MR-sequences for prostate cancer diagnostics: validation based on the PI-RADS scoring system and targeted MR-guided in-bore biopsy

Purpose

This study evaluated the accuracy of MR sequences [T2-, diffusion-weighted, and dynamic contrast-enhanced (T2WI, DWI, and DCE) imaging] at 3T, based on the European Society of Urogenital Radiology (ESUR) scoring system [Prostate Imaging Reporting and Data System (PI-RADS)] using MR-guided in-bore prostate biopsies as reference standard.

Methods

In 235 consecutive patients [aged 65.7?±?7.9 years; median prostate-specific antigen (PSA) 8 ng/ml] with multiparametric prostate MRI (mp-MRI), 566 lesions were scored according to PI-RADS. Histology of all lesions was obtained by targeted MR-guided in-bore biopsy.

Results

In 200 lesions, biopsy revealed prostate cancer (PCa). The area under the curve (AUC) for cancer detection was 0.70 (T2WI), 0.80 (DWI), and 0.74 (DCE). A combination of T2WI + DWI, T2WI + DCE, and DWI + DCE achieved an AUC of 0.81, 0.78, and 0.79. A summed PI-RADS score of T2WI + DWI + DCE achieved an AUC of 0.81. For higher grade PCa (primary Gleason pattern?≥?4), the AUC was 0.85 for T2WI + DWI, 0.84 for T2WI + DCE, 0.86 for DWI + DCE, and 0.87 for T2WI + DWI + DCE. The AUC for T2WI + DWI + DCE for transitional-zone PCa was 0.73, and for the peripheral zone 0.88. Regarding higher-grade PCa, AUC for transitional-zone PCa was 0.88, and for peripheral zone 0.96.

Conclusion

The combination of T2WI + DWI + DCE achieved the highest test accuracy, especially in patients with higher-grade PCa. The use of ≤2 MR sequences led to lower AUC in higher-grade and peripheral-zone cancers.

Key Points

? T2WI + DWI + DCE achieved the highest accuracy in patients with higher grade PCa ? T2WI + DWI + DCE was more accurate for peripheral- than for transitional-zone PCa ? DCE increased PCa detection accuracy in the peripheral zone ? DWI was the leading sequence in the transitional zone     

Prognostic Value of Metabolic Tumor Volume Estimated by 18 F-FDG Positron Emission Tomography/Computed Tomography in Patients with Diffuse Large B-Cell Lymphoma of Stage II or III Disease

Purpose

The purpose of this study was to evaluate the prognostic value of metabolic tumor volume (MTV) measured by ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT) in patients with diffuse large B-cell lymphoma (DLBCL) treated with rituximab-containing immunochemotherapy.

Methods

Patients with newly diagnosed DLBCL who underwent pre-treatment torso FDG-PET/CT scan taken within 10 days before treatment were included. MTV was defined as the volume of hypermetabolic tissue with a standardized uptake value (SUV) greater than a threshold value of 2.5 and calculated using volume viewer software. Association of MTV with patient characteristics and survival were compared.

Results

A total of 96 patients were evaluated. During a median follow-up period of 27.8 months, 3-year event-free survival (EFS) and overall survival was 69.5 % and 72.9 %, respectively. The Ann Arbor staging showed a limitation of prognosis because there was no difference of EFS between patients with Ann Arbor stage II and those with stage III. On the contrary, among patients with Ann Arbor stage II or III disease (n?=?53), the higher MTV group showed significantly inferior EFS compared with the lower MTV group.

Conclusions

In the current study, we identified the pre-treatment MTV measured by FDG-PET/CT as a potential predictor of survival in patients with DLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP), at least in Ann Arbor stage II and III disease.     

Conventional 2D (2DRT) and 3D conformal radiotherapy (3DCRT) versus intensity-modulated radiotherapy (IMRT) for nasopharyngeal cancer treatment

Purpose

Nasopharyngeal carcinoma represents a distinct entity as compared to other head and neck tumours. Radio-chemotherapy is the treatment of first choice in non-metastatic disease. Intensity-modulated radiation therapy (IMRT) allows the sparing of parotid glands, improving the toxicity profile. The aim of this study was to compare the results obtained with IMRT with those obtained with conventional 2D (2DRT) and 3D conformal radiation therapy (3DCRT) in terms of tumour control, survival, acute and late toxicity.

