Usefulness of the Trh Test in the Management of Patients with Differentiated Thyroid Cancer

Thirty patients thyroidectomized for differentiated thyroid cancer were studied. Serum TSH was assayed in basal conditions and after TRH stimulation, while patients were in suppressive therapy with thyroid hormones. The basal TSH was normal in all the patients and less than 2 μ/ml in 20 patients. The TRH test was negative (no TSH response) in 27 patients and in all the cases with the basal TSH lower than 2 μU/ml.

The Role of Whole Body Scan and Skeletal Radiography in the Preoperative Staging of Breast Cancer

442 patients with breast cancer were studied by means of radiologic and scintigraphic examination of the skeleton to detect the presence of bone metastases. All the patients have been clinically followed-up for a mean periode of 22 months. The overall prevalence of bone metastases at staging was 4.5 %. Bone scan showed a higher sensitivity in detecting bone metastases (90 % vs 45 %) and a lower positive predictive value (60 % vs 75 %) with respect to X-ray examination. In the present series no asymptomatic case with bone metastases was found in limited stages (T1-T2 N0-N1). The authors suggest that the bone scan be routinely included in the staging of advanced breast cancer cases and that the use of this procedure be restricted to the symptomatic patients in the more limited stages.

Human Papillomavirus (HPV) Cervical Lesions: Results from 300 Italian Women Studied with Dna Hybridization Techniques and Morphology

Human papillomavirus cervical infection was investigated in a series of 300 unselected women by comparing morphological diagnoses (cytology and histology) with results of DNA hybridization techniques (filter in situ hybridization of DNA from exfoliated cervical cells and Southern blot analysis of HPV-DNA in cervical biopsy specimens). The prevalence of HPV cervical infection diagnosed by PAP smears was 11.6 %. Despite disadvantages, filter in situ hybridization was confirmed to be particularly useful for screening purposes to detect HPV in cervical scrapings. In 3 cases it was the only applicable method for diagnosing « high-risk » HPV infection. Southern blot hybridization of tissue DNA with HPV 16-DNA revealed the presence of this virus in 8 cases, and HPV 31-DNA and HPV 42-DNA in 1 case each.

Lymphoscintigraphy and Gamma Probe Tracing in Detecting Breast Cancer Lymph Node Involvement: Can they Replace Axillary Lymph Node Dissection?

Background

Axillary lymph node status is the most important pathological determinant of prognosis in early breast cancer. However, axillary lymph node dissection (ALND) performed for pathological assessment is not without costs and morbidity. Recently, radioisotope-guided sentinel node biopsy (SNB) has been proposed as a promising technique for staging breast cancer patients.

Aim of the study

In this study we report our experience (76 patients) in radioguided sentinel node (SN) biopsy in breast cancer. The study was divided into two phases: the first represents our learning curve, necessary to establish our guidelines for its use in clinical practice, while the second phase was aimed at assessing the feasibility of SN localization using preoperative lymphoscintigraphy and intraoperative gamma probe (GP) detection.

Methods

All patients underwent lymphoscintigraphy (LS) up to two hours after tracer delivery (99mTc-micro-nanocolloid, four i.d. injections of 200 μCi/200 μL around the primary lesion) 24 hours before surgery and GP tracing during surgery. Subsequently ALND was performed for pathological assessment.

Results

SNs were identified in 73/76 patients using LS and in 72/76 using GP. In one case the SN was detected by GP alone while in two cases GP was not able to locate the SN although it had been identified by means of LS. Thirty-three of these 73 patients had axillary node involvement. In 31/33 cases the SN was the only positive node. No positive nodes were found in the remaining 40 ALNDs where SNs were identified. Thus, according to our experience 40/73 ALNDs could have been avoided. SNB seems to be a very interesting technique but further experience in lymph node radioisotope tracing is needed.

Radioisotopic Lymphatic Mapping of the Sentinel Node in Melanoma: Importance of Immunohistochemistry

Background

Elective lymph node dissection (ELND) for patients with malignant melanoma is still controversial. A possible alternative could be biopsy of the first tumor draining lymph node, the sentinel node (SN), which can be identified by means of radionuclide techniques.

Aim

Our study was undertaken to assess the accuracy of lymph node biopsy and to stress the importance of immunohistochemistry (IHC) in the pathological assessment of the SN for improved staging of the primary tumor.

Methods

We performed lymphoscintigraphy (LS) in 183 melanoma patients (89 with melanoma of the legs, 11 of the arms and 83 of the trunk). Our protocol consisted of preoperative peritumoral i.d. injection of 99mTc-labeled microcolloid to define the regional lymphatic basin and identify the sentinel node by means of planar scintigraphy. In 147 of the 183 cases a gamma probe (GP) was used during surgery to trace the SN. Vital blue dye was used during surgery in all cases. The SNs were excised for pathological examination. The pathological status of the SN was defined by means of examination of frozen sections, hematoxylin-eosin staining and immunohistochemistry for S-100 and HMB-45 MAb.

