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Introduction and objective Febrile syndromes of unknown origin (FSUO) are complex processes in hospital practice. Their management includes an exhaustive medical history and examination, as well as an extensive number of biochemical tests. If these are inconclusive, diagnostic imaging techniques such as SPECT/CT with 67-Gallium Citrate (67Ga-SPECT/CT) could play an important role. We evaluated its role in the management of FSUO in our healthcare area. Material and methods We reviewed 57 patients who underwent a 67Ga-SPECT/CT due to a FSUO (32 women and 25 men, age range: 32–83 years old) obtaining scintigraphic findings, previous treatments and final diagnosis. Values of sensitivity, specificity, positive predictive values (VPP) and negative predictive values (NPV) were obtained and compared with the results for PET/CT with 18Fluor-deoxy-glucose (18F-FDG PET/CT) found in the literature. Results The diagnoses found were: infection in 27/57 (47%), inflammatory disease in 15/57 (26%), neoplasm in 1/57 (1.75%) and patients without final diagnosis in 14/57 (24%). The statistical values of 67Ga-SPECT/CT were: sensitivity, specificity, PPV and NPV of 67%, 93%, 97% y 48%, respectively which were slightly lower than those found for the 18F-FDG PET/CT (86%, 52%, 70% and 92%, respectively). The diagnostic yield was 73% which increased to 80% in the patients who lacked empirical treatment. Conclusion Despite the better results of 18F-FDG PET/CT, 67Ga-SPECT/CT behaved as a useful technique in the management of FSUO. It is advisable to use it if 18F-FDG PET/CT is not available.

Cerebral malaria is a serious complication of infection with Plasmodium falciparum. Its pathophysiological mechanisms and clinical manifestations are still currently being studied. Structural imaging techniques such as CT and MRI provide non-specific information during the diagnostic process. However, there are hardly any references on the use and potential benefits of radioisotope procedures for this pathology. In this article we present the case of a patient diagnosed with cerebral malaria treated in our centre, subjected to progressive monitoring using SPECT perfusion.

The case is presented on a patient with abdominal pain and suspicion of neuroendocrine tumor in the tail of the pancreas shown in the abdominal CT and MRI. Whole-body scintigraphy and abdominal SPECT/CT with 99mTc-octreotide were performed that showed a nodular lesion partially on the posterior side of the pancreas tail. This nodule showed faint tracer uptake, and was reported as probable neuroendocrine tumor. Partial pancreatectomy and splenectomy were performed, and the histological study identified the lesion as an ectopic spleen. There are similar cases in the literature that match these findings, but this lesion is still frequently diagnosed after performing unnecessary surgery. When an asymptomatic intrapancreatic mass is detected, an accessory spleen should be considered and specific diagnostic techniques should be performed, such as labeled and denatured red blood cell SPECT/CT.

The case is presented on a patient with abdominal pain and suspicion of neuroendocrine tumor in the tail of the pancreas shown in the abdominal CT and MRI. Whole-body scintigraphy and abdominal SPECT/CT with

We present a patient with clinical suspicion of intestinal carcinoid relapse confirmed by a somatostatin receptor scintigraphy. A very intense somatostatin avid abdominal lesion was located and radioguided surgery was proposed. Prior to the procedure, we performed a SPECT-CT that made it possible to detect and localize the lesion anatomically, thus facilitating the performance of the radioguided procedure. Furthermore, it modified the planning of the intervention with the adequate physical and human resources to prevent the possible surgical complications.

We present a patient with clinical suspicion of intestinal carcinoid relapse confirmed by somatostatin receptor scintigraphy. A very intense somatostatin avid abdominal lesion was located and radioguided surgery was proposed. Prior to the procedure, we performed a SPECT-CT allowing detection and localization of the lesion anatomically, thereby facilitating the performance of the radioguided procedure. Furthermore, SPECT-CT modified the planning of the intervention with adequate physical and human resources to prevent possible surgical complications.