Materials and methods

We reviewed the clinical records of 52 patients with histologically proven carcinoma of the nasopharynx (stage I–IVB according to the 2002 American Joint Committee on Cancer staging system) treated with curative intent between January 2003 and August 2011: 26 patients were treated with 2D or 3D technique (arm A) and 26 with IMRT technique (arm B) with simultaneous integrated boost. Fifty patients (96 %) received chemotherapy. Local control (LC), locoregional control (LRC), disease-free survival (DFS), overall survival (OS), acute and late toxicity were retrospectively evaluated.

Results

After a median follow-up of 37.6 months (69 months in arm A and 23 months in arm B), 69 % of patients were alive and disease-free, 10 % were alive with disease and 21 % died of disease, with an OS of 81 % at 2 years and 79 % at 5 years, a LC rate of 88 % at 2 years and 78 % at 5 years, a LRC rate of 80 % at 2 years and 73 % at 5 years and a DFS of 74 % at 2 years and 65 % at 5 years, with no statistically significant differences between IMRT and 2DRT/3DCRT. In multivariate analysis, the TNM stage and the volume treated at high dose correlated with DFS. No factor was found to be related to OS. Chronic toxicity was not statistically different in the two study groups and in particular ≥G2 xerostomia rates were 67 and 41 % in arm A and B, respectively (p = 0.10).

Conclusions

The findings of this study confirm that IMRT associated with chemotherapy, even with moderately hypofractionated regimens, allows good disease control with better results in terms of late xerostomia, although without statistically significant differences compared to 2DRT and 3DCRT. The hypothesis of an impact of IMRT on survival has yet to be confirmed.     

A high-resolution computed tomography-based scoring system to differentiate the most infectious active pulmonary tuberculosis from community-acquired pneumonia in elderly and non-elderly patients

Objective

The objective of this study was to use high-resolution computed tomography (HRCT) imaging to predict the presence of smear-positive active pulmonary tuberculosis (PTB) in elderly (at least 65 years of age) and non-elderly patients (18–65 years of age).

Methods

Patients with active pulmonary infections seen from November 2010 through December 2011 received HRCT chest imaging, sputum smears for acid-fast bacilli and sputum cultures for Mycobacterium tuberculosis. Smear-positive PTB was defined as at least one positive sputum smear and a positive culture for M. tuberculosis. Multivariate logistic regression analyses were performed to determine the HRCT predictors of smear-positive active PTB, and a prediction score was developed on the basis of receiver operating characteristic curve analysis.

Results

Of 1,255 patients included, 139 were diagnosed with smear-positive active PTB. According to ROC curve analysis, the sensitivity, specificity, positive predictive value, negative predictive value, false positive rates and false negative rates were 98.6 %, 95.8 %, 78.5 %, 99.8 %, 4.2 % and 1.4 %, respectively, for diagnosing smear-positive active PTB in elderly patients, and 100.0 %, 96.9 %, 76.5 %, 100.0 %, 3.1 % and 0.0 %, respectively, for non-elderly patients.

Conclusions

HRCT can assist in the early diagnosis of the most infectious active PTB, thereby preventing transmission and minimizing unnecessary immediate respiratory isolation.

Key Points

? HRCT can assist in the early diagnosis of the infectious active PTB ? HRCT imaging is useful to predict the presence of smear-positive active PTB ? Predictions from the HRCT imaging are valid even before sputum smear or culture results     

Pulmonary veno-occlusive disease: the role of CT

Objective

The authors sought to evaluate the diagnostic accuracy of high-resolution computed tomography (HRCT) in the detection of pulmonary veno-occlusive disease (PVOD) in patients with pre-capillary pulmonary arterial hypertension (PAH) of unknown aetiology, and to identify the role of CT in diagnosis and therapy.

