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Background Immune checkpoint inhibitors have changed the paradigm of cancer treatment; however, non-invasive biomarkers of response are still needed to identify candidates for non-responders. We aimed to investigate whether immunotherapy [18F]FDG PET radiomics signature (iRADIOMICS) predicts response of metastatic non-small-cell lung cancer (NSCLC) patients to pembrolizumab better than the current clinical standards. Patients and methods Thirty patients receiving pembrolizumab were scanned with [18F]FDG PET/CT at baseline, month 1 and 4. Associations of six robust primary tumour radiomics features with overall survival were analysed with Mann-Whitney U-test (MWU), Cox proportional hazards regression analysis, and ROC curve analysis. iRADIOMICS was constructed using univariate and multivariate logistic models of the most promising feature(s). Its predictive power was compared to PD-L1 tumour proportion score (TPS) and iRECIST using ROC curve analysis. Prediction accuracies were assessed with 5-fold cross validation. Results The most predictive were baseline radiomics features, e.g. Small Run Emphasis (MWU, p = 0.001; hazard ratio = 0.46, p = 0.007; AUC = 0.85 (95% CI 0.69-1.00)). Multivariate iRADIOMICS was found superior to the current standards in terms of predictive power and timewise with the following AUC (95% CI) and accuracy (standard deviation): iRADIOMICS (baseline), 0.90 (0.78-1.00), 78% (18%); PD-L1 TPS (baseline), 0.60 (0.37-0.83), 53% (18%); iRECIST (month 1), 0.79 (0.62-0.95), 76% (16%); iRECIST (month 4), 0.86 (0.72-1.00), 76% (17%). Conclusions Multivariate iRADIOMICS was identified as a promising imaging biomarker, which could improve management of metastatic NSCLC patients treated with pembrolizumab. The predicted non-responders could be offered other treatment options to improve their overall survival.

Background: Sarcoidosis before and after treatment of malignancy is an important differential diagnosis that has to be distinguished from lymphoma., Patients and Methods: Hodgkin lymphoma, diffuse large B-cell lymphoma and aggressive follicular lymphoma are being staged and treatment effect is evaluated with PET-CT. We report three cases of aggressive lymphoma after high dose therapy and autologous stem cell transplantation with positive lymph nodes on PET-CT, which were histologically diagnosed as sarcoidosis/granulomatosis. In the literature, we found that false positive lymph nodes were more common after allogeneic than after autologous transplantation., Conclusions: Post-treatment PET-CT positive lymph nodes should always be examined histologically prior to any further treatment decision to avoid unnecessary toxic procedures.

Background: Incidental (18)F-FDG uptake in the thyroid on PET-CT examinations represents a diagnostic challenge. The maximal standardized uptake value (SUVmax) is one possible parameter that can help in distinguishing between benign and malignant thyroid PET lesions., Patients and Methods: We retrospectively evaluated (18)F-FDG PET-CT examinations of 5,911 patients performed at two different medical centres from 2010 to 2011. If pathologically increased activity was accidentally detected in the thyroid, the SUVmax of the thyroid lesion was calculated. Patients with incidental (18)F-FDG uptake in the thyroid were instructed to visit a thyroidologist, who performed further investigation including fine needle aspiration cytology (FNAC) if needed. Lesions deemed suspicious after FNAC were referred for surgery., Results: Incidental (18)F-FDG uptake in the thyroid was found in 3.89% - in 230 out of 5,911 patients investigated on PET-CT. Malignant thyroid lesions (represented with focal thyroid uptake) were detected in 10 of 66 patients (in 15.2%). In the first medical centre the SUVmax of 36 benign lesions was 5.6 ± 2.8 compared to 15.8 ± 9.2 of 5 malignant lesions (p < 0.001). In the second centre the SUVmax of 20 benign lesions was 3.7 ± 2.2 compared to 5.1 ± 2.3 of 5 malignant lesions (p = 0.217). All 29 further investigated diffuse thyroid lesions were benign., Conclusions: Incidental (18)F-FDG uptake in the thyroid was found in 3.89% of patients who had a PET-CT examination. Only focal thyroid uptake represented a malignant lesion in our study - in 15.2% of all focal thyroid lesions. SUVmax should only serve as one of several parameters that alert the clinician on the possibility of thyroid malignancy.