Introduction Sentinel node biopsy (SNB) by radioisotopes is a widely accepted and reliable surgical method for staging breast cancer in patients with unknown positive axillary lymph nodes involvement. The main limitation of this method is due to the appearance of false negatives that may be caused by tumor lymph node blockage of the sentinel lymph node and uptake in the neighboring lymph nodes. Infiltrated sentinel nodes are generally increased in size and firm. Thus, they can be detected by intraoperative palpation, even when there is no uptake by the radiotracer. Aim To reduce the false negative rates by applying intraoperative axillary palpation after SNB. Method Over a two-year period, we complemented the SNB in 168 patients with careful intraoperative axillary palpation, detecting and removing all the palpable suspicious lymph nodes (SLN) that were analyzed as sentinel nodes. Results In 32 out of 168 patients, 50 palpable SLN were found. In 3 out of 32 patients, 4 infiltrated SLNs were demonstrated with negative SNB and positive axillary lymphadenectomy. Thus, intraoperative palpation avoided false negative results. In one patient, one palpable SLN with tumor involvement was observed and SNB was also positive. In the remaining 28 patients, the histological analysis of 45 SLN was negative for tumor but SNB was positive in 3 patients. Conclusion Intraoperative axillary palpation, once the SNB was done, reduced the false negative rate. Thus, we consider that it should be included as one more part of this procedure.

Resumen Introduccion La biopsia selectiva de ganglio centinela (BSGC) es una tecnica estandar en la estadificacion del cancer de mama sin evidencia de afectacion axilar. Su limitacion es la aparicion de falsos negativos que podrian ser causados por bloqueo linfatico tumoral del ganglio centinela y captacion en los linfaticos vecinos. Los ganglios centinelas infiltrados suelen aumentar de tamano y consistencia, por lo que pueden ser detectados mediante una palpacion intraoperatoria sin que capten el radiotrazador. Objetivo Intentar disminuir la tasa de falsos negativos mediante la palpacion intraoperatoria. Metodo Durante 2 anos hemos completado la BSGC en 168 pacientes con una palpacion axilar cuidadosa, detectando y extirpando todos aquellos ganglios palpables sospechosos (GPS) que fueron analizados como ganglios centinela. Resultados De los 168 pacientes, en 32 se encontraron 50 GPS. De estos 32 pacientes, en 3 pacientes se encontraron 4 GPS infiltrados con BSGC negativa y afectacion tumoral en la linfadenectomia axilar, evitando asi la aparicion de falsos negativos. En un paciente se hallo un GPS infiltrado con BSGC igualmente patologica. En los 28 pacientes restantes, se encontraron 45 GPS que no estaban afectos y la BSGC fue patologica en 3 pacientes. Conclusion La palpacion manual axilar, una vez finalizada la BSGC, redujo la aparicion de resultados falsos negativos, por lo que consideramos que debe ser incluida como una parte mas de este procedimiento.

Resumen Objetivo en un paciente con trastorno del movimiento (TM) un SPI normal apoya una etiologia no degenerativa. Se ha evaluado retrospectivamente la situacion clinica de los pacientes a los 2 anos de realizarse un SPI con resultado normal para valorar cual fue la actitud de los especialistas en neurologia de nuestra area ante este tipo de pacientes. Metodo de un total de 196 SPI realizados durante el periodo 2004-2005, se seleccionaron 44 en los que la intencion era descartar un TM degenerativo (TMD) y cuyo resultado fue normal. Los historiales clinicos de estos pacientes sen revisaron en un periodo de, al menos, 24 meses (rango, 24-40), y se recogieron los diagnosticos alcanzados por los especialistas en neurologia. Los SPI fueron informados en consenso, atendiendo a criterios subjetivos y de cuantificacion. Resultados 36 de los 44 (81%) pacientes se etiquetaron a los 2 anos como TM no degenerativos (TMND): 18 temblores esenciales, 5 secundarios a farmacos, 4 vasculares, 3 neuropatias, 2 temblores posturales, 1 degeneracion corticobasal, 1 calambre del escribiente, 1 psicogeno, 1 hipertension intracraneal y 1 fibromialgia. Los 8 restantes estaban diagnosticados como TMD: 5 casos con enfermedad de Parkinson idiopatica, 1 degeneracion corticobasal, 1 atrofia multisistemica y finalmente un TMD sin filiacion etiologica definitiva. Conclusion el valor predictivo negativo del SPI (81%) fue levemente inferior al descrito en la bibliografia; hecho que puede explicarse por provenir los pacientes de una consulta de neurologia no experta en TM y por aquellos TMD que cursan con SPI normal.

