Lima MCL, Cunha DC, Ramos CD, Halbe HW, Miguel EO, Barros FB, Etchebehere EC, Camargo EE. Division of Nuclear Medicine, Department of Radiology (UNICAMP), Campinas, and Department of Gynecology and Obstetrics, Marília Medical School, Brazil.

Scintigraphic detection of breast lesions has been performed with many radiopharmaceuticals, including [Tc-99m]sestamibi, the most widely used. The purpose of this study was to evaluate the sensitivity and specificity of [Tc-99m]sestamibi mammoscintigraphy (MS) in patients (pts)with axillary or breast lesions. Fifty five female patients were studied (mean age 50.5 yrs), with clinical diagnosis of a palpable mass or suspicious mammographic findings. The size of the tumor ranged from 0.5 to 20 cm. Ten minutes after an intravenous injection of 740 MBq (20 mCi) of [Tc-99m]sestamibi, images were acquired in the posterior oblique and lateral projections of the breasts and anterior projection of the axillae. [Tc-99m] sestamibi uptake was graded as mild, moderate or marked. All pts underwent fine needle biopsy or lesion resection. MS was abnormal in 34 pts (4 mild, 18 moderate and 12 marked): 29 pts with histopathology of breast carcinoma and 5 with benign disease. Twenty one pts had normal MS, and only one had carcinoma at histopathology (non-palpable tumor). MS sensitivity was 96.7%, specificty 80%, positive predictive value 85.3% and negative predictive value 95.2%. MS was very sensitive in the diagnosis of primary breast carcinoma. However, false positive results due to uptake in benign lesions of the breast are not infrequent.

Joaquim AI, Severiche FAA, Ramos CD, Etchebehere ECSC, Carvalho DC, Shinzato JY, Vargas RF, Alvarenga M, Camargo EE. Division of Nuclear Medicine, Department of Radiology and Center for Integral Assistance to Woman’s Health (CAISM), Campinas State University (UNICAMP), Campinas, Brazil.

The precise evaluation of response of locally advanced breast carcinoma to primary chemotherapy is essential in treatment management. Evaluation by mammography and ultrassonography is not always reliable. Breast scintigraphy with [Tc-99m] sestamibi (BS) has been used to evaluate response of chemotherapy in various tumor types, such as sarcomas and brain tumors. The purpose of this study was to investigate the utility of BS in the evaluation of response to primary chemotherapy of locally advanced breast carcinoma. Twenty female patients with mean age 53.8 years were studied. Eleven were T2N0M0 IIA, 7 were T2N1M0 IIB and 2 were T2N2M0 IIIA. Two BS were performed: one prior to and the other 21 days after the third cycle of chemotherapy. Semi-quantitative analysis of tumor uptake before and after chemotherapy was performed. Results were compared with histopathology. The general sensitivity for the detection of breast carcinoma was 95%. The comparison between BS and histopathology in the evaluation of viable tumor after chemotherapy demonstrated an agreement of 75%. BS overestimated viable tumor one grade higher than histopathology in 30% of the concordant cases and in 5% of the discordant cases. Histopathology overestimated tumor viability in 20% of the concordant cases and in 20% of the discordant ones. Tumor viability grading by BS was concordant with histopatological grading in 25% of patients.

O. Alonso, L. Delgado, F. Mut, I. Alonso, G. Lago, M. Núñez, P. Guisoli, G. Sabini, I. Muse, E. Touya. - Nuclear Medicine Center and Department of Clinical Oncology of the Clinical Hospital, University of Uruguay, Montevideo, Uruguay.

Tc-99m MIBI has been reported to be extruded from tumor cells by the P-glycoprotein (Pgp), encoded by the MDR1 gene. This is one of the most frequent mechanisms of multidrug resistance in advanced breast cancer (ABC). The aim of the present study was to investigate the possible relation between MIBI tumor uptake and chemotherapy response using Pgp-substrate drugs. We studied 30 lesions (17 breast tumors and 12 axillary) corresponding to 17 patients with ABC: Ten patients with advanced local and regional disease and 7 patients with local, regional and metastatic disease. Images were obtained 2-8 days before chemotherapy using a dose of 740 MBq of Tc-99m MIBI, 10 minutes and 1 hour post injection. Tumor-to-normal ratios at 10 minutes were significantly higher in responding lesions than in non responding (1.95, 1.4-2.9 vs. 1.35, 0-1.6; median, range respectively; p=0.000092). This data suggests that Tc-99m MIBI scintigraphy can be a relevant tool for treatment planning in ABC.

