A retrospective cohort study of cancer incidence among patients treated with radiosynoviorthesis.

Radiosynoviorthesis (RS) is an intra-articular injection of a radioactive colloid for the treatment of synovitis administered most often to patients with rheumatoid arthritis or haemophilia. Although highly cost-effective in comparison with surgical or arthroscopic synovectomy, the risk of cancer associated with this treatment is not well known. We evaluated the incidence of cancer in a group of patients treated with RS. A cohort of 2412 adult patients with a variety of underlying conditions (mainly rheumatoid arthritis) and treated with at least one RS between January 1976 and December 2001, was recruited from two centres in Montréal. Cancer incidence and mortality data for cohort members over that time period were obtained from regulatory agencies using linkage. Background rates for all and specific types of cancer were obtained for the provincial (Québec) and national (Canada) population according to age, gender and calendar period categories. Category-specific rates in the cohort were compared with rates in similar categories from the general population generating standardized incidence ratios (SIR). The effects of specific isotope doses and of number of RS treatments were analysed using a Cox-regression model. No increase in the risk of cancer was observed (SIR 0.96; 95% confidence interval 0.82-1.12). There was no dose-response relationship with the amount of radioisotope administered or number of RS treatments. The study provides some indication for the safety of the procedure but homogenous diagnostic groups of younger patients (such as haemophilic patients) receiving RS will need more evaluation.

The pituitary-thyroid axis after hemithyroidectomy in euthyroid man.

The pathogenesis of euthyroid goiter is assumed to be TSH dependent, but most studies have not demonstrated elevation of serum TSH. To elucidate the early events involved in thyroid growth, we studied thyroid function in eight euthyroid patients subjected to hemithyroidectomy for solitary cold nodules preoperatively and 2, 15, 60, and 90 days and 36 months, postoperatively. Although within the euthyroid range, serum T4 decreased at 30 days and thereafter up to 90 days (P less than 0.01). Basal serum TSH rose significantly by the 30th day and remained elevated for the entire 90-day period (P less than 0.001). The serum TSH response to TRH was exaggerated from days 15-90 (P less than 0.001). Thirty-six months postoperatively, all parameters of thyroid function were similar to control values, with the exception of one patient who showed an exaggerated response of serum TSH to TRH. We conclude that 1) the dynamic phase of recuperation post hemithyroidectomy is TSH dependent, 2) the serum TSH increase occurs within normal limits and is a temporary event, and 3) 3 yr postoperatively, a new steady state is achieved with normal parameters of thyroid function. Thus, we believe that TSH plays a dominant role in the genesis of goiter.

Scintigraphic study of duodenal-gastric reflux in cases of primary gastropathy, chronic ulcer of the duodenal bulb, and Moynihan's disease.

There are several methods for detection of bile in the stomach, but none has proven satisfactory. It appears that the scintigraphic study with quantitation of duodenal-gastric reflux after corrections for the overlap of the stomach by the liver and bowel is more reliable, noninvasive, and physiologic. Fifty-four patients were divided into groups according to their clinical presentation; seven asymptomatic volunteers, 20 patients with duodenal-gastric reflux gastropathy (DRG), 16 patients with recurrent ulcers of the duodenal bulb (RUD), and 11 patients with Moynihan's disease. Each of the 47 dyspeptic patients underwent an endoscopic examination and a scintigraphic study with [99mTc]disofenin for detection and quantitation of duodenal-gastric reflux. Endoscopy revealed the presence of bile in the stomach of 16 out of 20 DRG and four out of 16 RUD, while ten out of 11 patients with Moynihan's disease had clear gastric juice. Most of the DRG cases (15 out of 20) and half of the RUD (eight out of 16) presented reflux greater than 1.5%, while of the 11 Moynhihan, ten presented reflux less than 1.5% and all the asymptomatic volunteer subjects less than 1%. This quantitation method allowed us to perceive clearly the low % of reflux in the "normal asymptomatic" subjects compared with the DRG-type of dyspeptic patients. Among the dyspeptic, the distinction seems more evident between the DRG type and the Moynihan type. Occasionally, the scintigraphic method permits identification of patients with slower gallbladder evacuation (eight out of 47 dyspeptic in our study), adding valuable information for the diagnostic approach to dyspeptic patients.

