ULTRASOUND-GUIDED PERCUTANEOUS ETHANOL INJECTION THERAPY IN A 92 YEAR-OLD PATIENT WITH PARATHYROID ADENOMA AND WITH A HISTORY OF TOTAL THYROIDECTOMY FOR PAPILLARY THYROID CARCINOMA.

Percutaneous Ethanol Injection Therapy (PEIT) of parathyroid adenoma under ultrasound guidance is individually used as an alternative procedure in management of primary hyperparathyroidism in polymorbid elderly patients with increased surgical risk. The treatment is also suitable for patients who already underwent surgery of the thyroid gland, and any other surgery is associated with a higher risk of postsurgical complications. We present a case of a 92-year-old male patient, who underwent thyroidectomy for papillary thyroid carcinoma three years ago. Part of the regular annual follow-up visits was also ultrasonography, which showed a solitary parathyroid adenoma at the site of the removed thyroid gland. Given the underlying condition, polymorbidity and age of the patient, the PEIT method was successfully used in the therapy. The coincidence of adenoma and papillary thyroid carcinoma is also interesting.

[Patient with atypical neurocytoma -  case report]. / Pacientka s atypickým neurocytomem -  kazuistika.

BACKGROUND: Neurocytoma represents a rare tumor of the central nervous system usually slowly growing and generally with good prognosis after surgical resection with or without adjuvant radiotherapy. CASE: A 25-year- old woman presented with sudden fainting. During the initial workup, brain CT was completed with finding of tumor inside the third ventricle spreading into both lateral ventricles. The patient underwent partial surgical resection followed by radical gross resection, no adjuvant radiotherapy was indicated during the initial treatment and the patient was followed up with regular brain MRIs and clinical examinations. Thirty six months after the initial resection, there was progression on MRI and radiotherapy was recommended. At this moment, patient is 12 months after radiotherapy with stable disease on MRI and with good stable performance status. CONCLUSION: One of the greatest problems in the management of neurocytoma is the timing of adjuvant radiotherapy. From published data, it is clear that adjuvant radiotherapy increases local control; however, this has to be considered carefully against the possible risks from late side effects of radiotherapy considering long-time survival of the patients.

Determining the extent and stage of disease in patients with newly diagnosed non-Hodgkin's lymphoma using 18F-FDG-PET/CT.

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (18F-FDG) combined with computed tomography (CT) represents a three-dimensional imaging method suitable for staging in patients with non-Hodgkin's lymphomas (NHLs). The aim of our prospective multicenter study was to assess the value of initial PET/CT as compared with CT and PET alone for determining the stage and extent of the disease. A total of 122 patients with newly diagnosed NHL were examined using PET/CT. Four patients with resected lymphoma lesion and negative PET/CT were therefore excluded from the study. Of the remaining 118 cases, a total of 117 (99%) were described as 18F-FDG-avid. When compared with PET/CT, CT and PET showed very good sensitivity of lymph node imaging (97% and 100%, respectively); the specificity, however, was significantly lower (66.7% and 94.4%, respectively; p=0.0001). When detecting organ lesions, the sensitivity of CT and PET was lower than that of PET/CT (92.5% and 96.3%, respectively; p=0.0001); specificity was significantly decreased in CT and a little lower in PET (59.5% and 91.9%; p=0.0001). When compared with CT alone, PET/CT changed staging of the disease in 11 patients (9%) and was able to detect a total of 82 discrepancies in 67 of the 117 patients (57%). In conclusion, PET/CT is a new standard in imaging the involvement of lymph nodes and extranodal organs in NHL patients regardless of their histopathological types. Both sensitivity and specificity of the examination are higher than those of CT as well as PET alone.

[18F-FDG PET/CT and 99mTc-MIBI scintigraphy in evaluation of patients with multiple myeloma and monoclonal gammopathy of unknown significance: comparison of methods]. / 8F-FDG PET/CT v diagnostice mnohocetného myelomu a monoklonální gamapatie nejistého významu: srovnání s 99mTc-MIBI scintigrafií.

