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Accurate assessment of disease extent is required to select the best primary treatment for advanced epithelial ovarian cancer patients. Estimation of tumour burden is challenging and it is usually performed by means of a surgical procedure. Imaging techniques and tumour markers can help to estimate tumour burden non-invasively. 2-[18F]FDG PET/CT allows the evaluation of the whole-body disease. This study aimed to correlate HE4 and CA125 serum concentrations with tumour burden evaluated by volumetric 2-[18F]FDG PET/CT parameters in advanced high-grade epithelial ovarian cancer. We included 66 patients who underwent 2-[18F]FDG PET/CT and serum tumour markers determination before primary treatment. Volumes of interest were delimited in every pathological uptake. Whole-body metabolic tumour volume (wb_MTV) and total lesion glycolysis (wb_TLG) were calculated summing up every VOI’s MTV value. SUVmax thresholds were set at 40% (MTV40 and TLG40) and 50% (MTV50 and TLG50). In addition, four VOI subgroups were defined: peritoneal carcinomatosis, retroperitoneal nodes, supradiaphragmatic nodes, and distant metastases. MTV and TLG were calculated for each group by adding up the corresponding MTV values. TLG was calculated likewise. wb_MTV and wb_TLG were found to be significantly correlated with serum CA125 and HE4 concentrations. The strongest correlation was observed between HE4 and wb_MTV40 (r = 0.62, p

International audience; Background - Infective endocarditis (IE) is a common and serious complication in patients receiving chronic hemodialysis (HD). Objectives - This study sought to investigate whether there are significant differences in complications, cardiac surgery, relapses, and mortality between IE cases in HD and non-HD patients. Methods - Prospective cohort study (International Collaboration on Endocarditis databases, encompassing 7,715 IE episodes from 2000 to 2006 and from 2008 to 2012). Descriptive analysis of baseline characteristics, epidemiological and etiological features, complications and outcomes, and their comparison between HD and non-HD patients was performed. Risk factors for major embolic events, cardiac surgery, relapses, and in-hospital and 6-month mortality were investigated in HD-patients using multivariable logistic regression. Results - A total of 6,691 patients were included and 553 (8.3%) received HD. North America had a higher HD-IE proportion than the other regions. The predominant microorganism was Staphylococcus aureus (47.8%), followed by enterococci (15.4%). Both in-hospital and 6-month mortality were significantly higher in HD versus non-HD-IE patients (30.4% vs. 17% and 39.8% vs. 20.7%, respectively; p

Objective To assess the diagnostic capability of PET/CT with [18F]F-Fluoromethylcholine in prostate cancer (PC) with biochemical recurrence and its therapeutic impact. Material and methods We included 108 patients, diagnosed with PC with biochemical criteria for recurrence. A PET/CT choline scan was performed by dynamic pelvic and whole body study at 60 min post-tracer injection. The relationship between the positive studies and the PSA value was analysed by classifying patients into three groups ( 2 ng/ml), and the diagnostic capacity was assessed with respect to pelvic MRI and the impact on the therapeutic decision. Results The location of recurrence was identified in 85 of 108 patients (78.7%): 34 local, 47 pelvic lymph nodes and 58 distant lesions, including retroperitoneal, mediastinal lymph nodes and distant organ lesions (bone and lung). Second tumors were diagnosed in 4 patients. No significant differences were found in the percentage of positive studies depending on primary treatment. Patients with PSA > 2 ng/ml showed a higher percentage of disease detection than patients with a lower PSA level, with significant differences (p Conclusions PET/CT with [18F]F-Fluoromethylcholine is a useful tool in the detection of locoregional and disseminated disease of PC treated with suspicion of recurrence, providing a change in therapeutic management in 62% of patients.

Resumen Objetivo Valorar la capacidad diagnostica de la PET/TC con [18F]F-Fluormetilcolina en la recidiva bioquimica del cancer de prostata (CP) y su impacto terapeutico. Material y metodos Se incluyeron 108 pacientes, diagnosticados de CP con criterios bioquimicos de recurrencia. Se realizo una PET/TC Colina mediante estudio dinamico de pelvis y estudio de cuerpo entero a los 60 min postinyeccion del trazador. Se ha analizado la relacion entre los estudios positivos y el valor del PSA clasificando a los pacientes en tres grupos ( 2 ng/ml); se ha valorado la capacidad diagnostica respecto a la RM pelviana y el impacto en la decision terapeutica. Resultados Se identifico la localizacion de la recurrencia en 85 de 108 pacientes (78,7%): 34 local, 47 ganglionar pelviana y 58 lesiones a distancia, incluyendo ganglios retroperitoneales, mediastinicos y lesiones en organos a distancia (hueso y pulmon). Se diagnosticaron segundos tumores en 4 pacientes. No se encontraron diferencias significativas en el porcentaje de estudios positivos dependiendo del tratamiento primario. Los pacientes con PSA > 2 ng/ml mostraron un porcentaje de deteccion de enfermedad mas alto que los pacientes con un nivel de PSA inferior, con diferencias significativas (p La PET/TC [18F]F-Colina fue capaz de detectar enfermedad local, no conocida previamente por la RM, en el 29,41% de los pacientes. La PET/TC Colina tuvo impacto en el manejo terapeutico en 67 de 108 pacientes (62%). Conclusiones La PET/TC [18F]F-Fluormetilcolina es una herramienta util en la deteccion de enfermedad locorregional y diseminada del CP tratado con sospecha de recurrencia, proporcionando un cambio de manejo terapeutico en un 62% de los pacientes.

Background The optimal surgical management of papillary thyroid cancer (PTC) for T1-T2 tumors without pre or intrasurgical evidence of lymph node metastasis (cN0) remains controversial, since approximately 40% of patients have lymph node involvement (pN1) which becomes evident when a prophylactic lymphadenectomy (PL) is performed. The aim of this study was to investigate the feasibility of sentinel lymph node (SLN) identification with SPECT/CT lymphoscintigraphy imaging along with intraoperatory image techniques in early stages of PTC undergoing PL of central neck compartment (CNC). Methods A single-center, prospective consecutive study was designed for SLN mapping in patients with high suspicion of PTC (Bethesda V or VI) in early stage (cT1-2, cN0). Twenty-four patients underwent SLN identification with preoperative SPECT/CT and planar images (99mTc-nanocolloid albumin intratumoral injection). During surgery, SLN located in CNC was found by means of a gamma probe and portable gamma camera, and excised. Afterwards, CNC lymphadenectomy was performed in all cases without modifying the established protocol. Results SLNs were identified and accurately located in 23 (95.8%) patients. Nodal metastases (pN1) were confirmed in 9 (37.5%) patients, with one false negative case. The sensitivity was 88.9% and negative predictive value (NPV) was 93.3%, would have allowed to avoid PL in more than half of cases, a higher proportion than those found in other similar studies. No complications associated with the procedure were observed. Conclusions Our results support that SLN biopsy by SPECT/CT along with intraoperatory image techniques is applicable in early stages of PTC (cT1-2, cN0), allowing to avoid unnecessary PL.