Materials and methods

The CT scans of 96 patients were retrospectively reviewed and assessed for specific HRCT findings: ground-glass opacities, septal lines and mediastinal lymph nodal enlargement (short diameter ≥1 cm). According to the HRCT findings, patients were divided into PVOD-suspicious and not PVOD-suspicious. Subsequently, a clinical-instrumental evaluation was performed, and the response to therapy and histopathological reports were evaluated.

Results

Radiological evaluation based on HRCT findings revealed 29 patients as PVOD-suspicious and 67 as not PVOD-suspicious. The final diagnosis was PVOD in 22 patients and idiopathic PAH in 74 patients. The CT scan showed 95.5 % sensitivity, 89 % specificity, 72.5 % positive predictive value, and 98.5 % negative predictive value, with a diagnostic accuracy of 90.5 % in identifying patients with PVOD.

Conclusions

Chest CT can be considered a screening test in the assessment of patients with PAH of unknown aetiology, and the radiologist can help the clinician to identify patients with CT findings that make PVOD highly probable.     

Diagnostic value of FDG-PET/(CT) in children with fever of unknown origin and unexplained fever during immune suppression

Purpose

Fever of unknown origin (FUO) and unexplained fever during immune suppression in children are challenging medical problems. The aim of this study is to investigate the diagnostic value of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and FDG-PET combined with computed tomography (FDG-PET/CT) in children with FUO and in children with unexplained fever during immune suppression.

Methods

All FDG-PET/(CT) scans performed in the Radboud university medical center for the evaluation of FUO or unexplained fever during immune suppression in the last 10 years were reviewed. Results were compared with the final clinical diagnosis.

Results

FDG-PET/(CT) scans were performed in 31 children with FUO. A final diagnosis was established in 16 cases (52 %). Of the total number of scans, 32 % were clinically helpful. The sensitivity and specificity of FDG-PET/CT in these patients was 80 % and 78 %, respectively. FDG-PET/(CT) scans were performed in 12 children with unexplained fever during immune suppression. A final diagnosis was established in nine patients (75 %). Of the total number of these scans, 58 % were clinically helpful. The sensitivity and specificity of FDG-PET/CT in children with unexplained fever during immune suppression was 78 % and 67 %, respectively.

Conclusions

FDG-PET/CT appears a valuable imaging technique in the evaluation of children with FUO and in the diagnostic process of children with unexplained fever during immune suppression. Prospective studies of FDG-PET/CT as part of a structured diagnostic protocol are warranted to assess the additional diagnostic value.     

Tumour volume doubling time of molecular breast cancer subtypes assessed by serial breast ultrasound

Objectives

The aim of our study was to evaluate the tumour volume doubling time (TVDT) of molecular breast cancer subtypes by serial ultrasound (US).

Methods

Sixty-six patients (mean age, 50 years; range, 29–78 years) with invasive breast cancer underwent initial and follow-up breast US examinations (at least three months apart) with no intervention. TVDT was determined using the tumours’ greatest dimensions in two orthogonal planes. The results were compared with clinical, imaging, and tumour variables and molecular subtypes (oestrogen receptor [ER]-positive, human epidermal growth factor receptor 2 [HER2]-positive, and triple negative) using a multiple linear regression analysis.

Results

TVDT exhibited a wide range (46–825 days; median, 141 days) with an overall mean of 193?±?141 days and mean values of 241?±?166 days for ER-positive tumours (n?=?37), 162?±?60 days for HER2-positive tumours (n?=?12), and 103?±?43 days for triple-negative tumours (n?=?17) (P?P?Conclusions TVDT differed significantly among the three molecular breast cancer subtypes, with the triple-negative tumours showing the fastest growth.

Key Points

? Knowledge of tumour volume doubling time provides clues for improving screening. ? TVDT assessed by serial US differed significantly between breast cancer subtypes. ? Triple-negative tumours had 2.4-fold shorter TVDT compared to ER-positive tumours. ? Tumours classified as BI-RADS 3 had shorter TVDT than BI-RADS 4.     