7.4 - Tc-99m]SESTAMIBI IN THE EVALUATION OF OSSEOUS SARCOMAS RESPONSE TO CHEMOTHERAPY IN CHILDREN AND ADOLESCENTS.

Ramos CD, Teixeira ABMJ, Epelman S, Braga HM, Etchebehere ECSC, Silva AM, Gonçalves JCB, Brandalise S, Camargo EE. Division of Nuclear Medicine, Department of Radiology, Campinas State University (UNICAMP) and Centro Infantil Boldrini, Campinas, Brazil.

Several studies have reported the use of [Tc-99m] sestamibi in the evaluation of tumor viability. The purpose of this study was to investigate the usefulness of this radiopharmaceutical in the evaluation of Ewing’s sarcoma and osteosarcoma response to preoperative chemotherapy in children and adolescents. Fourteen patients (pts) (8 males, 6 females; 6-17 years, mean 11.6 years), with biopsy-proven high grade osseous sarcomas (9 osteosarcomas and 5 Ewing’s sarcomas) were studied. The images were obtained before and after preoperative chemotherapy. Dynamic images were acquired at 2 seconds intervals for 1 minute immediately after the intravenous injection of 370-740 MBq (10 – 20 mCi) of [Tc-99m] sestamibi to assess tumor blood flow. Early planar images or whole body scans were obtained at 5 – 10 minutes and delayed images (whole body) after 30-60 minutes. Three pts were imaged after 2-3 hours. Tumor uptake of [Tc-99m] sestamibi before and after chemotherapy was graded visually using the 30-60 minutes images as follows: 0=absent or very mild, 1=mild, 2=moderate, 3=marked. The pts were divided into two groups based on the histopathological classification: good responders with 90% or higher of tumor necrosis and poor responders with less than 90% of tumor necrosis. All pts had uptake grade 2 or 3 prior to chemotherapy. After chemotherapy all eleven good responders had significant reduction of tumor uptake to grade 0. One poor responder with borderline amount of post-chemotherapy necrosis (88,4%) had reduction of uptake to grade 1. One of the 2 definitive poor responders (20% of necrosis) had a non-significant reduction of uptake to grade 2; however, the other poor responder (10% of necrosis) had a significant reduction to grade 0. These results support the concept that the reduction of [Tc-99m] sestamibi tumor uptake reflects the response to chemotherapy in most cases. This method was also able to detect two poor responders in this series. The reduction of uptake in a poor responder should be further investigated and may be related to the expression of the multidrug resistance glycoprotein P.

7.5 -DETECTION OF SENTINEL LYMPH NODE AND HYPERFUNCTIONING PARATHYROID GLANDS WITH RADIOGUIDED SURGERY: PRELIMINARY EXPERIENCE.

Lago,G., O. Alonso, J. Gaudiano, E. Touya. - Nuclear Medicine Center of the Clinical Hospital, University of Uruguay, and Nuclear Medicine Clinic of the Hospital Italiano, Montevideo, Uruguay.

The aim of this study was to describe our preliminary experience in the use of radioguided surgery for the detection of sentinel nodes (SN) and hyperfunctioning parathyroid glands. We studied 10 patients: Eight for the detection of SN (7 patients with primary melanoma and one patient with vulvar cancer), and two patients with secondary hyperparathyroidism (SHP) for the resection of hyperfuntioning glands. We used for both groups of patients an intraoperative gamma probe equipped with a CdTe detector (Gammed II, Eurorad). A dose of 250-450 µCi of Tc-99 Re-nanocolloid and of 10 mCi of Tc-99m MIBI was employed, 4-6 hours and 2 hours before surgery respectively. During surgery, one SN was identified corresponding to 9/10 primary melanomas and 2 GC corresponding to the vulvar lesion. In the group with SHP the hyperfuntioning parathyroid glands were clearly detected. We conclude that radioguided surgical techniques are technically feasible and clinically relevant surgical tools.

Santos AO, Martins AS, Tincani AJ, Melo GM, Steck JH, Lage HT, Valerio JB, Barros FB, Etchebehere ECSC, Ramos CD, Camargo EE. Division of Nuclear Medicine, Department of Radiology, Division of Head and Neck Surgery, Department of Surgery, Campinas State University (UNICAMP), and Medicina Nuclear de Campinas and MN&D - Medicina Nuclear Diagnóstico e Terapia - Campinas, Brazil.