Results

At least one separate focus of activity was identified by LS in 182 out of 183 patients; in all 147 cases where a GP was used, it was successful in tracing the SN. LS with cutaneous mapping of the SN successfully guided the surgical excision in 177 of the 183 cases; in the 7 remaining cases, i.e. 7 out of 83 cases with SNs in the axillary basin, GP was not used and no elective node dissection was performed. Metastases were found in 39 of these 177 cases. In all 39 cases the SNs were the only positive nodes in the basin. Of the 39 metastases 18 were identified by means of frozen section, 12 by means of hematoxylin-eosin, and 9 by means of immunohistochemistry. We therefore emphasize the importance of immunohistochemistry in the pathology of LS for improved staging of the primary tumor.

Predicting Prostate Biopsy Outcome by Findings at Digital Rectal Examination, Transrectal Ultrasonography, PSA, PSA Density and Free-To-Total PSA Ratio in a Population-Based Screening Setting

The study offers a retrospective analysis of the positive predictive value (PPV) of several variables, i.e. digital rectal examination (DRE), transrectal ultrasonography (TRUS), PSA value, PSA density (PSAD), and free/total PSA ratio (F/T), for the histologic outcome of 179 prostate biopsies performed within a population-based screening trial. The ratio of spared benign biopsies to missed cancers (SBB/MC) if biopsy results had been decided on the basis of single variables was also evaluated. PPV was 82.9% for DRE, 56.3% for TRUS, 26.6% for PSA (cutoff ≥4 ng/mL), 47.4% for PSA (cutoff ≥10 ng/mL), 42.0% for PSAD (cutoff 0.15), 59.2% for PSAD (cutoff 0.20), 34.9% for F/T (cutoff 0.20) and 40.0% for F/T (cutoff 0.15). SBB/MC was 121/23 for DRE, 96/12 for TRUS, 11/10 for PSA (cutoff ≥4 ng/mL), 107/34 for PSA (cutoff ≥10 ng/mL), 87/23 for PSAD (cutoff 0.15), 109/26 for PSAD (cutoff 0.20), 45/8 for F/T (cutoff 0.20) and 70/14 for F/T (cutoff 0.15). Multivariate analysis of the association with biopsy outcome showed the highest odds ratio for TRUS (13.24, 95% CI=4.4–30.7), and considerably lower values for DRE (4.17, 95% CI=2.0–8–9), PSAD (cutoff 0.20: 3.24, 95% CI=–1.8–5.7) and F/T (cutoff <0.15: 3.16, 95% CI =1.7–1.8). None of the possible variable combinations was clinically useful: the highest PPV (83.3%) was obtained with a combination of suspicious DRE/TRUS, PSAD >0.20 and F/T <0.15, which nevertheless missed 20 of 52 cancers.

The natural history of takotsubo syndrome: a two-year follow-up study with myocardial sympathetic and perfusion G-SPECT imaging

PURPOSE

To investigate changes in sympathetic activity, perfusion, and left ventricular (LV) functionality in takotsubo cardiomyopathy (TTC) patients from onset (T₀) to post-onset conditions at 1 month (T₁), 1-2 years (T₂, T₃).

METHODS

Twenty-two patients (70 ± 11 years) underwent serial gated single photon emission tomography (G-SPECT) studies with ¹²³I-mIBG and ^99mTc-Sestamibi. Statistics were performed using ANOVA/Sheffé post-hoc, correlation test, and receiver operating characteristic (ROC) curve analysis (p < 0.05).

RESULTS

Patients presented at T₀ with LV ballooning and reduced early-late mIBG uptake (95%, 100%), left ventricular ejection fraction (LVEF)_G-SPECT (86%) and perfusion (77 %). Adrenergic dysfunction was greater in apex, it overlaps with contractile impairment, and both were more severe than perfusion defect. During follow-up, LVEF_G-SPECT, contractility, and perfusion were normal, while 82% and 90% of patients at T₁ and 50% at T₂ and T₃ continued to show a reduced apical early-late mIBG distribution. These patients presented at T₀-T₁ with greater impairment of adrenergic function, contractility, and perfusion. A relationship was present within innervation and both perfusion and contractile parameters at T₀ and T₁, and between the extent of adrenergic defect at T₃ and both the defect extent and age at T₀ (cut-off point 42.5%, 72 years).

CONCLUSION

Outcome for TTC is not limited to a reversible contractile and perfusion abnormalities, but it includes residual adrenergic dysfunction, depending on the level of adrenergic impairment and age of patients at onset. The number of patients, as well as degree of perfusion abnormalities were found to be higher than those previously reported possibly depending on the time-interval between hospital admission and perfusion scan.

Interim Positron Emission Tomography Response-Adapted Therapy in Advanced-Stage Hodgkin Lymphoma: Final Results of the Phase II Part of the HD0801 Study

PURPOSE

The clinical impact of positron emission tomography (PET) evaluation performed early during first-line therapy in patients with advanced-stage Hodgkin lymphoma, in terms of providing a rationale to shift patients who respond poorly onto a more intensive regimen (PET response-adapted therapy), remains to be confirmed.

PATIENTS AND METHODS

The phase II part of the multicenter HD0801 study involved 519 patients with advanced-stage de novo Hodgkin lymphoma who received an initial treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and who underwent an early ifosfamide-containing salvage treatment followed by stem-cell transplantation if they showed a positive PET evaluation after two cycles of chemotherapy (PET2). The primary end point was 2-year progression-free survival calculated for both PET2-negative patients (who completed a full six cycles of ABVD treatment) and PET2-positive patients. Overall survival was a secondary end point.