Extrahepatic uptake of technetium-99m-phytate: a prognostic index in patients with cirrhosis.

We examined the usefulness of technetium-99m-phytate (99mTc-phytate) hepatic scintigraphy in the evaluation of hepatic function, and the assessment of prognosis in patients with cirrhosis. Ninety-four patients with biopsy-documented cirrhosis had, at the time of entry into the study, a scintigraphy with 99mTc-phytate complexed with calcium in vivo. Extrahepatic uptake (EHU) of 99mTc-phytate on scintigraphy was graded from 0 (absent EHU) to 5 (important EHU) according to the relative distribution of the radiotracer between the liver, the spleen and the bone marrow. The severity of liver disease was also assessed according to the index of Child and Turcotte as modified by Pugh et al. Mean follow-up was 2 yr. EHU was correlated to the Pugh score (r = 0.73) and to survival. Survival at 2 yr was 97% for an EHU equal or inferior to 2.5, 62% for grades 3-4.5, and 31% for grade 5. In conclusion, hepatic imaging with 99mTc-phytate, in addition to its diagnostic value, also contains valuable prognostic information in patients with cirrhosis.

Budd-Chiari syndrome: typical and atypical scintigraphic aspects.

Budd-Chiari syndrome, a well known entity, is often difficult to diagnose, mostly due to the nonspecificity of its symptomatology. Radiocolloid liver scans were evaluated in eight cases of this disease, proven by surgical biopsy. Five cases showed the "classic" scintigraphic pattern of caudate lobe hypertrophy (62.5%), and other abnormalities observed included segmental hepatic insufficiency, diffuse hepatic insufficiency, and relative hypertrophy of both the caudate lobe and a portion of the parenchyma of segment VI (one case each). An experimental study of hepatic venous drainage performed on livers at autopsy revealed four groups of accessory hepatic veins in addition to the main hepatic veins. The occlusion of various parts of this drainage appears to relate to the various scintigraphic patterns that were encountered in patients with Budd-Chiari syndrome. A review of the literature revealed three additional patterns previously reported in association with Budd-Chiari syndrome (normal scan, diffuse hepatomegaly, and multiple filling defects). If all these variations are appreciated, liver scanning can be a valuable screening tool for Budd-Chiari syndrome and may also serve as a noninvasive means of follow-up.

Scintigraphic aspect of Rotor's disease with technetium-99m-mebrofenin.

A 28-yr-old male with Rotor's disease was studied with 99mTc-mebrofenin. The scintigraphic pattern was that of a slow liver uptake with unimpaired excretion and persistent visualization of the cardiac blood pool, kidneys and urinary tract up to 6 hr. The gallbladder was visualized at 55 min postinjection.

Methodological validation and clinical usefulness of carbon-14-urea breath test for documentation of presence and eradication of Helicobacter pylori infection.

