Ventilation-perfusion lung scan for the detection of pulmonary involvement in Takayasu's arteritis.

The aim of study was to analyse ventilation and perfusion (V/Q) lung scan findings in a series of Italian patients with Takayasu's arteritis. Eighteen consecutive patients underwent V/Q lung planar scintigraphy and single-photon emission tomography (SPET). Before perfusion scan acquisition was started, a first-pass study with (99m)Tc-macroaggregates of albumin was performed to assess the right ventricular ejection fraction (RVEF). All patients had normal chest X-rays and were symptom free at the time of the investigation. They also underwent echocardiography to evaluate pulmonary artery pressure and in 13 patients respiratory function tests were performed. In four patients, perfusion lung scan was repeated after 1 year. In 10/18 patients (55.5%), 43 unmatched lobar, segmental or subsegmental perfusion defects were found on planar images; ventilation scintigraphy was normal in all cases. On SPET images, 55 defects were found; no defects were found with SPET in the remaining patients who had normal planar images. All patients had normal RVEF and 5/13 patients had mild restrictive-obstructive lung disease. The pulmonary artery pressure was increased in two patients with perfusion defects. In the four patients who had repeat scintigraphy, all defects remained unchanged. The prevalence of lung perfusion abnormalities observed in Italian patients with Takayasu's arteritis is within the range of values reported in other countries, and V/Q planar scintigraphy is sufficient for the screening of patients.

Role of Tc-99m sestamibi scintigraphy in the diagnosis and surgical decision-making process in primary hyperparathyroid disease.

PURPOSE: Ultrasound (US) and scintigraphy are used most frequently of all the available imaging techniques for the preoperative evaluation of patients with possible primary hyperparathyroid disease. The aim of this study was to assess the value of dual-phase Tc-99m MIBI scintigraphy compared with US in the detection of adenomatous or hyperplastic glands and in the surgical decision-making process for patients with a biochemical diagnosis of primary hyperparathyroid disease. METHODS: Ninety-seven patients with increased levels of parathyroid hormone and calcium, and at least 6 months' follow-up after US and scintigraphy, were examined retrospectively to assess the influence of the diagnostic work-up on the therapeutic decision of the referring clinicians and to evaluate the sensitivity of these diagnostic tools in the surgically treated patients. Forty-eight patients underwent surgery. RESULTS: Parathyroid adenomas were found in 43 patients and hyperplasia in 1, whereas 4 patients had no evidence at surgery. The sensitivity and specificity rates were 84.4% and 95.9% for scintigraphy, and 66.6% and 98.6% for US, respectively. Of the 49 nonsurgically treated patients, 35 had negative results with both MIBI and US; only 3 had positive findings with both imaging methods. Patients treated conservatively had significantly lower parathyroid hormone and serum calcium levels than did the patients who had surgery. CONCLUSIONS: The data suggest that the high sensitivity of dual-phase MIBI scintigraphy can improve the detection of hyperfunctioning parathyroid glands. Furthermore, despite the controversy surrounding the use of imaging methods in the preoperative assessment of primary hyperparathyroid disease, these data suggest that the decision of the clinician to order surgery for a patient with a moderate increase of serum PTH level may be influenced by the results of the imaging methods.

Dosimetry study in patients with autonomous thyroid nodule who are candidates for radioiodine therapy.

UNLABELLED: A dosimetry study was performed on 26 patients with an autonomous thyroid nodule and suppressed serum thyroid-stimulating hormone, to determine the dose to extranodular tissue when the nodule receives 300 Gy for 131I therapy. METHODS: Parameters of radioiodine turnover to be used in the dosimetry formula were separately obtained for the nodule and the contralateral lobe, as a measurable example of the extranodular tissue, using 55 MBq 123I and a computer-assisted gamma camera. The biologic half-life of 123I was then converted into the effective half-life of 131I, and the volumes of the nodule and the lobe were obtained by scintigraphy or sonography. RESULTS: The mean dose to the contralateral lobe from uptake and irradiation by the nodule was calculated to be 32 Gy, and that to the ipsilateral lobe was estimated to be 34 Gy. CONCLUSION: During radioiodine therapy for autonomous thyroid nodules, the extranodular tissue receives a higher dose than is generally assumed, which explains the relatively high rate of post-treatment hypothyroidism reported in the literature.

