Evaluation of blood supply and metabolism in tumor, axillary lymph node and normal breast tissue with F-18 FDG PET/CT in breast cancer: comparison with pathological prognostic factors.

BACKGROUND AND PURPOSE: Perfusion parameters obtained in F-18 FDG PET/CT performed for staging purposes in breast cancers may provide additional information about tumor biology as well as glucose metabolism. The aim of this study was to evaluate throughout F-18 FDG PET/CT the relationship between blood flow and glucose metabolism and histological parameters of the primary tumor, normal mammary gland, and axillary lymph nodes in breast cancer patients. MATERIALS AND METHODS: Sixty six female patients (mean age 51 y ± 12,81) were prospectively included to this study. We performed dynamic blood flow (f) study that started with 296-444 MBq (8-12 mCi) F-18 FDG injection and lasted for 10 minutes, and glucose metabolism (m) imaging one hour later. On each frame, mean activity concentration (AC) values (Bq/mL) were recorded on a spherical volume of interest (VOI) having a volume of ~ 1 cm3 on the hottest voxel of primary tumor (T), across normal breast gland (NG) and ipsilaterally axillary lymph nodes (iLN). Correlations among PET parameters and estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (c-erbB2) and Ki67 index were analyzed. RESULTS: T volume (TV) ranged from 1.1 to 85.28 cm3 [median (IR): 6.44 (11.78)]. There were positive correlations between c-erbB2 and TACf and between c-erbB2 and iLNACf (p = 0.045, r = + 0.248; p = 0.050, r = + 0.242). In the ER positive (ERP) patients, TV and TACm were significantly lower than those of ER negative (ERN) (respectively p = 0.044 and p = 0.041). In patients with two positive Ki-67 indices, iLN-SUVmax was significantly higher than one-positive patients (p = 0.020). There was a negative correlation between NGACm and histological grade of tumor (p = 0.005, r = - 0.365). CONCLUSIONS: Breast cancer shows differences in progression, metastasis and survival due to its diversity in terms of molecular, biological and angiogenesis. High glucose metabolism in breast cancers is associated with tumor aggressiveness. Being able to examine tumor tissue characteristics such as blood flow and glucose metabolism with a single diagnostic technique and to reveal its relationship with histological parameters can provide a reliable pretherapeutic evaluation in breast cancers.

Is SUVmax of 18F-FDG PET/CT Predictive Factor for Malignancy in Gastrointestinal Tract?

BACKGROUND: Increasing use of 18F-FDG PET/CT in cancer patients, has led to more common detection of 18F- FDG uptake in the gastrointestinal tract (GIT). AIMS: The objective of this study was to assess 18F-FDG uptake in incidental and known GIT malignancy. METHODS: A total of 6500 patients followed-up in a single and tertiary center between January 2010 and September 2016 were retrospectively reviewed. Of 2850 patients assessed with 18FDG-PET/CT, known GIT malignancy and 18F-FDG uptake cases during follow-up were included in the study. RESULTS: Of 658 patients with 18F-FDG uptake, 150 patients who underwent endoscopy were included in the study. Seventy-seven of these patients had known GIT malignancy and 73 had incidental 18F-FDG uptake. Among these 73 patients; 7 (9.6%) had malignancy, 20 (27,2%) adenoma and 24 (32.9%) inflammation that were confirmed. Endoscopy was normal in 22 (30.2%) patients. One hundred forty-three (95.3%) patients had focal and 7 (4.7%) had diffuse uptake. While no malignancy was detected in patients with diffuse uptake, 58.7% (84/143) of the patients with focal uptake presented malignancy. Mean the standardized uptake value (SUV) max values were found as 15.0 ± 10.6 (range, 3.8-56.5) in malignant disease, 10.2 ± 4.3 (range, 2.4-19.7) in adenoma, 7.3 ± 3.6 (range, 3.6-18.7) in inflammation, and 9.8 ± 4.2 (range, 3.8-19.9) in normal endoscopy groups (p < 0.001, rho = 0.378). CONCLUSION: Although this study demonstrated high probability of malignant disease with increased 18F-FDG uptake in the GIT, it would be a more appropriate approach to confirm all patients with 18F-FDG uptake through endoscopy as SUVmax values vary in a wide range.