A randomized study of the effect of carbonated water prior to myocardial SPECT

Objective

In myocardial perfusion single-photon emission computed tomography (SPECT), abdominal activity often interferes with the evaluation of perfusion in the inferior wall, especially after pharmacological stress. In this randomized study, we examined the effect of carbonated water intake versus still water intake on the quality of images obtained during myocardial perfusion images (MPI) studies.

Methods

A total of 467 MIBI studies were randomized into a carbonated water group and a water group. The presence of intestinal activity adjacent to the inferior wall was evaluated by two observers. Furthermore, a semi-quantitative analysis was performed in the adenosine subgroup, using a count ratio of the inferior myocardial wall and adjacent abdominal activity.

Results

The need for repeated SPECT in the adenosine studies was 5.3 % in the carbonated water group versus 19.4 % in the still water group (p = 0.019). The inferior wall-to-abdomen count ratio was significantly higher in the carbonated water group compared to the still water group (2.11 ± 1.00 vs. 1.72 ± 0.73, p < 0.001). The effect of carbonated water during rest and after exercise was not significant.

Conclusions

This randomized study showed that carbonated water significantly reduced the interference of extra-cardiac activity in adenosine SPECT MPI.     

Contrast-enhanced ultrasound of focal nodular hyperplasia: a matter of size

Objectives

To assess the contrast-enhanced ultrasound (CEUS) frequencies of centrifugal enhancement, spoke-wheel sign and central scar in focal nodular hyperplasia (FNH) as a function of lesion size.

Methods

Ninety-four FNHs were retrospectively reviewed to assess their largest diameter and enhancement pattern, including centrifugal enhancement from one central artery, spoke-wheel sign, diffuse or centripetal enhancement, central scar and late-phase washout.

Results

Mean FNH-lesion size was 3.7?±?2.1 cm. Only 43.6 % of FNHs had centrifugal enhancement, with a spoke-wheel pattern (23.4 %) or without (20.2 %), while 56.4 % showed diffuse or centripetal enhancement. Centrifugal enhancement was observed in 73.9 % of FNHs ≤3.1 cm and 14.6 % of FNHs >3.1 cm (P?–4). Size and frequency of centrifugal enhancement were negatively correlated (r?=?–0.57, P?–4). The spoke-wheel pattern was also seen more frequently in smaller (37 %) than in larger FNHs (10.4 %) (P?–3). Late-phase washout was described in 5.3 % of FNHs and was not size-dependent. Lesions with a central scar were larger than those without, respectively, 5.7?±?1.7 and 3.6?±?2.0 cm (P?=?0.012).

Conclusions

Typical centrifugal enhancement yielding a confident FNH diagnosis is seen significantly more frequently when the lesion is ≤3.1 cm.

Key Points

? CEUS yields confident diagnoses of FNHs ≤3.1 cm ? The larger the FNH, the lower the diagnostic sensitivity of CEUS ? Final diagnosis of FNHs >3.1 cm should be obtained with MRI not CEUS     

Safety of ventilation/perfusion single photon emission computed tomography for pulmonary embolism diagnosis

Purpose

The aim of this management outcome study was to assess the safety of ventilation/perfusion single photon emission computed tomography (V/Q SPECT) for the diagnosis of pulmonary embolism (PE) using for interpretation the criteria proposed in the European Association of Nuclear Medicine (EANM) guidelines for V/Q scintigraphy.

Methods

A total of 393 patients with clinically suspected PE referred to the Nuclear Medicine Department of Brest University Hospital from April 2011 to March 2013, with either a high clinical probability or a low or intermediate clinical probability but positive D-dimer, were retrospectively analysed. V/Q SPECT were interpreted by the attending nuclear medicine physician using a diagnostic cut-off of one segmental or two subsegmental mismatches. The final diagnostic conclusion was established by the physician responsible for patient care, based on clinical symptoms, laboratory test, V/Q SPECT and other imaging procedures performed. Patients in whom PE was deemed absent were not treated with anticoagulants and were followed up for 3 months.

