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Preoperative parathyroid localization in patients with persistent or recurrent hyperparathyroidism: Comparison between different imaging techniques
335 VIDEO-LAPAROSCOPY M TEE TREATMENT OF PRIMARY HYF’ERALDOSTFXONISM: A MULTICENTRIC STUDY FROM TEE VENETO REGION. P.Gmpamni, A..Wvador, C.LaGiadice, G.Giorduo, P.Vanzelto”, P.Zmduogo*, M.MucheRi”,P.Bcltr~eUo”,M.DeLnm, RArduiaiw,G.DiF~o”*,D.lbbella~~. Depmmentr of Endocrinology. Wcine, and ““Nepimk~gy, Hospital of Castelfranco V.to (TV); Weparlmcnt of Medicine, Hospital of MDntebetbma (TV); “Dqmtmml of Medicine, Hospital of Bassan DG (VI); ““Dep&mem of Snrgery, Hospaal of Treviso: **Service of Nuclear Medicine, Univetilary Hospnal of Padova.
PARANEOPLASTIC GUSHING SYNDROME: USEFULLNESS OF FLUOROI&DEOXYCLUCOSE (FDG) POSITRON EMISSION TOMOGRAPHY (PET) IN DETECTING UNKNOWN FRIMARY TUMOR. M.Roni. A.Voloi. L.TonioloS D.Pastorclli’. A.Sah%dor*“, P.Gasparoni**, D.R&eilo”. . Department of Medew, Hospital of Montebelhma 0V), D+rbnents of OSurgery, “Oncology, and **Endocrinology, Hospital of Castelfranco V.to (TV); Service of Nuclear Medicine, University Hospital of Padova.
Primam hwer.skkslemnim (PH) 1s a sm4rome related to al&swmne hywrwxetioo, charanenzed by hypertcnsmn hypokalemia;d met&tic alkalck. PH is responsibk for less rhanl%ofaUcasesof hypenension.~mostcommw~~ofPHiraslngleadrenal
FDG is a glucose analogne, atidily trap@ by tumoral ceils, phospborylated to 6-PFDG without followmg fbrther metabobom. FM; PEI’ has been demonstrated to be a highly sensitive imaging techmque in the staging and follow-up of many types of neoplasms due u) its abilrty to detect very small neoplastic foci (less than 5 m m in maximum diameter) winch are ch.ara&rized bv an increased glycolytic metabolism. FDG PET has been’fonnd to be us& also in ihe visnalizatio~~f unknown pnrnary tumors in patients wrtb known lymphnodal or distant llW&SS.TbecssCWepRsQU here IS the first, at our knowlwJge, of a successful FDG PET stndy m detecting the prnnary tnmor responsible for a pamneoplastic Cushmg syndrrme. Case report de patient, 41 year old, admitted to our Hospital for hypertensron, moon f&es, laboratory tests revealed hyperglycerma (152 mg/dL), lenkoc@srs with lvmohooenia and eosmownia elevated levels of plasma cmti.wl (32 n&U h. 8; 31 &&, d. LS), of urinary’free cortisol (1920 to 3 lb0 ug/24 h), and of p&na ACTH (207 to 238 rig/L). No significant variations m plasma cort~s~l and ACTH levels were documented a&r dexamethazone 8 m g orally adrninisnation. Pitnitary MRI did sot shown enlargements of the sella tnrcica as well as a first whole body CT scan rewked completely negative Whole body PET, performed after the administraticer of 444 MBq (12 mCi) of FLY& a focal anx of abnormally increased tract uptie was shown m the medium lobe of the right lung A second CT scan of the thorax revealed two suspected small lesions, IO-15 m m sized, rn the basal region of the right lung At surgery the first Ies~on, corresponding to the area of focal abnormal uptake showed at FDG PET, was demonstrated to be a carcmoid (it was crom~n positive, while PP. gastnn ad calcdonm negative); the second lesion revealed at CT scan was proven to be an intlammatory nodule (false positive CT scan result). Conclusions: paraneqhtic Cushmg syndrome represents about IO-15% of alI caxs of Cushina svnimme. It is due to the ectopic prcdwtion of ACTH or CFtH by varrous types of t&&s, as the small cells lung cancer, the bronchial or inlestinal or panaeadc and enatrc carcmnoid. the medullan tbwxd czmcer. the oheocbromowtoma. Often the tumor responsible fd the paran&&tic syndmme b small sired@ drus, non detectable by the conventional radiologrc nnaging techniques. In these patients, as the case presented, FDG PET can give an important diagnostic contribute in visnabzing the site of the prig tornor.