Quantitative comparison of low dose and standard dose radioiodine therapy effectiveness in patients with low risk differentiated thyroid cancer.

BACKGROUND: The aim of this paper was to compare the results of postoperative I-131 remnant ablation therapy using a quantitative data in the low activity (1110 MBq) and standard dose (3700 MBq). METHODS: The study included two groups of patients with low risk differentiated thyroid cancer (DTC): Group L (low dose group) included 54 patients who were treated with 1110 MBq I-131 and Group S (standard dose group) included 61 patients treated with 3700 MBq. The postoperative thyroid remnants were assessed with the pretreatment thyroid uptake test (PTUT) and the whole body scans (WBS) were performed in the 7th day after the ablation treatment. We obtained the average count per pixel from the standard region of interest analysis of the thyroid bed (Tavc), liver (Lavc), thigh (Thavc) and whole body (WBkc). At the sixth month after the treatment, WBS were performed to 106 patients (45 patients from Group L and 61 patients from Group S) to evaluate the success of ablation treatment. RESULTS: A significant difference in PTUT and Tavc was not found between the two groups (P>0.05). However, Lavc, Thavc and WBkc were significantly higher in Group S compared with Group L (P<0.001). Although the percentage of ablation was higher in Group S (49 of 61 patients, 80.3% versus 34 of 45 patients, 75.6%), the statistical difference was not significant (P>0.05). CONCLUSIONS: In low risk DTC patients, low dose radioactive iodine can ablate thyroid remnants as effectively as a higher dose with less radiation exposure to other non-target organs and the whole body.

Best prognostic factor of neuroendocrine tumors: Grade or Stage? A multidisciplinary single-center study.

BACKGROUND/AIMS: Currently, there is no definite consensus about the prognostic factors of neuroendocrine tumors (NETs). We evaluate epidemiology, survival and especially prognostic factors in NETs. MATERIALS AND METHODS: Patients who had a NET and were diagnosed between 2000 and 2014 at a tertiary care center were included. Demographic data, tumor characteristics and survival rates were evaluated, retrospectively. RESULTS: Two-hundred and thirty-three patients (123 male, 110 female; median age, 55 years [16-92 years]) took part in the study. Primary NET sites were the lung (n=56), stomach (n=50), pancreas (n=39), colorectal (n=21), small intestine (n=19), and appendix (n=19). According to the NET classification by the WHO in 2010, 60% (n=140) of patients were grade-1, 15% (n=35) were grade-2, and 25% (n=58) were grade-3. According to TNM staging, 88 patients (37.8%) were stage I, 30 patients (12.8%) were stage II, 22 patients (9.5%) were stage III, and 93 patients (39.9%) were stage IV. Univariate analysis revealed significant associations between gender, age, grade, lymph node metastasis, distant metastasis, stage, and the number of organs impacted by metastases and overall survival. However, with multivariate analysis only age greater than 55 years, advancing grade, and inoperable tumors were significantly associated with shortened survival. Five-year survival was 81% in grade-1, 34% in grade-2, and 9% in grade-3 NETs. CONCLUSION: This study is the most comprehensive study in Turkey that has evaluated NETs using a multidisciplinary approach. Also, we suggest that age, operability and especially grade rather than stage are the most important prognostic factors in NETs.

Combined imaging with 68Ga-DOTA-TATE and 18F-FDG PET/CT on the basis of volumetric parameters in neuroendocrine tumors.

