[Diagnostic options in chronic recurrent multifocal osteomyelitis: case reports]. / Moznosti diagnostiky chronickej multifokálnej recidivujúcej osteomyelitídy: kazuistiky.

Chronic recurrent multifocal osteomyelitis (CRMO) is the most severe form of chronic non-bacterial osteomyelitis. In children and adolescents, the metaphyses of long bones are affected most frequently, but the lesions can be found at any site on the skeleton, as well as in other organs such as the skin, eyes, gastrointestinal tract or lungs. Since the clinical signs of CRMO and its course are not invariable and clear, it is often very difficult to make a clinical diagnosis. The authors present their experience with the CRMO diagnosis in three cases. In the first patient, CRMO was localised in the left proximal tibia, left proximal femur, left sacrum and left clavicle bone. In the second patient, it was found in the left distal tibia, tarsometatarsal joints of the left foot and left distal femur. The third patient showed lesions in the inferior pubic ramus and ischial bone on the left side.With interdisciplinary co-operation it was possible to make the exact diagnosis of CRMO in all three female patients, and the disease was successfully managed. A precise therapeutic procedure could be derived from the results of randomised controlled studies which, however, cannot be made because of an infrequent occurrence of this disease. A meta-analysis of the cases so far published in the literature would be a more likely option.

Radionavigated detection of sentinel nodes in breast carcinoma--first experiences of our department.

INTRODUCTION: Biopsy and histological evaluation of sentinel lymphatic node limits the axillary node dissection only in cases of positive histological finding and decreases the occurrence of postoperative complications related to the axillary node dissection. METHODS: We used radiotracer SentiScint, Medi-Radiopharma Ltd, Hungary and preoperatively administered blue dye--Blue Patenté V, Guebert, Aulnay-Sous-Bios, France. 11 (18%) patients were subdued to deep peritimorous application of radiotracer, 10 (16.4%) to sub/intradermal application over the lesions and n 40 (65.6%) patients the application was sub/intradermal and periareolar. The patients underwent an operation protocol of corresponding quadrantectomy, radionavigated blue-dye sentinel node biopsy and axillary dissection. RESULTS AND CONCLUSIONS: From May 2006 to June 2008, we examined 61 patients with breast carcinoma. They underwent radionavigated and blue-dye sentinel node biopsy. We detected 57 (93.4%) sentinel nodes with preoperative scintigraphy, of which only 51 (83.6%) were detected peroperatively and underwent histological evaluation. In six (9.8%) cases, the "frozen cut" histology of the primary lesion had shown a benign lesion; hence no sentinel node biopsy or axillary disection was performed. 12 (19.7%) of 51 histologically evaluated sentinel nodes had metastatic invasion. We retrospectively compared the histological fund in sentinel and axillary nodes in patients with metastatic sentinel nodes. In 6 (16.6%) cases, the sentinel node was positive of metastatic invasion but axillary nodes were histologically negative, in 6 (16.6%) cases the sentinel node and axillary nodes were positive for metastatic invasion. We observed falsely negative findings in 3 (8.3%) patients with negative histological fund in the sentinel node, but positive axillary nodes (Tab. 3, Fig. 2, Ref. 11). Full Text (Free, PDF) www.bmj.sk.

MR imaging of late radiation therapy- and chemotherapy-induced injury: a pictorial essay.

Radiation to the brain and adjuvant chemotherapy may produce late delayed changes from several months to years after treatment of intracranial malignancies with a reported prevalence of 5-24%. The pattern of treatment-related injury may vary from diffuse periventricular white matter lesions to focal or multifocal lesions. Differentiation of treatment-related injury from tumor progression/recurrence may be difficult with conventional MR imaging (MRI). With both disease processes, the characteristic but nonspecific imaging features are vasogenic edema, contrast enhancement, and mass effect. This pictorial essay presents MRI spectra of late therapy-induced injuries in the brain with a particular emphasis on radiation necrosis, the most common and severe form. Novel MRI techniques, such as diffusion-weighted imaging (DWI), proton MR spectroscopy (MRS), and perfusion MRI, improve the possibilities of better characterization of treatment-related changes. Advanced MRI techniques allow for the assessment of metabolism and physiology and may increase specificity for therapy-induced changes.

