Resection of ectopic mediastinal parathyroid glands with the da Vinci robotic system.

BACKGROUND: Mediastinal ectopic parathyroid adenoma is a frequent cause of persistent or recurrent hyperparathyroidism, traditionally treated by open surgery. Thoracoscopic access is associated with reduced morbidity in mediastinal surgery. The aim of this study was to evaluate the feasibility and effectiveness of robot-assisted dissection for mediastinal ectopic parathyroid glands. METHODS: Two patients with recurrent secondary hyperparathyroidism and three with complicated primary hyperparathyroidism were operated on between July 2004 and August 2008 for ectopic mediastinal parathyroid glands. Fusion of single-photon emission computed tomography and computed tomography led to an exact identification of the culprit glands. Surgery was performed thoracoscopically with the da Vinci robotic system using a three-trocar approach. RESULTS: All procedures were completed successfully with the robotic system. No perioperative morbidity or mortality was noted. Median operating time was 58 (range 42-125) min. Intraoperative parathyroid hormone reduction indicated complete resection. Median hospital stay was 3 (range 2-4) days. CONCLUSION: Robot-assisted dissection is a promising approach for resection of ectopic parathyroid glands in remote narrow anatomical locations such as the mediastinum.

[Imaging techniques in rheumatology: PET in rheumatology]. / Bildgebende Verfahren in der Rheumatologie : PET in der Rheumatologie.

Positron emission tomography (PET) using F-18-fluoro-deoxyglucose (FDG) is suitable for many indications in oncology and can also be used in rheumatology to search for inflammatory foci and benign lesions with increased glucose metabolism in, for example soft tissue and joints (arthritis, vasculitis etc.) and fever of unknown origin. Usually a whole-body scanning technique is used for data acquisition in the search for foci of unknown localization or for the characterization of glucose metabolism of one or more known lesions - also for observation of the effect of, for example pharmacotherapy. Patients are admitted under fasting conditions and acquisition starts 1 h after i.v. injection of FDG with an acquisition time of 30-60 min. The method is sensitive and can measure glucose metabolism in an objective manner, but is not specific for inflammatory diseases (FDG also accumulates in malignant diseases).

[Radiation exposure in (90)Y-Zevalin therapy: results of a prospective multicentre trial]. / Strahlenexposition bei der (90)Y-Zevalin-Therapie: Ergebnisse einer prospektiven multizentrischen Studie.

UNLABELLED: AIM of this study was the assessment of the radiation exposure from preparation and application of (90)Y-Zevalin, the measurement of the dose rate at the patient, the exposure of family members as well as the determination of the activity concentration in urine of patients. METHODS: Overall data from 31 therapeutic administrations carried out in four institutions were evaluated. During preparation and application of (90)Y-Zevalin the finger exposures of radiochemists, technicians, and physicians were measured. The dose rate of the patient was measured immediately after radioimmunotherapy. In patients treated in a nuclear medicine therapy unit, urine was collected over a two day period and the corresponding activity was determined. Family members of outpatients were asked to wear a dosimeter over a seven day period. RESULTS: During the preparation we found a maximum skin dose of 6 mSv at the average, and during application of 3 mSv, respectively. After administration of (90)Y the dose rate was 0.4 +/- 0.1 microSv/h at 2 m distance. Urine measurements yielded a cumulated 24 h excretion of 3.9 +/- 1.4% and 4.4 +/- 1.4% within 48 h, respectively, that is equivalent to 43 +/- 18 and 50 +/- 20 MBq of (90)Y, respectively. Family members received a radiation exposure of 40 +/- 14 microSv over seven days. CONCLUSION: During preparation and application of (90)Y-Zevalin appropriate radiation shielding is necessary. For family members as well as nursing staff no additional special radiation protection measures beyond those being common for other nuclear medicine procedures are necessary.

[Imaging methods in rheumatology: imaging in psoriasis arthritis (PsA)]. / Bildgebende Verfahren in der Rheumatologie: Bildgebung bei der Psoriasisarthritis (PsA).