BACKGROUNDS: Newer imaging modalities, such as 18F-FDG PET/CT and 99mTc-MIBI scintigraphy, have been recently introduced to assess the activity and extent of disease in patients with multiple myeloma (MM) and gammopathy of undetermined significance (MGUS). The aim of our study was to compare the impact of these imaging modalities in the evaluation of MM and MGUS patients. MATERIALS AND METHODS: A total of 101 patients with MM (81 patients) and MGUS (20 patients) were enrolled in the study (21 newly diagnosed and 44 relapsed patients with symptomatic MM, 16 with asymptomatic MM and 20 with MGUS). All patients were without therapy and underwent 18F-FDG PET/CT and 99mTc-MIBI scintigraphy within a maximum interval of 14 days. The scans were classified as normal (N), diffuse (D), and focal or combined (F-FD) pattern. RESULTS: There was no significant difference in the detection of newly diagnosed MM and relapsed patients between the compared methods. 18F-FDG PET/CT performed better than 99mTc-MIBI scintigraphy in the detection of focal lesions (p < 0.039), whereas 99mTc-MIBI scintigraphy was superior in the visualization of diffuse disease (p = 0.042). 18F-FDG PET/CT visualised significantly more focal lesions than 99mTc-MIBI scintigraphy (p = 0.002), both generally in the cohort and when comparing the number of focal lesions per patient. Both the imaging modalities singly or in combination influenced the subsequent clinical management in 17% of patients. In our study, 18F-FDG PET/CT predicted asymptomatic MM and MGUS transformation into more aggressive forms with the necessity to start therapy more often than 99mTc-MIBI scintigraphy. CONCLUSION: 18F-FDG PET/CT appeared to be a better imaging technique than 99mTc-MIBI scintigraphy in the detection of focal lesions in patients with symptomatic MM. 99mTc-MIBI was superior in the visualization of diffuse disease. On the other hand, despite its limited capacity in detecting focal lesions, 99mTc-MIBI scintigraphy still remains the most rapid and inexpensive technique for whole-body evaluation and may be an alternative option when a PET/CT facility is not available.

[Benefit of PET/CT in the preoperative staging in pancreatic carcinomas]. / Prínos PET/CT v predoperacním stagingu karcinomu pankreatu.

OBJECTIVE: Prognosis of patients with pancreatic cancer is poor. Median survival from diagnosis without determining surgical treatment is 3-11 months, after surgical treatment between 13-20 months according to various studies. 5-year survival rate is below 5%. The only chance of cure remains a radical surgical resection. Early diagnosis and determining resectability of tumour is the most important objective in patients with pancreatic cancer. Aim of this work is to evaluate the benefits and define the role of 18F-FDG PET/CT in preoperative staging. MATERIAL AND METHODS: 195 patients (103 men, 92 women, mean age 66.7 year, range 32-88 years) with suspected pancreatic lesions underwent enhanced 18F-FDG PET/CT in the preoperative staging in addition to standard investigative methods (ultrasonography, contrast enhanced CT, EUS, EUS FNA). All PET/CT findings were compared with standard methods (CT, EUS, EUS FNA), with peroperative findings and definitive histology in surgical patients as the reference standards. Interpretation of the extent of the tumor defined by TNM classification. Limitations of the local resectability was advanced local stage (T4) and presence of distant metastases (M1). RESULTS: In 195 patients with suspected pancreatic lesions was pre-operatively performed PET/CT in the period 1/2007-3/2009. 153 patients with pancreatic cancer, of which 72 was not suitable for radical surgery because of local inoperability or a generalization of the disease. The sensitivity of PET/CT in the capture of primary lesions was 92.2%, specificity 90.5%. False negative findings in 12 patients, false-positive results occurred in 4 cases, positive predictive value (PPV) 97.2%, negative predictive value (NPV) 76.0%. In the assessment of regional lymph nodes sensitivity was 51.9%, specificity 58.3%, PPV 58.3%,NPV 51.9%. In detection of distant metastases PET/CT reached sensitivity 82.8%, specificity 97.8%, PPV 96.9%, NPV 87.0%. PET/CT found distant metastases in 12 patients, which standard methods failed to detect. Surgery was cancelled in 15 patients (15.6%) with potentially resectable tumour based on the performance of PET/CT findings and the management of treatment was changed. CONCLUSION: PET/CT is highly sensitive and specific method suitable for preoperative staging of pancreatic cancer. It improves the selection of patients for surgery, who can benefit from and reduces the number of incorrectly indicated operations.

