Onset of the neuromuscular block simulated in an anatomical model

Radioiodine scintigraphy is the gold standard exploration for imaging metastases of differentiated thyroid cancer and enables the decision of therapy with 131 radioactive iodine to be made. However, other approaches may be of use for diagnosis when there is no visible uptake after the administration of 131I, while elevated thyroblobulin levels suggest the presence of metastatic tissue in one third of metastatic patients. In order to detect recurrences or metastases, in conjunction with conventional imaging techniques (cervical and hepatic ultrasonography, lung CT scan..), other scintigraphic explorations with various radiopharmaceutics may be used, although none of them has any specificity towards thyroid cancer. Tl201 and MIBI which are used as perfusion tracers for myocardial explorations, are also used for detection of various tumors and for metastatic thyroid cancer. The performances of both radiopharmaceutics in imaging metastases are differently evaluated between investigators with a sensitivity ranging from 45 to 94% while the specificity varies less (82-97%). 18-Fluoro-deoxyglucose is retained in malignant tissue depending on the grade of malignancy. It has been shown to accumulate in thyroid cancer and metastases. Its detection by whole body PETscan represents a limitation for use which will be modified by new techniques. 111In-octreotide which binds to somatostatin receptors located on tumor cell membranes is able to show thyroid cancer metastases in some instances. We report on the very preliminary results of these combined scintigraphic approaches, performed in a limited number of patients who had no radioiodine uptake and elevated Tg levels, in order to determine the most appropriate exploration in terms of performance and cost.     

Management of 29 children with thyroid cancer following the Chernobyl accident]

As a consequence of the Chernobyl nuclear power plant accident, a considerable increase of thyroid cancer among contaminated children has been reported in Ukraine, Belarus and Russia. A group of 29 children aged from 5 months to 10 years (mean 4.7 years) at the time of the accident, with a papillary thyroid cancer, have been examined at the Pitié-Salpêtrière hospital in Paris. The cancer was discovered by systematic ultrasonography in only 25% of cases. No reliable dosimetric estimation was achieved. The initial surgical treatment was performed in Ukraine. Cervical lymph node and pulmonary metastases were present in 24 and 11 cases respectively. A complementary surgical treatment was necessary for 9 children and one to four radioiodine treatments were given to 24 children. With a mean delay of 7 years after the cancer discovery, an apparent cure or a remission was obtained for 20 children, 6 children have cervical lymph node metastases requiring a surgical treatment and 3 have evolving lung metastases. The management of the great number of foreseeable cases of thyroid cancer requires an improved systematic screening, a large number of rooms dedicated to high activity radioiodine treatments, funds for disposable material and training missions.     

Helicobacter pylori infection, gastritis, and the temperature of choice for hot drinks

A 44-year-old male presented with a solitary cerebellopontine angle (CPA) metastasis from lung cancer. His initial symptoms were vertigo and hearing loss beginning 5 months after the diagnosis of the primary cancer. Two months later, right facial paresis developed. His neurological deterioration was rapid. Magnetic resonance (MR) imaging with enhancement disclosed the CPA tumor. The tumor was partially removed through the retroauricular retromastoid approach. Histological examination of the specimen revealed adenocarcinoma. The characteristic rapidly progressive symptoms and MR imaging with enhancement are the most sensitive and essential examinations for this lesion.     

Radioiodine ablation of residual tissue in thyroid cancer: relationship between administered activity, neck uptake and outcome

A retrospective review was performed to evaluate the effectiveness of radioiodine in the ablation of residual thyroid tissue after surgery for differentiated thyroid cancer. 121 patients were treated at the Princess Margaret Hospital, Toronto, Canada between 1977 and 1989, with the activity of radioiodine determined empirically. Ablation of residual thyroid was determined by 131I nuclear scans, using absent visible uptake (compared with background) as the criterion for successful ablation. 97 patients (80%) had successful ablation of residual thyroid tissue after the first administration of radioiodine. Patients with higher iodine uptake in the neck had a tendency to receive higher activities of 131I. There were no statistically significant differences in age, sex, type of surgery, initial iodine uptake in the neck and administered radioiodine activity between those successfully ablated and those that were not. Patients receiving less than 3.7 GBq (100 mCi) tended to have lower iodine uptake (< 5% at 24 or 48 h), but their rate of thyroid ablation was just as high as those given 3.7 GBq or more. In order to take advantage of this, we have formalized our approach by deriving guidelines to the empiric determination of radioiodine activity based on the iodine uptake in the neck. Among the 11 patients treated with lobectomy only, the ablation rate was 64%. Although this was not significantly lower than for other forms of surgery, we continue to recommend completion thyroidectomy for this group of patients, if the goal of treatment is to ablate all thyroid tissue.     