RESULTS

In all, 103 of the 512 evaluable patients were PET2 positive. Among them, 81 received the scheduled salvage regimen with transplantation, 15 remained on ABVD (physician's decision, mostly because of minimally positive PET2), five received an alternative treatment, and two were excluded because of diagnostic error. On intention-to-treat analysis, the 2-year progression-free survival was 76% for PET2-positive patients (regardless of the salvage treatment they received) and 81% for PET2-negative patients.

CONCLUSION

Patients with advanced-stage Hodgkin lymphoma for whom treatment was at high risk of failing appear to benefit from early treatment intensification with autologous transplantation, as indicated by the possibility of successful salvage treatment in more than 70% of PET2-positive patients through obtaining the same 2-year progression-free survival as the PET2-negative subgroup.

The prognostic value of positron emission tomography performed after two courses (INTERIM-PET) of standard therapy on treatment outcome in early stage Hodgkin lymphoma: A multicentric study by the fondazione italiana linfomi (FIL)

This retrospective study included 246 patients with a new diagnosis of Hodgkin Lymphoma (HL) with a localized-stage (IA-IIA), consecutively admitted from January 2002 to December 2008, by twelve Italian hematological centers on behalf of Fondazione Italiana Linfomi (FIL). Patients were staged at baseline and after two cycles of chemotherapy with PET. All patients were treated with four cycles of ABVD followed by involved-field radiotherapy. No treatment change, based on PET-2 results was allowed. Endpoint of the study was the predictive role of PET-2 on 2-y failure-free survival (FFS). PET-2 was positive in 36 patients (15%) and negative in 210. After a mean follow-up of 46 (3-105) months 19/36 PET-2 positive patients progressed or relapsed and 17 achieved and maintained a CCR. The positive and negative predictive value of a PET2 was 53% and 95%, respectively. The sensibility, specificity and accuracy of PET2 were 65.5%, 92% and 89%, respectively. PET-2 positive scans were centrally reviewed according to the recently defined Deauville Criteria. Upon review the PPV and NPV was 73% and 96% overall. Factors with prognostic significance for progression in univariate analysis were a positive PET-2 (P = 0.000) and the presence of bulky disease (P < 0.01). In a multivariate analysis the only factor that affected negatively FFS was a positive PET-2 (P = 0.000). This study confirms that interim-PET could be considered a prognostic test also in early stage HL, but is unlikely to be a factor that will justify the change of therapeutical approach.

How to choose an anesthesia ventilator?

During the past few years, many manufacturers have developed a new generation anesthesia ventilators or anesthesia workstations with innovative technology and introduced so-called new ventilatory modes in the operating room. The aim of this article is to briefly explain how an anesthesia ventilator works, to describe the main differences between the technologies used, to describe the main criteria for evaluating technical and pneumatic performances and to list key elements not to be forgotten during the process of acquiring an anesthesia ventilator.

Improvement in clinical evaluation of PET/CT images with high resolution algorithms

AIM

Positron emission tomography/computed tomography (PET/CT) diagnosis relies on quality of the reconstructed images which strongly depends on the algorithms used. The aim of this work was to assess if the introduction of high resolution algorithms allows a better identification of reduced diameter lesions, leading to improved diagnosis in clinical setting.

METHODS

The performances of a Siemens Biograph6 True Point PET/CT used for this work were checked for both standard and high resolution algorithms. Clinical studies of thirteen patients referred for PET/CT were selected and grouped according to the metabolic tumor volume and their position in the FOV and then reconstructed with both algorithms; clinical studies were estimated in terms of geometric characteristics and uptake values (SUVmax, SUVmean) of the lesions.

RESULTS

FWHM, spatial resolution, contrast ratio and image quality of the PET/CT scanner used for this work are in agreement with the performances declared by the manufacturers. For the clinical studies, the results obtained using TrueX algorithm showed an increase in SUVmax and SUVmean of 20% and 10% respectively for lesions with volume higher than 2 cm3 and of about 26% and 15% for smaller lesions. The enhancement of SUVmean was around 10% for in axis lesions and of about 12% for off axis lesions. For SUVmax the increase was 23% for both the positions. For small lesions TrueX algorithm led to a metabolic volume higher than with the iterative one while no significant differences were found for big lesions.

CONCLUSION

The advances in 3D PET reconstruction algorithms lead to images with improved quantitative accuracy and image quality performance.

Early interim 18F-FDG PET in Hodgkin's lymphoma: evaluation on 304 patients

PURPOSE

The use of early (interim) PET restaging during first-line therapy of Hodgkin's lymphoma (HL) in clinical practice has considerably increased because of its ability to provide early recognition of treatment failure allowing patients to be transferred to more intensive treatment regimens.

METHODS

Between June 1997 and June 2009, 304 patients with newly diagnosed HL (147 early stage and 157 advanced stage) were treated with the ABVD regimen at two Italian institutions. Patients underwent PET staging and restaging at baseline, after two cycles of therapy and at the end of the treatment.