Carotid paragangliomas are usually slowly enlarging and painless lateral neck masses. These mostly benign lesions are recognized due to their typical location, vessel displacement and specific blood supply, features that are usually seen on different imaging modalities. Surgery for carotid paraganglioma can be associated with immediate cerebrovascular complications or delayed neurological impairment.We are reporting the case of a 36-year-old man who presented with a painless mass on the right side of his neck 11 months after being treated for testicular cancer. After a fine-needle aspiration biopsy, he was diagnosed with a testicular cancer lymph node metastasis. Neck US and fluorine [F-18]-fluorodeoxy-D-glucose (FDG) PET-CT showed no signs of hypervascularity or vessel displacement. The patient underwent a level II to V functional neck dissection. During the procedure, suspicion of a carotid paraganglioma was raised and the tumour was carefully dissected from the walls of the carotid arteries with minimal blood loss and no cranial nerve dysfunction.The histology report revealed carotid paraganglioma with no metastasis in the rest of the lymph nodes. The patient's history of testicular germ cell tumour led to a functional neck dissection during which a previously unrecognized carotid paraganglioma was removed.Surgery for carotid PG can be associated with complications that have major impact on quality of life. A thorough assessment of the patient and neck mass must therefore be performed preoperatively in order to perform the surgical procedure under optimal conditions.

Background: It is believed that chemotherapy (ChT) is ineffective in follicular thyroid carcinoma (FTC) and Hürthle cell thyroid carcinoma (HCTC). The aim of our retrospective study was to find out whether neodjuvant ChT before thyroid surgery had any effect on the size of primary tumor in patients with FTC or HCTC., Methods: The study included 29 patients (20 women, 9 men; mean age: 60.8 years) with FTC or HCTC who had T3 or T4 tumor and were treated with neoadjuvant ChT from 1979 to 2004. A mean tumor diameter was 9.3 cm. Extrathyroid growth of tumor was present in 15 patients. Regional and distant metastases were detected in 6 and 12 patients, respectively. With respect to the site of metastatic spread, the lung was involved in eight patients and the skeleton in five. ChT consisted of vinblastine in 19 cases, vinblastine with adriamycin in 5 cases, or other ChT regimens in 5 cases., Results: Altogether, 67 cycles of ChT were given and tumor size decreased by >50% in 13 patients (=45%). ChT was effective in patients with FTC and HCTC in 47% and 43%, respectively. In the patients with and without distant metastases, the primary tumor size decreased by >50% in 17% and 65% (p=0.02), respectively. R0, R1, and R2 resection was performed in 15, 10, and 4 cases, respectively. Histopathology revealed that ChT (i.e., wide areas of tumor necrosis) was effective in seven patients (24%). The 5- and 10-year cause-specific survivals of the patients were 77% and 47%, while the 5- and 10-year disease-free intervals were 57% and 46%, respectively. Six patients are alive (median survival: 162 months), four of them have no evidence of disease, six patients died of other causes (median survival: 101 months), while 17 patients died of FTC or HCTC (median survival: 72 months). Among them, 16 died of distant metastases, while only one succumbed to locoregional recurrence and distant metastases., Conclusions: ChT before surgical procedure may be effective in order to decrease the tumor size in FTC or HCTC in 45% of patients.

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) is the most frequently used ankylosing spondylitis activity assesment by which through 6 questions 5 basic diseases symptoms (fatigue, back pain, joint pain/swelling, enthesitic points, intensity and duration of morning stiffness) are being evaluated. In distinction from mentioned, Ankylosing Spondylitis Disease Activity Score (ASDAS) is the first validated index for the AS activity assessment with the patient's assessments of the disease symptoms (back pain, duration of the morning stiffess, activity of the disease, pains and swelling of the peripheral joints) includes the acute phase reactants (SE or CRP). We compared BASDAI and ASDAS indexes to the group of patients with the AS, in order to evaluate their congruence and to evaluate the inluence of SE, fatigue and back pain at obtained values. The cross-sectional study was performed in a group of 36 patients with the AS whose disease activity levels were evaluated by the BASDAI and ASDAS (SE) index. Statistical data analysis was performed by Student t-test and frequency tables for non-parameter data. As it has been expected the significant correlation between BASDAI and ASDAS indexes has been confirmed (r=0.796; p=0.00). BASDAI/ASDAS average value of all of the patients was 4.2/2.8. From 36 patients with the AS according to the BASDAI index 42% had mild active disease (BASDAI <4), while according to ASDAS index 44% patients had very active disease (ASDAS 2.1-.5.3). Higher activity of the disease according to ASDAS index is the result of the elevated sedimentation which is assessed only in ASDAS index. Patients with higher BASDAI index statistically have more significantly expressed fatigue and spinal pain without statistically significant difference in sedimentation (p=0.120). Examinees with higher ASDAS index have also significantly more expressed fatigue and back pain, but unlike BASDAI they have sedimentation (p=0.001). ASDAS is more recent clinical indicator of the AS activities which could be compared to BASDAI instrument. In this group of patients ASDAS seems to be more sensitive index because it discriminates more patients with the active disease.