Post-therapeutical changes in the brain: novel trends in imaging and their infuence on external beam radiotherapy.

UNLABELLED: Presented is the analysis of patients who underwent external beam radiotherapy (EBRT) to the brain in the period from 2003 to 2006 at the department of Radiation Oncology of the St. Elisabeth Cancer Institute.

The aim of our analysis was to identify risk factors of late delayed therapy induced injuries (LDTI) in the brain. The patients were regularly examined with magnetic resonance (MRI), including conventional and advanced techniques: perfusion imaging (pMRI), diffusion weighted imaging (DWI), MRI spectroscopy (MRS). The results from MRI were correlated with 18fluoro-deoxyglucose positron emission tomography (18FDG/PET) scans, as none of the listed method is sufficiently sensitive and specific by itself. Also clinical data records and treatment plans of these patients were analyzed.

In our cohort we found 6 patients with abnormal post-therapeutical changes, 4 of them with MR and 18FDG/PET scans characteristics for LDTI - radiation necrosis. In one patient biopsy was performed and radiation necrosis (RN) was confirmed.

[Symptomatic Meckel's diverticulum in children]. / Symptomatický Meckelov divertikul u detí.

Meckel's diverticulum (MD) is the most frequent anomaly of the small intestine, usually asymptotic. Complications of MD in children are usually bleeding and inflammation. Signs are non specific and diagnostics is prolonged. Scintigraphy is the method for the verification of bleeding from MD. A positive finding is the indication for exploration using laparoscopic or classic approach. In patients with bleeding of the MD, the literature presents, that there is usually gastric mucosa. The authors present patients with bleeding and the microscopic picture of the MD was intestinal mucosa with bleeding.

Epinephrine producing pheochromocytoma. Is the secretory pattern decisive for the clinical manifestation?

Adrenal incidentalomas are becoming a major clinical problem, due to increasingly frequent radiological examinations. We present two cases of patients referred to our department with a finding of an unsuspected adrenal mass. Both of them were normotensive and without symptomatology typical for pheochromocytoma. In one patient we found 20-times higher levels of epinephrine and 3-times higher levels of dopamine in 24-h urine, in the second patient there were 8-times higher levels of epinephrine alone. Norepinephrine in urine, as well as values of all adrenal cortical hormones were normal. The diagnosis of pheochromocytoma was confirmed in both cases by a 123I-metaiodobenzylguanidine (MIBG) scintigraphy. The patients underwent adrenalectomy, which was performed without complications. We conclude that levels of single catecholamines excreted are decisive for the clinical presentation of pheochromocytoma. Epinephrine producing pheochromocytoma is more often oligo- or asymptomatic. We stress the importance of a complete hormonal screening in every case of adrenal incidentaloma, with measuring levels of catecholamines and/or metanephrines.

The occurrence of malignant carcinoid syndrome in patients with carcinoid tumors.

BACKGROUND: The carcinoid syndrome occurs in about 10% of patients with carcinoid tumors. OBJECTIVES: The main objective of the present study was to determine the presence of the carcinoid syndrome in a group of patients with carcinoid tumor. SUBJECTS AND METHODS: 35 pts with carcinoid tumors (group A--24 pts with metastatic disease, group B--11 pts after resection of the primary tumor with no metastases detected at the time of the investigation) were included into the study. The localisation and the diameter of the primary tumor were ascertained. Somatostatin receptor scintigraphy--Octreoscan and echocardiography were done. The urinary excretion of 5-HIAA was performed. We estimated the presence of the carcinoid syndrome in all patients. RESULTS: We confirmed the difference in the diameter of the primary carcinoid tumor in patients with metastases--group A 3.0 (2.5-4.2) cm by comparison with group B 0.7 (0.6-0.8) cm, (p < 0.001). Patients in the metastatic group are older 64 year (42-70) than pts without metastases--33 y (20-54) (p < 0.01). The amount of the 5-hydroxyindolacetate acid in urine in pts with metastatic carcinoid was statistically significantly higher than in the pts without metastases (p < 0.001). The carcinoid syndrome in the metastatic group was found in 6 patients (25%), with maximum (12.5%) localised in midgut. Out of the whole sample it counts up to 15.1%. During the follow up period, 8 patients from group A died. CONCLUSION: The large diameter of the primary carcinoid tumor and the higher age are the bad prognostic factors in patients with carcinoid tumors. (Tab. 4, Ref. 27.)

