Localization of parathyroid tumours in the minimally invasive era: which technique should be chosen? Population-based analysis of 253 patients undergoing parathyroidectomy and factors affecting parathyroid gland detection.

A series of 253 consecutive patients with proved primary hyperparathyroidism due to parathyroid tumours was reviewed. There were 68 (26.9%) men and 185 (73.1%) women, with a median age of 57 years (range 13-82 years). All patients, prior to successful parathyroidectomy, underwent one or more preoperative localization procedures such as: neck ultrasonography (US) in 191 (75.5%), (201)Tl/(99m)Tc-pertechnetate subtraction scintigraphy (TPS) in 144 (56.9%), CT scan in 92 (36.4%), (99m)Tc-sestamibi/(99m)Tc-pertechnetate subtraction scintigraphy (MPS) in 90 (35.6%), selective venous sampling (SVS) with parathyroid hormone (PTH) assay in 30 (11.9%), and magnetic resonance imaging (MRI) in 6 (2.4%) patients. The results were compared with operative and histological findings that showed 235 (92.9%) solitary parathyroid adenomas, 13 (5.1%) carcinomas and 5 (2.0%) double adenomas. Sensitivity and positive predictive value were 82.9% and 93.8% for US, 83.6% and 91.8% for TPS, 81.3% and 98.7% for CT scan, 85.1% and 96.1% for MPS, 65.4% and 80.9% for SVS, and 80.0% and 80.0% for MRI respectively. No different results (P=NS) were found using US, TPS, MPS or CT scan, whereas SVS and MRI sensitivity was lower (P<0.05). The combination of MPS and US was 94.0% sensitive (P<0.05) but when TPS, CT scan or MRI were also used overall sensitivity did not improve significantly (P=NS). In conclusion, MPS should be used as the starting preoperative localization procedure, while US and MPS together represent the most reliable noninvasive localization tool. If MPS and US are negative or not in agreement, further studies are not cost-effective and the patient should undergo bilateral neck exploration.

[99mTc]-HM-PAO SPECT in Parkinson's disease.

Thirty-six patients affected by Parkinson's disease were studied using single photon emission computed tomography (SPECT) and [99mTc]-HM-PAO as a tracer. The scanning procedure was performed 16-24 h after discontinuation of specific therapy. Tracer activity ratios were determined in 10 pairs of cerebellar, cortical, and subcortical regions. Data were compared with those of 10 age-matched controls. Most of the regions examined did not show any relevant change between parkinsonian and control subjects. Notably, mean activity in striatal regions were similar in the two groups. Increased activity in caudate-putamen was found in patients who were on chronic DOPA therapy. Side-to-side asymmetries in the basal ganglia increased with the severity of the disease. Significant reductions of tracer uptake, from control values, were observed bilaterally in the parietal cortex. These deficits were more pronounced in patients with mental deterioration and in subjects who had been chronically treated with anticholinergic drugs. Parietal perfusion deficits in parkinsonian patients resemble those described in Alzheimer's dementia. These findings suggest that the heterogeneous alterations of regional cerebral blood flow (rCBF) in parkinsonian patients reflect the multifactorial pathophysiology of the disease.

New perspectives in localizing enlarged parathyroids by technetium-thallium subtraction scan.

Double-tracer scanning (Tc-99m as pertechnetate and Tl-201 as chloride) with an Anger camera and computerized image subtraction was performed in 61 patients whose clinical and biochemical findings had suggested primary hyperparathyroidism. This study showed intra- or extrathyroidal focal uptake of thallium in 37 cases. Among these, 24 patients underwent surgery, and 18 parathyroid adenomas, five carcinomas, and one hyperplastic gland were found exactly in the sites predicted by scintigraphy. Among 24 patients with negative scans, only two underwent surgery; a hyperplastic parathyroid gland (diam less than 0.5 cm) was found in both. The success rate was 92% in the cases in which operation was performed. We believe that the new method may be useful in the preoperative detection of parathyroid enlargements.

Proposal of a modified scintigraphic method to evaluate duodenogastroesophageal reflux.