Cervical lymph node metastasis of thyroid papillary carcinoma imaged with fluorine-18-FDG, technetium-99m-pertechnetate and iodine-131-sodium iodide

A 49-yr-old white woman with diffuse sclerosing variant of papillary carcinoma of the thyroid revealed abnormal [18F]FDG accumulation within cervical lymph node metastases prior to thyroidectomy. The abnormal cervical foci of glucose metabolism corresponded to similar areas of abnormal [99mTc]pertechnetate and radioiodine accumulation on presurgical scans. The primary thyroid tumor within the thyroid gland was not delineated as a focal defect on any of the three imaging studies. The relative thyroid-to-background soft-tissue ratio in the [18F]FDG study, however, appeared higher than usual. As with 131I and [99mTc]pertechnetate, this case demonstrates that [18F]FDG PET can detect cervical lymph node metastases in the preoperative thyroid cancer patient.     

The importance of total parenteral nutrition-associated tissue zinc distribution in wound healing

Differentiated thyroid cancer accounts for a majority of the nearly 200,000 people in the United States with thyroid cancer. A significant minority of patients with thyroid cancer do not respond to conventional therapy (surgery, radioiodine, levothyroxine [LT4]). Current therapy for progressive, radioiodine non-responsive differentiated thyroid cancer includes surgery and external-beam irradiation (with or without low-dose weekly Adriamycin) for neck disease, and high-dose Adriamycin therapy for widely metastatic disease. Adriamycin therapy provides a 30% to 40% partial response of disease, but long-term cures are rare. Studies of combination chemotherapy do not show greater benefit than therapy with Adriamycin alone and carry understandably greater toxicity. Retinoic acid, octreotide, and tamoxifen therapies are currently being studied as future therapeutic possibilities. Chemotherapy may prove useful not only as a tumoricidal agent but as therapy for tumor re-differentiation in preparation for radioiodine therapy.     

Breast cyst simulating metastases on iodine-131 imaging in thyroid carcinoma

False-positive radioiodine uptake has been reported in many organ systems. We describe a female patient who had mixed papillary and follicular thyroid carcinoma, and on radioiodine total-body imaging demonstrated focal, lower-right chest uptake. Special prone imaging with the right breast dependent proved that the uptake was inside the right breast. Review of a recent breast ultrasound and mammograms showed this uptake to correspond to a large breast cyst. It is known that 131I breast uptake may be functional within the mammary gland. In this patient, it was due to retention within the cyst after the background activity decreased. Knowledge of this phenomenon may improve the interpretation of total-body 131INa studies.     

Cytogenetic study of thyroid patients treated with external irradiation or radioiodine

Where clinically permitted, either external irradiation or radioiodine therapy is usually recommended for the treatment of differentiated thyroid cancer patients. This paper describes an attempt to clarify the radiation burden and the distribution of radiation doses on the lymphocytes in consequence of these two therapeutic modalities, and the circumstances of the applicability of biological dosimetry. Thyrotoxic patients with intact thyroid glands underwent 131I therapy were also analysed for this purpose. An analysis was made of the extent to which exposure to local neck irradiation (50 Gy) or radioiodine therapy (1734-2600 MBq) causes chromosomal aberrations in the lymphocytes of thyroid disease patients after total or subtotal thyroidectomy, or thyrotoxic patients with intact thyroid glands (185-595 MBq). The irradiated volume of lymphatic tissues played the most important role in the formation of chromosomal aberrations. External irradiation caused 10-times more aberrant cells than 131I therapy did in cancer patients. In thyrotoxic patients the lower therapy doses of radioiodine caused a significantly higher frequency of aberrations than that observed in thyroid cancer patients. Selective radiosensitivity of lymphocytes was supported by the analysis of the Poisson distribution of aberrations, which suggested a homogeneous dose distribution only in 131I-treated and thyroidectomized cancer patients. In conclusion, we suggest that the results of studies of the genetic alterations in the lymphocytes exposed to radioiodine, under well-defined circumstances should not be ignored before the mode of radiation treatment is chosen. On the other hand, in the modelling of accidental environmental radioiodine exposure, only thyrotoxic patients with an intact thyroid gland and heterogeneous dose-distribution are a suitable group.     