Malignant carcinoid in two brothers.

Familial occurrence of malignant carcinoid is rare (about 3%). Authors describe occurrence of the malignant carcinoid in two brothers. In the older one the diagnosis was estimated in 1991. He had multiple intestinal carcinoid tumor with multiple liver metastases histological type III by Soga classification. Patient is intermittently treated with somatostatin analogue--lanreotid and with interferon alfa. By this therapy the disease is stabile. In the younger of brothers the diagnosis was estimated in 1999. The disease had rapid progression and in ten months patient died despite of the therapy. Definitive diagnosis was a malignant neuroendocrine tumor of pancreas-mixed low differentiated carcinoid with calcitonin overproduction. (Fig. 4, Ref. 15.)

[Malignant fibrous histiocytoma of the hand]. / Malígny fibrózny histiocytóm ruky.

Most soft tissue sarcomas are malignant tumors of the mesodermal tissue of the head and neck, trunk, retroperitoneum or extremities, although neurosarcomas and primitive neuroectodermal tumors are of ectodermal origin. Soft-tissue sarcomas of the upper extremity constitute 14% of all soft-tissue sarcomas, they are one third as common as those of the lower extremity. A case of patient with malignant fibrous histiocytoma of the fourth finger of the left hand is presented. (Tab. 2, Fig. 10, Ref. 15.)

[Octreotide in the treatment of thyrotropin-secreting pituitary adenomas]. / Oktreotid v liecbe tyreotropín secernujúcich adenómov hypofýzy.

The authors detected in a 30-year-old patient a very rare type of hyperthyroidism caused by a thyrotropin secreting pituitary adenoma. Scintigraphic examination of the pituitary by means of 111In radiolabelled octreotide revealed an increased accumulation of the radiopharmaceutical preparation in the tumour, which confirmed the high density of somatostatin receptors. After onset of octreotide treatment (Sandostatin, Sandoz, Switzerland) 3 x 100 ug/day by the s.c. route a brisk decline and normalization of thyrotropin already after the first dose was recorded. The thyroxine concentration declined slowly to the upper range of normal values. After 5 months treatment despite the positive response to receptor scintigraphy diminution of the adenoma was not recorded. Again an increase of thyrotropin above the upper limit of the reference range and a marked rise of thyroxinaemia were observed. Six months after radical selective trans-sphenoidal adenomectomy normal pituitary function was confirmed.

[Thyrotropin-secreting adenomas of the hypophysis]. / Tyreotropín secernujúce adenómy hypofýzy.

Thyrotropin secreting pituitary adenomas are scarce. They may cause an extremely rare form of hyperthyroidism. The diagnosis is often delayed because the clinical symptoms are attributed to common types of hyperthyroidism. The diagnosis involves detection of elevated or normal (unsuppressed) thyrotropin levels in hyperthyroid patients and evidence of a pituitary adenoma by computed tomography or magnetic resonance imaging. The thyrotropin response in the thyrotropin-releasing hormone test is either absent or insufficient. When the pituitary microadenoma appears to be undetectable, the familiar syndrome of selective pituitary resistance to thyroid hormones has to be excluded. Treatment involves extirpation of the tumour. If the macroadenoma is not removed completely, external radiotherapy of the pituitary follows. If this conventional treatment does not produce an adequate effect, treatment with long-acting somatostatin analogues is recommended.

[Gammagraphic imaging of pheochromocytoma using 131I-metaiodobenzylguanidine]. / Gamagrafické zobrazenie feochromocytómu 131I-metajodobenzylguanidínom.

The authors present their first experiences with scintigraphic examination of pheochromocytoma by means of 131I-metaiodobenzylguanidine (MIBG). In two of the eight patients examined, the already established diagnosis of pheochromocytoma and paraganglioma was confirmed, in two the examination yielded confirmation of the presumed diagnosis, and in the remaining four patients presence of the tumor was excluded. In conformity with literary data, the authors found the given examination to be suitable for: 1. confirming the diagnosis of pheochromocytoma in cases with unequivocal CT findings, 2. excluding extraadrenal activity, 3. detecting relapses or the occurrence of an extraadrenal tumor, 4. detecting not suspect manifold endocrine neoplasias, 5. establishing the diagnosis of malignant pheochromocytoma, and 6. for examining patients presenting with a family history of pheochromocytoma.