Objective A non-degenerative etiology is supported by a normal SPI [normal SPECT with 123 I-Ioflupane (SPI)] in a patient with movement disorders (MD). Method A total of 196 SPIs were conducted during the period of 2004/05. Of these, 44 were selected in order to rule out degenerative MD (DMD), the results being normal in these patients. The clinical background of these patients were reviewed in a minimum period of 24 months (range 24-40), collecting the diagnoses reached by the neurology specialists. The SPIs were evaluated using a consensus, according to subjective criteria and quantification. Results Thirty-six of the 44 patients (81%) were identified at 2 years of having nondegenerative movement disorders: 18 as essential tremor, 5 as drug-induced disorder, 4 as vascular disease, 3 as peripheral polyneuropathy, 2 postural tremors, 1 writer's cramp, 1 psychogenic tremor, 1 intercranial hypertension and 1 fibromyalgia. The remaining 8 patients were diagnosed with Parkinson's disease in 5 cases, 1 corticobasal degeneration, 1 multisystemic atrophy and another degenerative Parkinsonism with unclear etiology. Conclusion The SPI in our hospital has a lower negative predictive value than the data reported in the literature. The false negatives could be explained because most of our patients come from neurologist physicians who are not movement disorder experts. In addition, a small proportion of degenerative Parkinsonism could evolve with normal SPI.

Resume A l’occasion de la 11e reunion Franco-Espagnole de medecine nucleaire, une enquete nationale a ete menee en Espagne sur les etudes de neuroimagerie dopaminergique. Ce type d’exploration represente 1,4 % des etudes realisees par un service de medecine nucleaire. Pour la plupart, il s’agit d’etudes des transporteurs presynaptiques de la dopamine, la principale indication etant l’etablissement d’un diagnostic differentiel entre tremblement essentiel et maladie de Parkinson. Le plus souvent, ces etudes sont acquises par gamma-camera a double-tete (93,9 %), avec collimateur a orifices paralleles dans 78,8 % des cas. La retroprojection filtree est la methode de reconstitution la plus employee (81,8 %). La plupart de ces etudes sont evaluees visuellement par un ou deux medecins nucleaires et 42,4 % des centres declarent utiliser la quantification dans leur pratique clinique quotidienne ; la moitie d’entre eux disposent de valeurs de normalite obtenues a partir de groupes temoins. Des resultats obtenus, il ressort une information fondamentale : cette technique reste dans l’ensemble peu utilisee. Neanmoins, l’augmentation observee ces dernieres annees semble indiquer une implantation progressive, qui decoule probablement de son impact clinique.

Cerebral malaria is a serious complication of infection with Plasmodium falciparum. Its pathophysiological mechanisms and clinical manifestations are still currently being studied. Structural imaging techniques such as CT and MRI provide non-specific information during the diagnostic process. However, there are hardly any references on the use and potential benefits of radioisotope procedures for this pathology. In this article we present the case of a patient diagnosed with cerebral malaria treated in our centre, subjected to progressive monitoring using SPECT perfusion.