AIM: To assess the additional contribution of the combined imaging approach with Ga-DOTA-TATE and fluorine-18 fluorodeoxyglucose (F-FDG) on the basis of volumetric parameters in neuroendocrine tumors (NETs). MATERIALS AND METHODS: Forty-one patients with NET (19 women, 22 men; age range: 30-79 years; mean age: 56.7±12.3 years) underwent Ga DOTA-TATE and F-FDG PET/computed tomography (CT) imaging. Within the drawn regions of interest, in addition to evaluating the maximum and mean standardized uptake values (SUVmax and SUVmean), the metabolic tumor volume (MTV) and total lesion glycolysis (TLG) in F-FDG PET/CT imaging, and the somatostatin receptor density and total lesion somatostatin receptor expression (TLSRE) in Ga somatostatin receptor imaging (SRI) were measured. The patients were graded on the basis of the proliferation index: well (G1; Ki-67 ≤2), moderately (G2; Ki-67=3-20), and poorly (G3; Ki-67>20) differentiated groups. RESULTS: Of the 41 NET patients, 22, 14, and five were in the G1 (53.7%), G2 (34.1%), and G3 (12.2%) groups, respectively. Liver metastases had significantly higher TLSRE values than the TLG values. Ki-67 levels showed a positive correlation with the primary tumor MTV and TLG values. Cg-A levels had a positive correlation with the volumetric parameters of the whole-body tumor burden (P<0.001). CONCLUSION: Ga SRI and F-FDG PET/CT provide complementary information on treatment protocol and response assessment. While assessing the prognosis and tumor aggressiveness, lesions and whole-body tumor burdens can be calculated on the basis of volumetric parameters by F-FDG PET/CT using MTV and TLG, and by Ga SRI using somatostatin receptor density and TLSRE.

PET/CT and Bremsstrahlung Imaging After 90Y DOTANOC Therapy for Rectal Net With Liver Metastases.

Peptide receptor radionuclide therapy with Lu or Y is promising with successful results in somatostatin receptor-positive tumors. In all radiation therapies, knowledge of the radiation dose received by the target, and other organs in the body is essential to evaluate the risks and benefits of any procedure. We report a case of liver metastases from a rectal neuroendocrine tumor, which was treated with Y DOTANOC. Posttreatment whole-body planar images were acquired through Bremsstrahlung radiations of Y on a γ-camera, and thoracolumbar PET/CT images were acquired on PET.

Evaluation of the diagnostic and prognostic use of gated myocardial perfusion single-photon emission computed tomography in patients with acute chest pain: comparison with the SYNTAX score.

OBJECTIVE: The aim of this study was to evaluate the diagnostic and prognostic efficacy of gated single-photon emission computed tomography (GSPECT) in patients with acute chest pain and to compare quantitative GSPECT parameters and the coronary angiographic SYNTAX score. MATERIALS AND METHODS: A total of 168 patients who presented with clinical symptoms of acute chest pain were enrolled in the study. Study participants were divided into two groups according to the risk of acute coronary syndrome (ACS): low-intermediate and high risk. All participants underwent rest or stress-GSPECT (R/S-GSPECT). Coronary angiography was performed in all high-risk patients and the SYNTAX score was determined. All patients were followed for 24 ± 3 months and monitored for the occurrence of major adverse coronary events (MACE). RESULTS: Among patients with low-intermediate ACS risk, R-GSPECT and S-GSPECT were associated with 100 and 86% sensitivity, 99 and 98% specificity, 100 and 98% negative predictive value, 80 and 86% positive predictive value, and 98 and 97% accuracy, respectively. At follow-up, MACE occurred in 16 patients. Among high-risk patients, GSPECT quantitative parameters were the most significant predictors of MACE in Cox regression analysis. CONCLUSION: R/S-GSPECT, a noninvasive diagnostic method, is associated with an excellent safety profile and exceptional diagnostic and prognostic accuracy in cases of ACS.

Comparison of salivary and calculated free cortisol levels during low and standard dose of ACTH stimulation tests in healthy volunteers.