Our aim was to test the efficacy of 131-I therapy (RIT) using recombinant human TSH (rhTSH) in patients with differentiated thyroid carcinoma (DTC) in whom endogenous TSH stimulation was not an option due to the poor patient's physical condition or due to the disease progression during L-thyroxin withdrawal. The study comprised 18 patients, who already have undergone total or near-total thyroidectomy and radioiodine ablation and 0-12 (median 5) RITs after L-thyroxin withdrawal. Our patients received altogether 44 RITs using rhTSH while on L-thyroxin. Six to 12 months after the first rhTSH-aided RIT, PR and SD was achieved in 3/18 (17%) and 4/18 patients (22%), respectively. In most patients (n = 12; 61%) disease progressed despite rhTSH-aided RITs. As a conclusion, rhTSH-aided RIT proved to add some therapeutic benefit in 39% our patients with metastatic DTC, who otherwise could not be efficiently treated with RIT.

Background: Increased level of serum S100B can serve as a marker of metastatic spread in patients with cutaneous melanoma (CM). In patients with elevated S100 B and/or clinical signs of disease progression PET-CT scan is a valuable tool for discovering metastases and planning treatment.The aims of this study were to determine whether regular measurements of serum S100B are a useful tool for discovering patients with CM metastases and to evaluate the diagnostic value of PET-CT during the follow-up., Methods: From September 2007 to February 2010, 115 CM patients included in regular follow up at the Institute of Oncology Ljubljana were appointed to PET-CT. There were 82 (71.3%) patients with clinical signs of disease progression and 33 (28.7%) asymptomatic patients with two subsequent elevated values of S100B. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) of S100B and PET-CT were calculated using standard procedures., Results: Disease progression was confirmed in 81.7% of patients (in 86.5% of patients with clinical signs of disease progression and in 69.7% of asymptomatic patients with elevated S100B). Sensitivity, specificity, PPV and NPV of S100B was 33.8%, 90.9%, 96.0% and 17.5% in patients with clinical signs of disease progression. In 20.0% of patients increased serum S100B was the only sign of disease progression. Sensitivity and PPV of S100 in this group of patients were 100.0% and 69.7%.With PET-CT disease progression was diagnosed in 84.2% of symptomatic patients and in 72.7% of asymptomatic patients with elevated S100B. The sensitivity, specificity, PPV and NPV of PET-CT for symptomatic patients was 98.5%, 90.9%, 98.5% and 90.9% and 100%, 90.0%, 95.8% and 100% for asymptomatic patients with elevated S100., Conclusions: Measurements of serum S100B during regular follow-up of patients with CM are a useful tool for discovering disease progression in asymptomatic patients. The value of its use increases if measurements are followed by extended whole body PET-CT.

Aim: To assess the axillary recurrence rate in operable breast cancer patients with clinically negative axilla after negative sentinel lymph node in whom axillary lymph node dissection had not been performed., Methods: Fifty consecutive female operable breast cancer patients with negative sentinel lymph node biopsy in whom axillary lymph node dissection had not been performed were included in the study and prospectively followed, with median follow-up time of 32 months (range 10-50 months). Sentinel lymph node biopsy was performed by the triple method., Results: The sentinel node identification rate was 100%. In only one of 50 patients with negative sentinel lymph node, axillary recurrence developed 26 months after surgery. This was the sole patient with sentinel lymph node biopsy after previous surgical biopsy. After treatment, all patients were alive and with no evidence of disease., Conclusions: Omitting axillary node dissection after negative sentinel node biopsy in operable breast cancer patients proved to be safe. Patients with previous open surgical biopsy should be given special attention in the follow-up.