pxas.unm values (3.8 and 4.0 mE&, respenwely); ream IV%- low-mle withcut mpnse to upright pmm in aU the pabents; aldostemne levels were elevated both in the serum (range 367-870 pg/mL) and in urhe (mnSelO-35 u&l4 h); CT sgn revealed an &mA ad-ma “I au the cases (4 0” the I&, 3 on die rlgh,). szed IO-35 mm. mean 17.9 mm. Ultrawnography was padive only in 1/S cas while 75Se-A&steml scintigclphy in 414 oatients and MIU in 212 cases In a w-v old wdent 80 wars old medical tbempy with kqxr&qy Nd surgical side&en WaE kc.xded. In au the c&s a nomlalizadcm of biockmical and hcmmnal makers as well as of blood pressure values was noted. Hospital adnnssion lasted fmm 3 to 4 davs. Cm, prew data suggests tint a) a pmkive family history for hwrteosion did not exclude the p~ence of PH. b) PH can be diamrosexl in elderly patients an4 in these cases medical iheripy can be admmistd c) some&s serum potzsium levels are in dx mmnl laoge in PH. d) CT scan, 75 Se-cholesterol scintigraphy and MRI. but rwt ul(nsmography, a-e -e ~rmcera~orv matie technianes in visnalizme &enal aderwnas nsDonsible for PH, e)
Preoperative parathyroid persistent or recurrent between different imaging
localization in hyperparathyroidism: techniques
patients with comparison
Piotto A, Bergamnsco A, Sarza C, Tomnsella G’, Rubella D**, Saladini I?*, Casara D*“, Pdizzo MR Cbmca Chwnrgxa 3’, Umversti di Padova, l Radiologla 2O, l * Medicina Nucleare 2’. Azienda Ospedaliera di Padova Surgery achieved successfnl m about 90-9556 of patients with primary hyperparathymidism. In ~rne cases, anatomic variations m par&mid localieaticm or the presence of multiple parathyoid lesions are reap~)s of surgical failun Altbougb there is snrne debate in Iiteratnre abwt the use of preoperative nnagmg investigations prior to primary surgery, there is general agreement about the need of parathymid(s) localization before a second look In this study 23 patients wim primary recurrent or persrstent hyperparathyroidism underwent prwperative evaluaron with the same imaging techniques: High Resolution - IO h!Hz - Ultrasonography (US), Tc-QQmMIBI scintigmphy, Computed Tomography scan (CT), Mapetic Resonance Imaging (MRO, Esophageal Endoscopic Sonography (EES) The resuks ofd~ere examinatmns were correlated to sur& and pathological findings At reuperatmn 34 parathyroid glands were removed Enlarged par&y&d(s) were localized in abnormal sites in 14 cam (41 2%): 5 in tie mediistinum (14.7%). 6 in a deep cervical s&e (17 6%), 1 intrathynxd (2-Q%)), 2 parathymic (5.8%). In I7 patwnts a srngie adenoma, m 2 patients 5 hyperplasic lesions, in 3 patients a double adenoma, in 3 patients mnklple paratbymld malignant lesions were found. At present 4 patients f3 with parathyroid carcmoma) remam hyperparathyroid The trne positive, false negative and false positive values were respectively, for US 34 9%, 34.4% and 30 4%; for Tc-QQmMIBI scan 445%. 30 4% and 26 I%, for CT scan. 39 9%, 27.1% and 33.2%; for MRI 40%, 40% and 20%; for EES: 33.3% 41 7% and 25.0%. The combmatron of all imagmg modalhes allowed us to correctly iden@ the enlarged pa&ymid(s) in 29/34 cases (85.3%) Tbe imagmg techniques utilized can be considered complementary. US was the best techmque in localizmg parathyrmds in a deep cervical s&e, near or within the tbyrmd, the EES pernnted us to accurately explore the paraerophageal glands, CT scan and MIU were pamcnlarly us&l to visualize ectopx paratbynxds m the m&astinum sued more than 1.5 cm MIBI scintigraphy was the most sensd~e technique able to localize parathymtd(s) bah in the neck and in the medrastinum (the smallest lesmn detected was 8 m m m maxnnnm diameter) In our experience the combrned use of US and MlBI scmtwaphy seems to be the most accurate, and less expensive, preoperatwe imaging approach for tie localiration of enlarged pamthymids in patients wrtb pewstent or recurrent hyperparatbyroidism.