Many reports have described the sentinel lymph node as the first lymph node infiltrated by regional lymphatic metastases. Selective biopsy of this node allows a more accurate staging of malignant melanoma and identifies patient (pts) groups that will benefit from lymph node dissection. Nine pts with malignant cutaneous melanoma (Clark IV, Breslow 1.8 – 3.5 mm, mean 2.7 mm) were studied. Six intradermal 1mCi injections of [Tc-99m] Dextran were performed around the lesion or biopsy scar. Dynamic images were acquired for 10 minutes, followed by static images with 30,000 counts every 5 minutes until visualization of the sentinel lymph node. The projection of the sentinel lymph node was labeled on the skin. The next day, at surgery, pts received an intradermal injection of toluidin blue. Surgical incision was performed at the site of the skin label and the sentinel lymph node identified by the dye stain. After excisional biopsy the lymph node was surveyed for radioactivity, and then sent to histopathology. Demonstration of the sentinel lymph node was possible in all pts. Histopathology showed micrometastases in 2 pts, that were then submitted to lymph node removal. In 7 pts the sentinel lymph nodes were not infiltrated and the surgical procedure was terminated. The detection of the sentinel lymph node was crucial to determine the surgical approach in all pts.

7.7 - Lymphoscintigraphy And Sentinel Lymph Node Biopsy In Breast Cancer.

Marcia G M Tavares, Valdir Di Agostinho, Marcelo T Sapienza, Irene S Endo, Sholomo Lewin, Jose Soares Jr, Marilia M S Marone, Nassif A Galeb Jr, Fatima C Waldvogel, Joao C S Gois, Instituto Brasileiro de Controle do Cancer - São Paulo - SP.

The identification and analyses of the Sentinel Lymph Node (SL) has been investigated to determine the axillary status in patients with breast carcinoma. In this preliminary study, 18 patients without clinic involvement of the axilla, were referred to lymphoscintigraphy with intradermal injection of Tc-99m phitate (2mCi and 0.8ml) around the tumor and compared to the peritumoral injection of blue dye. Acquisition was done with 5 min images of anterior, oblique and lateral views of the chest. Focal accumulations of radioactivity were marked on the skin. Lymphoscintigraphy identified SL in 17 patients and the blue dye in 14. Two patients were found to have axillary nodal metastases. Despite intraoperatively gamma-probe was not available, lymphoscintigraphy evidenced the Tc-99m phitate advantage over the blue dye technique to identify the SL.

7.8 - AVALIAÇÃO NÃO INVASIVA PÓS-QUIMIOEMBOLIZAÇÃO DE METÁSTASES HEPÁTICAS DE Ca DE CÓLON - A CONTRIBUIÇÃO DA MEDICINA NUCLEAR NO SEGUIMENTO DA RECUPERAÇÃO HEPÁTICA NA FASE AGUDA PÓS-EMBOLIZAÇÃO

Cintra*, FM; Martins**, ME; Martins***, HS - * Depto Oncologia Clínica São Carlos, ** Depto Medicina Nuclear Clínica São Carlos, *** Serviço de Hemodinâmica CT Scan - Rio de Janeiro / RJ

Para avaliar a extensão do comprometimento da função hepática na fase aguda pós-quimioembolização como tratamento primário da metástase hepática do câncer de cólon, foram realizadas cintilografias sequenciais com SPECT em gama-câmara tomográfica ADAC, e quantificação dos volumes da maior lesão e do tecido normal. Tomando como referência as imagens obtidas pela TC e angiografia digital nas fases de perfusão e pós-embolização, foram definidos os volumes pré e pós-quimioembolização da metástase, sendo os primeiros volumes cintilográficos obtidos no terceiro dia pós-embolização. O perfil bioquímico foi determinado diariamente; a cada 48 hs foram obtidas as imagens cintilográficas tomográficas e os gráficos dos volumes das áreas de embolização e de tecido normal. Os resultados obtidos com imagens cintilográficas, curvas, exames bioquímicos, TC e US, foram analisados conjuntamente. As curvas obtidas a partir das imagens cintilográficas demonstraram uma clara relação entre a fase aguda pós-embolização, a fase de recuperação do parênquima e a consolidação da resposta à quimioembolização. A metodologia não invasiva e de baixo custo, mostrou-se sensível na determinação e análise real da função hepática, no acompanhamento da recuperação pós- quimioembolização e na determinação do índice de resposta ao tratamento através das curvas tempo/atividade com relação aos volumes metástase / parênquima normal.