Conventional radiography is still the standard method of imaging in PsA since it displays many joints at the same time, thereby allowing different types of joint involvement to be recognized. Moreover, thanks to the high resolution of radiography, bony changes in a single joint are depicted in a brilliant way. Several features of psoriatic arthritis allow the distinction from rheumatoid arthritis, including the frequent involvement of the distal interphalangeal joints, asymmetry of joint involvement, axial involvement of finger joints, oligoarticular involvement; however, symmetric polyarthritis is also possible. At the level of the single joint, there are signs of severe destructive changes potentially leading to mutilation and at the same time signs of periostal bone proliferation and ankylosis may be present. Bony proliferation and/or osteolysis are not restricted to the joint region but can affect also the total phalanx with bone apposition or concentric osteolysis which may lead to a complete disappearance of phalanxes. For purposes of quantification of radiographic changes scoring methods are used that were originally developed for rheumatoid arthritis. So far, there is only one validated scoring method that was specifically designed for PsA and that takes into account both features of PsA, damage as well as proliferation of bone. In contrast to conventional radiography, MRI and sonography are able to visualize inflammatory processes within the soft tissue (joint capsules, tendon sheaths, tendon insertions, etc.), allowing an estimation of disease activity. Scintigraphy is nonspecific and can only be used to detect clinically silent inflammatory spots. The relatively frequent spinal (axial) involvement is similar to that seen in ankylosing spondylitis. However, unilateral sacroiliitis, asymmetry of syndesmophytes and development of parsyndesmophytes may distinguish PsA from ankylosing spondylitis. While conventional radiography demonstrates the bony consequences of inflammation in the spine, MRI also shows the active inflammatory changes in sacroiliacal joints and vertebrae.

Allogeneic hematopoietic cell transplantation following conditioning with 90Y-ibritumomab-tiuxetan.

Radioimmunotherapy (RIT) of relapsed lymphoma is gaining increasing importance. Especially the commercially available anti-CD20 antibody 90Y-ibritumomab tiuxetan is currently under investigation in various trials including dose escalation and autologous hematopoietic progenitor cell support. It is not clear, however, whether the implementation of this radiolabeled antibody into another treatment option for relapsed or poor risk lymphoma patients-allogeneic hematopoietic cell transplantation-interferes with or delays successful engraftment. This study reports encouraging results with 2 relapsed lymphoma patients (1 transformed marginal zone lymphoma and 1 mantle cell lymphoma) who underwent allogeneic hematopoietic cell transplantation from HLA-matched donors. The conditioning regimen consisted of Rituximab 250 mg m(-2) on days -21 and -14, 0.4 mCi kg(-1) body weight 90Y-ibritumomab tiuxetan on day -14 and fludarabine (30 mg m(-2)) plus cyclophosphamide (500 mg m(-2)) on days -7 to -3. The data demonstrate that engraftment is fast and reliable with leukocytes >1 x 10(9) L(-1) on day 12 and platelets >50 x 10(9) L(-1) on day 10. Thus, the incorporation of radioimmunotherapy into allogeneic transplant protocols combines established modalities with proven anti-lymphoma activity and, hence, offers an attractive new therapeutic option for relapsed lymphoma patients.

Scintigraphic results in patients with lung transplants: a prospective comparative study.

AIM: We addressed the feasibility of scintigraphy in the postoperative monitoring of lung transplants. METHOD: 37 patients (22 women, 15 men, 37 +/- 15 years) in good clinical condition were examined after lung transplantation. Scintigraphic procedures for assessing ventilation (133Xe), perfusion (99mTc microspheres) and aerosol-inhalation (99mTc aerosol) were performed for all patients. The findings were compared with those of established diagnostic modalities. RESULTS: All lung transplants showed homogeneous ventilation but with a non-physiologic difference of over 20% between both pulmonary lobes in one-third of the cases. There was a difference between the impairement of perfusion and ventilation in the presence of an impaired Euler-Liljestrand reflex in 14/37 (38%) patients. Furthermore, bronchoscopy and aerosol-inhalation scans often did not correlate, e. g. a bronchoscopically evident stenosis was not necessarily associated with an increased activity, and vice versa. Although peripheral mucociliary clearance was preserved after transplantation, stasis in central airways resulted in significantly impaired global clearance. CONCLUSION: Ventilation and perfusion scintigraphy reveal in a significant number of lung recipients pathologic findings and therefore can be recommended for postoperative monitoring. From a clinical point of view aerosol-inhalation scintigraphy (clearance) is not of any additional value.