RECENT
WITH
PROGRESS M ADVANCED hxUROBLASTOMA TARGETED BADIONUCLIDE TEERAPY 1311-MIBC
WITH
Troncone L , Rufni V., Tomesello A., Mashangelo R. Departmeatr of Nuclear Medioiae and Pediatric Oncology Catholic University of the Sacred Heart - Rome
An update of the results achieved with targeted radionucl& therapy with I311-MIBG in advanced neuroblastoms (NB) is carried out Feasibrhty of this treatment and its effectiveness were demonstrated at the International Workshops held in Rome m 1986 and 1991, where 276 children with disseminated or refractory NE had 35% objective response. The positive results obtained brought Nuclear Medicine physicians mmxiuce 13 1 I-MBG therapy as a front-line therapy in advanced NB. In this approach 38 high nsk patients - as reported by the Amsterdam Group - obtained 60% CR or PR Furthermore, the 2 year survival was 53% and the 3 year survival was 33% However, a combination of I311-MIBG therapy mth other therapeutx agents, that is a multimodal therapy, would have given better results, accordtng to other Authors. Two distinct therapeutic approaches of multimodal treatment were set up The first one, whrch utilizes high doses of 13 1 I-MIBG fat myeloeblative purposes and then proceeds to eradicate ti minimal residual disease with chem45eemsIa have given encouraging results. The second treatment, apphed by the Rome Group, which consists of a comhinatron of chemo and 13 I I-Ml&Ii therapy, gave an excellent response in I I relapsed and refractory NB. 82% PR.
to
PARANEOPLASTIC GUSHING SYNDROME: USEFULLNESS OF FLUOROI&DEOXYCLUCOSE (FDG) POSITRON EMISSION TOMOGRAPHY (PET) IN DETECTING UNKNOWN FRIMARY TUMOR. M.Roni. A.Voloi. L.TonioloS D.Pastorclli’. A.Sah%dor*“, P.Gasparoni**, D.R&eilo”. . Department of Medew, Hospital of Montebelhma 0V), D+rbnents of OSurgery, “Oncology, and **Endocrinology, Hospital of Castelfranco V.to (TV); Service of Nuclear Medicine, University Hospital of Padova.