RESULTS

Of the 304 patients, 53 showed a positive interim PET scan and of these only 13 (24.5%) achieved continuous complete remission (CCR), whereas 251 patients showed a negative PET scan and of these 231 (92%) achieved CCR. Comparison between interim PET-positive and interim PET-negative patients indicated a significant association between PET findings and 9-year progression-free survival and 9-year overall survival, with a median follow-up of 31 months. Among the early-stage patients, 19 had a positive interim PET scan and only 4 (21%) achieved CCR; among the 128 patients with a negative interim PET scan, 122 (97.6%) achieved CCR. Among the advanced-stage patients, 34 showed a persistently positive PET scan with only 9 (26.4%) achieving CCR, whereas 123 showed a negative interim PET scan with 109 (88.6%) achieving CCR.

CONCLUSION

Our results demonstrate the role of an early PET scan as a significant step forward in the management of patients with early-stage or advanced-stage HL.

Pharmacokinetic analysis of plasma curves obtained after i.v. injection of the PET radioligand [11C] raclopride provides a likely explanation for rapid radioligand metabolism

Positron emission tomography (PET) is an imaging technique that provides direct measurements of receptor binding in neurons. The present study was performed to find reasons for the common observation of rapid metabolism of receptor radioligands during time of a brain PET scan. To this aim, the 1-h phase during which imaging-data are acquired was evaluated by using a pharmacokinetic approach. The values of half-lives, volumes of distribution, and dilution calculated for a set of metabolite corrected plasma curves of D2-receptor radioligand [(11)C]raclopride (PETc) during 50 min after radioligand injection in tracer dose were compared with the reference values obtained from a set of plasma curves (REFc) during 30 h after i.v. infusion of unlabelled raclopride in pharmacological doses. We found that the half-life of PETc correspond to the distribution half-life of REFc. Accordingly, the distribution volume during the terminal phase of PETc (13.6 ± 10.8 L) was significantly lower than that during the terminal phase (82.2 ± 30.5 L) and at steady state (59.4 ± 20 L) for REFc, and the dilution of raclopride in body for PETc at 50 min was 38 L, whereas it was 1015 L for REFc at 30 h. The [(11)C]raclopride in plasma at 50 min was higher (10% of dose) than the value for unlabelled raclopride at 30 h (4%). We concluded that the kinetic behavior of the radiolabelled drug [(11)C]raclopride during the 1 h time of a PET corresponds to the distribution phase. The high percentage of [(11)C]raclopride in plasma during this phase is a likely reason for the observed rapid radioligand metabolism.

[A single effective way to reduce post-thyroidectomy discomfort: a clinical trial]

AIM

Nausea, with or without vomiting (postoperative nausea and vomiting, PONV), occurs up to 60-76% after thyroidectomy and other head and neck surgeries. Due to the fact that patients typically have only mild-to-moderate pain after thyroid or parathyroid surgery, PONV might be the main source of discomfort, and it may be perceived as the most unpleasant aspect of postoperative recovery. This study aims to assess the effects of a preoperative single dose of 8 mg dexamethasone on the nausea, vomiting, pain, and subjective vocal function after thyroidectomy in patients undergoing surgery for benign disease.

METHODS

Seventy patients operated on for thyroidectomy were randomized in two groups: Group A, 8 mg/2 mL of dexamethasone administered in 100 mL of physiologic saline given intravenously (i.v.) 20 minutes before the induction of anesthesia; group B, 2 mL NaCl 0.9% in 100 mL of physiologic saline. Postoperative therapy has been standardized. PONV have been evaluated with a scale of 4, degrees (0-3), pain by a Visual Analog Scale (0-100) and subjective vocal function by a Visual Analog Scale (0-100) at 8, 24, 32 and 48 hours after surgery.

RESULTS

The severity of nausea was less in patients of group A (P=0.0001); Dexamethasone patients reported significantly less pain (P=0.008); no differences were noted about the subjective voice analysis (P=0.693). No steroid-related complications occurred.

CONCLUSION

Dexamethasone 8 mg i.v. is a safe and effective method to reduce PONV and pain after thyroid resection and we advise its routine use.

Feasibility of an accurate assessment of myocardial salvage by comparing functional and perfusion abnormalities in post-reperfusion gated SPECT

BACKGROUND

Because of persistent stunning, post-treatment functional abnormalities could identify the initial risk area. The study aims to detect myocardial salvage using post-revascularization gated SPECT in acute myocardial infarction (AMI) treated by reperfusion therapy.

METHODS

In 36 AMI patients, we performed a first gated SPECT injecting (99m)Tc-sestamibi before primary percutaneous coronary intervention (PCI), and a second 5 days later. The salvage index defined by the two perfusion images was compared with the value obtained by subtracting in the second gated SPECT the extent of perfusion defect from the extent of wall thickening abnormalities.

RESULTS

The wall thickening salvage index correlated with the reference perfusion salvage index (Spearman's ρ = .92, P < .0001), with a 95% limit of agreement = ±.25. The agreement between the classifications in salvage index tertiles of the reference and of the wall thickening salvage index was good (kappa = .75). All patients with optimal PCI result and 18/24 of those with intermediate or poor outcome were correctly classified.

CONCLUSIONS

Comparing function and perfusion in a single post-PCI (99m)Tc-sestamibi gated SPECT it is possible to estimate myocardial salvage. This could have useful implications in studies comparing different treatment strategies for AMI.