Imaging of mediastinal lymph nodes: CT, MR, and FDG PET

The evaluation of mediastinal lymph nodes is an important aspect of staging in patients with non-small cell lung cancer. Anatomic imaging of lymph nodes with computed tomography (CT) and magnetic resonance (MR) imaging has been limited by the relatively low sensitivity and specificity of these techniques. Advances in physiologic imaging of mediastinal lymph nodes with 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) have resulted in improved diagnostic accuracy in the determination of nodal status. Despite the limitations of CT, this technique still plays an important role by aiding in the selection of the most appropriate procedure for staging, by guiding biopsy, and by providing anatomic information for visual correlation with FDG PET images. At present, anatomic MR imaging of lymph nodes is primarily a problem-solving tool for cases with inconclusive CT results. Physiologic MR imaging with iron oxide is an exciting area of investigation, and the accuracy of this technique is being assessed in clinical trials. Anatomic and physiologic imaging techniques should be considered complementary rather than competitive imaging strategies.     

Applications of PET in lung cancer

An estimated 180,000 new cases of lung cancer will be diagnosed in the United States this year, and lung cancer accounts for approximately 25% of all cancer deaths. The overall 5-year survival rate is 14%, and this has not changed over the past several decades. Lung cancer diagnosis and treatment is a major health problem globally. Most lung cancers are detected initially on chest radiographs, but many benign lesions have radiologic characteristics similar to malignant lesions. Thus, additional studies are required for further evaluation. Computed tomography (CT) is most frequently used to provide additional anatomic and morphologic information about the lesion, but it is limited in distinguishing benign from malignant abnormalities in the lung, pleura, and mediastinum. Because of the indeterminate results from anatomic imaging, biopsy procedures including thoracoscopy and thoracotomy may be used even through one-half of the lesions removed are benign and do not need to be removed. FDG-PET imaging provides physiologic and metabolic information that characterizes lesions that are indeterminate by CT and that accurately stages the distribution of lung cancer. Exploiting the fundamental biochemical differences between cancer and normal tissues, FDG imaging takes advantage of the increased accumulation of FDG in transformed cells. FDG-PET is very sensitive (approximately 95%) for the detection of cancer in patients who have indeterminate lesions on CT. The specificity (approximately 85%) of PET imaging is slightly less than the sensitivity because some inflammatory processes such as active granulomatous infections accumulate FDG avidly. The high-negative predictive value of PET suggests that lesions considered negative on the study are benign, biopsy is not needed, and radiographic follow-up is recommended. Several studies have documented the increased accuracy of PET compared with CT in the evaluation of the hilar and mediastinal lymph node status in patients with lung cancer. If the mediastinum is normal on PET imaging and there is no other evidence of metastatic disease, the patient has a thoracotomy. If the mediastinum is abnormal on PET imaging, mediastinoscopy is performed with the PET images providing the lymph node stations to target. Whole-body PET studies detect metastatic disease that is unsuspected by conventional imaging and demonstrate some of the anatomic abnormalities detected by CT to be benign lesions. Management changes have been reported to occur in up to 41% of patients based on the results of the whole-body studies.     

CYFRA 21-1, a sensitive and specific new tumour marker for squamous cell lung cancer. Report of the first European multicentre evaluation. CYFRA 21-1 Multicentre Study Group

The present study was designed to determine whether CYFRA 21-1, measuring cytokeratin 19, could be a specific and sensitive tumour marker for non-small cell lung cancer (NSCLC). Serum measurements were made at diagnosis in 2250 patient samples by an immunoradiometric "sandwich type" assay, using two cytokeratin 19 specific monoclonal antibodies. Among healthy individuals (n = 711) and patients with benign lung disease (n = 546), 95 percentiles were 1.2 and 2.95 ng/ml, respectively. Cumulative distribution analysis curves were established. From these data, 3.3 ng/ml gave 96% specificity. Using this cutoff, the sensitivity for small cell lung cancer was 16% (n = 74) compared to 41% for NSCLC (n = 547). In histological sub-groups, sensitivity was 57% for squamous cell lung cancer, 34% for undifferentiated large cell carcinoma and 27% for adenocarcinoma, the level of CYFRA 21-1 was correlated with tumour size and UICC stage. In squamous cell lung cancer, the sensitivity of the squamous cell carcinoma marker was 30%, 25% for carcinoembryonic antigen and 46% for tissue polypeptide antigen, using the same series of samples and cutoffs defined at 96% specificity. In conclusion, CYFRA 21-1 is a sensitive tumour marker for NSCLC, especially squamous cell lung cancer.     

The radiologic appearance of lung cancer

A solitary pulmonary nodule (SPN) is the most common radiographic presentation of lung cancer. The imaging characteristics of solitary pulmonary nodules are described and illustrated. The appearance and implications of extension of lung cancer to the pleura are explored. Finally, the contribution of various thoracic imaging modalities to the diagnosis and staging of lung cancer are discussed briefly.     