Primam hwer.skkslemnim (PH) 1s a sm4rome related to al&swmne hywrwxetioo, charanenzed by hypertcnsmn hypokalemia;d met&tic alkalck. PH is responsibk for less rhanl%ofaUcasesof hypenension.~mostcommw~~ofPHiraslngleadrenal
FDG is a glucose analogne, atidily trap@ by tumoral ceils, phospborylated to 6-PFDG without followmg fbrther metabobom. FM; PEI’ has been demonstrated to be a highly sensitive imaging techmque in the staging and follow-up of many types of neoplasms due u) its abilrty to detect very small neoplastic foci (less than 5 m m in maximum diameter) winch are ch.ara&rized bv an increased glycolytic metabolism. FDG PET has been’fonnd to be us& also in ihe visnalizatio~~f unknown pnrnary tumors in patients wrtb known lymphnodal or distant llW&SS.TbecssCWepRsQU here IS the first, at our knowlwJge, of a successful FDG PET stndy m detecting the prnnary tnmor responsible for a pamneoplastic Cushmg syndrrme. Case report de patient, 41 year old, admitted to our Hospital for hypertensron, moon f&es, laboratory tests revealed hyperglycerma (152 mg/dL), lenkoc@srs with lvmohooenia and eosmownia elevated levels of plasma cmti.wl (32 n&U h. 8; 31 &&, d. LS), of urinary’free cortisol (1920 to 3 lb0 ug/24 h), and of p&na ACTH (207 to 238 rig/L). No significant variations m plasma cort~s~l and ACTH levels were documented a&r dexamethazone 8 m g orally adrninisnation. Pitnitary MRI did sot shown enlargements of the sella tnrcica as well as a first whole body CT scan rewked completely negative Whole body PET, performed after the administraticer of 444 MBq (12 mCi) of FLY& a focal anx of abnormally increased tract uptie was shown m the medium lobe of the right lung A second CT scan of the thorax revealed two suspected small lesions, IO-15 m m sized, rn the basal region of the right lung At surgery the first Ies~on, corresponding to the area of focal abnormal uptake showed at FDG PET, was demonstrated to be a carcmoid (it was crom~n positive, while PP. gastnn ad calcdonm negative); the second lesion revealed at CT scan was proven to be an intlammatory nodule (false positive CT scan result). Conclusions: paraneqhtic Cushmg syndrome represents about IO-15% of alI caxs of Cushina svnimme. It is due to the ectopic prcdwtion of ACTH or CFtH by varrous types of t&&s, as the small cells lung cancer, the bronchial or inlestinal or panaeadc and enatrc carcmnoid. the medullan tbwxd czmcer. the oheocbromowtoma. Often the tumor responsible fd the paran&&tic syndmme b small sired@ drus, non detectable by the conventional radiologrc nnaging techniques. In these patients, as the case presented, FDG PET can give an important diagnostic contribute in visnabzing the site of the prig tornor.
pxas.unm values (3.8 and 4.0 mE&, respenwely); ream IV%- low-mle withcut mpnse to upright pmm in aU the pabents; aldostemne levels were elevated both in the serum (range 367-870 pg/mL) and in urhe (mnSelO-35 u&l4 h); CT sgn revealed an &mA ad-ma “I au the cases (4 0” the I&, 3 on die rlgh,). szed IO-35 mm. mean 17.9 mm. Ultrawnography was padive only in 1/S cas while 75Se-A&steml scintigclphy in 414 oatients and MIU in 212 cases In a w-v old wdent 80 wars old medical tbempy with kqxr&qy Nd surgical side&en WaE kc.xded. In au the c&s a nomlalizadcm of biockmical and hcmmnal makers as well as of blood pressure values was noted. Hospital adnnssion lasted fmm 3 to 4 davs. Cm, prew data suggests tint a) a pmkive family history for hwrteosion did not exclude the p~ence of PH. b) PH can be diamrosexl in elderly patients an4 in these cases medical iheripy can be admmistd c) some&s serum potzsium levels are in dx mmnl laoge in PH. d) CT scan, 75 Se-cholesterol scintigraphy and MRI. but rwt ul(nsmography, a-e -e ~rmcera~orv matie technianes in visnalizme &enal aderwnas nsDonsible for PH, e)
Preoperative parathyroid persistent or recurrent between different imaging
localization in hyperparathyroidism: techniques
patients with comparison