Plasma pancreatic polypeptide response to secretin.

OBJECTIVE: Intravenously administered secretin stimulates pancreatic polypeptide (PP) release in patients with endocrine enteropancreatic tumors, but data in patients with nontumorous disorders are controversial. Therefore, we aimed to evaluate the plasma PP pattern after secretin administration in healthy subjects and in patients with gastroduodenal diseases investigated for recurrent ulcer disease and/or hypergastrinemia. METHODS: Synthetic secretin was given as an intravenous bolus (2U/kg) in ten patients with Zollinger Ellison syndrome, ten with duodenal ulcer, ten with atropic gastritis and ten healthy volunteers. Blood samples were taken before and at regular intervals for 30min after secretin injection. Plasma PP and gastrin levels were measured by radioimmunoassay. RESULTS: Secretin promptly and significantly (P<0.01) increased PP plasma levels in all groups of subjects without any differences in peak values. There were no significant correlations between PP and gastrin plasma levels. CONCLUSIONS: Secretin at pharmacological doses is a powerful stimulus for PP release.

Indium-111 pentetreotide lung uptake in infectious lung disease.

Bilateral diffuse lung uptake of In-111 pentetreotide (OCT) was observed during a whole-body scan performed in a 68-year-old woman with Cushing's syndrome and suspected ectopic adrenocorticotropic hormone secretion. A few days later, she was found to have bilateral bacterial pneumonia (of mixed anaerobic origin). Cushing's syndrome was finally proved to be of pituitary origin. The OCT lung uptake in pneumonia probably resulted from tracer binding by somatostatin receptors on the inflammatory leukocytes. Although the rapid wash-out from experimentally induced abscesses does not make OCT a suitable tracer for detecting acute infections, the images and data here reported suggest that infectious lung disease should be excluded before diagnosing lung involvement by neuroendocrine tumors.

Changes in radioiodine turnover in patients with autonomous thyroid adenoma treated with percutaneous ethanol injection.

UNLABELLED: In 24 patients with autonomous thyroid adenoma, we studied the hormonal pattern (free thyroxine, free triiodothyronine and thyroid stimulating hormone) and markers of radioiodine turnover before and after nodule ablation with percutaneous ethanol injection. METHODS: The hormonal pattern was studied before treatment and at various intervals after nodule ablation. Changes in radioiodine turnover were studied measuring 131I protein-bound iodine and the biologic half-life of radioiodine in the thyroid (calculated from thyroid uptake at 24 and 48 hr) before and after ethanol treatment. RESULTS: The hormonal pattern was normalized by treatment in all patients and remained normal for the follow-up period. Before treatment, protein-bound 131I was elevated in all patients but 4; after treatment, it normalized in 15 patients with the disappearance of the adenoma on scintigraphy. In the remaining 9 patients with only partial nodule destruction on scintigraphy, protein-bound 131I remained elevated although markedly reduced. Biologic half-life was shortened in 18 of 24 patients before treatment; after treatment, it was normal in 18 of 24 patients (13 of 15 with complete nodule ablation and 5 of 9 with partial ablation). CONCLUSION: Ethanol treatment normalized the hormonal pattern in all patients. Measures of radioiodine turnover were better markers of residual disease in that they normalized in almost all patients with complete nodule ablation, whereas they remained abnormal in a high proportion of patients with incomplete ablation. Thyroid hormones remained normal over a follow-up period of 3-7 yr in all patients.

Treatment of autonomous thyroid nodules with percutaneous ethanol injection: 4-year experience.

PURPOSE: To evaluate the long-term efficacy of treatment of autonomous thyroid nodules with percutaneous ethanol injection under ultrasound guidance. MATERIALS AND METHODS: Treatment was performed in 101 patients. The mean ratio of injected ethanol volume to nodule volume was approximately 1.5; ethanol was usually administered in four to eight sessions. RESULTS: Complete cure was achieved in 59 patients. Partial cure was achieved in 34 patients. Eight patients had remission of thyrotoxicosis but persistence of thyroid-stimulating hormone level suppression and radionuclide uptake only in the nodule. The extent of the response was inversely proportional to the nodule volume. Marked nodule shrinkage was observed in all groups. No recurrences were observed. Transient vocal cord paresis occurred in four patients, with full recovery in all cases. CONCLUSION: This method compares favorably with both surgery and radioiodine treatment, especially when the very low prevalence of posttreatment hypothyroidism is considered.