SPECT-CT in the detection of the sentinel lymph node (SLN) of breast cancer offers known advantages over conventional planar lymphoscintigraphy. Sometimes, it shows atypical findings like mediastinal lymphatic drainage. We have evaluated these atypical findings showed by SPECT-CT performed in patients with migration to the internal mammary chain (IMC) and their roles in the management of the patients. We reviewed the 56 lymphoscintigraphies (planar and SPECT-CT) of 56 women (average age: 55 years) diagnosed with breast cancer with IMC migration observed in the planar images. We compared the two techniques, obtaining the number of depicted nodes, atypical locations, their exact anatomical location and their role in the management of the patient. Planar images showed a total number of 81 IMC nodes. SPECT-CT showed 74 nodes in the IMC territory and 14 mediastinal lymphatic nodes in 6 patients. Out of the 81 IMC nodes reported by planar images, seven corresponded to mediastinal nodes. Planar and hybrid images showed 110 and 130 axillary nodes, respectively. SPECT-CT showed additional findings in five patients: three infraclavicular and two supraclavicular nodes that were exactly located. One intramammary node was discarded by the SPECT-CT as a focal skin contamination. Mediastinal nodes are unexpected, but not uncommon findings that are important in the planning of SLN biopsy. SPECT-CT found more nodes than planar images, being able to separate mediastinal and IMC nodes, helping to exactly depict the SLN and its relations with anatomical structures.

m Tc-Sestamibi double-phase scintigraphy has been improved with digital and tomographic procedures as well as additional projections. Since two years ago, we have introduced additional early lateral views of neck to the conventional double-phase scintigraphy. We have tried to give anatomic data about the depth of the adenomas and to evaluate the possibility of obviating the late images of the double-phase study. Method: Two observers reviewed 50 studies performed for primary hyperparathyroidism in two different ways. The first one reviewed only conventional double-phase studies and the second one, with the additional report of the lateral views. Results: in 32/50 patients (64 %) the report of the additional lateral views and the conventional early views was enough to diagnose parathyroid adenomas. No additional lesions were observed in the late views. These views did not provide any additional useful data and could have been obviated. Four ectopic adenomas were found, 1 mediastinal and 3 in paraesophagic area; three intrathyroidal focus; all of these atypical lesions were identified by lateral pinhole views. Conclusion: The performance of additional lateral projections of the parathyroids supplies additional information to the surgeon on the depth of the lesion in atypical sites and would have made it possible to obviate the late phase in more than half of the patients since this did not supply additional information to that of the early images that had reached a diagnosis.

Resumen El sindrome de Sjogren es una enfermedad autoinmune sistemica y cronica que muestra mayor riesgo de desarrollar linfomas no Hodgkin. En estos pacientes es rara tanto la afectacion neoplasica pulmonar como la coexistencia de diferentes tipos histologicos de linfoma. Frecuentemente los enfermos presentan procesos infecciosos asociados, la mayoria por candidiasis oral. En situaciones de inmunodeficiencia, la diseminacion hematogena del hongo puede causar afectacion pulmonar. Presentamos el caso de una paciente diagnosticada de linfoma no Hodgkin folicular en el contexto clinico de un sindrome de Sjogren de larga evolucion, en el que el estudio PET-TAC mostro, ademas del proceso neoplasico a nivel ganglionar y esplenico, extensa afectacion pulmonar. Ante la sospecha de un resultado falso positivo por infeccion candidiasica pulmonar se inicio tratamiento antifungico, sin obtener respuesta. Posteriormente un estudio histologico mostro la presencia de un segundo tipo de linfoma.

Sjogren syndrome is a chronic systemic autoimmune disease in which there is an increased risk of developing non-Hodgkin's lymphoma. Neoplastic lung involvement and the coexistence of different histological types of lymphoma are uncommon in these patients. These patients frequently have associated infectious processes, most of them due to oral candidiasis. When there is immunodeficiency, the hematogenous spread of the fungus may affect the lungs. We present the case of a female patient diagnosed with follicular non- Hodgkin lymphoma within the context of long-term Sjogren syndrome. In addition to the neoplastic nodal and splenic disease, the PET-CT study showed extensive lung involvement. Due to suspicion of a false positive result for pulmonary Candida infection, antifungal treatment was initiated, with no response. A further histological study showed the presence of a second and different type of lymphoma.

Sjögren syndrome is a chronic systemic autoimmune disease in which there is an increased risk of developing non-Hodgkin's lymphoma. Neoplastic lung involvement and the coexistence of different histological types of lymphoma are uncommon in these patients. These patients frequently have associated infectious processes, most of them due to oral candidiasis. When there is immunodeficiency, the hematogenous spread of the fungus may affect the lungs. We present the case of a female patient diagnosed with follicular non- Hodgkin lymphoma within the context of long-term Sjögren syndrome. In addition to the neoplastic nodal and splenic disease, the PET-CT study showed extensive lung involvement. Due to suspicion of a false positive result for pulmonary Candida infection, antifungal treatment was initiated, with no response. A further histological study showed the presence of a second and different type of lymphoma.