Upper airway mucosa temperature in obstructive sleep apnoea/hypopnoea syndrome, nonapnoeic snorers and nonsnorers

BACKGROUND: This study was performed to assess chemical shift magnetic resonance imaging (CSMRI) for characterizing adrenal masses in patients with lung cancer, and to compare charges associated with two algorithms for assessing adrenal masses in these patients. METHODS: Forty-two patients with lung cancer underwent both CSMRI (using in-phase and opposed-phase gradient echo images) and computed tomography-guided percutaneous biopsy of adrenal masses. Adrenal-to-spleen signal intensity ratios on the opposed-phase images were correlated with histopathologic results. The normalized charges for two algorithms were compared. In algorithm A, computed tomography-guided biopsy is used first to evaluate an adrenal mass; in algorithm B, CSMRI is used first, followed by computed tomography-guided biopsy only if CSMRI findings are not diagnostic of adenoma. RESULTS: Biopsy showed 24 (57%) adrenal adenomas and 18 (43%) metastases. Chemical shift magnetic resonance imaging was 96% sensitive for adenoma and 100% specific. The average normalized charges associated with algorithm A were $1,905 per patient versus $1,890 with algorithm B. CONCLUSIONS: Initial use of CSMRI in evaluating an adrenal mass in lung cancer patients can obviate biopsy in 55% of patients, and its charges are similar to those for performing computed tomography-guided biopsy in all patients.     

F-qi-FDG PET of the thyroid gland in Graves' disease

AIM: This study evaluates F-18-FDG PET of the thyroid in Graves' disease. METHODS: Thirty patients were investigated the day before radioiodine therapy, 15 patients 3-10 days after radioiodine therapy. Twenty patients with cancer of the head or neck and normal thyroid function served as controls. RESULTS: F-18-FDG uptake was higher in Graves' disease patients than in controls. Negative correlations of F-18-FDG uptake with half-life of radioiodine and absorbed radiation dose due to radioiodine therapy were found along with a positive correlation to autoantibody levels. CONCLUSION: Thus F-18-FDG PET is likely to give information on the biological activity of Graves' disease as well as on early radiation effects.     

FDG PET in head and neck cancer

In our extensive experience with FDG PET imaging in head and neck cancer, we have found the technique to be of high accuracy but of limited usefulness. This seeming paradox arises from several causes. Competing techniques such as CT, MR imaging, and even clinical examination already have good accuracy. In addition, high-resolution studies such as CT and MR imaging provide information required for treatment planning that is unavailable from FDG PET images. The high cost of FDG PET militates against its use in this setting, in which only a small marginal gain can be expected. In the special problem areas in which FDG PET might be expected to offer unique advantages, such as screening for second primary lesions, searching for unknown primary lesions, or differentiating benign salivary rumors from malignant lesions, the results of FDG PET have been disappointedly poor. Of these special problem areas, only the question of accuracy in finding occult primary lesions appears unresolved and in need of further study. The single application in which FDG PET appears to be advantageous is the posttherapy setting. In this setting, the technique is definitely superior to alternative methods of determining tumor recurrence and differentiating posttherapy sequelae such as radiation necrosis from tumor recurrence. We believe that considerable opportunity remains for further research on the use of FDG PET in head and neck cancer. Other agents such as 11C-methionine for example, might improve the diagnostic accuracy of FDG PET in some of the problem areas that we have identified, such as the early postirradiation period. We currently have such a study under way. Also, because FDG PET offers a unique way to measure tumor metabolism, further investigation of the use of FDG PET tracers to evaluate various biologic parameters such as proliferation rates or tumor hypoxia are needed. Such studies could provide a noninvasive technique to identify which fractionation schemes or combinations of therapy might be useful for individual patients. A final caveat is in order. Although our findings of the usefulness (and lack thereof) of FDG PET in head and neck cancer may be disappointing to many, these results should not be generalized to other applications of FDG PET in oncology. Each tumor type and setting presents its own specific problems, and in some instances FDG PET offers unique advantages over other imaging techniques. A good example is the setting of primary lung cancer, in which FDG PET appears clearly superior to all other methods of pretherapy screening [19-20].     