Salivary cortisol (SC) has been increasingly used as a surrogate biomarker of free cortisol (FC) for the assessment of hypothalamo-pituitary-adrenal (HPA) axis, but there are not enough data regarding its use during ACTH stimulation tests. Therefore, we aimed to determine the responses of SC, calculated free cortisol (cFC) and free cortisol index (FCI) to ACTH stimulation tests in healthy adults. Forty-four healthy volunteers (24 men and 20 women) were included in the study. Low-dose (1 µg) and standard-dose (250 µg) ACTH stimulation tests were performed on two consecutive days. Basal and stimulated total cortisol (TC) and cortisol-binding globulin (CBG) levels and SC levels were measured during both doses of ACTH stimulation tests. cFC (by Coolens' equation) and FCI levels were calculated from simultaneously measured TC and CBG levels. The minimum SC, cFC, FCI levels after low-dose ACTH stimulation test were 0.21, 0.33, 16.06 µg/dL, and after standard-dose ACTH were 0.85, 0.46, 26.11 µg/dL, respectively, in healthy individuals who all had TC responses higher than 20 µg/dL. Peak CBG levels after both doses of ACTH stimulation tests were found to be higher in women than in men. So, by its effect, peak cFC and FCI levels were found to be lower in female than in male group. Neither TC nor SC levels were affected by gender. cFC and FCI levels depend on CBG levels and they are affected by gender. Cut-off levels for SC, cFC, FCI levels after both low- and standard-dose ACTH stimulation are presented. Studies including patients with adrenal insufficiency would be helpful to see the diagnostic value of these suggested cut-off levels.

A Comparison between Quantitative Gated Myocardial Perfusion Scintigraphy and Strain Echocardiography as Indicators of Ventricular Functions in Patients with Anterior Myocardial Infarction.

The purpose of this study is to compare the strain echocardiographic and scintigraphic parameters for evaluating of the left ventricular (LV) functions in patients with anterior myocardial infarction (MI). Fifty-four patients (male/female: 36/18; mean age 62 ± 13 years) with anterior MI were prospectively enrolled. All patients were performed gated myocardial perfusion scintigraphy gated single-photon emission computed tomography (GSPECT) and echocardiography (EC). GSPECT data were processed and analyzed using 4D-MSPECT (4DM, Invia Medical Imaging Solutions, Ann Arbor, MI, USA). The echocardiographic strain (S) and strain rate (SR) values were calculated. The results obtained by these techniques were compared each other. A total of 918 segments of LV wall were evaluated. In all patients, 385 segments were automatically scored as normokinetic, 206 as hypokinetic, 122 as akinetic, 205 as dyskinetic and 300 as normal thickening, 348 as decrease thickening and 270 as no thickening. The means of S and SR values in thickening and motion score groups according to GSPECT were statistically different from each other (P < 0.001). There was a negative significant correlation between LV wall thickening sum score and S and SR and between LV wall motion sum score and S and SR (P < 0.001). There was a good correlation between GSPECT and echocardiographic LV-ejection fraction (r = 0.7, P < 0.001). GSPECT and strain EC are similar in quantitative grading of the severity of regional and global myocardial dysfunction in patients with anterior MI and these techniques provide valuable diagnostic information.

Comparison of arthroscopic, radioactive and combined synovectomy in the treatment of chronic non-specific knee synovitis.