[Percutaneous ethanol injections in the treatment of autonomous thyroid nodules. 4 years' experience]. / L'iniezione percutanea di etanolo (PEI) nella terapia dei noduli tiroidei autonomi. Esperienza dopo quattro anni.

We treated with PEI 81 patients carriers of autonomous thyroid nodule, 65 toxic and 16 non toxic, all with undetectable serum TSH and suppressed extranodular tissue on scintigraphy. The treatment schedule was: 1-2 sessions per week, 1-8 ml per session, 3-13 sessions in total, In relation to the size and the therapeutic response. The signs of hyperthyroidism disappeared in all cases. Complete cure was obtained in 51 patients; hormonal remission was obtained in 24 patients; partial compensation was obtained in six patients. No recurrences were observed, but two dysphonias lasting three months were reported. PEI seems to be an alternative to surgery and 131I for the ablation of toxic nodules with a volume less than 30 ml.

Thyroid scintigraphy during antithyroid treatment for autonomous nodules as a means of imaging extranodular tissue.

The scintigraphic appearance of the thyroid gland after a course of methimazole treatment was studied in 22 patients with autonomous hot nodules. After 2-3 months of treatment the extranodular tissue was reactivated in almost every patient. This treatment constitutes an endogenous TSH stimulation test and may be used clinically in selected cases.

Comparison of pertechnetate and radioiodine thyroid scintiscans in thyroid disease.

In a retrospective study, thyroid scintiscan with technetium-99m-pertechnetate at 30 minutes was compared with the iodine-131 scan at 24 hours in 273 patients with various thyroid diseases. The pertechnetate scan showed normal or diffusely enlarged thyroid glands in 64 patients, cold nodules in 36, and hot or warm nodules in 173. The radioiodine and pertechnetate scintiscans were concordant in all patients without nodules and in those with cold nodules. Minor discrepancies were observed in 24 patients with hot or warm nodules. Only 2 patients, both euthyroid, showed major discrepancies in which nodules appeared hot with pertechnetate and cold with radioiodine. Sequential scintiscans with radioiodine performed in both of these patients, and a perchlorate test performed in one, demonstrated organification defects in the nodules. The data indicate that there is a high correlation between the results of scintiscans using the two tracers; discrepancies in results with the two imaging techniques were rare.

Scintigraphic study of extra-adrenal ganglioneuroma in a patient with overlap between multiple endocrine neoplasia types 1 and 2.

A 27-year-old woman was diagnosed with a pituitary prolactinoma. Seven years later, when she was 34, an abdominal mass was incidentally discovered and ascribed to the right adrenal gland on the basis of evidence from ultrasonography, computed tomography, and arteriography. Adrenal scintigraphy with Se-75 selenomethylcholesterol imaged both adrenal glands, but the right gland was distorted, suggesting external compression. I-131 MIBG was not taken up by the mass. At surgery, an extra-adrenal ganglioneuroma was found and excised. This case represents an overlap between multiple endocrine neoplasia types 1 and 2. The failure of the ganglioneuroma to concentrate MIBG was likely caused by secretory inactivity of a biologically mature tumor.

Percutaneous intranodular ethanol injection: a new treatment for autonomous thyroid adenoma.