[Sentinel lymph node detection using 99mTc-nanocolloid in endometrial cancer]. / Detekce sentinelových lymfatických uzlin pomocí 99mTc-nanokoloidu u karcinomu endometria.

OBJECTIVE: The aim of this study was to evaluate the feasibility of pre-operative lymphoscintigraphy and radio-guided surgery in endometrial cancer patients after intramyometrial administration of labelled colloid. DESIGN: Prospective study. SETTING: Department of Obstetrics and Gynaecology of the Palacký University Medical School and University Hospital, Olomouc, Czech Republic. PATIENTS AND METHODS: Between April 2002 and March 2005, thirty three patients with endometrial cancer received pre-operatively 50 MBq of 99mTc-nanocolloid. The radiopharmaceutical agent was administered by a 25 Gauge needle transcervically into the myometrium. Subsequently, series of static lymphoscintigrams were made 20 to 90 min after injection. Two hours after injection the surgery started. Twenty eight patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Five patients were scheduled for laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy and pelvic lymphadenectomy. Paraaortal lymphadenectomy was performed in 11 cases. A gamma detecting probe was used to locate radioactive lymph nodes during operation. Each hot lymph node was removed separately. RESULTS: Sentinel lymph nodes (SLN) were identified in 26 (79%) of 33 patients. The mean number of sentinel nodes detected was 2.9 (range 1-10). Seventy two (15.3%) of 472 nodes obtained in total, were identified as radioactive-colloid positive. Histopathological analysis revealed five (7%) of 72 lymphonodes to be positive of metastases. Sentinel nodes in paraaortic area were identified in 11 (33%) patients. No false negative sentinel lymphonodes were observed. CONCLUSION: The preoperative lymphoscintigraphy and intraoperative gamma probe guided biopsy may be useful in identifying sentinel nodes in endometrial cancer. No false negative sentinel lymphonodes were observed if representative SLNs were diagnosed with tumor.

[The technique of securing sentinel lymph nodes in tumors of the distal oesophagus and the stomach ]. / Technika získání sentinelových uzlin u tumoru v oblasti distálního jícnu a zaludku.

The authors discuss the technique of identification and biopsy of sentinel lymph nodes in tumors of the upper gastrointestinal tract. They describe difficulties and problems of the technique, in which the identified sentinel lymph node is obtained mainly employing endoscopical and minimally invasive techniques.

Optimal sampling times for OIH-clearance calculations using a two-compartment/two-sample method.

Orthoiodohippurate (OIH) clearance data obtained with the two-compartment/two-sample method of Lear which uses varying sampling time combinations, were compared with those of the reference two-compartment/multi-sample method of Sapirstein. A total of 35 studies were performed in 33 adult patients. The OIH clearance values determined by the reference method ranged from 107 to 883 ml/min/1.73 m2, with a median of 406 ml/min/1.73 m2. It was ascertained that the precision of the Lear method is partially dependent upon the sampling time combination. The most reliable results with the Lear method in this patient population were obtained by taking a first sample at approximately 8 min p.i., and a second sample at 32 min p.i. or later.

Hepatic perfusion changes in patients with cirrhosis indices of hepatic arterial blood flow.

PURPOSE: This study used radionuclide angiography to evaluate semiquantitatively the hepatic arterial blood flow changes associated with cirrhosis. METHODS: The parameters of net arterial hepatic perfusion were estimated by analysis of first-pass flow studies in 11 control participants and in 15 patients with cirrhosis (Child-Pugh classification B-C). Hepatic, renal, and splenic time-activity curves were generated, normalized per pixel, and corrected for background. The rate of hepatic arterial blood flow was compared with the reference kidney and spleen perfusion using the hepatorenal and hepatolienal perfusion indices, respectively. These indices were defined as: PI = area under hepatic curve limited by time of the renal (splenic) curve peak/area under renal (splenic) curve to its peak RESULTS: The values of both these perfusion indices are significantly greater in the patients with cirrhosis than in controls (hepatorenal perfusion index, P < 0.01; hepatolienal perfusion index, P < 0.05). The values of the hepatic perfusion index (the ratio of the arterial to the total liver blood flow), which were also calculated, were elevated in the patients with cirrhosis (P < 0.01). CONCLUSIONS: The results confirm that the net hepatic arterial blood flow is increased in patients with cirrhosis. Radionuclide angiography accompanied by calculation of arterial perfusion indices may provide semiquantitative parameters of net hepatic arterial blood flow.