Background: Columnar cell carcinoma is a rare variant of papillary thyroid carcinoma associated with aggressive clinical behaviour., A Case Report: of a 34-year-old male patient, who presented with the rapidly growing mass in the neck, extending to the anterior and middle mediastinum, tightly closing the upper thoracic apperture and causing tracheal and oesophageal deviation, with minimal compression and stenosis. A diagnosis of columnar cell carcinoma, arising from the ectopic thyroid tissue just adjacent to the left thyroid lobe was based on histological and intraoperative findings. Near total thyroidectomy and lymph-node dissection were followed by external beam radiotherapy of the neck and mediastinum, chemotherapy and radioiodine ablation of the remaining functional thyroid tissue. Pre-and post-operative radionuclide imaging (99mTc(V)-DMSA, 99mTc-MIBI, 123-I-mIBG and Octreoscan findings are discussed, with a special emphasis given to the dilemmas in histological characterisation of the tumor, the problems in therapeutic approach and the dilemmas and pitfalls in the interpretation of radionuclide findings in this patient, especially the ones performed post radiotherapy of the neck and mediastinum.

Purpose: To describe and analyze the appearances of autosomal recessive polycystic kidney disease (ARPKD) on Tc-99m DMSA and Tc-99m HIDA scintigraphy., Materials and Methods: The authors evaluated scintigraphic findings for 13 boys and 9 girls (age range, 2 months to 22.75 years; mean, 7.5 years) with ARPKD. Fourteen children underwent Tc-99m DMSA and 20 underwent Tc-99m HIDA scintigraphy according to European guidelines. Kidney outline, internal structure, tracer uptake, and differential function were analyzed on Tc-99m DMSA images, whereas relative liver lobe sizes, hepatocyte tracer uptake, time to peak, and excretion into the biliary tree and gut were evaluated on Tc-99m HIDA scans., Results: On Tc-99m DMSA images, loss of kidney outline and internal structure was seen in 75% of the scans, and patchy tracer uptake with focal defects throughout the kidneys, particularly at the poles, was evident in 93%. In 85% of the cases, the Tc-99m DMSA changes did not correlate with the ultrasonographic findings where the kidneys are uniformly affected. Characteristic findings on Tc-99m HIDA scans were enlarged left liver lobe in 80%, a delay in maximal hepatocyte uptake in 68%, delayed tracer excretion into the biliary tree in 32% (with stasis in the prominent intrahepatic biliary ducts in 50% or pooling into the segmentally dilated biliary ducts in 25%), and delayed excretion into the gut in 40% of patients., Conclusions: In a child with clinically enlarged kidneys that appear diffusely hyperechoic on ultrasound, the appearances on Tc-99m DMSA imaging strongly support the diagnosis of ARPKD. The Tc-99m HIDA findings, especially of an enlarged left lobe of the liver with bile stasis or dilatation, further support the diagnosis.

Subscapular skinfold, elbow breadth and upper arm indicators of nutritional status were studied in the population of Dalmatia in Croatia. Age- and sex-specific percentiles were obtained from 4373 subjects, 18 to 74 years of age, and compared to the U.S. NHANES I and II reference data. There were significant differences between these data sets in all studied variables. The results complement those reported previously for BMI and triceps skinfold and indicate that high prevalence of overweight in Dalmatians largely reflects their muscularity and skeletal robustness rather than excess body fatness. The findings suggest that the U.S. upper percentiles of BMI and skinfolds are inadequate for the assessment of excess body fatness in Dalmatian population. The obtained population-specific percentile distributions should be used provisionally as the reference data for group comparisons in the Dalmatian region.

Most of the patients in the intensive care unit for children are newborns and infants having an infection of the central nervous system, with systemic septic and respiratory infections. Therefore, mobile X-ray equipment including mobile shields is routinely used for diagnosis of the respiratory tract, heart and endovascular catheterization. The aim of this work was to determine the radiation exposure to the children in the vicinity of the exposed patient in the same or next room. Three measurement runs were carried out with thermoluminescence dosimetry system. The results show that the homogeneity of the irradiation field is adequate, the exposure of children to radiation in the vicinity of the exposed patient in the same or next room is very low, practically in the range of the lowest detectable dose. The entrance dose on the breast of the patient was found to be 0.07 mSv. Therefore, there is no basis for the risk estimation of genetic, leukemogenic and cancerogenic detriment.