Predictive potential of pre-operative functional neuroimaging in patients treated with subthalamic stimulation

PURPOSE

The aim of this study was to investigate the predictive potential of pre-operative regional cerebral blood flow (rCBF) in the pre-supplementary motor area (pre-SMA) and clinical factors in Parkinson's disease (PD) patients treated with subthalamic nucleus (STN) stimulation.

METHODS

Ten patients underwent rCBF SPECT and motor Unified Parkinson's Disease Rating Scale (UPDRS) pre- and post-operatively during stimulation at 5 and 42 months. Statistical parametric mapping (SPM) was used to extract rCBF values in the pre-SMA because it is related with motor improvement. Post-operative outcomes included motor response to stimulation and percent improvement in UPDRS. Pre-operative predictors were explored by correlation test, linear regression and multivariate analyses.

RESULTS

Higher pre-operative rCBF in the pre-SMA and younger age were associated with favourable outcomes at 5 and 42 months. Pre-operative rCBF results were significantly associated with baseline clinical factors.

CONCLUSION

This study shows that PD patients with younger age have higher rCBF values in the pre-SMA and better outcome, thus giving the rationale to the hypothesis that STN stimulation could be considered early in the course of disease.

Use of coagulant spray glue (Glubran 2) for aerostatic purposes in pulmonary parenchyma resections in pigs: a preliminary study

BACKGROUND

The aim of our study was to test the aerostatic validity of a cyan-acrylic glue (Glubran 2), applied by means of a spray catheter, on an experimental pig model.

MATERIALS AND METHODS

15 young pigs were divided into three study groups of 5 based on surgical techniques: (1) atypical pulmonary resection with mechanical suturing and reinforcement with continuous suturing; (2) resection of the pulmonary parenchyma with a cold scalpel, followed by local application of Glubran 2; (3) atypical pulmonary resection with mechanical suturing followed by application of Glubran 2.

RESULTS

The mean aerostasis time was calculated at 3.5 +/- 1.26 s. The histopathological analysis did not show any particular differences when comparing the effects of the treatments carried out with Glubran 2 spray glue and the standard treatments. No statistically significant differences were recorded in the short- and medium-term survival of pigs treated with Glubran 2 compared with the respective control groups.

CONCLUSIONS

The application of Glubran 2 spray on wounds caused by pulmonary resections in pigs proved to have a rapid and effective influence for the purposes of aerostasis without significant differences in air losses and survivals.

PET Scan Evaluation of Thymic Mass After Autologous Peripheral Blood Stem-cell Transplantation in an Adult with Non-Hodgkin's Lymphoma

We report the case of a 31-year-old man with anaplastic large-cell lymphoma successfully treated with chemotherapy who showed mediastinal widening 5 months after autologous stem-cell transplantation. CT scan and PET evaluations were consistent with the diagnosis of benign thymic hyperplasia. Because of the rapid and aggressive course of this type of lymphoma, and the progressive widening of the mass at CT scan, we performed a mediastinal biopsy that confirmed these findings, showing normal thymic tissue. This is the first case of benign thymic hyperplasia defined with FDG-PET and confirmed by histologic evaluation.

Positron emission tomography in the staging of patients with Hodgkin’s lymphoma. A prospective multicentric study by the Intergruppo Italiano Linfomi

In this prospective multicentric study, we investigated the contribution of positron emission tomography (PET) scanning to the staging of Hodgkin's lymphoma (HL) by computed tomography (CT) and attempted to determine whether it has any impact on therapeutic approach. One hundred eighty six consecutive patients with HL from six Italian centers were enrolled in this study. They were staged with conventional methods; 2-[fluorine-18]fluoro-2-deoxy-D: -glucose PET scanning were prospectively compared to CT. CT and FDG-PET stages were concordant in 156 patients (84%) and discordant in 30 patients (16%). PET stage in comparison to CT stage was higher in 27 patients (14%) and lower in 3 patients (1%). The programmed treatment strategy was modified in 11 out of 30 patients (37%) after the definition of final stage. If we considered the 123 CT staged patients with localized stage, ten patients (8%) with a change of stage from localized to advanced after PET evaluation were treated with different strategy. FDG-PET was shown to be a relevant, non-invasive method that supplements conventional procedures and should therefore be used routinely to stage HL, particularly in early stage patients, where a change in stage may modify disease management.

Are there adaptive changes in the human brain of patients with Parkinson’s disease treated with long-term deep brain stimulation of the subthalamic nucleus? A 4-year follow-up study with regional cerebral blood flow SPECT

PURPOSE

The aim of this follow-up study was to assess persistent motor and regional cerebral blood flow (rCBF) changes in patients with Parkinson's disease (PD) treated with high-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN).

METHODS

Ten PD patients with STN-DBS underwent three rCBF SPECT studies at rest, once preoperatively in the off-drug condition (T(0)), and twice postoperatively in the off-drug/off-stimulation conditions at 5 +/- 2 (T(1)) and 42 +/- 7 months (T(2)). Patients were assessed using the UPDRS, H&Y and S&E scales. SPM was used to investigate baseline rCBF changes from the preoperative condition to the postoperative conditions and the relationship between rCBF and UPDRS scores used as covariate of interest.