Prognostic value of myocardial perfusion tomographic imaging in patients after percutaneous transluminal coronary angioplasty.

PURPOSE: The authors assessed the prognostic value of stress myocardial perfusion tomographic imaging (SPECT) in patients with recurrent angina or inconclusive results of exercise electrocardiographic tests after successful percutaneous transluminal coronary angioplasty (PTCA). MATERIALS AND METHODS: After PTCA, 70 patients (54 men, 16 women; 41 after myocardial infarction; mean age, 56 +/- 9 years) underwent TI-201 or Tc-99m sestamibi SPECT studies. SPECT patterns were divided into normal (n = 25), fixed defects (n = 15), and reversible or combined fixed plus reversible defects (n = 30). A cardiac event was defined as either cardiac death, nonfatal myocardial infarction, or unstable angina requiring further revascularization. RESULTS: During an average follow-up of 25 +/- 10 months, two patients had severe outcomes (one cardiac death and one nonfatal myocardial infarction), and revascularization was required in 13 patients. In patients with normal SPECT or fixed defects, the annual event rate was low (1.2%), with only one revascularization. In patients with reversible or combined defects, the annual event rate was significantly greater (22.4%; chi square = 17.32, P = 0.00003). CONCLUSIONS: Normal perfusion or fixed defects predict a benign prognosis in patients after successful PTCA. The presence of stress-induced reversible defects appears to be the best predictor of future cardiac events.

The accuracy of myocardial perfusion SPECT imaging in the evaluation of coronary artery disease in women and men.

BACKGROUND: The purpose of this study is to compare sensitivity, specificity and accuracy of myocardial perfusion SPECT for the detection of coronary artery disease (CAD) in women and men. MATERIAL AND METHODS: 588 patients (455 males and 133 females, 273 after a previous myocardial infarction) underwent stress myocardial perfusion SPECT. The accuracy of myocardial perfusion SPECT was proved by coronary angiography (stenosis > 50% was considered as a CAD). RESULTS: The sensitivity of SPECT was slightly higher, but statistically not significant, in men than in women (94% versus 91%, p > 0.05). The specificity was higher in women than in men (93% versus 82%), but this difference was not statistically significant either (p > 0.05). The accuracy of SPECT was the same for both sexes (92%). In angiographically verified group of patients the selection bias was obvious--patients with CAD dominated (74%) and the fraction of patients with CAD in men's group (83%) was significantly higher than in women's group (50%), p < 0.05. CONCLUSIONS: No significant difference was revealed in the accuracy of myocardial perfusion SPECT in men and women. Our results are in accordance with the prevailing opinion in literature that discovered differences in sensitivity, specificity and diagnostic accuracy are usually not statistically significant or that they can be explained by the selection bias of patients in angiographically verified groups (significantly higher fraction of patients with CAD in men's group).

[Prognostic significance of stress tomographic scintigraphy of myocardial perfusion in diabetic patients]. / Prognostický význam zátezové tomografické scintigrafie myokardiální perfuze u diabetických pacientu.

OBJECTIVE: To assess the prognostic value of SPECT in patients with diabetes (DM) and without DM. METHOD: A total of 366 patients (104 women, 262 men) were examined by T1 +/- 201 or Tc-99m-MIBI SPECT of the myocardium. DM was recorded in 149 patients, 217 patients did not suffer from DM. The SPECT findings were classified as normal and abnormal perfusion (fixed or reversible perfusion defect). A serious cardiac event was defined as sudden cardiac death or non-fatal myocardial infarction. Also angina pectoris requiring revascularization was recorded. RESULTS: During the average investigation period of 24 +/- 7 months we recorded in 147 patients with a normal load perfusion only one non-fatal myocardial infarction and the risk of a serious cardiac event was low: 0.3% per annum in the whole group. A significantly higher incidence of a severe cardiac event, 5.9% per year, was recorded in 219 patients with an abnormal finding on SPECT (10 deaths and 16 non-fatal myocardial infarctions, P < 0.01). On comparison of the frequency of serious cardiac events in groups of patients with and without DM no significant difference was found as regards normal load perfusion of the heart muscle (1.1% vs. 0%, P = NS) even in patients with an abnormal SPECT finding (5.8% vs. 6.1, P = NS). CONCLUSION: SPECT myocardial perfusion makes it possible to stratify the risk in patients with DM similarly as proved previously in non-selected groups. Similarly as in patients without DM normal perfusion in diabetic patients predicts a benign prognosis.