GAMES Investigators., [Background] Enterococcal endocarditis (EE) is a growing entity in Western countries. However, quality data from large studies is lacking., [Objectives] The purpose of this study was to describe the characteristics and analyze the prognostic factors of EE in the GAMES cohort., [Methods] This was a post hoc analysis of a prospectively collected cohort of patients from 35 Spanish centers from 2008 to 2016. Characteristics and outcomes of 516 cases of EE were compared with those of 3,308 cases of nonenterococcal endocarditis (NEE). Logistic regression and Cox proportional hazards regression analysis were performed to investigate risk factors for in-hospital and 1-year mortality, as well as relapses., [Results] Patients with EE were significantly older; more frequently presented chronic lung disease, chronic heart failure, prior endocarditis, and degenerative valve disease; and had higher median age-adjusted Charlson score. EE more frequently involved the aortic valve and prosthesis (64.3% vs. 46.7%; p < 0.001; and 35.9% vs. 28.9%; p = 0.002, respectively) but less frequently pacemakers/defibrillators (1.5% vs. 10.5%; p < 0.001), and showed higher rates of acute heart failure (45% vs. 38.3%; p = 0.005). Cardiac surgery was less frequently performed in EE (40.7% vs. 45.9%; p = 0.024). No differences in in-hospital and 1-year mortality were found, whereas relapses were significantly higher in EE (3.5% vs. 1.7%; p = 0.035). Increasing Charlson score, LogEuroSCORE, acute heart failure, septic shock, and paravalvular complications were risk factors for mortality, whereas prior endocarditis was protective and persistent bacteremia constituted the sole risk factor for relapse., [Conclusions] Besides other baseline and clinical differences, EE more frequently affects prosthetic valves and less frequently pacemakers/defibrillators. EE presents higher rates of relapse than NEE.

Background. Prosthetic vascular graft infection (PVGI) is a severe complication associated with high morbidity and mortality. Clinical diagnosis is complex, requiring image testing such as CT angiography or leukocyte scintigraphy, which has considerable limitations. The aim of this study was to know the diagnostic yield of PET/CT with 18F-Fluorodeoxyglucose (18F-FDG) in patients with suspected PVGI. Methods. We performed a prospective cohort study including 49 patients with suspected PVGI, median age of 62 ± 14 years. Three uptake patterns were defined following published recommendations: (i) focal, (ii) patched (PVGI criteria), and (iii) diffuse (no PVGI criterion). Results. Sensitivity, specificity, and positive and negative predictive values for 18F-FDG-PET/ CT were 88%, 79%, 67%, and 93%, respectively. 18F-FDG-PET/CT identified 14/16 cases of PVGI showing a focal (n = 10) or patched pattern (n = 4), being true negative in 26/33 cases with either a diffuse pattern (n = 16) or without uptake (n = 10). Five of the seven false-positive cases (71%) showed a patched pattern and all coincided with the application of adhesives for PVG placement. Conclusions. 18F-FDG-PET/CT is a useful technique for the diagnosis of PVGI. A patched pattern on PET/CT in patients in whom adhesives were applied for prosthetic vascular graft placement does not indicate infection. (J Nucl Cardiol 2018) Key Words: Fluorodeoxyglucose (FDG) Æ diagnostic and prognostic application Æ PET/CT imaging

Resumen Introduccion La adrenalectomia con preservacion cortical se indica como tratamiento del feocromocitoma bilateral hereditario y esporadico, en casos de bajo riesgo de malignidad, para reducir la posibilidad de insuficiencia suprarrenal asumiendo la eventualidad de una recidiva local. El objetivo del estudio es analizar los resultados funcionales de la adrenalectomia parcial por via endoscopica retroperitoneal en pacientes monoadrenales o que necesiten una adrenalectomia bilateral. Metodos Entre enero de 2015 y febrero de 2016 se incluyeron de forma prospectiva pacientes con feocromocitoma asociado a mutaciones con bajo riesgo para malignidad, que aceptaron participar en el estudio. Todos fueron operados por cirujanos especialmente entrenados en este tipo de cirugia, utilizando la misma tecnica quirurgica. Se recogieron variables demograficas y caracteristicas clinicas, realizando posteriormente el analisis descriptivo de dichas variables. Resultados Se registraron un total de 6 pacientes, cuatro asociados al sindrome MEN tipo 2 y dos en contexto del sindrome VHL. No fue precisa ninguna conversion a abordaje laparoscopico o abierto y tampoco complicaciones postoperatorias, la estancia hospitalaria media fue de 2,5 dias. Se logro la preservacion de corteza adrenal funcionante sin requerimiento corticoideo en 5 (83%) de 6 casos. Con un seguimiento medio de 26,2 ± 6 meses, estos 5 pacientes presentan una funcion adrenal conservada sin aporte hormonal sustitutivo. Conclusiones La adrenalectomia con preservacion cortical por via endoscopica retroperitoneal, en manos expertas, es segura y factible para el tratamiento del feocromocitoma hereditario y esporadico en contexto de baja malignidad, permitiendo evitar la necesidad de aporte corticoideo en la mayoria de los casos.

Introduction Cortical-sparing adrenalectomy is a suitable treatment for hereditary and sporadic bilateral pheochromocytoma, in cases of low risk of malignancy, to reduce the possibility of adrenal insufficiency assuming the chance of local recurrence. The aim of the study is to analyze the functional results of partial adrenalectomy by retroperitoneal endoscopic approach in single-adrenal patients or patients requiring bilateral adrenalectomy. Methods Prospective study between January 2015 and February 2016 including pheochromocytoma patients diagnosed with low risk of malignant mutations. All patients agreed to be included in the study. Experienced endocrine surgeons who have been trained in minimally invasive endocrine surgery performed the procedure using the same surgical technique. Demographic variables and clinical characteristics were collected, subsequently carrying out the descriptive analysis of the data. Results A total of 6 patients were registered, four associated with MEN type 2 syndrome and two in the context of VHL syndrome. Retroperitoneoscopic resection was performed without laparoscopic or open conversion and no postoperative complications; the average hospital stay was 2.5 days. Preservation of the functional cortex without corticosteroids was achieved in 5 (83%) of out 6 cases with a follow-up of 26.2±6 months. Today, these 5 patients have a preserved adrenal function without hormone replacement. Conclusions Cortical-sparing adrenalectomy by the retroperitoneal endoscopic approach, in expert hands, is safe and feasible for the treatment of hereditary and sporadic pheochromocytoma in a context of low malignancy, making it possible to avoid the need for corticoid replacement in most cases.

Purpose: To analyze the influence of adding gentamicin to a regimen consisting of β-lactam or vancomycin plus rifampicin on survival in patients suffering from Staphylococcal prosthetic valve endocarditis (SPVE). Methods: From January 2008 to September 2016, 334 patients with definite SPVE were attended in the participating hospitals. Ninety-four patients (28.1%) received treatment based on β-lactam or vancomycin plus rifampicin and were included in the study. Variables were analyzed which related to patient survival during admission, including having received treatment with gentamicin. Results: Seventy-seven (81.9%) were treated with cloxacillin (or vancomycin) plus rifampicin plus gentamicin, and 17 patients (18.1%) received the same regimen without gentamicin. The causative microorganism was Staphylococcus aureus in 40 cases (42.6%) and coagulase-negative staphylococci in 54 cases (57.4%). Overall, 40 patients (42.6%) died during hospital admission, 33 patients (42.9%) in the group receiving gentamicin and 7 patients in the group that did not (41.2%, P = 0.899). Worsening renal function was observed in 42 patients (54.5%) who received gentamicin and in 9 patients (52.9%) who did not (p = 0.904). Heart failure as a complication of endocarditis (OR: 4.58; CI 95%: 1.84–11.42) and not performing surgery when indicated (OR: 2.68; CI 95%: 1.03–6.94) increased mortality. Gentamicin administration remained unrelated to mortality (OR: 1.001; CI 95%: 0.29–3.38) in the multivariable analysis. Conclusions: The addition of gentamicin to a regimen containing vancomycin or cloxacillin plus rifampicin in SPVE was not associated to better outcome.