[Imaging techniques in rheumatology: scintigraphy in rheumatoid arthritis]. / Bildgebende Verfahren in der Rheumatologie: Szintigraphie bei rheumatoider Arthritis.

Bone scintigraphy is an important tool for staging and follow-up in patients with rheumatoid arthritis, and is part of the training for board certified physicians in nuclear medicine in Germany. Bone scintigraphy uses the accumulation of i.v. injected technetium-99m labeled phosphonates imaged with a gamma camera. Different phases can be defined: perfusion phase (0-60 s p. i.), blood pool phase (2-5 min p. i.), and bone (turnover) phase (2-5 h p. i.). The blood pool phase allowes judgement of inflammatory (soft tissue) components of joint disease ("arthritis"), the bone (turnover) phase of longer lasting bone processes ("arthrosis"). The technical details including documentation of the scintigraphic results are presented according to the procedure guidelines of the German Society of Nuclear Medicine (www.nuklearmedizin. de).

Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints.

OBJECTIVE: To carry out a prospective two year follow up study comparing conventional radiography, three-phase bone scintigraphy, ultrasonography (US), and three dimensional (3D) magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examination in detecting early arthritis. The aim of the follow up study was to monitor the course of erosions during treatment with disease modifying antirheumatic drugs by different modalities and to determine whether the radiographically occult changes like erosive bone lesions of the finger joints detected by MRI and US in the initial study would show up on conventional radiographs two years later. Additionally, to study the course of soft tissue lesions depicted in the initial study in comparison with the clinical findings. METHODS: The metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints (14 joints) of the clinically more severely affected hand (soft tissue swelling and joint tenderness) as determined in the initial study of 49 patients with various forms of arthritis were examined twice. The patients had initially been divided into two groups. The follow up group I included 28 subjects (392 joints) without radiographic signs of destructive arthritis (Larsen grades 0-1) of the investigated hand and wrist, and group II (control group) included 21 patients (294 joints) with radiographs showing erosions (Larsen grade 2) of the investigated hand or wrist, or both, at the initial examination. RESULTS: (1) Radiography at the two year follow up detected only two erosions (two patients) in group I and 10 (nine patients) additional erosions in group II. Initial MRI had already detected both erosions in group I and seven (seven patients) of the 10 erosions in group II. Initial US had depicted one erosion in group I and four of the 10 erosions in group II. (2) In contrast with conventional radiography, 3D MRI and US demonstrated an increase in erosions in comparison with the initial investigation. (3) The abnormal findings detected by scintigraphy were decreased at the two year follow up. (4) Both groups showed a marked clinical improvement of synovitis and tenosynovitis, as also shown by MRI and US. (5) There was a striking discrepancy between the decrease in the soft tissue lesions as demonstrated by clinical findings, MRI, and US, and the significant increase in erosive bone lesions, which were primarily evident at MRI and US. CONCLUSIONS: Despite clinical improvement and a regression of inflammatory soft tissue lesions, erosive bone lesions were increased at the two year follow up, which were more pronounced with 3D MRI and less pronounced with US. The results of our study suggest that owing to the inadequate depiction of erosions and soft tissue lesions, conventional radiography alone has limitations in the intermediate term follow up of treatment. US has a high sensitivity for depicting inflammatory soft tissue lesions, but dynamic 3D MRI is more sensitive in differentiating minute erosions.

[Imaging in rheumatology]. / Bildgebende Verfahren in der Rheumatologie.