OBJECTIVE: To compare the outcomes of arthroscopic, radioactive and combined synovectomies in patients with chronic non-specific recurrent synovitis who did not respond to conservative therapy. SUBJECTS AND METHODS: Twenty-nine patients enrolled between 2007 and 2011 were divided into 3 groups: group 1 was treated with arthroscopy, group 2 received a radioactive drug and group 3 received a combined (radioactive and arthroscopic) synovectomy. Treatment efficacy was evaluated by comparing pre- and post-operative Lysholm knee scores (LKS), night pain, resting pain, activity pain and effusions using visual analogue scales (VAS). Patient satisfaction was assessed using the visual analogue patient satisfaction scale (VAPSS). RESULTS: The mean age of the study participants was 41.5 ± 5.2 years (range 14-76), and the mean follow-up period was 33.6 ± 3.2 months (range 17-78). Before treatment, the mean LKS was 41.4 ± 3.4 in group 1, 39.6 ± 3.3 in group 2 and 37.1 ± 4.6 in group 3. After treatment, the corresponding mean LKS were 77.7 ± 2.1, 81.6 ± 2.8 and 91.3 ± 2.7 in groups 1, 2 and 3, respectively; the increase was statistically significant (p < 0.05). The VAS scores before and after treatment decreased significantly (p < 0.05). The mean VAPSS score, a measure of patient satisfaction, was 5.1 ± 1.7, 5.8 ± 1.5 and 7.4 ± 1.8 in groups 1, 2 and 3, respectively, and the difference between groups 1 and 2 was not statistically significant, while that between group 3 and the other two groups was significant (p < 0.05). CONCLUSION: This study showed that the three methods used in individuals with chronic non-specific recurrent synovitis were effective; however, arthroscopic synovectomy in combination with radioactive synovectomy was more effective than the other methods and superior in terms of patient satisfaction.

Imaging of primary liver carcinosarcoma scintigraphically; a case report.

UNLABELLED: Primary liver carcinosarcoma is a very rare disease. There have been only a few cases described to date, none of which has been imaged by bone scintigraphy. A 69-year-old man who developed right back pain and weight loss was admitted to our hospital. Tenderness of the right upper abdomen, hepatomegaly, and a giant mass were the main physical examination signs. Abdominal ultrasonography showed a large lobulated heterogeneous echogenic solid mass with multiple cystic areas of varying size and a highly echogenic region that had posterior acoustic shadowing within the mass in the right lobe of the liver. Labeled erythrocyte imaging and (99m)Tc-nanocolloid liver-spleen scan were performed to exclude hemangioma, showing a large intrahepatic photon deficient area. (99m)Tc-methylene diphosphonate (MDP) bone scintigraphy revealed heterogeneous, irregular and dense activity accumulation thought to be osteoblastic activity in the liver mass. Postsurgical pathological diagnosis revealed "carcinosarcoma". CONFLICT OF INTEREST: None declared.

Can left ventricular parameters examined by gated myocardial perfusion scintigraphy and strain echocardiography be prognostic factors for major adverse cardiac events?

Assessment of left ventricular (LV) function in patients with myocardial infarction (MI) provide useful diagnostic and prognostic information. Up to date, single photon emission tomography (SPET), positron emission tomography (PET), multidetector computed tomographic angiography, echocardiography (EC) and magnetic resonance imaging (MRI), have been used to examine LV parameters. However, due to limitations of some imaging methods, new studies are directed to improve myocardium function evaluation. In conclusion, SEC and GSPET can be applied to semi-quantitatively assess LVEF and regional wall motion abnormalities in a noninvasive manner. These techniques can provide strong diagnostic and prognostic information related to anterior myocardial infarction. In addition to this, nitrate enhanced GSPET allows to identify stunning and hibernating myocardium. New methods of reconstruction on GSPET systems will better improve image quality using lower count rates.

Assessment of the effects of access count in percutaneous nephrolithotomy on renal functions by technetium-99m-dimercaptosuccinic Acid scintigraphy.

Objective. To determine the effects of percutaneous nephrolithotomy on renal functions by using DMSA scintigraphy while considering access counts. Material and Methods. A total of 37 patients who had undergone percutaneous nephrolithotomy were included. Preoperative DMSA scans were performed a day before the surgery, whereas postoperative scans were randomized by evaluating them before (n = 25) and after (n = 12) the 6th postoperative month. Twenty-six of 37 cases underwent percutaneous nephrolithotomy with a single access site and 11 with multiple access sites. Results. There were no significant changes of total renal functions in the whole study group (P = 0.054). In the single access group, total functions were significantly elevated (P = 0.03) In the multiple access group, while treated site functions were significantly decreased (P = 0.01), total functions did not change significantly (P = 0.42). There was an insignificant decrease in those evaluated before the 6th postoperative month (P = 0.27) and an insignificant increase in the others (P = 0.11). Conclusion. We could not find a superiority of single access over multiple accesses. There is a temporary functional loss in the treated site.