PURPOSE The aim of this study was to evaluate F-FDG PET/CT compared with conventional imaging techniques in the clinical management of patients with locally advanced gastric cancer (LAGC). METHODS A prospective study between January 2010 and December 2011 in patients with suspected LAGC was conducted in our hospital. F-FDG PET/CT, contrast-enhanced CT (CECT), endoscopic ultrasound, and laparoscopy were performed in all cases. Standard whole-body F-FDG PET/CT images were obtained centered on the stomach at 1 and 2 hours after injection of 4.0 MBq/kg of F-FDG. Findings were confirmed by histopathology or by imaging follow-up in nonoperable patients. RESULTS Fifty consecutive patients with confirmed LAGC (20 women, 30 men) with a mean ± SD age of 65.7 ± 12.1 years were included. Using Lauren classification, 24 patients were intestinal subtype, and 26 were diffuse subtype. Thirty-five patients with locoregional lymph node involvement and 22 with distant metastases were confirmed as peritoneal metastases (n = 15), retroperitoneal (n = 2) or mediastinal lymph nodes (n = 1), and liver (n = 3) or bone metastases (n = 1). Patients with signet ring carcinoma showed significantly less F-FDG uptake (P = 0.001). SUVmax correlated with tumor grading (P < 0.05). Standard and delayed F-FDG PET/CT and CECT images identified LAGC in 24, 27, and 28 of 30 patients, respectively. The sensitivity and specificity for F-FDG PET/CT and CECT to detect metastases were 68% and 100% and 64% and 93%, respectively. Contrast-enhanced CT and F-FDG PET/CT diagnosed only 6 of the 15 patients with confirmed peritoneal metastases. The impact in therapeutic management of F-FDG PET/CT and CECT was 24% and 22%, respectively. Kaplan-Meier survival curves for the LGAC showed a significant correlation between SUVmax and overall survival using an SUVmax threshold of less than 3.96 (P = 0.04). CONCLUSIONS F-FDG PET/CT should be recommended for staging of LAGC; however, F-FDG PET/CT and CECT cannot replace laparoscopy to rule out peritoneal metastases. Delayed F-FDG PET/CT images show an increase of F-FDG uptake in most cases, improving LAGC detection. The grade of F-FDG uptake represents a significant prognostic tool in this series.

FOSIMI Investigators., This work was supported by the Ministerio de Sanidad y Consumo of Spain (Fondo de Investigaciones Sanitarias, Instituto de Salud Carlos III, Madrid, Spain, Grant #EC0800190). JMP received a “Rio Hortega” Research Grant (CM14/00135; 2015-16) from Instituto de Salud Carlos III and the Ministerio de Economia and Competitividad, Madrid (Spain) and the ESCMID/FEMS Research Fellowship 2016. JMM received a personal 80:20 research grant from the Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, during 2017–19.

The case involves a 34-year-old woman who underwent surgical removal of a retroperitoneal paraganglioma adjacent to the left kidney's lower pole, previously visualized by CT and MRI. The 123I-MIBG scan was positive for this lesion and, in addition, another uptake was observed located caudally at the level of L5 and of smaller size and less intensity. The second lesion was not considered for surgical removal, due to its lack of morphological definition. One week after surgical intervention, the patient presented difficult-to-control high blood pressure. A second 123I-MIBG scan was performed. The previously described second image was more intense in this study, and surgery was planned to remove it. A combination of techniques including freehand-SPECT and a portable hybrid gamma camera (with optical camera) were used pre-operatively to identify the location of the lesion. The combination of intra-operative laparoscopic gamma probe and portable hybrid gamma camera enabled the tumor to be located, excised, and its complete removal to be monitored. The histopathology analysis confirmed a second paraganglioma.

Intravenous thrombolysis is contraindicated in acute ischemic stroke secondary to infective endocarditis. We report our initial experience in 6 cases of proximal vessel occlusion treated with mechanical thrombectomy, which was safe (no bleeding) and effective (significant early neurological improvement) and might be useful in this clinical setting.

BackgroundInfective endocarditis (IE) caused by Abiotrophia (ABI) and Granulicatella (GRA) species is poorly studied. This work aims to describe and compare the main features of ABI and GRA IE.MethodsWe performed a retrospective study of 12 IE institutional cases of GRA or ABI and of 64 cases published in the literature (overall, 38 ABI and 38 GRA IE cases).ResultsABI/GRA IE represented 1.51% of IE cases in our institution between 2000 and 2015, compared to 0.88% of HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella)–related IE and 16.62% of Viridans group streptococci (VGS) IE. Institutional ABI/GRA IE case characteristics were comparable to that of VGS, but periannular complications were more frequent (P = .008). Congenital heart disease was reported in 4 (10.5%) ABI and in 11 (28.9%) GRA cases (P = .04). Mitral valve was more frequently involved in ABI than in GRA (P < .001). Patient sex, prosthetic IE, aortic involvement, penicillin susceptibility, and surgical treatment were comparable between the genera. New-onset heart failure was the most frequent complication without genera differences (P = .21). Five (13.2%) ABI patients and 2 (5.3%) GRA patients died (P = .23). Factors associated with higher mortality were age (P = .02) and new-onset heart failure (P = .02). The genus (GRA vs ABI) was not associated with higher mortality (P = .23).ConclusionsGRA/ABI IE was more prevalent than HACEK IE and approximately one-tenth as prevalent as VGS; periannular complications were more frequent. GRA and ABI genera IE presented similar clinical features and outcomes. Overall mortality was low, and related to age and development of heart failure.

Purpose The outcome of locally advanced adenocarcinoma of the esophagogastric junction (AEG) treated with preoperative chemoradiotherapy is heterogeneous, and favorable response to this treatment is a key factor in the patient's prognosis. The aim of this study was to evaluate F-FDG PET/CT in assessing metabolic response in patients with AEG. Materials and methods This prospective study evaluated all consecutive patients with potentially operable locally advanced AEG who were candidates for neoadjuvant chemoradiotherapy. PET/CT and contrast-enhanced thoracoabdominal CT were performed at baseline and 2 weeks after completion of chemoradiotherapy for response evaluation. The response rate was assessed using Response Evaluation Criteria in Solid Tumors criteria for contrast-enhanced thoracoabdominal CT and Positron Emission Tomography Response Criteria in Solid Tumors criteria for PET/CT. The regression rate was assessed using a 5-grade histopathology scoring system of the surgically resected tumor. Metastatic lesions were confirmed by histopathology examination or imaging and clinical follow-up at 6 months. Results A total of 40 cases were finally included in the study. Distant metastases were found in the baseline PET/CT in 6 of 40 cases (retroperitoneal [2] or mediastinal/hiliar [1] lymph nodes and liver [2] or bone [1] metastases) and were therefore excluded from surgery. Pathologic response correlated with the ΛSUVmax threshold of ≤45% (P = 0.033). CT response correlated well with both the baseline SUVmax (P = 0.039) and the ΛSUVmax (P = 0.001). Five-year survival curves for AEG correlated with the ΛSUVmax using a threshold of ≤45% for both progression-free and overall survival. Conclusions F-FDG PET/CT is useful for diagnosing nonsuspected metastasis before neoadjuvancy in potentially operable AEG. The ΛSUV correlates with pathologic response and is a long-term independent prognostic factor of survival.