RESULTS

Parkinsonian patients showed a clinical improvement which was significant only on follow-up at 42 months. The main effect of treatment from T(0) to T(1) was to produce baseline rCBF increases in the pre-supplementary motor area (pre-SMA), premotor cortex and somatosensory association cortex. From T(1) to T(2) a further baseline rCBF increase was detected in the pre-SMA (p < 0.0001). A correlation was detected between the slight improvement in motor scores and the rCBF increase in the pre-SMA (p < 0.0001), which is known to play a crucial role in clinical progression.

CONCLUSION

Our study suggests the presence of adaptive functional changes in the human brain of PD patients treated with long-term STN-DBS. Such adaptive processes seem to occur in the pre-SMA and to play only a slightly beneficial role in terms of functional compensation of motor impairment.

Advanced thyroid carcinoma: An experience of 385 cases

AIMS

To report clinical outcomes of a large series of cases with advanced thyroid cancer.

STUDY DESIGN

Three hundred and eighty-five patients at the UICC stages III and IV were selected for the study with thyroid cancer.

RESULTS

Papillary carcinoma and sclerosing carcinoma have better survival than the Hürthle cell and insular types. Lymphatic metastasis does not appear to worsen the prognosis. All the tumour forms offer the chance of long survival.

CONCLUSIONS

Surgical treatment is the primary treatment of thyroid carcinoma. The combined treatments of surgery, metabolic beam therapy, suppressive hormone therapy, radiotherapy and chemotherapy cure a high percentage of patients with the tumour at an advanced stage.

Specific features of differentiated thyroid carcinoma in patients over 70 years of age

BACKGROUND AND OBJECTIVES

Among the geriatric population, there is a lower incidence of thyroid carcinoma (TC), but it accounts for 30% of all thyroid disorders compared to 6-8% in younger subjects. Prognosis, moreover, is worse in the elderly, as demonstrated by the fact that 81% of deaths related to these tumors occur in patients over 55. The aim of this retrospective study was to identify the characteristics of differentiated thyroid carcinoma (DTC) peculiar to the elderly.

METHODS

Of 638 patients who underwent surgery for DTC over a period of 30 years, 46 were more than 70 years old. All the elderly patients had undergone radioioidine and TSH-suppression therapy following surgical resection.

RESULTS AND CONCLUSIONS

Despite these measures, the rate of recurrence was 26.5% at 5 years and 63.6% at 10 years. The 5- and 10-year disease-specific survival rates were 87.8% and 63.6%, respectively. On an average, survival was 55.1 months when death was disease-related, and with regard to histological type, it was longer in papillary carcinoma than in the follicular variant, and longest of all in occult sclerosing carcinoma. Survival was greatest in patients with tumors less than 2 cm in diameter, characterized by the absence of extraglandular spread and by lymph node metastasis.

The predictive value of positron emission tomography scanning performed after two courses of standard therapy on treatment outcome in advanced stage Hodgkin's disease

BACKGROUND AND OBJECTIVES

We explored the predictive value on therapy outcome of an early evaluation of treatment response by 18F-fluorodeoxyglucose position emission tomography (18F-FDG-PET) scan performed after two courses of conventional standard-dose chemotherapy in advanced-stage Hodgkin's disease.

DESIGN AND METHODS

One hundred and eight patients with newly-diagnosed Hodgkin's disease in stage IIA with adverse prognostic factors, or in stage IIB through IVB, were re-staged with FDG-PET after two cycles of ABVD (PET-2). The end-point of the study was the predictive value of PET-2 on 2-year progression-free survival and 2-year failure-free survival. No treatment variation based only on PET-2 results was allowed.

RESULTS

Eighty-eight patients attained complete remission (CR) while 20 showed disease progression during therapy or within 6 months after having reached CR; one patient relapsed. PET-2 was positive in 20 patients: 17 progressed during therapy, one relapsed and two remained in CR. By contrast, 85/88 (97%) patients with a negative PET-2 remained in CR; three progressed or relapsed early after the end of the chemotherapy. Thus, the positive predictive value of a PET-2 was 90% and the negative predictive value was 97%. The sensitivity, specificity and overall accuracy of PET-2 were 86%, 98% and 95%, respectively. The 2-year probability of failure-free survival for PET-2 negative and for PET-2 positive patients was 96% and 6%, respectively (log rank test = 116.7, p < 0.01).

INTERPRETATION AND CONCLUSIONS

18F-FDG-PET scan performed after two courses of conventional standard-dose chemotherapy in advanced-stage Hodgkin's disease was able to predict treatment outcome in 103/108 (95%) of the patients.

18FDG-positron emission tomography in post treatment evaluation of residual mass in Hodgkin's lymphoma: long-term results

In patients with Hodgkin's lymphoma (HL) at the end of first line therapy an accurate imaging technique with high prognostic value is needed to assess response to treatment and predict those patients who will suffer disease relapse. This technique and its results permit the quick initiation of a second line therapy in patients suffering from a progressive disease or those unresponsive to treatment avoid over-treatment of patients in complete remission or those having a non-active residual disease. We included a (18)FDG-positron emission tomography (PET) scan to the diagnostic set-up to investigate 28 patients following the end of their treatment. Fifteen patients out of the 28 (54%) had positive CT scans while 13 (46%) had negative ones. Eleven patients out of the 15 CT positive (73%) had negative PET scans and no relapse. The remaining four patients (27%) had positive PET scans with only one relapse (25%). With respect to the 13 patients who had negative CT scans, 9 patients (69%) had negative PET scans and no relapse. The remaining 4 patients (31%) had positive PET scans with 3 relapse cases (75%). In our final assessment after a median follow-up period of 45 months, starting from PET execution to the last follow-up, overall sensitivity of the CT and the PET were 25 and 100% respectively, specificity 42 and 83% respectively, positive predictive value (PPV) 7 and 50% respectively, negative predictive value (NPV) 77 and 100% respectively, and accuracy 39 and 86% respectively. In our experience, FDG-PET performed in patients after induction therapy appears to offer important additional information: FDG-PET results are predictors of prognosis giving 100% DFS in PET negative patients and 54% DSF in PET positive patients.

