Evaluation of patients with coronary artery disease. IQ-SPECT protocol in myocardial perfusion imaging: Preliminary results.

UNLABELLED: Quantification of myocardial perfusion scintigraphy is often performed to assist physicians in detecting coronary artery disease (CAD). Modern software and hardware packages provide improvements able to shorten scan time and/or reduce administered activity, without compromising image quality in radionuclide myocardial perfusion imaging (MPI). Recently, multifocal collimators were introduced with dedicated reconstruction software, named IQ-SPECT, able to shorten considerably scan time. The aim of our study was to compare this new protocol to the already validated standard ones. PATIENTS, METHODS: We enrolled 43 patients with suspected or diagnosed CAD. All patients underwent a two-days protocol radionuclide myocardial perfusion scan at rest and after a standard stress test (exercise or dipyridamole) after administering 99mTc-tetrofosmin. Images were acquired on a 2-head gamma camera and reconstructed with attenuation correction. All the images were scored using a 17-segments model by three experienced physicians, blind to clinical data and to acquisition and processing modality. RESULTS, CONCLUSION: No significant differences were recorded in perfusion scores on paired t-test and Wilcoxon among the full-time images reconstructed with standard protocol or IQ-SPECT, both overall on a 17-segments evaluation and when considering different territories of distribution. MPI with IQ-SPECT protocol can be acquired at about a quarter scan time without disagreement compared to full time scan acquisition performed with standard protocols.

Interval sentinel lymph nodes: an unusual localization in patients with cutaneous melanoma.

Background. Recent studies have demonstrated that there exists a great variation in the lymphatic drainage in patients with malignant melanoma. Some patients have drainage to lymph nodes outside of conventional nodal basins. The lymph nodes that exist between a primary melanoma and its regional nodal basin are defined "interval nodes". Interval node occurs in a small minority of patients with forearm melanoma. We report our experience of the Melanoma Unit of University Hospital Spedali Civili Brescia, Italy. Methods. Lymphatic mapping using cutaneous lymphoscintigraphy (LS) has become a standard preoperative diagnostic procedure to locate the sentinel lymph nodes (SLNs) in cutaneous melanoma. We used LS to identify sentinel lymph nodes biopsy (SLNB) in 480 patients. Results. From over 2100 patients affected by cutaneous melanoma, we identified 2 interval nodes in 480 patients with SLNB . The melanomas were both located in the left forearm. The interval nodes were also both located in the left arm. Conclusion. The combination of preoperative LS and intraoperative hand-held gamma detecting probe plays a remarkable role in identifying these uncommon lymph node locations. Knowledge of the unusual drainage patterns will help to ensure the accuracy and the completeness of sentinel nodes identification.

Late computed tomography scan response improvement and gallium scintigraphy evaluation as on-treatment prognostic parameters to tailor treatment intensity in patients with Hodgkin's lymphoma. A prospective phase II study.

BACKGROUND: Tailoring treatment intensity is critical in Hodgkin's lymphoma (HL). Ongoing prognostic parameters may be an useful adjunct to pretreatment stratification. We used the kinetics of computed tomography (CT) scan response and residual gallium (Ga)-67 uptake to better stratify risk. MATERIALS AND METHODS: Patients received 4-8 adriamycin, bleomycin, vinblastine and dacarbazine courses according to stage. Disease was reassessed evaluating late computed tomography scan response improvement (CTRI) and Ga-67 uptake. Patients received no further treatment, radiotherapy (RT) or additional chemotherapy + RT according to the presence of none (low risk), one (intermediate risk) and both parameters (high risk). Patients with bulky mediastinum received RT anyhow. RESULTS: Among 102 assessable patients, 35 showed late CTRI and 9 residual Ga-67 uptake. In 30 patients with bulky mediastinum, the 3-year progression-free survival (PFS) was significantly better when neither parameter was present (100% versus 69%; P = 0.02). In 72 patients without bulky mediastinum, treatment was tailored according to risk assignment. Relapses occurred in 5 of 47 low-risk and 3 of 21 intermediate-risk patients, with no differences between the two groups, and in 3 of 4 high-risk patients. CONCLUSION: This study shows that two on-treatment parameters, late CTRI and residual Ga-67 uptake, can predict PFS in HL and identify patients in which RT can be spared without apparently affecting the outcome.

[Right ventricular heart failure in hyperthyroidism]. / Scompenso cardiaco destro in corso di ipertiroidismo.