Objective: To investigate the rate of colorectal neoplasms (CRNs) in patients who have Enterococcus faecalis infective endocarditis (EFIE) with available colonoscopies and to assess whether this is associated with the identification of a focus the infection. Patients and Methods: Retrospective analysis of data from a prospective multicenter study involving 35 centers who are members of the Grupo de Apoyo para el Manejo de la Endocarditis en Espana [Support Group for the Management of Infective Endocarditis in Spain] cohort. A specific set of queries regarding information on colonoscopy and histopathology of colorectal diseases was sent to each participating center. Four-hundred sixty-seven patients with EFIE were included from January 1, 2008, to December 31, 2017, from whom data on colonoscopy performance and results were available in 411 patients. Results: One hundred forty-two (34.5%) patients had a colonoscopy close to the EFIE episode. The overall rate of colorectal diseases was 70.4% (100 of 142), whereas the prevalence of CRN (advanced adenomas and colorectal carcinoma) was 14.8% (21 of 142), with no significant differences between the group of EFIE of unknown focus and that with an identified focus. Conclusion: Our study adds to prior evidence suggesting a much higher rate of CRN among patients with EFIE than in the general population of the same age and sex. In addition, our findings suggest that this phenomenon might take place both in EFIE with an unknown and an identified source of infection.

Objectives: The aim of this study was to analyse outcomes over 2 decades using cryopreserved vascular allografts to treat vascular infection. Methods: We conducted a retrospective study of patients identified from our institutional database who were treated for primary or secondary vascular infection using implanted allografts. Results: Between October 1992 and May 2014, 54 patients underwent surgery for vascular infection out of 118 patients implanted with cryopreserved vascular allografts. The 52 patients for whom we had full information form the basis of the study with a 96% follow-up. The average age was 64 ± 11 years ; 87% were men ; 65% had previous vascular surgery ; 19% had emergency operations. A total of 75% of the patients had aortoiliofemoral infections. Five patients underwent surgery with cardiopulmonary bypass. Fifty percent required more than 1 allograft and 15% had concomitant procedures. Seventy-three percent (38/52) of specimen cultures yielded positive results with polymicrobial flora in 29%. Surgical specimens most frequently grew coagulase-negative staphylococci. The early postoperative reoperation rate was 15% for allograft- related complications. There were 20 (38%) early deaths, including deaths of acute myocardial infarction, anastomosis rupture and persistent sepsis and shock. Uncontrolled infection leading to septic shock and multiple organ failure was the cause of death in 50% of the cases. The mean duration of freedom from allograft reintervention was 12.2 years. The mean duration of freedom from allograft occlusion or limb loss was 12.1 years [95% confidence interval (CI) 9.9-14.4]. Of the 32 surviving patients, we had patency information for 66% obtained by angiography or computed tomography. The mean survival for the cohort was 5.9 years (95% CI 3.9-7.8). Mean freedom from cardiovascular infection-related death was 9.3 years (95% CI 7.2- 11.4). Conclusions: Allografts can be indicated for treatment of primary/secondary infection and have remarkable results in multimorbid patients. Patients with vascular infection have a high-risk profile, around 40% mortality during the first 6 months, with reduction in overall mortality thereafter. We believe that allografts may play a role in the surgical treatment of vascular infection.

Background: There is little information concerning infective endocarditis (IE) in patients with bicuspid aortic valve (BAV) or mitral valve prolapse (MVP). Currently, IE antibiotic prophylaxis (IEAP) is not recommended for these conditions. Objectives: This study sought to describe the clinical and microbiological features of IE in patients with BAV and MVP and compare them with those of IE patients with and without IEAP indication, to determine the potential benefit of IEAP in these conditions. Methods: This analysis involved 3,208 consecutive IE patients prospectively included in the GAMES (Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España) registry at 31 Spanish hospitals. Patients were classified as high-risk IE with IEAP indication (high-risk group; n = 1,226), low- and moderate-risk IE without IEAP indication (low/moderate-risk group; n = 1,839), and IE with BAV (n = 54) or MVP (n = 89). Results: BAV and MVP patients had a higher incidence of viridans group streptococci IE than did high-risk group and low/moderate-risk group patients (35.2% and 39.3% vs. 12.1% and 15.0%, respectively; all p < 0.01). A similar pattern was seen for IE from suspected odontologic origin (14.8% and 18.0% vs. 5.8% and 6.0%; all p < 0.01). BAV and MVP patients had more intracardiac complications than did low/moderate-risk group (50% and 47.2% vs. 30.6%, both p < 0.01) patients and were similar to high-risk group patients. Conclusions: IE in patients with BAV and MVP have higher rates of viridans group streptococci IE and IE from suspected odontologic origin than in other IE patients, with a clinical profile similar to that of high-risk IE patients. Our findings suggest that BAV and MVP should be classified as high-risk IE conditions and the case for IEAP should be reconsidered. Sin financiación 18.639 JCR (2018) Q1, 3/136 Cardiac & Cardiovascular Systems 9.280 SJR (2018) Q1, 1/365 Cardiology and Cardiovascular Medicine No data IDR 2018 UEM

Background International guidelines recommend 4 weeks of treatment with ampicillin plus gentamicin (A+G) for uncomplicated native valve Enterococcus faecalis infective endocarditis (EFIE) and 6 weeks in the remaining cases. Ampicillin plus ceftriaxone (A+C) is always recommended for at least 6w, with no available studies assessing its suitability for 4w. We aimed to investigate differences in the outcome of EFIE according to the duration (4 versus 6 weeks) of antibiotic treatment (A+G or A+C). Methods Retrospective analysis from a prospectively collected cohort of 78 EFIE patients treated with either A+G or A+C. Results 32 cases (41%) were treated with A+G (9 for 4w, 28%) and 46 (59%) with A+C (14 for 4w, 30%). No significant differences were found in 1-year mortality according to the type of treatment (31% and 24% in A+G and A+C, respectively; P = 0.646) or duration (26% and 27% at 4 and 6w, respectively; P = 0.863). Relapses were more frequent among survivors treated for 4w than in those treated for 6w (3/18 [17%] at 4w and 1/41 [2%] at 6w; P = 0.045). Three out of 4 (75%) relapses occurred in cirrhotic patients. Conclusions A 4-week course of antibiotic treatment might not be suitable neither for A+G nor A+C for treating uncomplicated native valve EFIE.