SUMMARY: Conventional radiography, ultrasonography, scintigraphy, computed tomography, and magnetic resonance imaging (MRI) are important diagnostic tools in rheumatology additional to clinical investigation. Radiography provides information both of the juxtaarticular and the abarticular bone. It is relevant in the diagnosis of rheumatoid arthritis, osteoarthritis, spondylarthropathies, and osteoporosis, and for the investigation of other regions like the thorax. Sonography is superior to radiography to delineate soft tissue structures such as effusions, tenosynovitis, tendinitis, paratendinitis, bursitis, and soft-tissue tumors, but also to evaluate bone surfaces. It helps to perform injections and punctures. Furthermore it is a new diagnostic tool for the diagnosis of temporal arteritis, Takayasu's arteritis, and Sjögren's syndrome. Echocardiography, abdominal and pleural sonography are also frequently used. MRI is useful to detect soft tissue lesions and bone lesions. It is helpful to depict synovial membrane, tendon, tendon sheaths, ligaments, cartilage, destructive joint processes, and rupture of synovial cysts. MRI is an established imaging technique in diagnosis of sacroiliitis and cervical arthritis as well as in diagnosis of osteonecrosis. It is an important diagnostic modality for demonstrating early arthritis. MRI is also of interest in diagnosis of neurological disorders of connective tissue diseases or vasculitis in rheumatology. Bone scintigraphy is an established imaging technique in diagnosis of skeletal diseases as well as in diagnosis of tumors. "Hot spots" are seen in locations of high bone turn over. Scintigraphy is also helpful to localize or exclude inflammation.

Imaging of low-grade bone infection with a technetium-99m labelled monoclonal anti-NCA-90 Fab' fragment in patients with previous joint surgery.

Low-grade bone infection represents a serious clinical problem. Diagnostic options are often insufficient, yet the therapeutic implications of proven disease are important, especially in patients with prosthetic joint replacement. Technetium-99m labelled monoclonal anti-NCA-90 granulocyte antibody Fab' fragment (MN3 Fab') has been shown to be useful in bone and joint infection, but there are no data specifically referring to low-grade bone infection. We therefore analysed 38 scans in 30 consecutive patients (age range, 30-85 years; median age, 62 years) referred for suspected low-grade bone infection. There were 17 patients (21 scans) with total hip arthroplasty (THA), six with total knee arthroplasty (TKA), three who had undergone hip or knee surgery for trauma and five (seven scans) with resected hips and no endoprostheses (Girdlestone situations); one of these five patients had been investigated before with THA in situ and another prior to surgery for low-grade coxitis. There were no patients with rheumatoid arthritis as the underlying disease. Results were verified by means of bacteriological cultures, histopathological findings and/or follow-up and compared with the respective Zimmerli scores, which were used for clinical assessment of inflammatory activity. In one patient, the final diagnosis could not be established. One, 5 and 24 h after intravenous injection of up to 1.1 GBq of MN3 Fab', whole-body and planar scans were performed using a dual-head gamma camera. Scans were analysed visually and semiquantitatively adopting an arbitrary score ranging from 0 to 3. There were 13 true positive, 14 true negative and 10 false positive outcomes, yielding an overall sensitivity of 100%, an overall specificity of 58%, an accuracy of 73% and positive and negative predictive values of 57% and 100%, respectively. In patients with THA or TKA, accuracy was 81% and 80%, respectively, while it dropped to 43% in patients with Girdlestone situations owing to a high proportion of false positive findings (4/7) in this subgroup. Scintigraphic score was 1 in all of the false positive and in 11/13 true positive findings. The two remaining true positive findings displayed scintigraphic scores of 2 and 3, respectively. Scintigraphic and Zimmerli scores were loosely correlated (Spearman rho=0.38, P<0.05). Infection was excluded in 22/24 investigations with Zimmerli scores of <6. In this group, there were 13 scintigraphically true negative, nine false positive outcomes, and just two true positive outcomes. In 11/12 investigations with Zimmerli scores of 6 or 7, infection was verified and scintigraphic outcome was accordingly true positive, while the remaining patient was true negative. In conclusion, MN3 Fab' scintigraphy proved to be highly sensitive but not specific in diagnosing low-grade infections of the hip and knee regions in patients with previous joint surgery. The method seems reliable in excluding but not in proving the presence of infection. MN3 Fab' scintigraphy should not be applied in patients with Girdlestone situations. Assessment of infection using the Zimmerli score was more reliable than MN3 Fab' scintigraphy in this group of patients without rheumatoid arthritis as the underlying disease. Considering results from the literature concerning leucocyte scintigraphy, MN3 Fab' scintigraphy may be clinically useful in evaluating low-grade bone infection in THA and TKA patients with Zimmerli scores above 5 and concomitant rheumatoid arthritis or other inflammatory diseases.

Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging.

OBJECTIVE: A prospective study was performed comparing conventional radiography, 3-phase bone scintigraphy, ultrasound, and magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examinations in 60 patients with various forms of arthritis including rheumatoid arthritis (RA), spondyl-arthropathy, and arthritis associated with connective tissue disease. METHODS: A total of 840 finger joints were examined clinically and by all 4 imaging methods. Experienced investigators blinded to the clinical findings and diagnoses analyzed all methods independently of each other. The patients were divided into 2 groups. Group 1 included 32 patients (448 finger joints) without radiologic signs of destructive arthritis (Larsen grades 0-1) of the evaluated hand and wrist and group 2 included 28 patients (392 finger joints) with radiographs revealing erosions (Larsen grade 2) of the evaluated hand and/or wrist. RESULTS: Clinical evaluation, scintigraphy, MRI, and ultrasound were each more sensitive than conventional radiography in detecting inflammatory soft tissue lesions as well as destructive joint processes in arthritis patients in group 1. All differences were statistically significant. We found ultrasound to be even more sensitive than MRI in the detection of synovitis. MRI detected erosions in 92 finger joints (20%; 26 patients) in group 1 that had not been detected by conventional radiography. CONCLUSION: Our data indicate that MRI and ultrasound are valuable diagnostic methods in patients with arthritis who have normal findings on radiologic evaluation.

Scintigraphic localization of lymphatic leakage site after oral administration of iodine-123-IPPA.

UNLABELLED: Chylothorax can occur secondary to traumatic lesions of the thoracic duct caused by chest injuries, surgical procedures involving the pleural space, neoplasms or malformations of the lymphatics. METHODS: Lymphatic leakage sites were localized by scintigraphy after oral administration of the 123I-labeled long-chain fatty acid derivative iodophenyl pentadecanoic acid (IPPA). We report on three patients with different lymphatic leakage sites and on one normal control subject. RESULTS: IPPA scintigraphy localized the lymphatic leakage site correctly in all three patients. In two of them, the method even guided the successful surgical treatment of the leakage. CONCLUSION: This approach is suitable for detecting lymphatic leakages of intestinal origin.

Changes in perfusion pattern using ECD-SPECT indicate frontal lobe and cerebellar involvement in exercise-induced paroxysmal dystonia.

The clinical features of exercise-induced paroxysmal dystonia (EPD) are delineated in a pedigree including two affected members (both male) showing an autosomal-dominant inheritance trait. Gait analysis using kinematic electromyography during the motor attacks revealed coactivation of antagonistic calf muscles characteristic of dystonia. In the interval, impaired muscular alternation was observed. To characterize further the pathophysiological basis of the condition, ictal and interictal cerebral perfusion SPECT studies using technetium 99m-ethyl cysteinate dimer (ECD) were performed to establish whether cortical hyperactivity indicative of epilepsy is present during the motor attacks and to identify regional changes in the ictal perfusion pattern that could indicate an anatomic structure relevant to the disease. During the motor attacks, decreased ictal perfusion of the frontal cortex was found in both patients. In contrast, increased cerebellar perfusion was observed. The perfusion of the basal ganglia also decreased. No cortical hyperperfusion indicative of an epileptic nature was seen. Cerebellar hyperactivity in connection with prominent frontal hypoactivity has also been described in both the idiopathic and the symptomatic forms of dystonia. Our findings therefore suggest that EPD represents a paroxysmal movement disorder rather than epilepsy. It is concluded that changes in frontal and in cerebellar function are relevant to the pathophysiology of EPD.

[Does the pouch modify food transit after gastrectomy?]. / Beeinflusst der Pouch den Nahrungstransit nach Gastrektomie?

A prospective, randomized study of patients with gastric cancer was performed to examine whether or not the jejunal pouch interposition between esophagus and duodenum after gastrectomy is of importance. At fixed postoperative times, standardized scintigraphic measurements were performed; the quality of life was evaluated by the EORTC quality of life questionnaire. Our findings suggest that interposition of a jejunal pouch reservoir between esophagus and duodenum may be due to a prolonged transit time and a better quality of life.