[Ergonomic improvements obtained by the realization of an automatic methane cylinder-storage system in a control station]

In a control station where liquid-methane cylinder for vehicle transport are inspected, the realization of an automatic cylinder-storage system not only managed to reduce space shortage inside the plant so avoiding possible accidents due to collisions between fork lift trucks and gathered cylinders or lorries, but also noticeably improved environment by reducing noise, total dust concentration and whole body vibration transmitted through the seats to lift truck operators.

[Assessment of microclimate at a natural gas compression plant]

The Authors evaluate microclimatic conditions in a natural gas compression plant, inside the turboblower station, and find that technical maintenance operators may be subject to heat stress hazard during summer months.

[Risk of electromagnetic fields in control board and switchboard rooms at petrochemical plants]

Authors evaluate electromagnetic field exposure (in the range (5-30,000 Hz) in control board and switchboard rooms of petrochemical plants. According to measured values and international guidelines, they conclude that operators should be exposed without adverse effects.

[Risk of electromagnetic fields in electric power stations and substations of a petrochemical plant]

Authors evaluate electromagnetic field exposure in the low-frequency range (5-30,000 Hz) in electric power stations and substations of petroleum processing plant. According to the measured values and the reference exposure limits considered, they conclude that operators should be exposed without adverse effects.

Octreoscan SPET evaluation in the diagnosis of pancreas neuroendocrine tumors

The study describes the results of Octreoscan SPET (OCTSPET) qualitative and semi-quantitative evaluation in 38 patients with suspected pancreatic neuroendocrine tumors. SPET studies were acquired at 4 and 24 hours after the injection of 111-220 MBq of 111-In-pentetreotide (Octreoscan). Qualitative and semi-quantitative evaluations were performed. The semi-quantitative approach was based on the time course of Tumor/Non Tumor ratios (TNTinc) from 4 and 24 hours. The OCTSPET results were true positive in 18 of 19 patients (10 gastrinoma, 5 insulinoma, 1 neuroendocrine tumor, 1 glucagonoma and 1 carcinoid) and false negative in one insulinoma. Besides, 20 of 38 patients (52%) had clinical plans modified after OCTSPET; OCTSPET was the only positive diagnostic test in 14 of 19 patients (73%) and guided the surgery decision in 14 of 25 patients (56%). In conclusion, these data indicate that Octreoscan represents an excellent tool for the diagnosis of pancreatic neuroendocrine tumors.

Evaluation with breast scintigraphy of breast lesions of indeterminate significance after conventional triple diagnostic approach

The role of breast scintigraphy in the evaluation of 30 women with an uncertain diagnosis following triple assessment was investigated. Scintigraphy was positive in 7 of 13 cancers and 3 of 17 benign lesions and dubious in 1 of 13 cancers and 2 of 17 benign lesions. Sensitivity ranged from 61.5% to 53.8% depending whether dubious lesions were designated as positive or negative. This study shows that breast scintigraphy is not sufficiently sensitive or specific to use in the evaluation of lesions of uncertain diagnosis following triple assessment.

Cytogenetic, molecular and phenotypic characterization of the newly established renal carcinoma cell line KJ29. Evidence of translocations for chromosomes 1 and 3

The established non papillary human renal carcinoma cell line (RCC) KJ29 was submitted to a multiparametric characterization to evaluate its potential use for in vitro and in vivo studies. The cell line grows in vitro as monolayer as well as cell suspension. Cytogenetic analysis has shown a modal chromosome number of 50 with some marker chromosomes, including rearrangements of chromosomes 1 and 3. The antigenic phenotype is characterized by co-expression of cytokeratin and vimentin, as well as expression of urothelium differentiation antigens, low levels of class II MHC antigens and no class I antigens. A differential expression of the VLA-3 integrin heterodimer has been detected between the adherent and non adherent cell population. The cell line which is highly tumorigenic in athymic mice displays expression of erb B-2 and c-met oncogenes and high expression of cell-cycle related and Ha-ras 1 genes.

Serum amylase and tissue polypeptide antigen as biochemical indicators of salivary gland injury during iodine-131 therapy

The study evaluated the possibility of using serum alpha-amylase and tissue polypeptide antigen (TPA) as biochemical markers of radiation injury in the salivary gland of patients with thyroid carcinoma treated with iodine-131. The results demonstrated that the two molecules increased 1 day after 131I administration and returned to near control values on the 3rd day. The increase was greater and longer lasting in those patients treated with the higher 131I administered activity. However, when the patients were divided into groups based on recovery time, which determined patients with different radionuclide elimination rates, the increase in the two molecules was greater and more lasting in those subjects with a longer period of hospitalization. A comparison with the values obtained from patients with tumours of the head and neck treated with external radiotherapy demonstrated that after the 1st day of treatment the salivary gland received an absorbed dose which, based on alpha-amylase levels, ranged between 0.24 and 1.89 Gy and, based on TPA levels, between 0.28 and 2.29 Gy.