UNLABELLED: A simple [14C]urea breath test (C-14-UBT) was validated with aims of determining accuracy in documenting both the presence and proof of eradication of Helicobacter pylori infection. METHODS: Fifty-six dyspeptic patients had endoscopy with biopsies and C-14-UBT. Eleven biopsy-proven H. pylori-negative patients allowed C-14-UBT normal value determination. Forty-three patients with recurrent peptic ulcer disease and biopsy-proven H. pylori infection were included in an antimicrobial eradication protocol. Endoscopy with biopsies and C-14-UBT were done again 8 wk after initiation of treatment in 35 patients. For C-14-UBT, 185 kBq (5 microCi) of [14C]urea was swallowed. Breath samples obtained up to 20 min were counted to calculate AS20, [(% 14CO2 dose excreted/mmol of CO2) x kg] at 20 min. Combined histologic and microbiologic analyses of antral biopsies were used as a gold standard. RESULTS: The positivity value was set as AS20 > 0.33% (mean + 3 s.d. of AS20 in H. pylori-negative patients). Diagnosis of H. pylori infection was correct with C-14-UBT in 55/56 patients (44 true-positive, 11 true-negative and 1 false-negative; sensitivity = 98%; specificity = 100%). As a proof of eradication, C-14-UBT correctly classified 33/35 patients (5 true-positive, 28 true-negative and 2 false-positive; sensitivity = 100%; specificity = 93%). The C-14-UBT global performance yielded sensitivity, specificity and accuracy of 98%, 95% and 97%, respectively. A significant correlation (r = 0.84) was found between AS20 and the number of H. pylori colonies on culture. CONCLUSION: This C-14-UBT is highly accurate both for diagnosis and proof of eradication of H. pylori infection and reflects the antral bacterial load. It is simple, fast and inexpensive, and it is therefore suitable for clinical practice.

Reduction of allogeneic blood transfusions after open heart operations by lowering cardiopulmonary bypass prime volume.

BACKGROUND: Despite recent advances in blood conservation techniques, up to 30% to 80% of patients undergoing open heart operations require allogeneic blood transfusions. A prospective, randomized study was performed to test the effect of lowering cardiopulmonary bypass prime volume (as an additional component of an integrated blood conservation strategy) on clinical outcome and allogeneic blood transfusion. METHODS: One hundred fourteen patients undergoing open heart operations were randomized to either full prime (FP) volume (1,400 mL of Plasmalyte solution) or reduced prime (RP) volume (600 to 800 mL). The reduction of prime volume was achieved by slowly draining the cardiopulmonary bypass circuit into a cell-saving device before the initiation of bypass. Firm transfusion thresholds were observed. RESULTS: There were no significant differences between the groups with respect to baseline characteristics, body surface area, type and urgency of the procedures, perfusion technique, and hematologic profile. Mortality (FP, 1.7%; RP, 0%; p approximately 1.0) and overall morbidity (FP, 28.1%; RP, 22.8%; p = 0.53) were similar. However, transfusion requirements were significantly lower in the RP group: total donor exposure, 3.8 +/- 10.1 versus 1.0 +/- 2.4 units (p = 0.044); percentage of patients transfused, 54% (n = 31) versus 35% (n = 20) (p = 0.036). Twenty-four-hour chest tube drainage was similar: 455 +/- 223 mL for FP versus 472 +/- 173 mL for RP (p = 0.66). The lowest hematocrit on bypass was significantly higher in the RP group: 29.3% +/- 4% versus 26.3% +/- 5.3% (p = 0.009). CONCLUSIONS: Lowering cardiopulmonary bypass prime volume resulted in a significant decrease in allogeneic blood product use. Because postoperative 24-hour chest tube drainage was similar in both groups, and hematocrit during bypass was higher in the RP group, the reduction in allogeneic blood transfusions appears to be related to a decrease in prime-induced hemodilution. This technique is effective, simple, and safe. It therefore should be strongly considered for patients undergoing operations using normothermic or near-normothermic cardiopulmonary bypass who are at high risk for allogeneic blood transfusion.

Effect of dietary fat sources on systemic and intrauterine synthesis of prostaglandins during early pregnancy in gilts.