7.9 - CARCINOID TUMOR WITHOUT [I-131]MIBG UPTAKE STUDIED WITH [F-18]FDG AND [In-111]OCTREOTIDE. A CASE REPORT.

Ramos CD, Sagarra A, Sagarra R, Etchebehere ECSC, Santos AO, Camargo EE. Division of Nuclear Medicine, Department of Radiology, Campinas State University (UNICAMP) and Division of Oncology, PUCC, Campinas, Brazil.

A 64 year old white female underwent left nephrectomy several years ago due to kidney stones. Carcinoid tumor was diagnosed 4.5 years ago during resection of an uterine myoma, with invasion of several organs. The pt underwent hysterectomy and sigmoidectomy. An IVP study performed 3.5 yrs ago detected a right sided hydronephrosis, interpreted as due to extrinsic compression. Exploratory laparotomy revealed hepatic invasion and peritoneal carcinomatosis. The patient developed intestinal sub-occlusion diagnosed at laparotomy and a colectomy was performed. Histopathology revealed intense desmoplastic reaction and microscopic foci of carcinoid tumor. Multiple, diffuse hepatic metastases measuring 10 to 12 mm, were visualized. A whole body [I-131]MIBG scintigraphy failed to detect any of the known lesions or other abnormalities. Two years ago the pt began a one year interferon-2-alfa treatment, with improvement of the heat waves, the diarrhea and the arthritic pain. The urinary levels of 5-OH-indolacetic acid decreased to the upper limits of the normal range. However, US of the abdomen showed enlargement of the hepatic lesions. Mammography revealed a focal lesion in the left breast diagnosed as carcinoid tumor by biopsy. Two months ago [F-18]FDG SPECT images in combination with [Tc-99m]sulfur colloid images showed multiple focal areas of increased tracer uptake in the base of the left lung, left breast, liver, ascending colon and left inferior quadrant of the abdomen. After 24 hours of the [F-18]FDG SPECT images, [In-111]octreotide SPECT images were performed and detected all the lesions seen with [F-18]FDG, with a better target-to-background ratio. [In-111]octreotide SPECT images also detected a lesion in the left parietal region, not demonstrated by any other method.

Whemberton M. Araújo, Dilma M. Morita, Nilton M. Hanaoka, Marcelo L. da Cunha. - Institutions: DIMEN – Medicina Nuclear – Campinas/SP/Brazil.

The authors present a case of thyroid medullary carcinoma in a female 52 years old patient, on clinical evaluation after total thyroidectomy, with progressive increase of serum calcitonine level. Whole-body scans and SPECT images were acquired after I.V. infusion of Tc-99m-Dimercaptossuccinic Pentavalent Acid (Tc-99m-[V]-DMSA), and 10 days later, with I-131-Metaiodobenzilguanidine (I-131-MIBG) and Tc-99m-Sestamibi (Tc-99m-MIBI). Focal areas of increased uptake of Tc-99m-[V]-DMSA were observed at right lateral cervical region and proximal third of sternum. No abnormalities have been observed in studies with the other tracers. Patient underwent another surgical procedure to explore those areas. Eleven lymphonodes were found and resected, and nine of them were affected by the baseline pathology. Scintigraphic study with Tc-99m-[V]-DMSA has shown to be suitable in detection of tumoral recurrence of thyroid medullary carcinoma, which was not achieved with other used tracers.

Michelle A. Kassis, Adriana I. Joaquim, Horácio J. Ramalho, Eleuses V. Paiva - Serviço de Medicina Nuclear e de Nefrologia do Hospital de Base -FUNFARME– São José do Rio Preto

P.C.S., 28 yo, male, black, complaining of pulsatile headaches of recent onset, associated with dizziness and episodic/temporary loss of vision, weakness in lower limbs. During the hypertensive episodes, the blood pressure may reach levels as high as 240x170 mmHg. Urinary cathecolamines were normal. The abdominal ultrasound and CT revealed a mass in the right suprarenal region. To further evaluate this finding a scintigraphic study with MIBG-I131 was performed and revealed significantly increased uptake of the radiopharmaceutical by the tumor. The histology revealed a benign pheochromocytoma, nevertheless there was local invasion of the right kidney and of the inferior vena cava. After surgery there was improvement of blood pressure levels, however persistence of hypertension (up to 170x140 mmHg). Due to persistent hypertension, a new MIBG-I131 study was performed searching for remaining tumoral tissue, but was negative. This case demonstrates an example of a patient with pheochromocytoma where the MIBG-I131 was the only test to show the neuroendocrin origin of the tumor mass.