Hepatobiliary scintigraphy with 99mTc-HIDA offers a noninvasive method to detect duodenogastric reflux. Biliary reflux was graded using the persistence rather than the intensity of the radioactive refluxate: Grade 0 was considered the absence of reflux, minimal reflux, or reflux in the first 10-15 min; Grade 1 was repetitive reflux lasting less than 10 min; Grade 2 was persistent reflux; and Grade 3 was reflux up to the esophagus. Twenty-five patients with foregut symptoms were studied and results were compared to 24-hr gastric pH monitoring. Scintigraphy and pH monitoring agreed in 15 out of 25 patients (60%), but no correlation was found with the endoscopic findings. The rationale for this approach is based on pathophysiologic evidence that damage to gastric and/or esophageal mucosa is mainly related to the prolonged contact time with duodenal contents. This technique seems to allow a complete functional evaluation of the esophagogastroduodenal tract without causing adjunctive irradiation or discomfort to the patient.

Retrospective analysis of the association of nodular goiter with primary and secondary hyperparathyroidism.

BACKGROUND: The association of hyperparathyroidism (HPT) with thyroid disease has long been known, but the mechanisms underlying such an association have not yet been clarified. OBJECTIVE: To elucidate the main factors determining this combination of endocrine diseases, in a retrospective multicenter study. METHODS: We retrospectively reviewed all patients referred for parathyroid scintigraphy in the period 1990-1999. A total of 487 patients in the age range 17-65 years were selected for the analysis (339 women and 148 men); group A included 241 patients with primary and group B 246 patients with secondary HPT. RESULTS: A total of 124/241 patients in group A (51.5%), but only 92/246 patients in group B (38.2%) had thyroid disorders (notably nodular goiter) associated with HPT (P=0.0035). Thyroid disorders were evenly distributed throughout the entire 17-65 years age range in group A, but 17-40-year-old patients in group B had significantly fewer thyroid disorders than the older patients of the same group (15.5% compared with 43.3%, P<0.002), as expected in a general population. In patients with primary HPT there was no difference in the prevalence of thyroid disease between women and men, whereas the ratio of women to men in secondary HPT patients with thyroid disease was about 3:1. CONCLUSIONS: These results demonstrate an increased prevalence of nodular goiter in patients with primary rather than secondary HPT, and are consistent with a possible role of increased endogenous calcium concentrations (a hallmark of primary, but not of secondary, HPT) as a goitrogenic factor in patients with HPT.

Diagnosis of bone and liver metastases in breast cancer comparing tumor markers and imaging techniques.

One hundred and forty-seven patients were examined by bone scintigraphy, ultrasonography and scintigraphic scan of the liver, at different times after surgical removal of a breast cancer, to rule out skeletal and hepatic metastases. At the same time as imaging procedures, serum levels of tumor markers (CEA, TPA and CA 15-3) were determined using radioimmunometric methods. One or more markers were elevated in all 13 patients with hepatic metastases; 9 out of 46 patients with bone metastases had all serum markers normal, with a sensitivity of 80%. Combined assay of the markers proved useful, TPA and CA 15-3 showing the best sensitivity in bone metastases, and all three markers in liver metastases.

Scintigraphy of the parathyroid glands with 201TI: experience with 250 operated patients.

Parathyroid scintigraphy confirmed its validity in the preoperative localization of enlarged parathyroids, showing a sensitivity of 82% in a series of 250 patients suffering from primary hyperparathyroidism and successfully operated on. The glands better visualized were in an ectopic site or they were completely or partially outside the thyroid so that they were easily visible without employing digital image subtraction. This is nevertheless necessary to visualize parathyroids in a retrothyroid site but some problems arise, related not only to movements of the patient but also to the instrumentation to perform a correct image subtraction.

Tumors of the parathyroid glands. Changes in clinical features and in noninvasive localization studies sensitivity.

Primary hyperparathyroidism is the most common cause of hypercalcemia and 80-85% of the patients have parathyroid tumors. The purpose of this retrospective review was to analyse whether differences exist between patients with parathyroid tumors treated in the 1980s and 1990s. Between 1980-1997, 253 patients underwent initial surgical neck exploration for hyperfunctioning parathyroid tumors. Renal (polyuria, nocturia, renal colic due to lithiasis), rheumatologic (bone and joint pain), neurological (fatigue, memory loss, depression) and gastrointestinal (dyspepsia, anorexia, nausea) symptoms were recorded and main biochemical parameters were measured. In all patients one or more preoperative localization procedures were carried out prior to successful parathyroidectomy, and the confirmation of imaging findings was obtained after surgery. The patients were divided in two groups. Group A: 121 (47.8%) patients who underwent surgery from 1980-1989; Group B: 132 (52.2%) patients in whom parathyroidectomy was performed from 1990-1997. There were no differences (p=NS) between the two groups in average age, preoperative serum creatinine and intact-PTH levels. Symptoms were most common in Group A, and pre-operative serum calcium levels were significantly lower in Group B. Ultrasonography (n=191) sensitivity did not improve significantly (82.8% vs 82.9%), but positive predictive value (PPV) was higher (89.8% vs 96.0%). CT-scan (n=73) sensitivity was 79.2% and 82.6%, and PPV was 95.0% and 100% in Groups A and B, respectively. 201Tl/99mTc subtraction scintigraphy (n=111, Group A) was 84.6% sensitive (PPV=92.6%) whereas 99mTc-sestamibi scanning (n=90, Group B) was 85.1% sensitive (PPV=96.1%). In conclusion, the clinical features of parathyroid tumors has changed in the nineties and increasing asymptomatic pHPT rate has been found. Although sensitivity and PPV of preoperative localization procedures has improved moderately, at present noninvasive techniques may offer excellent results and should be used in all patients with suspected parathyroid tumors.

