Hell J Nucl Med
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A 35 years old primigravida hailing from a humble, rural background with no previous history related to thyroid carcinoma, presented with acute paraparesis at the last trimester of pregnancy and was diagnosed to harbor metastatic papillary thyroid carcinoma (PTC) following magnetic resonance imaging (MRI) of the spine with guided biopsy, which demonstrated near complete collapse of D5 and D10 vertebral bodies with altered signal on the D4 to D6 and D9 to D11 vertebral bodies, in addition to a gravid uterus and a large goiter. There was also evidence of bilateral nodular lesions in the lung parenchyma and a fairly large hepatic lesion in segment 8 of the liver . Histopathology revealed metastatic follicular variant of thyroid papillary carcinoma. This case with challenging presentation had multiple issues to be resolved during its management: a) acute paraparesis and the requirement of radioiodine ((131)I) treatment soon after total thyroidectomy, b) her first valuable pregnancy that required to be managed successfully, c) the poor general condition, d) the abstinence from iodine containing medications, in relation to the Cesarean section planned, e) the timing of total thyroidectomy, f) postnatal care of the newborn and g) radioprotective measures. All were important considerations in the management of this patient. Iodine restricted diet and medications were recommended and were communicated to the obstetricians involved in the patient. ⋯ Similar emphasis has also been given by other authors while dealing with these patients. In our experience, patients with PTC metastatic lesions in the vertebrae show better response compared to those with large flat bone metastases likely related to the small size of the former. In conclusion, a teamwork of surgeons, obstetricians, nuclear medicine physicians as well as the strong support by the relatives, was necessary to favorably treat this patient with metastatic PTC, paraplegia and pregnancy.
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Letter Case Reports
(18)F-FDG positron emission tomography/computed tomography and (99m)Tc-MDP skeletal scintigraphy in a case of Erdheim-Chester disease.
Erdheim-Chester disease (ECD), first described by Jakob Erdheim and William Chester in 1930, is a rare form of non-Langerhan's cell histiocytosis with unknown aetiology, is charaterized by systemic xanthogranulomatous infiltrative disease. To date, about 350 cases of ECD have been described in the medical literature. The typical ECD diagnostic triad is bone pain, diabetes insipidus and bilateral exophthalmos. ⋯ The typical bone pattern of (18)F-FDG PET/CT scan is specific for ECD and (99m)Tc-MDP skeletal scintigraphy may be performed in patients in whom initial (18)F-FDG PET/CT scans present the possibility of ECD diagnosis. Others reported that (18)F-FDG PET/CT scans had good sensitivity (66.7%) and specificity (92.3%) as compared with MRI of the CNS involvement or lesions. In conclusion, the (18)F-FDG PET/CT scan and the (99m)Tc-MDP scan depicted many of the most relevant lesions of ECD for the initial assessment of ECD in our patient.
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Sentinel node biopsy can decrease the morbidity of breast cancer treatment significantly by sparing many patients of axillary lymph node dissection and resulting arm lymphedema. Despite widespread use of sentinel node mapping for breast cancer patients almost all aspects of this procedure are controversial; such as: type of the radiotracer, eligibility, time of injection, etc. One of these controversial issues is the efficacy of 2 days protocol (injection of the tracer on one day and sentinel node mapping and surgery on the following day). The main reason to perform 2 days protocol is the ease of operation room scheduling the patient does not need to complete injection and imaging in the nuclear medicine department. ⋯ Although we didn't evaluate radiation exposure in our study, this was acceptable in other studies and Buscombe et al showed a maximum effective dose of 2.6μSv/MBq for these patients and even assuming this highest value the patient exposure was very low compared to many other procedures. In conclusion, two days protocol gives the sentinel node biopsy team considerable flexibility and lymphoscintigrpahy imaging can be completed before surgery. Finding of the axillary sentinel node during surgery is also being easier. False negative rates as well as the detection rate for one day and two days protocols are comparable.
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Locally advanced breast cancer (LABC) is a distinct entity in breast carcinoma with high incidence of distant metastases (M). However, there is scarce data in the literature addressing the role of fluorine-18-fluorodeoxyglucose-positron emission tomography/computed tomography ((18)F-FDG PET/CT) in LABC. This study was performed to assess the sensitivity of (18)F-FDG PET/CT in confirming known lymph nodal and M and in identifying new ones in LABC. ⋯ Lymph nodal and distant metastases detected by all other examinations were detected by (18)F-FDG PET/CT in all patients, except subcentimetric metastases in 2 patients in the axilla that were detected in another examination later. Additionally, (18)F-FDG PET/CT identified unknown ipsilateral, supraclavicular, internal mammary metastases and upstaged disease in 3 patients and additional distant metastases were noted in 3/16 patients. In conclusion, our study suggests that more extra axillary lymph nodal and distant metastases can be identified by (18)F-FDG PET/CT as compared to a group of clinical, X-rays, ultrasound and bone scan examinations together.