Sentinel node biopsy (SNB) by radioisotopes is a widely accepted and reliable surgical method for staging breast cancer in patients with unknown positive axillary lymph nodes involvement. The main limitation of this method is due to the appearance of false negatives that may be caused by tumor lymph node blockage of the sentinel lymph node and uptake in the neighboring lymph nodes. Infiltered sentinel nodes are generally increased in size and firm. Thus, they can be detected by intraoperative palpation, even when there is no uptake by the radiotracer.To reduce the false negative rates by applying intraoperative axillary palpation after SNB.Over a two-year period, we complemented the SNB in 168 patients with careful intraoperative axillary palpation, detecting and removing all the palpable suspicious lymph nodes (SLN) that were analyzed as sentinel nodesIn 32 out of 168 patients, 50 palpable SLN were found. In 3 out of 32 patients, 4 infiltrated SLNs were demonstrated with negative SNB and positive axillary lymphadenectomy. Thus, intraoperative palpation avoided false negative results. In one patient, one palpable SLN with tumor involvement was observed and SNB was also positive. In the remaining 28 patients, the histological analysis of 45 SLN was negative for tumor but SNB was positive in 3 patients.Intraoperative axillary palpation, once the SNB was done, reduced the false negative rate. Thus, we consider that it should be included as one more part of this procedure.

A non-degenerative etiology is supported by a normal SPI [normal SPECT with 123I-Ioflupane (SPI)] in a patient with movement disorders (MD).A total of 196 SPIs were conducted during the period of 2004/05. Of these, 44 were selected in order to rule out degenerative MD (DMD), the results being normal in these patients. The clinical background of these patients were reviewed in a minimum period of 24 months (range 24-40), collecting the diagnoses reached by the neurology specialists. The SPI were evaluated using a consensus, according to subjective criteria and quantification.Thirty-six of the 44 patients (81%) were identified at 2 years of having nondegenerative movement disorders: 18 as essential tremor, 5 as drug-induced disorder, 4 as vascular disease, 3 as peripheral polyneuropathy, 2 postural tremors, 1 writer's cramp, 1 psychogenic tremor, 1 intercranial hypertension and 1 fibromyalgia. The remaining 8 patients were diagnosed with Parkinson's disease in 5 cases, 1 corticobasal degeneration, 1 multisystemic atrophy and another degenerative Parkinsonism with unclear etiology.The SPI in our hospital has a lower negative predictive value than the data reported in the literature. The false negatives could be explained because most of our patients come from neurologist physicians who are not movement disorder experts. In addition, a small proportion of degenerative Parkinsonism could evolve with normal SPI.

99mTc-Sestamibi double-phase scintigraphy has been improved with digital and tomographic procedures as well as additional projections. Since two years ago, we have introduced additional early lateral views of neck to the conventional double-phase scintigraphy. We have tried to give anatomic data about the depth of the adenomas and to evaluate the possibility of obviating the late images of the double-phase study.Two observers reviewed 50 studies performed for primary hyperparathyroidism in two different ways. The first one reviewed only conventional double-phase studies and the second one, with the additional report of the lateral views.in 32/50 patients (64 %) the report of the additional lateral views and the conventional early views was enough to diagnose parathyroid adenomas. No additional lesions were observed in the late views. These views did not provide any additional useful data and could have been obviated. Four ectopic adenomas were found, 1 mediastinal and 3 in paraesophagic area; three intrathyroidal focus; all of these atypical lesions were identified by lateral pinhole views.The performance of additional lateral projections of the parathyroids supplies additional information to the surgeon on the depth of the lesion in atypical sites and would have made it possible to obviate the late phase in more than half of the patients since this did not supply additional information to that of the early images that had reached a diagnosis.