The present experiment was conducted to determine the influence of dietary fatty acids C18:2n-6 and C18:3n-3 on the modulation of intrauterine synthesis of prostaglandin E2 (PGE2) and F2alpha (PGF2alpha) during early pregnancy in pigs. Prostaglandin E2 in uterine fluid has been previously reported to be associated with embryo survival and development. Thirty-two Yorkshire-Landrace nulliparous gilts were randomly allocated to four diets containing 5% supplemental fat. The four dietary treatments were: HT, hydrogenated tallow (26.5% C16:0 and 54.8% C18:0); SO, sunflower oil (61.3% C18:2n-6); LO, linseed oil (50.4% C18:3n-3); and SO(CLA), a mixture of sunflower oil and conjugated linoleic acids to provide 20% CLA. Treatments started 2 d after the first pubertal estrus (d -21) and lasted for 36 d (slaughter), which was 15 d after the second estrus (d 0; insemination). Fatty acids and PGE2 were measured in the peripheral blood plasma on d -19, d -7, d 0, and d 14. Fatty acids in endometrial tissues and PGE2 and PGF2alpha in the uterine fluid collected on d 15 were also measured. Concentrations of fatty acids in the plasma reflected the content of fatty acids in the diet as early as d -7. From d -7, PGE2 concentrations in the plasma were higher in gilts fed SO compared with HT (P < 0.05). Plasma PGE2 concentrations were lower (P < 0.01) on d 14 in gilts fed LO compared with HT. Total PGF2alpha contents in the uterine fluid of gilts fed LO were more than 70% lower (P < 0.05) than for the HT group. A similar trend was observed for total PGE2 content and for the ratio PGF2alpha:PGE2, but the effect (LO vs HT) was less marked (P < 0.07 and P < 0.10, respectively). There was no effect of SO or SO(CLA) on total PGE2 contents in the uterine fluid. Dietary enrichment in C18:2n-6 and/or C18:3n-3 for early pregnant gilts can influence fatty acids in plasma and endometrial tissue and can modulate circulatory and intrauterine prostaglandins.

Asynchronous washout of the liver as a sign of partial biliary obstruction.

This case is another example of the usefulness of hepatobiliary scan for the evaluation of biliary-enteric anastomoses and stresses the point that performing late scan could help reveal pathologic process in an obvious way.

Abdominal patterns of indium-111 labeled leukocyte imaging.

In-111 oxine WBC abdominal scanning is now a widely accepted technique for the detection of abdominal infectious processes. High sensitivity and specificity are achieved. In-111 labeled leukocyte accumulation, however, does not always suggest the diagnosis of abscess. Higher specificity could be obtained by the knowledge of the In-111 leukocyte distribution pattern in the abdomen in other pathologic states like inflammation of abdominal wounds, stoma; surgical complication without abscess formation; inflammatory or ischemic bowel disease; or swallowing leukocytes which subsequently are visualized in the intestinal lumen. One hundred fifty-two consecutive WBC scans performed over 18 months were reviewed and classified according to their pattern of uptake: 96 cases showed no abdominal uptake, and 56 had accumulation of leukocytes in the abdomen. Twenty-eight of these patients had proven abdominal abscess, and the remaining 26 were positive due to other causes. This report briefly discusses the distribution pattern of In-111 labeled leukocytes in the latter patients and compares the results obtained using different diagnostic criteria.

Demonstration of abnormal peritoneal communication in patients with ascites.

Patients with ascites are known to have complications such as pleural effusions and hernias. Special diagnostic procedures are occasionally necessary to determine the nature of the abnormality and to determine the corrective medico-surgical approach. The two cases described illustrate the usefulness of intraperitoneal as well as intrapleural injection of a radionuclide in diagnosing the leakage of ascitic fluid.

Localization of abnormal parathyroid gland(s) using thallium-201/iodine-123 subtraction scintigraphy in patients with primary hyperparathyroidism.