[Restoration of digestive passage after total gastrectomy]. / Obnova pasáze po totální gastrektomii.

In a group of 20 patients the authors evaluate possibilities of reconstruction of the digestive tract after TGE from the aspect of quality of life. The evaluating criterion are subjective complaints, the necessity to restrict the volume of meals and evaluation of the gastric substitution. The authors did not find a significant difference between reconstructions using a Roux loop and bilateral interposition of a jejunal loop between the oesophagus and duodenum, while the consider the creation of a reservoir very beneficial for the patient.

[Experimental verification of the hepatic perfusion index for monitoring direct liver perfusion by portal blood]. / Experimentální overení hepatoperfúzního indexu (HPI) pro sledování prímé perfúze jater portální krví.

The reliability of HPI measurement was studied in animal experiment. The portal vein of experimental dogs was narrowed by application of a metallic coil. The induced portal hypertension with important hepatofugal collaterals appeared to be a suitable model for the study of changes in HPI. A decrease in the index was statistically significant and corresponded to the hemodynamical efficiency of collateral circulation. The original experiment verified the reliability of HPI for an assessment of direct perfusion of the liver by portal blood.

Absolute quantitation of gallium-67 citrate accumulation in the lungs and its importance for the evaluation of disease activity in pulmonary sarcoidosis.

Our modification of a method for the absolute quantification of gallium-67 uptake in lungs with a scintillation camera and computer is described. The uptake of 67Ga in lungs, expressed in percentage of administered radioactivity, was determined by the transmission-emission method. We proved theoretically and experimentally that a 67Ga planar source could be replaced with a 57Co planar source. The performance of lung perfusion scans allows a more accurate delineation of the regions of interest on gallium scans. The method was applied to control subjects (n = 27) and to patients (n = 114) suffering from biopsy-proven pulmonary sarcoidosis (28 with inactive and 86 with active disease). The obtained results were compared with chest X-ray findings, the percentage of lymphocytes in the bronchoalveolar fluid (BAF-ly%), and serum angiotensin-converting enzyme (SACE) values. The method seems suitable for the assessment of disease activity in sarcoidosis. It is more accurate in detecting parenchymal involvement in lung sarcoidosis than the commonly used X-ray criteria. No correlation was found between 67Ga uptake and the BAF-ly% and SACE values.

Diagnostic angioscintigraphic evaluation of malignant hepatic tumors before catheter embolization: determination of shunt, flow distribution, and reflux.

PURPOSE: The aim of this study was to evaluate quantitatively arteriovenous shunts in malignant liver tumors by injection of 99mTc macroaggregates of albumin (MAA) into the tumor-feeding artery after selective catheterization. METHODS: In 40 patients with malignant liver tumors (33 hepatocellular carcinomas and 7 metastases of colorectal cancer), a mean dose of 200 MBq 99mTC MAA was injected arterially during angiography. The embolized area and the lungs were then visualized using a gamma camera. A dedicated computer program calculated pulmonary shunt rates. RESULTS: The majority of patients (n = 30) with hepatocellular carcinoma showed small shunts varying from 0 to 15%; only 3 of these patients had shunts ranging from 18% to 37%. In patients with colorectal carcinoma metastases (n = 7) the shunt varied from 0 to 3% (2 +/- 1%), probably due to a physiological shunt in normal liver tissue in the embolized area. Importantly, the degree of shunt found bore no correlation to the tumor volume or to the pattern of vascularity on angiography. CONCLUSION: Diagnostic angioscintigraphy is a useful tool for pretherapeutic evaluation of the capacity of an individual tumor to retain particles and to measure extratumoral shunting; these are essential for therapy planning, as they can help to increase the safety and effectiveness of embolization.