Results

Of the 393 patients, the prevalence of PE was 28 %. V/Q SPECT was positive for PE in 110 patients (28 %) and negative in 283 patients (72 %). Of the 110 patients with a positive V/Q SPECT, 78 (71 %) had at least one additional imaging test (computed tomography pulmonary angiography or ultrasound) and the diagnosis of PE was eventually excluded in one patient. Of the 283 patients with a negative V/Q SPECT, 74 (26 %) patients had another test. The diagnosis of PE was finally retained in one patient and excluded in 282 patients. The 3-month thromboembolic risk in the patients not treated with anticoagulants was 1/262: 0.38 % (95 % confidence interval 0.07–2.13).

Conclusion

A diagnostic management including V/Q SPECT interpreted with a diagnostic cut-off of “one segmental or two subsegmental mismatches” appears safe to exclude PE.     

Local recurrence of breast cancer in reconstructed breasts using TRAM flap after skin-sparing mastectomy: clinical and imaging features

Objectives

To evaluate clinical and imaging features of cancer recurrence in reconstructed breasts following skin-sparing mastectomy (SSM) or nipple areolar skin-sparing mastectomy (NASSM).

Methods

This study was approved by our Institutional Review Board. In this retrospective study, we included patients with pathologically confirmed recurrent cancer who had transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after SSM or NASSM and whose follow-up radiological studies were available. Each patient’s demographic data, imaging studies and clinical outcomes were reviewed. Two breast radiologists analysed the imaging findings of follow-up mammography, ultrasound and magnetic resonance imaging.

Results

Of the 964 patients, 16 (1.7 %) had local cancer recurrence. The average follow-up period until the detection was 31.1 months (range, 7–84 months). Fourteen (87.5 %) patients had recurrence on the skin or in subcutaneous fat. Of the 16 patients, recurrence was detected by breast self-examination in 13 (81.3 %) patients. Eight (50 %) lesions mimicked benign lesions. The other eight (50 %) lesions manifested various degree of suspicion for the malignancy.

Conclusions

Recurrent cancer after TRAM flap reconstruction following SSM and NASSM is often recognised by breast self-examination and mimics imaging findings of benign lesions. Therefore, meticulous physical examination and history-taking are important. Pathological confirmation is worthwhile even in the benign-appearing lesions.

Key Points

? Overview of clinical and imaging features of cancer recurrence in reconstructed breasts ? 50 % of recurred malignant lesions mimicking imaging findings of benign lesions ? Patients may benefit from thorough self-breast examination     

Nuclear myocardial perfusion imaging with a cadmium–telluride semiconductor detector gamma camera in patients with acute myocardial infarction

Objective

Since myocardial perfusion imaging (MPI) with conventional sodium iodine (NaI) device has low spatial resolution, there have been some cases in which small structures such as non-transmural myocardial infarction could not be properly detected. The purpose of this study was to evaluate potential usefulness of cadmium–telluride (CdTe) semiconductor detector-based high spatial resolution gamma cameras in detecting myocardial infarction sites, especially non-transmural infarction.

Methods

A total of 38 patients (mean age ± SD: 64 ± 21 year) who were clinically diagnosed with acute myocardial infarction were included. Twenty-eight cases of them were with ST segment elevation myocardial infarction (STEMI) and 10 cases with non-ST segment elevation myocardial infarction (NSTEMI). In all patients, myocardial perfusion single photon emission computed tomography images were acquired with Infinia (NaI device) and R1-M (CdTe device), and the images were compared concerning the detectability of acute myocardial infarction sites.

Results

The detection rates of the myocardial infarction site in cases with STEMI were 100 % both by NaI and CdTe images. In cases with NSTEMI, detection rate by NaI images was 50 %, while that of CdTe images was 100 % (p = 0.033). The summed rest score (SRS) value derived from CdTe images was significantly higher than that from NaI images in cases with STEMI [NaI images: 12 (7–18) versus CdTe images: 14 (9–20)] (p < 0.001). SRS derived from CdTe images was significantly higher than that derived from NaI images in cases with NSTEMI [NaI images: 2 (0–5) versus CdTe images: 6 (6–8)] (p = 0.006).