Somatostatin receptor scintigraphy in the staging of lymphomas.

In this prospective study we evaluated the somatostatin receptor scintigraphy in the initial staging of 19 patients suffering from Hodgkin's (HD) and non-Hodgkin's lymphomas (NHL) and in the restaging of 16 patients. Scintigraphy was compared to the results of the methods applied for adequate staging of lymphoma patients in the large multicentre trials. Planar imaging and SPECT was performed after intravenous injection of 110 or 220 MBq of 111In-pentetreotide. The patient-based analysis yielded an overall sensitivity of 88%, contrasting lesion-based sensitivities of 57%, 35%, and 43% in HD, low-grade NHL and high-grade NHL, respectively. The best results were obtained in the head-and-neck region and the worst in the abdomen (sensitivities of 61% and 24%, respectively). Bone marrow infiltration was visible in 1/12 cases only. There was no significant difference between the outcomes of patients in the initial staging and restaging and no influence of the amount of injected radiopharmaceutical on the results. In terms of the Ann-Arbor classification, 10/35 patients were concordant whereas 22 were understaged and 3 overstaged scintigraphically. In conclusion, somatostatin receptor scintigraphy is not useful in the initial staging or restaging of malignant lymphomas, especially NHL, due to low lesion detection rates most probably because of low receptor densities. In addition, intraindividual heterogeneity of somatostatin receptor expression has to be considered.

Leakage measurement during selective limb perfusion using a gamma probe.

The objective of this study was to establish a probe system for intraoperative quantitative leakage measurement during selective limb perfusion for adjuvant high-dose chemotherapy in patients with malignant melanomas. We used a portable gamma probe with digital display and investigated the physical properties in a phantom study simulating blood pool activity at different angles of the probe to the surface and different distances. In 20 patients the limb circulation was surgically separated from the systemic blood circulation, and the limb was then selectively perfused (cytostatics added) for 60 min. Initially, 15 MBq technetium-99m labelled autologous red blood cells was injected into the limb circulation, and an equal amount was kept as a standard. Every 10 min, blood samples were drawn from the body circulation and count rates were simultaneously measured by the probe system at the lower end of the sternal body. At the end of perfusion, the circulation of the limb was reconnected, the standard injected into the systemic circulation, and a blood sample drawn after 10 min. All blood samples were counted for calculation of leakage in terms of percent of the injected dose, and the results compared with the intraoperative count rates of the probe system. In the range of leakage observed in this study (0%-86%), the count rate of the probe system (corrected for blood volume, i.e. for body surface) correlated with the results of conventional measurement (r=0.92) according to the equation: %leakage=counts per sx[1.2xbody surface (m2)-1.19]. In conclusion, the use of the described probe system is a feasible approach for leakage quantification which continuously yields data during selective limb perfusion.

Immunoscintigraphy for the detection of brain abscesses.

The aim of this prospective study was to assess the diagnostic usefulness of a 99Tcm-anti-granulocyte antibody in the early differentiation of the aetiology of a ring-enhancing structure on computed tomography (CT) scans following neurosurgical intervention. In 26 patients (15 males, 11 females) aged 20-82 years with suspected intracranial infection, 29 SPET scans of the head were obtained 4-6 h following the intravenous injection of 555 MBq 99Tcm-anti-granulocyte antibody. The patients had antibiotic, antimycotic or corticosteroid therapy. The diagnosis was confirmed by surgery (19 cases) or subsequent CT/MRI (magnetic resonance imaging) scans and clinical follow-up (10 cases). The immunoscan was true-positive (abscess) in 6 (sensitivity = 100%), true-negative in 19 and false-positive in 4 (specificity 83%) cases. There was no obvious detrimental effect on the results due to the antibiotic, antimycotic or corticosteroid therapy. In conclusion, despite false-positive results, the 99Tcm-anti-granulocyte antibody is a useful tool in the early detection and exclusion of intracranial abscess after neurosurgical interventions.