Turra MA, Joaquim AI, Borim LNB, Paiva EV - Serviço de Medicina Nuclear e de Oncologia Pediátrica do Hospital de Base- FUNFARME -São José do Rio Preto, SP

A female patient, 1 year and 6 months old, with a known diagnosis of neuroblastoma stage IV and palpable masses involving the left zigomatic and parietal regions and the right masseter muscle region. Staging was completed using MIBG- I131 which revealed uptake in the left side of the skull, anterior neck and posterior mediastinum. Scintigraphy with MDP-Tc99m showed increased uptake in the entire left side of the skull, right iliac crest, right sacroiliac joint and proximal third portion of the left femur. These findings demonstrated the importance to performing 2 studies, in some cases, as some bone lesions are demonstrated only in the bone scintigraphy with MDP-Tc99m, despite the commom knowledge that the MIBG-I131, in general, has a higher sensitivity and specificity to evaluate patients with neuroblastoma.

Araújo WA, Morita DM, Hanaoka NM, Cunha ML, Steck LH. - Institutions: DIMEN – Medicina Nuclear & Campinas/SP/Brazil.

The Authors present a case of a male adult 59 years old patient with soft palate epidermoid carcinoma, following surgery and local radiotherapy, with tumoral recidivate, identified by scintigraphy with [F-18]-2-deoxi-D-glucose (F-18-FDG) and Tc-99m-Sestamibi (Tc-99m-MIBI). Scintigraphic study with F-18-FGD was performed 45 minutes after endovenous infusion of 10 mCi (370 MBq), in gamma-camera Elscint model Varicam, with coincidence detection. Frames with Tc-99m-MIBI were acquired using a low energy and high resolution collimator, 15 minutes after 15 mCi (555MBq) of Sestamibi endovenous injection. Interval between these two studies was about one week. The images that have been acquired were reconstructed into three spatial grounds (saggital, coronnal and tranverse), and afterward, these two studies were compared between them. Both studies have shown focal increased tracer uptake at suspect area. We’ve concluded that both tracers were suitable in detection of tumoral recidivate in the presented case.

7.14 - AVALIAÇÃO NÃO INVASIVA PÓS-QUIMIOEMBOLIZAÇÃO DE METÁSTASES HEPÁTICAS DE Ca DE CÓLON & A CONTRIBUIÇÃO DA MEDICINA NUCLEAR NO SEGUIMENTO DA RECUPERAÇÃO HEPÁTICA NA FASE AGUDA PÓS-EMBOLIZAÇÃO

Cintra*,FM; Martins**, ME; Martins, HS*** - *Depto. Oncologia, Clínica São Carlos, **Depto. Medicina Nuclear Clínica São Carlos, ***Serviço de Hemodinâmica CT Scan - Rio de Janeiro - RJ.

Para avaliar a extensão do comprometimento da função hepática na fase aguda pós-quimioembolização como tratamento primário da metástase hepática do câncer de cólon, foram realizadas cintilografias sequenciais com SPECT em gama-câmara tomográfica ADAC, e quantificação dos volumes da maior lesão e do tecido normal. Tomando como referência as imagens obtidas pela TC e angiografia digital nas fases de perfusão e pós-embolização, foram definidos os volumes pré e pós-quimioembolização da metástase, sendo os primeiros volumes cintilográficos obtidos no terceiro dia pós-embolização. 0 perfil bioquímico foi determinado diariamente; a cada 48 hs foram obtidas as imagens cintilográficas tomográficas e os gráficos dos volumes das áreas de embolização e de tecido normal. Os resultados obtidos com imagens cintilográficas, curvas, exames bioquímicos, TC e US, foram analisados conjuntamente. As curvas obtidas a partir das imagens cintilográficas demonstraram uma clara relação entre a fase aguda pós-embolização, a fase de recuperação do parênquima e a consolidação da resposta à quimioembolização. A metodologia não invasiva e de baixo custo, mostrou-se sensível na determinação e análise real da função hepática, no acompanhamento da recuperação pós-quimioembolização e na determinação do índice de resposta ao tratamento através das curvas tempo/atividade com relação aos volumes metástase / parênquima normal.

Villela, JR; Abuhid, I; Junqueira Júnior, H - Laboratório de Patologia Clínica Hermes Pardini - Belo Horizonte – MG