INTRODUCTION Bisphosphonates may aid in treating and preventing bone loss promoted by chronic immunosuppressive treatment and secondary hyperparathyroidism in renal transplant (RT) patients. However, the effectiveness of bisphosphonates is compromised by poor patient compliance. The objective of the study was to compare the effects of once monthly ibandronate with those of weekly risedronate administration on bone mineral density (BMD) and renal function in RT patients. PATIENTS AND METHODS Sixty-nine patients were prospectively recruited who were at least 12 months post-RT and were treated with either oral ibandronate 150 mg monthly (n=35) or oral risedronate 35 mg weekly (n=34). At baseline and 1 year, creatinine, calcium, alkaline phosphatase, and i-parathyroid hormone were measured, and BMD was determined by dual-energy X-ray absorptiometry. RESULTS Group I consisted of 35 patients (28 women) treated with ibandronate who were of a mean age of 63±12 years. Group II consisted of 34 patients (30 women) treated with risedronate who were of a mean age of 64±10 years. Lumbar BMD was as follows: baseline T-score (group I vs. group II) of -1.7±0.8 versus -1.9±0.8 (P=NS); and annual T-score of -1.3±0.6 versus -1.4±0.8 (P=NS). After 1 year, lumbar BMD improved to reveal a T-score of -1.3±0.6 in the ibandronate group (P

Resumen Objetivo Analizar la utilidad de la fase angiogammagrafica de la gammagrafia osea en 3 fases como posible metodo de cribado en el diagnostico de infeccion de protesis de cadera y de rodilla, previa a la realizacion de la gammagrafia con leucocitos marcados. Material y metodos Se analizaron prospectivamente 120 pacientes (70 mujeres y 50 hombres) con edad media de 71 ± 11 anos y sospecha clinica de infeccion de protesis de cadera (n = 63) o rodilla (n = 57), a los que se realizo gammagrafia osea en 3 fases (angiogammagrafia, fase vascular y fase osea) y gammagrafia con leucocitos marcados con 99mTc-HMPAO. El diagnostico definitivo se realizo mediante estudio microbiologico o seguimiento clinico minimo de 12 meses. Resultados Se establecio el diagnostico de infeccion de la protesis articular en 18/120 pacientes: 10 pacientes con protesis de cadera y 8 pacientes con protesis de rodilla. La angiogammagrafia fue positiva en 15/18 pacientes infectados y en 21/102 pacientes no infectados, mostrando una sensibilidad del 83%, una especificidad del 79% y un valor predictivo negativo del 97%. La gammagrafia con leucocitos marcados mostro una sensibilidad y una especificidad del 72 y del 95%, respectivamente. Si se realizara la gammagrafia con leucocitos marcados exclusivamente a los pacientes con angiogammagrafia positiva, se reduciria un 70% de gammagrafias con leucocitos practicadas. No hubo ningun caso de infeccion con gammagrafia con leucocitos marcados positiva y angiogammagrafia negativa. Conclusiones La angiogammagrafia es una buena tecnica de cribado de infeccion de protesis articulares de cadera y rodilla, disminuyendo significativamente el numero de gammagrafias con leucocitos marcados, sin afectar la sensibilidad de la tecnica.

Aim To evaluate the impact of the angioscintigrapy of the three phase bone scan as screening method to rule out infection of the hip and knee prosthesis prior to performing the 99mTc-HMPAO leukocyte scintigraphy. Material and methods A total of 120 (70 women, 50 men; mean age 71 ± 11 years) with clinical suspicion of hip (n = 63) or knee (n = 57) infection of the prosthesis and clinical suspicion of infection were evaluated prospectively. All patients underwent three-phase bone scan (angioscintigraphy, vascular and bone phase) and 99mTc-HMPAO-labeled white blood cell scintigraphy. Final diagnosis of infection was made by microbiological documentation or clinical follow-up for at least 12 months. Results Eighteen out of 120 patients were diagnosed of infection of hip prosthesis (n = 10) or knee prosthesis (n = 8). The angioscintigraphy was positive in 15/18 infected cases and in 21/102 of the non-infected cases with a sensitivity of 83%, specificity of 79% and negative predictive value of 97%. Sensitivity and specificity of 99mTc-HMPAO leukocyte scintigraphy were 72% and 95%, respectively. If the leukocyte labeled scintigraphies had been used exclusively for patients with positive angioscintigraphy, this would have saved up to 70% of the 99mTc-HMPAO leukocyte scintigraphies performed. There were no cases of infection with positive labeled leukocyte scintigraphy and negative angioscintigraphy. Conclusion Angioscintigraphy (blood flow phase of bone scan) is a useful technique for screening for hip and knee joint prosthesis infection, significantly reducing the need for 99mTc-HMPAO leukocyte scintigraphy without affecting the sensitivity of the technique.

The aim of this in vivo study was to compare the efficacy of vancomycin at standard doses (VAN-SD) to that of VAN at adjusted doses (VAN-AD) in achieving a VAN area under the curve/MIC ratio (AUC/MIC) of ≥400 against three methicillin-resistant Staphylococcus aureus (MRSA) strains with different microdilution VAN MICs in an experimental endocarditis model. The valve vegetation bacterial counts after 48 h of VAN therapy were compared, and no differences were observed between the two treatment groups for any of the three strains tested. Overall, for VAN-SD and VAN-AD, the rates of sterile vegetations were 15/45 (33.3%) and 21/49 (42.8%) ( P = 0.343), while the medians (interquartile ranges [IQRs]) for log 10 CFU/g of vegetation were 2 (0 to 6.9) and 2 (0 to 4.5) ( P = 0.384), respectively. In conclusion, this VAN AUC/MIC pharmacodynamic target was not a good predictor of vancomycin efficacy in MRSA experimental endocarditis.

To prospectively compare 18F-FDG PET/CT and MRI in the diagnosis of haematogenous spondylodiscitis The study included 26 patients (12 women, 14 men; mean age 59 ± 17 years) with clinical symptoms of infection of the spine. Patients who had had prior spinal surgery or any type of antibiotic therapy in the previous 3 months were excluded from the study. Whole-body PET/CT 60 min after injection of 4.07 MBq/kg of 18F-FDG and an MRI scan of the spine was performed in all patients. SUVmax in an area surrounding the lesions with the suspicion of infection as well as a background SUVmean in a preserved area of the spine were calculated for quantification. Infection was diagnosed by microbiological documentation in cultures of image-guided spinal puncture fluid or blood. Infection was excluded if symptoms were absent without antimicrobial therapy during a follow-up of at least 6 months. Spondylodiscitis was confirmed in 18 of the 26 patients. Staphylococcus aureus was found in 8 patients, Mycobacterium tuberculosis in 4, Escherichia coli in 2 and other pathogens in 4. Of the remaining 8 patients, the diagnoses were degenerative spondyloarthropathy in 5 and vertebral fracture in 3. The sensitivity, specificity, and positive and negative predictive value were 83 %, 88 %, 94 % and 70 % for 18F-FDG PET/CT, and 94 %, 38 %, 77 % and 75 % for MRI, respectively. The accuracies of 18F-FDG PET/CT and MRI were similar (84 % and 81 %, respectively). The combination of 18F-FDG PET/CT and MRI detected the infection in 100 % of the patients with spondylodiscitis. 18F-FDG uptake, quantified in terms of SUVmax corrected by the background SUVmean, was significantly higher in patients with spondylodiscitis than in those without infection (p

Little is known about the effects of the administration of cinacalcet in dialytic patients who are scheduled for kidney transplantation, and in particular about the changes in FGF23 and other mineral metabolism parameters after surgery compared with recipients not on cinacalcet at kidney transplantation. We performed a prospective observational cohort study with recruitment of consecutive kidney transplant recipients at our institution. Patients were classified according to whether they were under treatment with cinacalcet before transplantation. Bone mineral metabolism parameters, including C-terminal FGF23, were measured at baseline, on day 15, and at 1, 3, and 6 months after transplantation. In previously cinacalcet-treated patients, cinacalcet therapy was discontinued on the day of surgery and was not restarted after transplantation. A total of 48 kidney transplant recipients, 20 on cinacalcet at surgery and 28 cinacalcet non-treated patients, completed the follow-up. Serum phosphate declined significantly in the first 15 days after transplantation with no differences between the two groups, whereas cinacalcet-treated patients showed higher FGF23 levels, although not significant. After transplantation, PTH and serum calcium were significantly higher in cinacalcet-treated patients. We conclude that patients receiving cinacalcet on dialysis presented similar serum phosphate levels but higher PTH and serum calcium levels during the initial six months after kidney transplantation than cinacalcet non-treated patients. The group previously treated with cinacalcet before transplantation showed higher FGF23 levels without significant differences, so further studies should investigate its relevance in the management of these patients.