Exercise technetium 99m sestamibi single-photon emission computed tomography late after coronary artery bypass surgery: long-term follow-up.

BACKGROUND AND HYPOTHESIS: The prognostic value of exercise technetium 99m sestamibi single-photon emission computed tomography (SPECT) imaging in patients with previous bypass surgery is unknown. The aim of our study was to assess the prognostic information obtained with exercise scintigraphy performed for routine follow-up or reappearance of symptoms. METHODS: We studied 75 patients referred to our Center at a mean of 38 +/- 53 months from the revascularization procedure and prospectively followed them for 38 +/- 24 months. RESULTS: Fifteen patients (20%) had events at follow-up: there were 4 cardiac deaths, 3 nonfatal acute myocardial infarctions, 8 late revascularization procedures (4 percutaneous transluminal angioplasty and 4 repeat bypass surgery). Univariate analysis identified a history of typical angina (p = 0.001), a clinically positive ergometric test (p = 0.009), peak exercise heart rate (p = 0.0003), percentage of maximal predicted heart rate (p = 0.0001), peak exercise double product (p = 0.048), therapy during exercise (p = 0.003), scintigraphic summed reversibility score (i.e., the summation of the segmental differences between stress and rest) (p = 0.014), as significant predictors of events. Three multivariate models were built, with clinical variables (Model 1, chi square 15.97), ergometric variables (Model 2, chi square 19.66), and with scintigraphic variables added to clinical/ergometric variables (Model 3, chi square 31.13). The scintigraphic variable selected in the model as significant predictor of events was the summed reversibility score (p = 0.008). CONCLUSIONS: Exercise sestamibi SPECT scintigraphy provides optimal prognostic information after clinical and ergometric parameters in patients with previous bypass surgery.

Treatment of secondary hyperparathyroidism with low dose intermittent calcitriol in hemodialysis patients. Imaging and cost analysis.

Calcitriol therapy is effective in the treatment of secondary hyperparathyroidism both during intravenous and oral administration, but there are doubts about the length of therapy and the duration of results. There are conflicting reports about results in size and activity of enlarged glands studied by ultrasound and double-tracer-subtraction-scintigraphy (DTSS). In 12 patients, 1 microgram of calcitriol was administered three times a week, intravenously and orally in alternate modes, for 46 weeks (therapy period) and orally for 46 weeks (follow-up period). During therapy, parathyroid hormone levels decreased in all patients, and in eight decreased by about 50% and were maintained at low levels during follow-up in five patients. Nine enlarged glands were detected by ultrasonography at the start of the study, and four hotspots were detected by DTSS; ultrasonography and DTSS were repeated at the end of the therapy and at the end of the follow-up: ultrasonography did not yield any significant variation in size, while one hot spot disappeared on DTSS. Basing their judgment on the lower cost of oral rather than intravenous administration, and on the good results of oral therapy, the authors stress the advisability of taking into account clinical and financial considerations before choosing the route of administration.

[Basal prolactinemia and level after stimulation with TRH in juvenile gynecomastia]. / La prolattinemia basale e dopo stimolo con TRH nella ginecomastia giovanile.

TSH and PRL in basal conditions and after stimulus with TRH, gonadotrophin in basal conditions and after stimulus with GnRH, plasma testosterone, urinary oestrogens and peripheral thyroid hormones have been evaluated in 11 subjects with puberal gynaecomastia, 7 with post-puberal gynaecomastia and 14 normal controls. With respect to the normal controls, only patients with post-puberal gynaecomastia showed higher levels of basal PRL and after TRH stimulus. The behaviour of these patients could suggest that in subjects with post-puberal gynaecomastia there may be persistent endocrine imbalance, whereas in puberal gynaecomastia such imbalance is only transitory and is exhausted prior to the onset of mammary tumefaction.