Cardiovascular disorders in patients affected with hyperthyroidism are very common; the increase in the heart rate and in inotropism combines with a rise in the cardiac index towards which the reduction in peripheral resistances and an increase in the venous return to the heart contribute. The increase in myocardial excitabi1ity, caused above all by triiodothyronine, may be attended with atrial extrasystoles or even with atrial fibrillation. Congestive heart failure during hyperthyroidism, even if rare, may either reveal itself in association with pre-existent cardiopathy or to be precipitated by tachyar-rhythrmia, particu1arly, by paroxysmal atrial fibrillation. The case is described of a young woman affected with Graves' disease, presenting an ingravescent dyspnoea, in which sinusal tachycardia, the S1Q3 electrocardiographic figure and the echocardiographic reports of a right ventricu1ar overload with pulmonary hypertension and systemic venous congestion, suggest picture of acute pulmonary embolism. The isolated dysfunction of the right ventricle resolved quickly after an adequate antithyroid therapy. The oddness of presentation of Graves' disease in this case would suggest the execution of the thyroid profile for all patients with a primary diagnosis of heart failure, in order to single out hyperthyroid subjects with reversible myocardial dysfunction.

Radionuclide therapy for painful bone metastases. An Italian multicentre observational study. Writing Committee of an Ad Hoc Study Group.

BACKGROUND: It has been affirmed that observational studies give analogous results to randomised controlled ones. METHODS: A multicentre observational trial was conducted between 1996-1998 in order to evaluate the efficacy of palliative radionuclide therapy for bone metastases in a large number of patients. An evaluation was made on 510 patients with prostate cancer and painful bone metastases, treated with a single iv. dose of 89Sr-chloride (527 treatments) or 186Re-HEDP (83 treatments), in 29 Italian Nuclear Medicine Departments. Eighty-one patients received up to five injections, totalling 100 retreatments. Patients were followed up for a period of 3 months-2 years. Results were expressed at four levels of response: excellent, good, mild, and nil. RESULTS: Responses were excellent in 26.4%, good in 33.3%, mild in 21.3% and nil in 19% of all treatments, while good and excellent responses were obtained in 48% of retreatments. No statistically significant correlations were found between response and age of patients, skeletal extension of tumour, pretherapeutic PSA levels, evidence of non-bony metastases, previous chemotherapy and/or external-beam radiotherapy; osteolytic lesions responded worse than osteoblastic or mixed ones. Hematological toxicity (mild to moderate), mainly affecting platelets, was observed in 25.5% of all treatments and in 38.9% of retreatments. No clear differences were found between the two radiopharmaceuticals employed. CONCLUSIONS: Bearing in mind that observational studies can provide just as accurate results as randomised controlled trials, this study confirms the main findings of various limited monocentre trials.

Gated blood pool tomography for the evaluation of global and regional left ventricular function in comparison to planar techniques and echocardiography.

BACKGROUND: Multigated radionuclide ventriculography (MUGA) is a simple and reliable tool for the assessment of global systolic and diastolic function and in several studies it is still considered a standard for the assessment of left ventricular ejection fraction. However the evaluation of regional wall motion by MUGA is critical due to two-dimensional imaging and its clinical use is progressively declining in favor of echocardiography. Tomographic MUGA (T-MUGA) is not widely adopted in clinical practice. The aim of this study was to compare T-MUGA to planar MUGA (P-MUGA) for the assessment of global ejection fraction and to transthoracic echocardiography for the evaluation of regional wall motion. METHODS: A 16-segment model was adopted for the comparison with echo regional wall motion. For each one of the 16 segments the normal range of T-MUGA ejection fraction was quantified and a normal data file was defined; the average value -2.5 SD was used as the lower threshold to identify abnormal segments. In addition, amplitude images from Fourier analysis were quantified and considered abnormal according to three different thresholds (25, 50 and 75% of the maximum). RESULTS: In a study group of 33 consecutive patients the ejection fraction values of T-MUGA highly correlated with those of P-MUGA (r = 0.93). The regional ejection fraction (according to the normal database) and the amplitude analysis (50% threshold) allowed for the correct identification of 203/226 and 167/226 asynergic segments by echocardiography, and of 269/302 and 244/302 normal segments, respectively. Therefore sensitivity, specificity and overall accuracy to detect regional wall motion abnormalities were 90, 89, 89% and 74, 81, 79% for regional ejection fraction and amplitude analysis, respectively. CONCLUSIONS: T-MUGA is a reliable tool for regional wall motion evaluation, well correlated with echocardiography, less subjective and able to provide quantitative data.

Sentinel node biopsy in breast cancer: the experience of Brescia Civic Hospital.