The objective of this retrospective study was to evaluate our results with one-stage revision using cementless femoral stem for infected hip arthroplasties. Twenty-four patients were included in the study. The acetabular component was cemented in 9 cases. In 2 patients a structured bone allograft was necessary to fill an acetabular defect. After a mean follow-up of 44.6months, 23 patients showed no signs of infection (95.8%), the mean functional response according to the Merle d'Aubigne scale was 13.8 and the mean Harris Hip Score was 65.4. One-stage revision hip arthroplasty using cementless femoral stem was associated with a high success rate.

Nuclear medicine traditionally employs planar and single photon emission computed tomography (SPECT) imaging techniques to depict the biodistribution of radiotracers for the diagnostic investigation of a range of disorders of endocrine gland function. The usefulness of combining functional information with anatomy derived from computed tomography (CT), magnetic resonance imaging (MRI), and high resolution ultrasound (US), has long been appreciated, either using visual side-by-side correlation, or software-based co-registration. The emergence of hybrid SPECT/CT camera technology now allows the simultaneous acquisition of combined multi-modality imaging, with seamless fusion of 3D volume datasets. Thus, it is not surprising that there is growing literature describing the many advantages that contemporary SPECT/CT technology brings to radionuclide investigation of endocrine disorders, showing potential advantages for the pre-operative locating of the parathyroid adenoma using a minimally invasive surgical approach, especially in the presence of ectopic glands and in multiglandular disease. In conclusion, hybrid SPECT/CT imaging has become an essential tool to ensure the most accurate diagnostic in the management of patients with hyperparathyroidism.

Noncutaneous melanoma is a rare entity for which there is still no agreement about management. The rarity of this disease has resulted in a lack of significant investigation and insufficient opportunity to evaluate the epidemiologic features, risk factors, and the most useful diagnostic and therapeutic approaches. Noncutaneous melanomas are characterized by poor prognosis, and the diagnosis is usually delayed because of their unusual locations and lack of physician awareness. This review focuses principally on ocular melanoma, the most frequent noncutaneous melanoma, for which each aspect of the disease is described. The potential utility of nuclear medicine procedures is also considered.

This study aimed to prospectively evaluate the usefulness of PET/CT using F-FDG in comparison to bone scan and Ga in the diagnosis of spondylodiskitis.This prospective study included 34 patients (15 women and 19 men) aged 59 (18) years with clinical symptoms of spondylodiskitis. Whole-body PET/CT and bone scan combined with planar and SPECT/CT Ga was performed in all patients. Diagnosis of spondylodiskitis was made by microbiology and/or on the basis of clinical and laboratory findings and imaging follow-up.Spondylodiskitis was confirmed in 18 of 34 patients. In the other 16 patients, spondylodiskitis was finally excluded, and the most frequent findings observed were degenerative spondyloarthropathy (n = 7), vertebral fracture (n = 3), endocarditis (n = 2), and other processes (n = 4). The sensitivity and specificity of combined bone scan and Ga were 78% and 81%, with a positive predictive value of 82%, a negative predictive value of 76%, and an overall accuracy of 79%. SPECT/CT with Ga helped identify soft tissue involvement in 10 of 18 patients. The sensitivity and specificity of PET/CT were 89% and 88%, with a positive predictive value of 89%, a negative predictive value of 87%, and an overall accuracy of 88%. Concordance between Ga and PET/CT was good (κ = 0.71; 95% confidence interval, 0.48-0.94). PET/CT was able to detect soft tissue involvement in 12 of 18 patients. In 2 patients, a multifocality was found, which was only diagnosed by PET/CT.PET/CT is useful in the diagnosis of spondylodiskitis, with more accurate results than combined bone scan and Ga. SPECT/CT with Ga is recommended, especially when planar bone scan and Ga pattern is suggestive of spondylodiskitis.

Aim To analyze the potential improvement of 18F-fluorodeoxyglucose (FDG) PET/CT using additional delayed images of the liver in operated colorectal cancer. Material and methods The study prospectively included 71 patients (22 women, 49 men) with mean age of 65 ± 11 years with clinical, biochemical or radiological suspicion of current disease. A whole body PET/CT scan was performed at 60 min (standard images) and after 2 h (delayed images) post-injection of 4.07 MBq/kg of 18F-FDG. Visual and quantitative SUV analysis of PET/CT findings were done. All findings were confirmed by histopathology and/or at least 6 months follow-up. Results Thirty-seven out of 71 patients were diagnosed of liver metastases (79 metastases). In 38/71 cases there was extra-hepatic disease in the form of local recurrence (10), abdominopelvic (3) or mediastinal (3) lymph nodes, bone (1) or lung metastases (16) and carcinomatosis (10). Sensitivity and specificity for the diagnosis of liver metastases in a patient-by-patient basis in standard (81% and 91%) and in delayed images (95% and 97%) were calculated. The number of lesions detected in delayed images was significantly higher (66/79) than in standard images (57/79). Sensitivity and specificity for PET/CT in the diagnosis of extra-hepatic disease were 84% and 70%, contributing to the detection of synchronous tumors in 5 patients. Conclusions PET/CT may be useful in the diagnosis of extra-hepatic disease in suspected recurrence of colorectal cancer. Delayed images on PET/CT may increase the sensitivity to identify liver metastases.

Meta-analytic reviews of Randomized Clinical Trials (RCT) have reached contradictory conclusions regarding the benefit of medical interventions in Advanced Colorectal Cancer (ACRC). Surrogate markers of survival benefit, such as response rate (RR) and progression free-survival (PFS) often show contradictory and highly variable correlations [1-6]. These contradictions can be due to differences in 1) the studies analysed (sources), 2) the quality of clinical trials (intrinsic bias in the design, biased data analysis, heterogeneous PFS definitions) and 3) the second-line strategies between arms. PFS is a more vulnerable target than overall survival (OS), but the latter can also be affected by different biases and additional medical interventions such as secondary resection of metastases or second-line therapies. Therefore the correlation between PFS and survival must be clearly stated if PFS is to be considered as a primary endpoint. Of the differences between studies, only the quality of clinical trials can be improved by a deeper knowledge of both the area of study (i.e. colorectal cancer) and the methodology needed (i.e., clinical and translational trials). The aim of this manuscript is to offer the basic resources to develop experimental trials in ACRC. To this end, techniques for diagnosis and for response assessment are discussed, prognostic factors and treatment standards are critically exposed, and notes about how to design useful translational studies are provided.

OBJECTIVE To evaluate the effect of calcimimetics with 99mTc-methoxy-isobutyl-isonitrile (MIBI) parathyroid scintigraphy in secondary hyperparathyroidism. METHODS This prospective study included 30 consecutive haemodialysis patients with inadequately controlled secondary hyperparathyroidism despite standard medical treatment. Patients were given a single daily oral dose of 30 mg of cinacalcet. A baseline and 1-year follow-up dual-phase 99mTc-MIBI scintigraphy were performed. 99mTc-MIBI uptake in each parathyroid gland was graded on a semiquantitative scale (scoring 0-3). RESULTS Twenty-one of the 30 patients responded to cinacalcet (70%). Abnormal positive glands were identified by 99mTc-MIBI scintigraphy in 27 out of 30 patients (53 glands). The sensitivity and specificity of 99mTc-MIBI in detecting cinacalcet response were 90 and 89%, respectively. The mean baseline and posttreatment grades of 99mTc-MIBI uptake were 2.9 ± 1.8 and 1.1 ± 1.2 (P < 0.0001) in the responder group and 3.1 ± 2.1 and 3.9 ± 2.2 (P = ns) in the nonresponder group. CONCLUSION 99mTc-MIBI scintigraphy is useful in monitoring the response to calcimimetics in secondary hyperparathyroidism.