Piotto A, Bergamnsco A, Sarza C, Tomnsella G’, Rubella D**, Saladini I?*, Casara D*“, Pdizzo MR Cbmca Chwnrgxa 3’, Umversti di Padova, l Radiologla 2O, l * Medicina Nucleare 2’. Azienda Ospedaliera di Padova Surgery achieved successfnl m about 90-9556 of patients with primary hyperparathymidism. In ~rne cases, anatomic variations m par&mid localieaticm or the presence of multiple parathyoid lesions are reap~)s of surgical failun Altbougb there is snrne debate in Iiteratnre abwt the use of preoperative nnagmg investigations prior to primary surgery, there is general agreement about the need of parathymid(s) localization before a second look In this study 23 patients wim primary recurrent or persrstent hyperparathyroidism underwent prwperative evaluaron with the same imaging techniques: High Resolution - IO h!Hz - Ultrasonography (US), Tc-QQmMIBI scintigmphy, Computed Tomography scan (CT), Mapetic Resonance Imaging (MRO, Esophageal Endoscopic Sonography (EES) The resuks ofd~ere examinatmns were correlated to sur& and pathological findings At reuperatmn 34 parathyroid glands were removed Enlarged par&y&d(s) were localized in abnormal sites in 14 cam (41 2%): 5 in tie mediistinum (14.7%). 6 in a deep cervical s&e (17 6%), 1 intrathynxd (2-Q%)), 2 parathymic (5.8%). In I7 patwnts a srngie adenoma, m 2 patients 5 hyperplasic lesions, in 3 patients a double adenoma, in 3 patients mnklple paratbymld malignant lesions were found. At present 4 patients f3 with parathyroid carcmoma) remam hyperparathyroid The trne positive, false negative and false positive values were respectively, for US 34 9%, 34.4% and 30 4%; for Tc-QQmMIBI scan 445%. 30 4% and 26 I%, for CT scan. 39 9%, 27.1% and 33.2%; for MRI 40%, 40% and 20%; for EES: 33.3% 41 7% and 25.0%. The combmatron of all imagmg modalhes allowed us to correctly iden@ the enlarged pa&ymid(s) in 29/34 cases (85.3%) Tbe imagmg techniques utilized can be considered complementary. US was the best techmque in localizmg parathyrmds in a deep cervical s&e, near or within the tbyrmd, the EES pernnted us to accurately explore the paraerophageal glands, CT scan and MIU were pamcnlarly us&l to visualize ectopx paratbynxds m the m&astinum sued more than 1.5 cm MIBI scintigraphy was the most sensd~e technique able to localize parathymtd(s) bah in the neck and in the medrastinum (the smallest lesmn detected was 8 m m m maxnnnm diameter) In our experience the combrned use of US and MlBI scmtwaphy seems to be the most accurate, and less expensive, preoperatwe imaging approach for tie localiration of enlarged pamthymids in patients wrtb pewstent or recurrent hyperparatbyroidism.
RECENT
WITH
PROGRESS M ADVANCED hxUROBLASTOMA TARGETED BADIONUCLIDE TEERAPY 1311-MIBC
WITH
Troncone L , Rufni V., Tomesello A., Mashangelo R. Departmeatr of Nuclear Medioiae and Pediatric Oncology Catholic University of the Sacred Heart - Rome
An update of the results achieved with targeted radionucl& therapy with I311-MIBG in advanced neuroblastoms (NB) is carried out Feasibrhty of this treatment and its effectiveness were demonstrated at the International Workshops held in Rome m 1986 and 1991, where 276 children with disseminated or refractory NE had 35% objective response. The positive results obtained brought Nuclear Medicine physicians mmxiuce 13 1 I-MBG therapy as a front-line therapy in advanced NB. In this approach 38 high nsk patients - as reported by the Amsterdam Group - obtained 60% CR or PR Furthermore, the 2 year survival was 53% and the 3 year survival was 33% However, a combination of I311-MIBG therapy mth other therapeutx agents, that is a multimodal therapy, would have given better results, accordtng to other Authors. Two distinct therapeutic approaches of multimodal treatment were set up The first one, whrch utilizes high doses of 13 1 I-MIBG fat myeloeblative purposes and then proceeds to eradicate ti minimal residual disease with chem45eemsIa have given encouraging results. The second treatment, apphed by the Rome Group, which consists of a comhinatron of chemo and 13 I I-Ml&Ii therapy, gave an excellent response in I I relapsed and refractory NB. 82% PR.
to