The accuracy of the sentinel node technique in the evaluation of axillary node involvement in breast cancer was evaluated in 83 consecutive patients with monofocal T1-2 carcinoma, who were clinically N0 and who underwent lymphoscintigraphy with 99mTc-colloid integrated with intraoperative sentinel node detection by a portable probe. Lymphoscintigraphy revealed at least one sentinel node in 75 patients (90.4%), always identified by the probe. In eight patients (9.6%) the sentinel node was detected neither by lymphoscintigraphy nor by the probe. All removed lymph nodes were analyzed by hematoxylin-eosin histology and the sentinel node by immunostaining. In 28/75 patients (37.3%) at least one metastatic axillary lymph node was detected; in 16 of the 28 N+ subjects (57%) only the sentinel node was positive. The false negative rate (sentinel node negative/other axillary lymph nodes positive) was 17.85% (5/28 patients). In 9/23 patients (39%) micrometastases were found in the sentinel node only. In conclusion, specific sentinel node positivity in 57% of cases supports the validity of the sentinel node concept. Moreover, nine patients would have been considered N0 by standard hematoxylin-eosin histology without sentinel node-aided immunostaining. A 17.8% false negative rate calls for caution in patients with negative sentinel nodes.

Sentinel node biopsy in melanoma: the experience of Brescia Civic Hospital.

The accuracy of the sentinel node (SN) technique in the evaluation of lymph node involvement in melanoma was evaluated in 71 consecutive patients with localized disease and Breslow index >1 mm. Lymphoscintigraphy identified at least one SN in 70 of the 71 patients (98.5%). The following day 69 patients underwent selective SN excision. The SN was identified by portable probe. One hundred and twenty-two lymph nodes were removed, 14 (11.4%) of which were metastatic in 9 patients (13%). No metastases were found in 40 patients with Breslow <2 mm. Eight of the 9 patients with positive SNs underwent lymphadenectomy of the whole basin and in two patients new metastatic nodes were found. At 4-26 months' follow-up 1 of the 60 patients with negative SN (scalp melanoma with Breslow 6.2 mm) developed bilateral cervical metastatic nodes. Two more patients with Breslow 3.7 and 5 mm, respectively, developed liver and lung metastases. The remaining 57 patients are still disease free. Among the 9 patients with tumor-positive SNs, 1 was lost to follow-up, 3 died and 5 are still alive. Our data confirm the clinical reliability of the SN technique in melanoma; we feel the technique should be considered a standard tool in the evaluation of melanoma patients.

85Sr contaminant as a reliable tracer of 89Sr for monitoring urinary radioactivity in patients treated with 89Sr for bone metastases.

Measurement of radioactivity levels in the urine of patients undergoing strontium-89 therapy can be used to evaluate the efficacy of therapy or for patient's management (radiation protection rules and waste disposal). The complex beta counting procedures require extensive sample manipulation during preparation of the liquid scintillation cocktail. The high activity levels that may be found permit one to measure 89Sr activity sample by counting the low yield gamma emission (909 keV) of the radionuclide. However, the contamination of 85Sr due to the reaction for producing 89Sr, if measured with sufficient precision, could be used to evaluate 89Sr activity in urine samples. In other words, the contaminant 85Sr can be used as a tracer of 89Sr. This method was tested in four patients and the accuracy was found to be sufficient to obtain the individual time-activity curves of the urinary excretion.

Results of [131I]metaiodobenzylguanidine treatment in metastatic malignant phaeochromocytoma.

The results obtained with [131I]metaiodobenzylguanidine (131I-MIBG) treatment in 6 patients affected by metastatic phaeochromocytoma are reported. Single doses of 3.7-7.4 GBq were given, in 1-6 courses, up to cumulative doses of 5.4-37.8 GBq. Objective responses were observed in 5 patients (2 tumour shrinkages, even if small; 5 lowering of blood pressure), which were only temporary in 3 patients and stable in 2. Complete disappearance of pain was obtained in 2/2 patients. No adverse side-effects were observed. The problem of treatment strategy in situations of stable disease deserves further study.

Results of [131I]metaiodobenzylguanidine treatment in metastatic carcinoid.

The results obtained with [131I]metaiodobenzylguanidine (131I-MIBG) treatment in 6 patients affected by metastatic carcinoid are reported. 131I-MIBG was given in single doses of 3.7-8.0 GBq, reaching a maximum cumulative dose of 29.5 GBq in 4 courses. Objective responses were not observed, but in 4 cases an apparent stabilisation of the disease for more than 1 year was obtained. A subjective response regarding the carcinoid syndrome was observed in 4 cases. No response was seen in 2 cases. No adverse side-effects of any importance were observed, usually being prevented by a mild medication.

Therapeutic possibilities of 131I-MIBG in metastatic carcinoid tumors--preliminary report.