Tl-201/I-123 subtraction scintigraphy was performed in 17 patients with clinical symptoms and biochemical measurements suggestive of primary hyperparathyroidism. Nineteen abnormal sites were identified. These results were correlated with PTH measurements and surgical findings. Three sites were considered unrelated to the parathyroid glands, two corresponding to palpable thyroid nodules and one to muscle uptake of unknown origin. One scintigram did not reveal either of two abnormal glands while two others were considered falsely positive in view of surgical failure. Fourteen sites corresponded to abnormal parathyroid gland at surgery; five glands, weighing more than 2000 mg, could be correctly located on the Tl-201 scintigraphy prior to the subtraction procedure; six glands, weighing between 500 and 2000 mg, were easily localized after the subtraction procedure; three glands, weighing between 180 and 200 mg, were correctly localized after further manipulation of the subtraction procedure. In a patient with parathyroid hyperplasia, one gland, weighing 150 mg, was not located and another was not found upon surgery. Overall sensitivity was 87.5%. A positive correlation between PTH levels, tumor weight, and ease of detection on scintigraphy was found. This correlation was particularly useful in excluding large abnormal uptake related to thyroid disorder or artifact. The results suggest that Tl-201/I-123 parathyroid scintigraphy could become an alternative to Tl-201/Tc-99m parathyroid scintigraphy, with possibly improved detection of low weight abnormal parathyroid glands.

Cystic hypernephroma mimicking an hepatic mass.

A renal mass was correctly identified with Tc-99m sulfur colloid liver-spleen scan and Tc-99m glucoheptonate scintigraphy while CT scan was misinterpreted as showing a hepatic lesion.

Spinal cerebrospinal fluid leak demonstrated by radioisotopic cisternography.

Many conditions are known to cause a cerebrospinal fluid (CSF) fistula; one of them is lumbar puncture for contrast myelography. Reported here is the case of a man who underwent contrast myelography at the L2-L3 level and who presented with postural headaches and lumbalgia with radiation to the legs three weeks after the procedure. Tc-99m albumin isotopic cisternography at the L5-S1 level was performed and clearly depicted a functional CSF leak through the dura at the L2-L3 level and CSF suffusion along several rachidian roots. Scinticisternography may thus be used to localize accurately a CSF leak.

Gallium-67 pulmonary uptake in eosinophilic pneumonia.

Eosinophilic pneumonia is usually diagnosed based on the findings on chest x-ray, white blood count, and transbronchial biopsy. After reporting a case of Ga-67 lung uptake in eosinophilic pneumonia, its histopathology is discussed and the mechanisms of Ga-67 uptake by inflammatory lesions are reviewed.

Vascular complication of a transjugular intrahepatic portacaval stent.

The percutaneous transjugular intrahepatic portacaval stent shunt is a nonsurgical approach to portosystemic shunting. The case of a large defect seen on a radiocolloid liver--spleen scan is attributed to a hepatic infarct related to the shunting procedure.

Tc-99m sestamibi and other agents in the detection of metastatic medullary carcinoma of the thyroid.

The 10-year survival rate for medullary carcinoma of the thyroid (MCT) is 50%; thus, good tumor-seeking radiopharmaceuticals are needed to localize foci of recurrence and metastasis during follow-up. Two patients with metastatic MCT were studied with Tl-201, I-131 MIBG, Tc-99m (V)-DMSA, and Tc-99m MIBI. A SPECT study with the latter agent allowed the visualization and precise localization of a metastatic mediastinal lymph node. More studies need to be done to evaluate the role of Tc-99m MIBI in the detection of recurrence and metastases of MCT.

Technetium-99m HMPAO imaging in Sturge-Weber syndrome.

The Tc-99m HMPAO brain imaging confirmed marked hypoperfusion secondary to anomalous cerebral venous drainage of the Sturge-Weber syndrome. Until now, this had been a hypothesis suggested by results obtained from conventional brain scans and cerebral arteriography.

Noninvasive diagnosis of Caroli syndrome associated with congenital hepatic fibrosis using hepatobiliary scintigraphy.

A patient who was studied for portal hypertension had an enlarged liver and multiple hepatic cysts on abdominal CT scan. He underwent hepatobiliary scintigraphy using Tc-99m mebrofenin which documented communication of the cysts with the main biliary tree and allowed a noninvasive diagnosis of Caroli syndrome associated with congenital hepatic fibrosis.