Background: The aim of the study was to evaluate the interobserver variability and reproducibility of the renal scintigraphy reports., Methods: The study was prospective performed in 60 99mTc DMSA scintigraphies (116 kidneys), done in one centre, displayed on X ray films as analogue 300 kcounts images in 4 standard projections. Six observers from 4 different centres (group A), including three observers from one institution (group B), were asked to interpret original scans. Seven parameters of scintigraphy protocol were analysed with at least two responses: kidney size (1), uptake (2), outlines (3), scars (4), SOL (5), differential function (6) and conclusion (7)., Results: Among 116 kidneys, concordant results in interpretation of seven points of report from 1 to 7, in the group A were found in 62%, 42.5%, 45%, 9%, 47%, 52% and 34%, and In the group B in 72%, 55%, 59%, 22%, 62%, 60% and 41% respectively. Some improvement in concordant reporting was noted in the group of 3 observers, in comparison of group of all, statistically significant in category of scar reports (p < 0.01)., Conclusions: Results suggest to use of standardised criteria and terminology in interpretations, to improve low interobserver reproducibility and objectivity of renal scintigraphy reports, particularly in evaluation of renal scars.

Since February 1990, 74 patients (116 studies) underwent scintigraphy with meta-[131I]iodobenzylguanidine ([131I]MIBG). Eighteen patients had pheochromocytomas, 2 paragangliomas, 2 malignant insulinomas, 1 carcinoid, 2 medullary thyroid carcinoma and 49 children had neuroblastomas. Scintigraphy was performed following a thyroid blockade, at 24 and 48 hours after i.v. injection of 0.5 mCi/1.7 m2 [131I]MIBG. Grade of heart intensity (GHI) uptake and the intensity of salivary gland visualization (SGI) were estimated semiquantitatively, according to the method of Nakajo et al. Sensitivity in the primary pheochromocytomas was 93.9%; sensitivity and specificity in the primary neuroblastomas were 93.7% and 100% respectively; in the secondary neuroblastomas they were 100%, and 100%. Metastases in 2 malignant insulinomas and in 1 case of medullary thyroid carcinoma were also demonstrated. Only one false negative (in pheochromocytoma) and one false positive (Conn's syndrome) result was obtained. Mean values and range of MIBG uptake measured according to Shulkin's procedure were: for pheochromocytoma 3.95% (0.1-15), primary neuroblastoma 0.7% (0.05-1.92%), and neuroblastoma metastases 0.12% (0.002-0.83%). Assessment of [131I]MIBG uptake seems to be helpful in the follow-up of some neural crest tumors and is essential as a prelude to [131I]MIBG therapy.

Whole-body scintigraphy with 131I-meta-iodo-benzylguanidine 131I-MIBG) was performed in 41 patients with neuroblastoma. In patients with clinical remission no pathological concentration of 131I-MIBG was found. In 30 patients with residual, recurrent or metastatic disease neuroblastoma was correctly localized by 131I-MIBG scintigraphy. It is concluded that 131I-MIBG whole-body scintigraphy is useful in the diagnosis and follow-up of neuroblastoma.

Dynamic radionuclide sialography (DRS) provides data about the aptitude of salivary glands to accumulate the tracer and to secrete the saliva. Visual interpretation of the t/a curves may be onerous when salivary glands uptake function is impaired. The purpose of the study has been to quantify the ascorbic acid (AA) response by means of salivary excretion index (SEI). DRS was performed in 10 healthy subjects and in 118 patients with various diseases of the parotid glands. Data acquisition (80 frames/15 s) started simultaneously with i.v. administration of 99mTcO4. Fifteen minutes later AA was given per os. Regions of interest were set over parotid glands. SEI was derived using the formula: SEI = (2b-a-c)/b, where a, b and c were cpm 3 minutes prior, in the moment when, and 3 minutes after AA was given. In 9 of 10 controls SEI was greater than 55 (mean = 63.2). Results in patients with Sjögren's and Mikulicz's syndrome and sialoadenitis, were significantly lower than in healthy subjects. Lowest results were found in patients with sialolithiasis. It may be concluded that SEI improves objective assessment of the AA response particularly in patients with minute or asymmetric disorders of salivary glands function.