The aim of this study was to prospectively evaluate 18F-FDG PET/CT in predicting response to neoadjuvant chemotherapy in large primary breast cancer. Fifty consecutive patients underwent PET/CT at baseline and after the second cycle. Baseline MRI was performed to establish tumour size. All findings were confirmed by histopathological analysis. Changes in maximum standardized uptake value (SUVmax) between baseline study and after two cycles of neoadjuvant chemotherapy (epirubicin + cyclophosphamide + taxanes) were compared using response evaluation criteria in solid tumours (RECIST) criteria and the Miller and Payne (M&P) scale. The mean tumour size was 4.3 ± 1.4 cm. Forty patients were considered responders and ten as non-responders. SUVmax changes in patients with good prognosis (M&P grades 4–5) were higher than in patients with bad prognosis (M&P grades 1–3) (p = 0.025). SUVmax changes between responders and non-responders following RECIST criteria were also statistically significant (p = 0.0028). A cut-off ΔSUV value of 40% differentiates both groups, with a sensitivity of 77% and a specificity of 80%. 18F-FDG PET/CT can predict response to neoadjuvant chemotherapy at an early stage.

Objetivo. Analizar la utilidad de la gammagrafia de medula macrofagica en el diagnostico diferencial de infeccion de protesis total de cadera dolorosa valorada con gammagrafia con leucocitos marcados. Material y metodos. Se han estudiado prospectivamente 70 pacientes (42 mujeres, 28 hombres) con una edad de 68 ± 13 anos con protesis total de cadera y dolor local. Se determino la velocidad de sedimentacion globular (VSG) y proteina C reactiva (PCR) y se realizo gammagrafia osea con leucocitos marcados con 99mTc-HMPAO y de medula macrofagica con 99mTc-sulfuro coloidal a todos los pacientes. El diagnostico definitivo se realizo mediante estudio microbiologico o seguimiento clinico minimo de 12 meses. Resultados. Se diagnostico infeccion en 12 de los 70 casos (3 estafilococo coagulasa negativo, 2 Staphylococcus aureus, 2 Staphylococcus epidermidis, 2 Enterococcus y 3 polimicrobianas). La VSG y la PCR en el grupo de pacientes con infeccion resulto significativamente mayor que en el grupo de no infectados (51,8 ± 29,4 frente a 25,4 ± 16,4 y 2,8 ± 2,2 frente a 1,1 ± 1,3 respectivamente; p < 0,05). La gammagrafia osea no mostro un patron de captacion que permitiese diferenciar entre infeccion y aflojamiento aseptico. La fase vascular de la gammagrafia osea fue positiva en 3 de 12 pacientes infectados. La gammagrafia con leucocitos marcados aislada mostro una sensibilidad y especificidad de 83 y 57 %, respectivamente. La gammagrafia de medula macrofagica incremento estos resultados a cifras de 92 y 98 %, respectivamente. Conclusiones. La practica adicional de una gammagrafia de medula macrofagica mejora significativamente los resultados de la gammagrafia con leucocitos marcados en el diagnostico de infeccion de protesis total de cadera. La gammagrafia osea no permite diferenciar entre aflojamiento aseptico e infeccion protesica en esta serie de pacientes.

Summary Aim To evaluate the usefulness of 99m Tc-Sulphur colloid when combined with leukocyte scintigraphy in suspected prosthetic hip infection, comparing the results with information from 99m Tc-HMPAO-leukocyte scintigraphy alone. Materials and methods Seventy patients (42 women, 28 men; mean age ± 13 years) with painful hip prostheses and suspicion of infection were evaluated prospectively. All patients had bone scintigraphy, 99m Tc-HMPAO-labelled white blood cell scintigraphy and 99m Tc-Sulphur colloid bone marrow scintigraphy. ESR and CRP levels were measured in all patients. The final diagnosis was made with microbiological findings or by clinical follow up of at least 12 months. Results Infections were diagnosed in 12 of the 70 patients (3 coagulase-negative Staphylococcus , 2 Staphylococcus aureus , 2 Staphylococcus epidermidis , 2 enterococcus and 3 polymicrobial agents). ESR and CRP values were higher in patients with infection than in patients without infection (51.8 ± 29.4 vs. 25.4 ± 16.4 and 2.8 ± 2.2 vs. 1.1 ± 1.3, respectively; p Conclusion Performing bone marrow scintigraphy significantly improves results when compared with leukocyte scintigraphy alone in the diagnosis of infected hip prostheses. Bone scintigraphy did not help to differentiate aseptic loosening from infection in this series.

Purpose To evaluate the utility of positron emission tomography (PET) and [18F]fluorodeoxyglucose in the initial staging of large primary breast tumors. Patients and Methods This prospective study was approved by the ethics committee, and all patients gave their informed consent before enrollment. Sixty consecutive patients with large (> 3 cm) primary breast cancer diagnosed by clinical examination and breast magnetic resonance imaging (MRI) were entered onto the study. The mean age was 57 ± 13 years. Chest computed tomography (CT), liver ultrasonography, bone scan, and PET/CT were performed in all patients. All findings were histologically confirmed, and/or at least 1 year of follow-up was required. Correlation between parameters was calculated using Pearson's correlation coefficient. P < .05 was considered statistically significant. Results Primary tumor was identified by both PET/CT and MRI in all patients. Multifocal and/or multicentric tumors were found in 19 patients by MRI. Axillary lymph node metastases were found in 20 of 52 patients. Extra-axillary metastatic lymph nodes were also found in three patients. One patient showed an infiltrated lymph node in the contralateral axilla. The sensitivity and specificity for PET/CT to detect axillary lymph nodes metastases were 70% and 100%, respectively. PET/CT diagnosed all extra-axillary lymph nodes. The overall sensitivity and specificity of PET/CT in detecting distant metastases were 100% and 98%, respectively; whereas the sensitivity and specificity of conventional imaging were 60% and 83%, respectively. PET led to a change in the initial staging in 42% of patients. Conclusion PET/CT underestimates locoregional lymph node staging in large primary breast cancer patients. PET/CT is a valuable tool to discard unsuspected extra-axillary lymph nodes and distant metastases.