Parathyroid imaging with pertechnetate plus perchlorate/MIBI subtraction scintigraphy: a fast and effective technique.

We set up a modified technetium-99m (Tc-99m) pertechnetate/Tc-99m MIBI (Tc-MIBI) subtraction scintigraphy for parathyroid imaging by introducing the use of potassium perchlorate (KCLO4). Initially, the effect of KCLO4 on technetium thyroid wash-out was evaluated in five healthy volunteers: 40-minute dynamic studies of the thyroid were obtained 20 minutes after the injection of technetium 150 MBq (4 mCi), both in baseline conditions and after the oral administration of 400 mg KCLO4. After an average latency time of 10.5 minutes, KCLO4 administration resulted in fast and relevant technetium thyroid wash-out with a mean half-time of 16.2 minutes (the half-time was 142.8 minutes in baseline conditions), and a 40-minute reduction of thyroid activity of 78% (it was 14% in baseline conditions). Based on these findings, a new Tc-MIBI subtraction procedure was established as follows: 1) 150 MBq technetium (4 mCi) injection; 2) 400 mg KCLO4 administered orally; 3) patient neck immobilization; 4) acquisition of a 5-minute technetium thyroid scan; 5) 500 MBq MIBI (13.5 mCi) injection; 6) acquisition of a sequence of seven MIBI images, each lasting 5 minutes; and 7) processing (image realignment when necessary, background subtraction, normalization of MIBI images to the maximum pixel count of the technetium image, and subtraction of the technetium image from the MIBI images). In addition, high-resolution neck ultrasound (US) was performed in all cases on the same day as the scintigraphic evaluation. Eighteen consecutive patients with primary hyperparathyroidism were enrolled in the study. Tc-MIBI scintigraphy revealed a single adenoma in all cases and US showed this finding in 15 of 18 cases (83.3%). Furthermore, in three patients, a thyroid nodule associated with hyperparathyroidism was detected by technetium thyroid scans and neck US. In all patients, the parathyroid adenoma was easily identified on both the 20- to 40-minute MIBI and subtracted (MIBI-Tc) images. Regarding the scintigraphic parameters, no difference was found between parathyroid adenomas located in the region of the thyroid bed or in ectopic sites and in parathyroid adenomas with a retrothyroid location. Surgical findings confirmed the presence of a single parathyroid adenoma in all cases. In the three patients with a concomitant thyroid nodule, thyroid lobectomy was performed. These preliminary data suggest that 1) double-tracer subtraction scintigraphy, combined with neck US, appears to be the preferable preoperative imaging procedure in hyperparathyroidism patients with concomitant thyroid nodular disease, 2) in the Tc-MIBI parathyroid scan, the use of KCLO4 results in a rapid and relevant technetium thyroid clearance, improving the quality of MIBI images and making the visualization of parathyroid adenomas, particularly those located behind the thyroid gland, easier.

[Functional evaluation of the intrathoracic stomach after esophagectomy for esophageal cancer]. / Valutazione funzionale del paziente operato di esofagectomia ed esofagogastroplastica intratoracica per cancro dell'esofago.

Sixteen patients underwent evaluation of duodenogastric reflux and gastric function 1 to 7 years after esophagectomy, high intrathoracic anastomosis, and pyloric divulsion for esophageal cancer. Ten patients (62%) had either postoperative digestive symptoms or endoscopic mucosal lesions, cholescintigraphy demonstrated duodenogastric reflux in 11 cases (69%). No gastric motor activity was recorded on manometry. 24-hour pH gastric monitoring showed that the area under the curve less than 4 was significantly less than in controls (p = 0.0003). The results of the present study show that duodenogastric reflux is a common event after esophageal replacement with the stomach. The interaction between acid and alkaline secretions plays a role in the pathogenesis of mucosal lesions, and it may explain the partial failure of the current therapeutic strategies.

[Thyroid nodular pathology: retrospective study of 917 surgical interventions]. / Patologia nodulare tiroidea: studio retrospettivo su 917 interventi chirurgici.

A retrospective investigation of the surgical cases of seven hospitals in the Veneto region was made in order to assess the malignancy rate in thyroid nodular pathology, and the predictive value of scintiscanning with positive indicator.

[Non-secretory myeloma syndrome]. / La sindrome del mieloma non secernente.