[Arteriography, lymphography, gammagraphy and computer tomography in the diagnosis of musculoskeletal tumors]. / Artériografia, lymfografia, gamagrafia a pocítacová tomografia v diagnostike muskuloskeletárnych nádorov.

The authors emphasize the importance of early and exact diagnosis of musculoskeletal tumours of the extremities and spine. This aim cannot be achieved by common biochemical, haematological and X-ray examinations. Therefore the authors recommend to use already during the initial examination of the patient a combination of classical roentgenography, arteriography, possibly lymphography, gammagraphy and computed tomography. The authors present a detailed account of experience with the application of the above diagnostic methods in 146 patients. On arteriograms of 37 patients dislocated main arteries were found 16 times, blood lakes 20 times. Lymphography revealed metastatic affection of regional lymph nodes in 21% of all patients, most frequently in bone reticulosarcoma and in synovial sarcoma. All-body gammagraphy helped to make the localization and assessment of size of the tumour more accurate, in two-thirds of the patients it was larger when visualized by this method than on native roentgenograms. In 3 of 14 Ewing sarcomas all-body gammagraphy revealed a polyostotic localization of the tumour. Computed tomography revealed the extent of infiltration and destruction of bone and soft tissues in pelvic and spinal tumours.

Radioimmunoscintigraphy of human malignant melanoma. I. Pharmacokinetics and localization of 125I-labeled monoclonal antibody RG-12 in thymectomized mice bearing renal melanoma xenotransplants.

The novel RG-12 monoclonal antibody (MoAb) recognizing a high-molecular-weight antigen of human melanoma cells was radioiodinated and its biodistribution and tumor imaging was determined in immunosuppressed mice bearing xenografted human malignant melanoma HMB-2. Control and tumor-bearing mice were injected with 6 micrograms of 125I-labeled RG-12 IgG (8.9 MBq 125I-IgG/animal). Clearance of the MoAb from plasma had a mean half life of 20.6 hours. At day 2 after injection, radiolabeled RG-12 IgG localized in the tumor was 1.43% of the injected dose bound per gram tissue (ID/g), whereas the localization in the healthy kidney was below 0.5%. Tumor to tissue ratio of MoAb accumulation was low for hepatic tissue (1.25) but high for spleen (3.30) and kidney (3.25), respectively. Scanning with a gamma camera localized tumor mass in the right kidney and implanted peritoneal metastases.

The status of nuclear medicine techniques in the diagnosis of bone metastases in breast cancer.

In this article, the authors present their experience with the diagnosis of bone metastases in patients with breast cancer using bone scintigraphy with 99mTc phosphonate and radioimmunological determination of carcinoembryonic antigen (CEA) and tissue polypeptic antigen (TPA). In a group of 395 patients, there was agreement between tumour markers (CEA, TPA) and the results of bone scintigraphy in 331 cases (84%)--negative in 193 cases (49%) and positive (i.e. in terms of bone scintigraphy results and the presence of at least one tumour marker) in 138 cases (35%). On the basis of this good agreement of the results between bone scintigraphy and CEA and TPA levels, the authors recommend the following algorithm in monitoring patients with breast cancer: follow-up of tumour markers at several-month intervals and, any increase in their levels will refer the patient to further examination using imaging techniques including bone scintigraphy.

Significance of carcinoembryonic and tissue polypeptide antigen determination in the diagnosis of metastases in breast cancer.

A radioimmunological assay of CEA and TPA levels in breast cancer patients revealed a 93.7% concordance of negative and 93.4% of positive values with the clinical activity of the disease. In 26 out of a group of 38 patients (68.4%) with progressive breast carcinoma, an enhanced CEA and TPA level was the first indicator of the presence of metastases. In view of the results obtained, the authors consider this procedure to be a suitable method for monitoring and early detection of metastases in patients with breast cancer.