Successful Treatment of Gastric Relapse in Multiple Myeloma with Bortezomib after Autologous Hematopoietic Stem Cell Transplantation (autoHSCT).

We report a case of 59-year-old Turkish man with history of mitral valve replacement (MVR) and chronic obstructive pulmonary disease (COPD) who was diagnosed with stage IIIA IgG lambda multiple myeloma (MM) in 1997. He underwent autologous hematopoietic stem cell transplantation after a conditioning regimen with melphalan 200mg per body area (m(2)) in February 2006. On February 2011, he was admitted to the emergency service of university hospital with complaints of hematemesis and melena. Pathological evaluation of gastric biopsy, obtained from a lesion of small gastric curvature, showed the gastric mucosa infiltrated by neoplastic plasma cells, monoclonal lambda light chain positive. The patient was considered as having local gastric relapsed disease and was treated with 2 cycles of bortezomib. He achieved an excellent local response after 2 cycles of bortezomib, cyclophosphamide and prednisone (BEP) regimen, with healing of gastric ulcer and no recurrence of the hematemesis or melena.

Octreotide uptake in parathyroid adenoma.

The patient with a history of bone pain and muscle weakness, was thought to have oncogenic osteomalacia as a result of biochemical investigations and directed to Nuclear Medicine Department for a whole-body bone scintigraphy and 111In-octreotide scintigraphy. There was no focal pathologic tracer uptake, but generalized marked increase in skeletal uptake on bone scintigraphy. Octreotide scintigraphy showed accumulation of octreotide in the region of the left lobe of the thyroid gland in the neck. Thereafter, parathyroid scintigraphy was performed with technetium-99m labeled metroxy-isobutyl-isonitryl (99mTc-MIB) and MIBI scan demonstrated radiotracer uptake at the same location with octreotide scintigraphy. The patient underwent left inferior parathyroidectomy and histopathology confirmed a parathyroid adenoma. Somatostatin receptor positive parathyroid adenoma may show octreotide uptake. Octreotide scintigraphy may be promising and indicate a possibility of using somatostatin analogues for the medical treatment of somatostatin receptor positive Conflict of interest:None declared.

Is Every Patient Followed up as a Papillary Thyroid Cancer Patient Really That?

UNLABELLED: We report the case of a 64-year-old man followed up for two years as suffering from differentiated thyroid cancer (DTC). In the patient's follow up, despite thyroglobulin level and I-131 whole body scan results being normal, metastases were identified at the 4th thoracic vertebra corpus by MR. Histopathological findings were carcinoma metastases. F-18 FDG PET/CT showed increased metabolic activity in the right renal mass, bilaterally in the surrenal gland, multiple lymph nodes in the thoracic and abdominal para-aortic region and in multiple vertebral and pelvic bones. An excisional biopsy of the right renal mass was reported as renal cell carcinoma. Immunohistochemical staining performed retrospectively to the first thyroid preparation showed renal cell carcinoma metastases. Consequently, any patient who presents with a thyroid nodule can also be considered as possibly suffering from metastatic disease. F-18 FDG PET/CT can provide valuable information in finding the primary focus and metastases. CONFLICT OF INTEREST: None declared.

Assessment of the effects of zoledronic Acid therapy on bone metabolic indicators in hormone-resistant prostate cancer patients with bone metastatasis.