Asbestos: current knowledge and perspectives

Diseases due to asbestos inhalation are not only a concern for occupational physicians, but also for general practicioners and pneumologists. The real or supposed risk has extended beyond the factories employing "primary asbestos workers" to thousands of people exposed to this material or simply working in buildings insulated with asbestos. The spectrum of asbestos-related diseases has changed: asbestosis (parenchymal fibrosis due to asbestos) tends to disappear, whereas the incidence of pleural lesions, which can be associated with lower cumulative exposures, increases. Patients with asbestos related diseases do not die any more from respiratory failure but from late neoplastic complications, such as mesothelioma and lung cancer. The lack of interest and of training in occupational medicine leads to an underrecognition and an underestimation of cancers due to asbestos by the physicians. Recent progresses in CT imaging and evaluations of exposure to fibers through mineralogical analysis of lung samples have led to improve the diagnostic approach of fiber-related diseases.     

Systemic reactive amyloidosis associated with Castleman''s disease: serial changes of the concentrations of acute phase serum amyloid A and interleukin 6 in serum

Surgery has become one of the major treatments for lung cancer, increasing in number as well. Four times more patients undergo operation for lung cancer compared to 20 years age. The 5-years-survival rate of surgically treated patients this past 9 years was 55.2%. Technological advances in imaging and technical progress of diagnosis has lead to accurate staging prior to surgery. Group examination inables us to discover early lung cancer patients. Post operative adjuvant therapy such as LAK immunotherapy is also effective. The progress of extended surgery, surgical techniques such as bronchoplasty is also important. These factors are all responsible for the improvement of the survival rate for surgically treated patients.     

Pulmonary delivery of nanoparticles of insoluble, iodinated CT X-ray contrast agents to lung draining lymph nodes in dogs

Lung cancer continues to be a leading cause of death around the world. Staging of this disease is critically dependent upon the involvement or noninvolvement of the lymph nodes which drain the region of lung containing the lesion/tumor. Palpation, unenhanced CT, and lymph node excision (i.e., mediastinectomy) are currently used to ascertain the status of these regional draining lymph nodes. The work reported herein details the first efforts toward the pulmonary instillation of iodinated nanoparticles for contrast-enhanced CT of lung draining lymph nodes. The data reflect the impact of dose, time post instillation, and formulation (surfactant) upon the observed CT enhancement of the tracheobronchial lymph nodes of beagle dogs. In addition, initial safety is discussed with both macroscopic and microscopic observations. The results indicate that pulmonary instillation of small volumes of iodinated nanoparticles could be successfully used to aid staging of lung cancer by CT imaging.     

Can dual-headed 18F-FDG SPET imaging reliably supersede PET in clinical oncology? A comparative study in lung and gastrointestinal tract cancer

In this study, we prospectively compared the sensitivity of PET and planar SPET (collimated gamma camera) 18F-FDG imaging in patients with lung and gastrointestinal tract cancer and analysed their respective impact on patient management. Twenty-eight patients with lung cancer and 14 with gastro-intestinal tract tumours were scanned on the same day with a PET and a collimated planar SPET gamma camera. The planar SPET procedure consisted of whole-body planar views and a tomographic acquisition centred over the torso or the abdomen, with the total imaging time within the same range as the whole-body PET procedure. The staging of lung cancer patients was accurate in 86% with PET and 64% with planar SPET. Planar SPET would have led to inappropriate therapeutic decisions in 8 of 28 patients, mainly due to undetected distant metastases. In patients with suspected gastrointestinal tract cancer, planar SPET identified 7 of 15 (47%) proven tumour sites, whereas PET identified 14 of 15 (93%). Our results suggest that collimated planar SPET cameras are not a substitute for dedicated PET scanners. The sensitivity for the detection of tumours is unacceptably low and can impair patient management. The use of multiple tomographic acquisitions could improve the sensitivity but would require a longer scanning time.     

Genetic mapping of lung cancer modifier loci specifically affecting tumor initiation and progression

Mouse inbred strains with inherited predisposition and resistance to lung cancer provide a tool for the dissection of the complex genetics of this disease. In the present report, we have crossed the BALB/c with the SWR/J strain and performed whole-genome scanning for loci affecting lung tumor development in their F2 progeny. Both parental strains carry the pulmonary adenoma susceptibility 1 (Pas1) locus, a major locus affecting predisposition to lung cancer in mice. On distal chromosome 18 and on centromere of chromosome 6, we have mapped two pulmonary adenoma resistance loci (Par2 and Par4, respectively), which reduce lung tumor multiplicity strongly, up to 15-fold. Par2 and Par4, however, do not affect lung tumor size, which is instead controlled by an additional locus that we have mapped on the central region of chromosome 4. We designated this locus as "pulmonary adenoma progression 1" (Papg1), because it specifically modifies lung tumor size but not multiplicity. The present results, therefore, provide evidence for the existence of cancer modifier loci acting on specific stages of lung tumorigenesis.