Established methods for definitive ablation of autonomous thyroid nodules are surgery and radioiodine. Since it has been demonstrated that percutaneous ethanol injection can inactivate parathyroid adenomas and small hepatocellular carcinomas, we started a trial of this treatment in patients with autonomous thyroid nodules. Twenty-eight patients, 22 toxic and 6 nontoxic, all with undetectable thyrotropin serum levels and suppressed extranodular tissue on scintigraphy, were treated. Treatment consisted of percutaneous intranodular ethanol injection under ultrasound guidance. The total amount of alcohol injected ranged from 0.4 to 2.2 times the estimated nodule volume, divided into 4 to 9 injections performed at 2 to 7 day intervals. Most patients were treated with a single cycle of injections, but 7 of them required 2 cycles. The signs and symptoms of hyperthyroidism disappeared in all cases. Apparently complete cure (normal serum free thyroid hormones, thyrotropin in basal conditions and after thyrotropin releasing hormone, reactivation of extranodular tissue on scintigraphy with nodule no longer visible) was obtained in 17 patients (13 after 1 cycle and 4 after 2 cycles). Partial cure (normal serum free thyroid hormone levels, detectable thyrotropin levels with normal or blunted response to thyrotropin releasing hormone and partial reactivation of extranodular tissue on scintigraphy with nodule or parts of it still visible) was obtained in 10 patients (8 after 1 cycle and 2 after 2 cycles). In 1 patient with a very large nodule thyrotropin levels remained undetectable, but thyroid hormone levels eventually became normal. No recurrences were observed after a follow-up of 12 to 32 months (mean 20 months). No serious side effects were encountered. A clinically valuable result was obtained in all patients. These data suggest that this form of treatment could constitute an alternative to surgery and radioiodine for the ablation of autonomous thyroid nodules.

Clinical experience with two simple methods of measurement of 99mTc-methylene diphosphonate body retention in bone disease.

Whole-body retention (WBR) of 99mTc-methylene diphosphonate was measured in 15 control subjects and in 99 patients with various metabolic bone diseases (osteoporosis, Paget's disease of the bone, hyperparathyroidism). In all the subjects WBR was measured indirectly from urinary excretion and in 30 it was also measured directly using a simple detector. Mean WBR values did not differ between control subjects and osteoporotic patients, whereas patients with Paget's disease and patients with hyperparathyroidism had significantly higher mean WBR levels than the controls. However, overlapping of results among the groups was high, and consequently the diagnostic value in the individual patients was low. In the patients whose WBR levels were measured simultaneously by both the direct and the indirect urinary method, the results were essentially the same, provided urine losers were excluded. Comparison of the two detection methods showed that urine loss occurred frequently and this was probably partly responsible for the low diagnostic sensitivity of the WBR. When WBR was measured at different time intervals in untreated individuals, the values remained markedly constant. The method would probably be of value in monitoring treatments influencing bone turnover in metabolic bone diseases.

Clinical experience with the adrenal scanning agents iodine 131-19-iodocholesterol and selenium 75-6-selenomethylcholesterol.

Adrenocortical scintigraphy with iodine 131-19-iodocholesterol or selenium 75-6-selenomethylcholesterol was performed in 94 patients with proven or suspected adrenal disease. According to the final diagnosis, 36 patients suffered from primary aldosteronism, 33 from Cushing's syndrome, 8 from low renin hypertension, 6 from nonfunctioning adrenal tumour, 4 from simple obesity, 3 from adrenal metastases, 1 from congenital adrenal hyperplasia, 1 from virilizing adrenal adenoma, 1 from extraadrenal phaeochromocytoma, 1 from ganglioneuroma. Surgical confirmation of the diagnosis was obtained in most cases. With a few exceptions, the scintigraphy results were consistent with the final diagnosis. The two tracers were equally effective adrenal scanning agents. Tracer concentration was measured in a number of surgical specimens, mostly from patients given selenocholesterol. This measurement in surgical samples has not been reported in previous studies with this agent. The results provided a direct validation of uptake measurements in vivo. The data, collected over a 17-year period, demonstrate that despite the advent of new imaging techniques, adrenal scintigraphy that gives both functional and morphologic information still has an important role in the diagnosis of adrenal disease.

Asymptomatic parathyroid adenoma manifested by intratumoral hemorrhage.

A 48-year-old woman whose past history was unrevealing presented with sudden swelling of the neck with pain and dysphonia. Neck ultrasonography suggested the possibility of hemorrhage in a parathyroid adenoma. Surgical exploration revealed a hemorrhagic parathyroid adenoma of the chief cell type. This event is exceedingly rare, but should be considered in the differential diagnosis of suddenly appearing masses of the neck region.