Purpose. Assessment of effects of zoledronic acid therapy on bone metabolic indicators in hormone-resistant prostate cancer patients with bone metastasis. Material and Methods. Hormone-resistant prostate cancer patients who were identified to have metastases in their bone scintigraphy were taken to trial group. Before administration of zoledronic acid, routine tests for serum calcium, total alkalen phosphates were studied. Sample sera for bone metabolic indicators BALP, PINP, and ICTP were collected. Bone pain was assessed via visual analogue scale and performance via Karnofsky performance scale. Four mg zoledronic acid was administered intravenously once a month. Results. When serum levels of bone forming indicators PINP; BALP were compared before and after therapy, there were insignificant decreases (P = .33, P = .21, resp.). Serum levels of bone destruction indicator ICTP was compared, and there was a significant decrease after zoledronic acid therapy (P = .04). When performances of the patients were compared during therapy period, performances decreased significantly due to progress of illness (P = .01). All patients had ostalgia caused by bone metastases at various degrees. Significant decrease in pain scores was observed (P < .01). Conclusion. Zoledronic acid therapy decreased bone destruction and was effective in palliation of pain in patient with bone metastasis. Using bone metabolic indicators during followup of zoledronic acid therapy might be useful.

Efficacy of different therapeutic regimens on hepatic osteodystrophy in chronic viral liver disease.

BACKGROUND AND AIMS: Metabolic bone disease is common in patients with chronic liver disease. Comparative studies on the efficacies of antiosteoporotic agents in hepatic osteodystrophy have not been conducted yet. The aim of this study was to evaluate the safety and efficacy of different therapeutic regimens on hepatic osteodystrophy. METHODS: Eighty-one patients (mean age 48.9 ± 10 years; 50 cases with chronic viral hepatitis and 31 patients with cirrhosis) were enrolled in the study. Treatment groups consisted of 61 patients who had reduced T scores in at least one region, selected randomly and treated for 1 year with vitamin D 400 IU, calcitonin 200 IU, alendronate 10 mg, alendronate 70 mg, or risedronate 5 mg. An untreated group consisting of 20 patients who had no reduction in T scores was followed up during the study period. RESULTS: No significant adverse effects, including esophageal variceal hemorrhage, were detected. According to the T score at the end of the first year compared with baseline, significant improvements in bone mineral density were observed at all regions with alendronate 70 mg; improvements at the lumbar spine (LS) and distal radius regions with alendronate 10 mg; at the LS and distal radius regions with risedronate; at the LS region with calcitonin; and at the femoral neck region with vitamin D. CONCLUSION: All therapeutic regimens seemed to be safe, and oral biphosphonates were the most effective in preventing both cortical and trabecular bone loss in patients with chronic viral liver disease. Larger studies with longer follow-up are warranted in hepatic osteodystrophy of chronic viral liver diseases.

The comparison of low and standard dose ACTH and glucagon stimulation tests in the evaluation of hypothalamo-pituitary-adrenal axis in healthy adults.

Evaluation of the HPA axis is still a challenge; due to different sensitivities and stimulation efficiencies of dynamic tests, lack of standard assays for cortisol measurement and lack of data regarding the effects of age and gender on the results of the HPA axis evaluation with different dynamic tests. This study was performed to compare 1 µg ACTH, 250 µg ACTH and glucagon tests in the evaluation of HPA axis. The study was carried out on 55 healthy individuals (28 men, 27 women). 10-12 volunteers were included from every decades between 20 and 70 years. Low dose short synacthen test (1 µg ACTH), standard dose short synacthen test (250 µg ACTH) and glucagon tests were performed consecutively. The mean peak cortisol response to standard dose ACTH stimulation test was found to be significantly higher than the low dose ACTH and glucagon stimulation tests. The mean peak cortisol responses to low dose ACTH and the glucagon stimulation tests were not significantly different. The mean peak cortisol responses did not differ significantly between different age or sex groups. The lowest peak cortisol responses obtained after low dose ACTH and glucagon stimulation tests were 12.5 and 9.1 µg/dl respectively in the volunteers who all had cortisol responses higher than 20 µg/dl after standard dose ACTH stimulation test. The lowest cortisol responses obtained during 250 µg ACTH, 1 µg ACTH and glucagon stimulation tests were found to be 20.1, 12.5 and 9.1 µg/dl in a known group of healthy people. So the consideration of appropriate hormonal cut-off levels for each test seems reasonable. The age, sex and body mass indeces were not shown to affect the cortisol response to dynamic stimulation tests.