Non secretory myeloma is a rare and unusual form of myeloma, characterized by the absence of monoclonal component in serum and urine. This peculiarity is usually believed to be caused by the incapacity of neoplastic plasmacells to synthesize or secrete M-component, but it is probably due to several pathogenetic mechanisms which are different from case to case. The diagnosis can be delayed by the non specific clinical pattern, especially in those cases where skeletal radiological studies do not reveal lytic lesions. The authors report two recently diagnosed cases of non secretory myeloma, underlying the main clinical and laboratory findings which led to the diagnosis of this singular syndrome. The diagnostic suspicion is often based, beside the clinical pattern at the onset, on the absence of serum and urinary monoclonal component, on the increase of PCR, of beta 2 microglobulin and on low levels of serum immunoglobulins. CT scans, MRI and Tc 99 MIBI bone marrow radionuclide studies are also useful in evaluating the therapeutic response which cannot be based on quantitative variations of the M-component. The clinical suspicion is confirmed by the bone marrow aspiration and trephine biopsy, showing a typical infiltration by plasmacells at various degree of maturation.

[Determination of glomerular filtration during sequential scintigraphy in the evaluation of separate renal function]. / La determinazione del filtrato glomerulare in corso di scintigrafia sequenziale nella valutazione della funzione renale separata.

The serial renal scan, a rapid series of images obtained with a scintillation camera, is explained; it visualizes the arrival to the kidneys and the passage through the parenchyma and the pelvocalyceal system of 99mTc-DTPA, a tracer cleared by glomerular filtration. Dynamic imaging of the kidneys provides more extensive information regarding anatomical structure and renal function that cannot be obtained by other noninvasive techniques. Computerized data analysis provides a lot of parameters, such as global and parenchymal transit times, useful in differentiating obstructive from non-obstructive uropathy, and total and separate glomerular filtration rate. 99mTc-DTPA computer-assisted scintigraphy is recommended as a routine method in nephro-urologic conditions where an accurate evaluation of separate renal function is required.

Positive 131cesium scanning in parathyroid adenoma.

In a case of primary hyperparathyroidism, a palpable nodule, at the base of the right lobe of the thyroid, proved 'cool' during 99mTc scanning, but 'hot' when scanned with radiocesium. The uptake of this tracer was higher than the uptake of 75Seselenomethionine after suppression with T3. The authors discuss the possibility of cases of 'false-positive' radiocesium uptake in extrathyroid nodules, and in particular, the use of this tracer for the detection of parathyroid adenoma by scanning.

Factor X Friuli: An immunological study in plasma and in serum using several methods.

An immunological study of factor X Friuli was carried out using an anti-human-factor X antiserum. The results obtained with different methods were compared. Only an ill-defined factor X band or precipitate was evident on standard immuno-electrophoresis and on immunodiffusion. Using a non-absorbed antiserum a precipitate was evident on eletroimmunoassay, in normal, factor X Friuli and in factor X deficient plasma. On the contary, using an antiserum which had been previously absorbed with factor X deficient plasma, a precipitate was evident only with factor X Friuli plasma or normal plasma. Excellent results were obtained with the cross-over electrophoresis. Using this method a major or factor X band was evident in normal plasma, factor II,P FACTOR VII, factor IX deficient plasmas and in the factor X FRIULI PLASMA. No factor X band was evident in factor X deficient plasmas and in absorbed normal plasma. Lighter, more cathodic bands were seen in all plasmas. These were due to secondary activities of the antiserum and could be disregarded. Friuli serum factor X and normal serum factor X showed a slightly more anodic migration as compared to their plasma counterparts. In coumarin plasma two factor X bands were evident; one normal in position and one slightly more catholidic. In the bidimensional immunoelectrophoresis two precipitates are visible in normal plasma and in factor X Friuli plasma. In factor X deficient plasma only one precipitate is evident. This latter precipitate is due to the secondary activity of the antiserum used. On the basis of these data it is concluded that factor X Friuli behaves, immunologically, as normal factor X.

An immunological investigation of factor VIII associated antigen in combined factor V and factor VIII deficiency.

The behavior of factor VIII associated antigen of three patients with combined factor V and factor VIII deficiency has been evaluated in several immunological systems. Factor VIII associated antigen resulted to be normal or higher than normal in all three patients in the radial immunodiffusion and in the electroimmunoassay systems. In the bidimensional electrophoresis system only one factor VIII precipitate was evident and such factor VIII precipitate showed the same electrophoretic mobility as normal factor VIII antigen. These findings firmly establish the fact that the factor VIII defect in congenital combined factor V and factor VIII deficiency is of the hemophilia type.