Conclusions

These results indicate that MPI using CdTe-semiconductor device will provide a much more accurate assessment of acute myocardial infarction in comparison to current methods.     

I-123 mIBG and Tc-99m myocardial SPECT imaging to predict inducibility of ventricular arrhythmia on electrophysiology testing: A retrospective analysis

Objectives

The purpose of this study is to assess mIBG uptake in scar border zone and its relation with ventricular arrhythmia (VA) inducibility on electrophysiology (EP) testing using I-123 mIBG SPECT and resting Tc-99m SPECT myocardial perfusion imaging (MPI).

Methods

Forty-seven patients from a previous clinical trial were retrospectively analyzed. These patients underwent I-123 mIBG and resting Tc-99m tetrofosmin SPECT, and EP testing. Twenty-eight patients were positive (EP+) and 19 patients were negative (EP?) for inducibility of sustained (>30 seconds) VA on EP testing. MPI scar extent, border zone extent, and mIBG uptake in border zone were used to predict VA inducibility on EP testing, respectively.

Results

There was no significant difference in scar extent between the EP+ and EP? groups. The EP+ group had significantly larger border zone and lower mIBG uptake ratio in the border zone than the EP? group. Receiver operating characteristic (ROC) curve analysis showed that the prediction accuracy for border zone extent (area under ROC = 0.75) was better than scar extent (area under ROC = 0.66). The prediction accuracy was further improved (area under ROC = 0.78), when assessing mIBG uptake in the border zone.

Conclusion

A new tool has been developed to measure scar and border zone and to assess mIBG uptake in scar and border zone from combined I-123 MIBG SPECT and resting Tc-99m SPECT MPI. The mIBG uptake in the border zone predicted VA inducibility on EP testing with a promising accuracy.     

Femoral fixation of hamstring tendon grafts in ACL reconstructions: the 2-year follow-up results of a prospective randomized controlled study

Purpose

Hamstring tendon grafts are commonly used in anterior cruciate ligament (ACL) reconstructions. A number of fixation devices are available; however, several have limited clinical support. To our knowledge, no randomized controlled study comparing the EZLoc and the Bone Mulch Screw for femoral fixation in ACL reconstruction exists. Therefore, the purpose of this study was to compare the results following the use of these two femoral fixation devices. Time in surgery for the two methods was also to be compared.

Methods

A total of 110 patients between 18 and 45 years old at two orthopaedic departments, A (n = 55) and B (n = 55), were randomized to ACL reconstruction with femoral fixation of the hamstring graft with either the EZLoc or the Bone Mulch Screw. Surgical time was measured for each group. The patients were evaluated after 6 weeks and 3, 6, 12 and 24 months. The clinical examination included range of motion, evaluation of intraarticular swelling, tenderness at the lateral femoral condyle, the Lachman test, the Pivot shift test and the KT-1000 arthrometer. In addition, the visual analogue scale score for pain, the Tegner activity score, the Lysholm functional score and the knee injury and osteoarthritis outcome score were recorded. Knee extension and flexion muscle strength were also measured with a Biodex.

Results

There were no significant differences in any of the parameters mentioned above at the 2-year follow-up evaluation. Three patients in each group underwent revision ACL reconstruction during the study. More than 95 % of the knees in both groups were found to be stable. Good to excellent results were found for all selected knee scores in both groups. There were no statistically significant differences between the two groups in any of the muscle strength parameters. Time in surgery was statistically significantly shorter in the EZLoc group compared with the Bone Mulch group.

Conclusion

There were no statistically significant differences in clinical findings, knee scores or in muscle strength between the EZLoc group and the Bone Mulch group at the 2-year follow-up evaluation. Time in surgery was statistically significantly shorter for patients undergoing ACL reconstruction with hamstring grafts when the EZLoc femoral fixation device was used.

Level of evidence

II.