The poor results of traditional therapy in advanced carcinoid tumors and the well-proven uptake of 131I-MIBG shown by some of these tumors induced us to attempt a radiometabolic approach. We selected for the treatment 5 patients (3 men and 2 women) who showed progression of disease, a fairly good uptake of 131I-MIBG with severe related symptoms, and a poor response to traditional therapy. A cumulative radioactivity of 5.5-29.6 GBq was given. Acute side effects after 131I-MIBG administration or late radiation-induced damages were not observed. Symptoms increased during the first 2-4 weeks in 2 patients: in one of these relief was achieved with drugs. Results concerning objective remission of the disease were unsatisfactory. In contrast, definite improvement of symptoms was shown in 2 of 5 patients, resulting in a better quality of life.

New tracers for the imaging of the medullary thyroid carcinoma.

I-MIBG and 99Tcm(V)-DMSA have been recently proposed as scintigraphic markers of the medullary thyroid carcinoma (MTC). Thirty two patients were examined with 131I- or 123I-MIBG and 26 of these were re-examined with 99Tcm(V)-DMSA (planar and SPECT). From our experience we can draw the following conclusions: (1) the scintigraphic attempt was useless in patients with normal levels of plasma calcitonin (CT): (2) in patients with high plasma CT levels, the sensitivity of the MIBG was better in familiar (3/3 true positive) than in sporadic disease (7/21 true positive; overall sensitivity = 42%); the 99Tcm(V)-DMSA was positive in 16/19 cases, (overall sensitivity = 84%) even in cases which had been false negative with MIBG (6 patients); (3) no false positive results were found; (4) the scan with 99Tcm(V)-DMSA is then suggested as the first imaging approach during the follow up in patients affected by MTC and still having high levels of plasma CT. The MIBG scan should be limited to the patients in whom the possible use of MIBG therapy has to be investigated.

[Acute and chronic effects of verapamil on indices of systolic and diastolic function of the left ventricle in patients with hypertrophic cardiomyopathy]. / Effetti acuti e cronici del verapamil sugli indici di funzione sistolica e diastolica del ventricolo sinistro in pazienti con cardiomiopatia ipertrofica.

The aim of this study has been the analysis of acute and chronic effects of Verapamil on resting left ventricular (LV) systolic and diastolic function indices derived from ECG gated radionuclide Angiocardiography (GRA) in patients (pts) affected by Hypertrophic Cardiomyopathy (HCM). 18 pts with HCM were imaged in basal conditions (twice in two different days) and after i.v. infusion of Verapamil 0.1 mg/kg (1st acute test); than chronic oral treatment of Verapamil (240 mg/die) was started. Three months later 14 pts were studied again, during oral chronic therapy and after a second administration of Verapamil i.v. 0.1 mg/kg (2nd acute test). After acute infusion we observed a significant increase of the peak filling rate (PFR) (from 3.3 +/- 0.9 to 3.51 +/- 0.71 EDV/sec, P less than 0.01) and a shortening of the time to PFR (from 188.1 +/- 24.9 to 165 +/- 30 msec, P less than 0.005). No significant variations of the contribution of atrial systole to the ventricular filling (AS) (from 17.03 +/- 5.96 to 18.15 +/- 6.91%), of the heart rate (from 70 +/- 12 to 69 +/- 12 bat/min), and of systolic function indices, ejection fraction (EF) (from 74.4 +/- 9.7 to 74.30 +/- 10.02), peak ejection rate (ER) (from 4.17 +/- 0.92 to 4.10 +/- 0.9), ejection time (ET) (from 307.4 +/- 46.4 to 322.22 +/- 48.6) were noticed. After chronic oral therapy we observed a significant shortening of the time to PFR (from 197.5 +/- 16.7 to 182.8 +/- 13.7 msec, P 0.01), while the remaining indices of diastolic function we analyzed (PFR from 3.2 +/- 0.6 to 3.3 +/- 0.8 EDV/sec; AS from 17.1 +/- 4.9 to 17.1 +/- 6.6%), the systolic function indices (EF from 74.4 +/- 10.5 to 75.4 +/- 9.4%; ER from 4.2 +/- 0.8 to 4.2 +/- 0.6 EDV/sec; ET from 309.6 +/- 48.5 to 308.9 +/- 40.5 msec) and the heart rate (from 67.7 +/- 8 to 66 +/- 8) were not modified. If a 30 msec time to PFR variation was considered significative (confidence limit of 95% between absolute changes measured on two basal studies) the 1st acute test was predictive of chronic efficacy in 10/14 (71%) pts. Four of five pts in which a shortening of TTPFR was observed during the 2nd acute test, showed the same effect with a higher chronic dose of Verapamil (360 mg/die). Our results suggest that Verapamil after acute or chronic treatment improves diastolic filling of LV, without worsening systolic indices.(ABSTRACT TRUNCATED AT 400 WORDS)