Vitamin D deficiency is prevalent in kidney transplant recipients (KTR) and recommendations on how to replenish vitamin D deposits are scarce. To evaluate, in KTR, the safety and efficacy of calcifediol in two different vitamin D supplementation regimens, in order to assess the most suitable dose. Prospective observational study with two calcifediol supplementation regimens randomly prescribed by clinicians in liquid form, at 266 mcg doses, monthly or biweekly. We analyzed 168 KTR with a functioning allograft for more than 6 months. Patients receiving other vitamin D forms, calcimimetics or bisphosphonates were excluded. Before calcifediol initiation (pre-treatment levels) and after at least 3 months of treatment (post-treatment levels), we measured serum levels of 25-OH vitamin D (25(OH)D), parathyroid hormone (PTH), alkaline phosphatase (ALP), calcium (sCa), phosphate (sPO4) and creatinine (sCreat). In the monthly group (n = 72), 25(OH)D levels increased from 14 ng/ml [interquartile range, IQR 9–22] at baseline to 31 [20–38] (p = 0.000), PTH decreased from 124 pg/ml [87–172] to 114 [78–163] (p = 0.006), while sCa and sPO4 remained stable. In the biweekly group (n = 96), 25(OH)D increased from 14 ng/ml [9–20] at baseline to 39 [28–52] (p = 0), PTH decreased from 141 pg/ml [95–221] to 112 [90–180] (p = 0.000), sCa remained stable and sPO4 increased from 3.3 ± 0.6 mg/dl to 3.5 ± 0.6 (p = 0.003). Renal function remained stable in both groups. Vitamin D reposition with oral calcifediol, in a biweekly or monthly regimen, is safe and effective in improving 25(OH)D blood levels and in decreasing PTH in kidney transplant recipients.

Objectives To assess the usefulness of [ 1 8 F]fluorodeoxy-glucose positron emission tomography in the detection of bone marrow involvement in malignant lymphoma, and its impact in clinical management. Methods One hundred and six consecutive patients with a confirmed diagnosis of lymphoma, referred for staging or restaging of Hodgkin's lymphoma (n=18) or non-Hodgkin's lymphoma (n=88), were reviewed retrospectively. A positron emission tomography scan and bone marrow biopsy of the iliac crest were performed in all patients. The assessment of bone marrow involvement by lymphoma was confirmed by histology and/or progression of bone marrow lesions in clinical follow-up. Results In 28 of 106 patients, bone marrow involvement was found. Positron emission tomography was more sensitive (86%) than bone marrow biopsy (57%). Positron emission tomography and bone marrow biopsy were concordant by positive correlation in 12 of 28 cases (43%) and by negative correlation in 77 of 78 cases (99%). Ten cases of non-Hodgkin's lymphoma and two cases of Hodgkin's lymphoma with positive positron emission tomography results and an initial negative bone marrow biopsy showed clinical progression of the bone marrow lesions and/or subsequent positive histology. These were considered as false-negative results for bone marrow biopsy. In seven of the 12 positive cases with negative bone marrow biopsy, positron emission tomography uptake distant from the site of the biopsy was seen. In four cases of follicular lymphoma, the bone marrow biopsy was positive and the positron emission tomography scan was normal. Conclusions Positron emission tomography and bone marrow biopsy are complementary in assessing the presence of bone marrow involvement in patients with malignant lymphoma. In our series, positron emission tomography was more sensitive than bone marrow biopsy in Hodgkin's and non-Hodgkin's lymphoma, except in follicular lymphoma.

The value of 18F-FDG PET/CT in the initial diagnosis and in the locoregional staging of esophagogastric junction adenocarcinoma is not fully established. However, 18F-FDG PET/CT is widely accepted as the best modality for identification of suspected metastases in staging of the disease. Results published in the literature suggest that 18F-FDG PET/CT may provide useful information for response assessment to neoadjuvancy and to differentiate responding and nonresponding tumors. We review the potential role of 18F-FDG PET/CT imaging in staging, restaging, and prognostic value after chemoradiation therapy in esophagogastric junction adenocarcinoma.

Simultaneous pancreas-kidney transplant (SPKT) has been associated with an increased risk of fracture. We prospectively evaluated the long-term effects of SPKT on bone mineral density (BMD) and fracture risk. During 1998 to 1999, 29 participants were consecutively monitored, and 18 completed the 10-year follow-up. Laboratory blood parameters, lumbar-dorsal radiography, and DEXA were determined at baseline, 1 year, and 10 years. The medical record was reviewed for peripheral fragility fractures. The BMD revealed no changes between baseline and 1 or 10 years after SPKT. Lumbar-dorsal radiography showed 0% asymptomatic vertebral fractures at baseline and after 1 year with 16.7% at 10 years. Vertebral asymptomatic fractures were correlated with acute rejection episodes (P = 0.025). During the first year, no nonvertebral fractures were identified. At the end of the follow-up, 5 nonvertebral fractures in 4 patients were reported. Dorsal and lumbar spine fractures correlated with lumbar spine t score (r = -0.591, P =0.022) and peripheral fractures with femoral neck t score (r = -0.633, P = 0.013). Patients with SPKT did not show long-term significant loss of BMD. The incidence of vertebral fractures was low and related to steroid treatment; the incidence of peripheral fractures was higher and independent of clinical or biochemical parameters.

Objective: Transmyocardial laser revascularization is a new technique that improves symptoms in patients with refractory angina not amenable to conventional revascularization. The aim of this study was to assess whether transmyocardial laser revascularization produces changes in innervation, perfusion scintigraphy, or both that could explain the benefit to patients.Methods: Sixteen patients (12 men and 4 women; mean age, 60 ± 8 years) with coronary artery disease were studied. Transmyocardial laser revascularization was performed in 39 myocardial areas supplied by a stenotic vessel. A technetium 99m-labeled tetrofosmin stress-rest tomographic scan and iodine 123-labeled metaiodobenzylguanidine planar scans were performed before and after transmyocardial laser revascularization (3 and 12 months later) to evaluate myocardial perfusion and innervation. Stress and rest perfusion images were quantified on a polar map. Ischemia uptake was also defined as the difference between rest and stress uptake for each area. Innervation planar images were visually analyzed and semiquantified.Results: A significant decrease in angina class from baseline was observed at 3, 6, and 12 months after transmyocardial laser revascularization (P < .005). A significant decrease in ischemia uptake was also found between the pre-transmyocardial laser revascularization and the post-transmyocardial laser revascularization studies in treated areas (P < .001). A significant improvement in stress myocardial perfusion at 3 and 12 months after transmyocardial laser revascularization was only found in treated areas that were considered ischemic in the pre-transmyocardial laser revascularization study (P < .05). At 3 months, a significant myocardial innervation worsening was observed in treated areas (P < .001), with partial recovery at 12 months (P < .05).Conclusion: The transmyocardial laser revascularization mechanism involves both perfusion improvement and denervation, mainly at 3 months, that partially recovered at 12 months.

The major factor influencing scintigraphic detection of abnormal parathyroid glands seems to be their size. However, false-negative results have been reported in large glands while some very small adenomas have been identified. Other factors can influence 99mTc-MIBI and 99mTc-Tetrofosmin uptake and therefore the accurate detection of hyperfunctioning glands depends also on these. Increases in both perfusion and functional activity and targeting of abundant mitochondria-rich oxyphil cells seem to be relevant mechanisms of uptake. A relationship has been observed between the intensity of focal uptake in the parathyroid glands and the cell cycle phases for patients with secondary hyperparathyroidism. Higher uptake grades correlated with the active growing phase, showing that scintigraphy accurately reflects the functional status of the hyperplastic parathyroid glands. Serum calcium levels may modify radiotracer kinetics by influencing the membrane potential. In addition, P-glycoprotein or multidrug resistance (MDR) associated protein expression may play an important role in the false-negative results of parathyroid scintigraphy. If the lipophilic cationic radiotracers used in parathyroid scintigraphy are transported by the same mechanism as the anticancer drugs, they will be quickly eliminated from the parathyroid glands containing P-glycoprotein or MDR-related protein expression and the uptake in images will be negative. In parathyroid glands with no P-glycoprotein or MDR-related protein expression, the radiotracers remain in the cells, making it easier to detect them by scintigraphy.