Tumor and growth suppression of breast cancer cells by chromosome 17-associated functions

Losses of functions from chromosome 17 are the most frequent genetic abnormalities in human breast cancer. To assess the biological role of chromosome 17 in the development of breast cancer, we transferred a normal human chromosome 17 to two breast cancer cell lines. No viable clone maintaining an intact chromosome was obtained in either MDA-MB-231 or MCF-7. Only one MDA-231/H17 clone contained the long arm of the transferred chromosome 17. Interestingly, this clone lost the ability to induce tumors in nude mice, indicating that at least one gene mapping to the long arm of chromosome 17 could suppress the tumorigenic phenotype. The p53 protein most likely was responsible for the selective loss of the short arm of the chromosome. Both cell lines have no wild-type p53 activity. MDA-MB-231 carries a single mutant TP53 allele, while MCF-7 carries two wild-type alleles, but p53 protein is excluded from the nucleus. Transfection in both cell lines of vectors expressing wild-type p53 produced only clones with rearrangements of the transfected TP53 complementary DNA. Thus, nonregulated expression of the p53 protein driven by the strong cytomegalovirus promoter may have triggered a rapid process of cell death. Stable expression of a mutant p53 in MCF-7 cells proved that nuclear localization of the protein was possible; however, no progression toward an estrogen-independent tumorigenic phenotype was induced. This work indicates that functional inactivation of the wild-type p53 protein and of the product of a gene located on 17q are essential to the development of breast neoplasms.

Quantitative comparison between 99mTc-HMPAO and 99mTc-ECD: measurement of arterial input and brain retention

This report describes a comparative study between technetium-99m ethyl cysteinate dimer (ECD) and 99mTc-hexamethylpropylene amine oxime (HMPAO) in five neurological patients. The conversion kinetics of the tracers in the blood from forms capable of diffusion across the blood-brain barrier to non-diffusible forms were studied by arterial sampling and rapid octanol extraction. We observed that HMPAO has a faster conversion rate in the blood but that the fraction of the injected dose available for brain extraction is higher than in the case of ECD. Regional brain concentrations of the tracers were measured with single-photon emission tomography (SPET) 35 min and 60 min after the injection and remained stable within this interval. On the basis of the measurements of the arterial input and of SPET brain concentrations of the tracers, the regional steady-state influx constants (Ki in ml/min/g) were determined for several brain regions. In the grey matter the Ki values were (mean +/- SD) 0.32 +/- 0.03 and 0.35 +/- 0.04 for HMPAO and ECD, respectively; in the white matter the values were 0.23 +/- 0.01 and 0.23 +/- 0.02, respectively. The Ki values of the two tracers in corresponding regions were closely correlated (P < 0.001). The correspondence of the Ki values of ECD and HMPAO demonstrates that ECD can also be considered a tracer that may be used for quantitative measurements of brain perfusion.

Quantitation of brain perfusion with 99mTc-bicisate and single SPECT scan: comparison with microsphere measurements

This study describes and validates in a preliminary manner a method to measure the steady-state influx constant (Ki) of 99mTc-bicisate with one single photon emission computed tomography (SPECT) scan. The method is based on the analysis of the arterial concentration of the radioactivity. The results of this quantitation procedure were compared with regional CBF (rCBF) measurements made using 99mTc-microspheres (MI). Two quantitative indexes of perfusion, fractional brain uptake (FBU) and normalized (with cerebellum) brain uptake (NBU), were also evaluated. Two SPECT studies were performed on seven cardiovascular patients who had no signs of neurological disease. In the first of these, 99mTc-bicisate was used, while in the other, which was performed 2 days later, MI were injected into the left heart ventricle. The values of the FBU, NBU, and Ki of 99mTc-bicisate were calculated in several gray and white matter brain regions of interest (ROIs) and compared with the rCBF values measured with MI in coupled ROIs. Mean FBU values were 0.00008 +/- 0.00002 and 0.00004 +/- 0.00001 in the gray and the white matter, respectively. Mean NBU values were 0.99 +/- 0.04 and 0.54 +/- 0.05, mean Ki values were 0.36 +/- 0.06 and 0.19 +/- 0.03 ml g-1 min-1 and mean rCBF values were 0.51 +/- 0.04 and 0.27 +/- 0.04 ml g-1 min-1 in gray and white matter, respectively. Analysis of variance of the regression gave different F values for the regressions with rCBF of FBU (F = 19, n = 126), NBU (F = 289, n = 112), and Ki (F = 117, n = 126).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term ambulatory enterogastric reflux monitoring. Validation of a new fiberoptic technique

A new technique for the long-term ambulatory detection of enterogastric and nonacid gastroesophageal reflux has been conceived, developed, and validated. It is based on the use of a fiberoptic sensor that utilizes the optical properties of bile. In vitro studies have shown good precision, good stability, sensitivity of 2.5 mumol/liter bilirubin concentration, as well as a useful working range of 2.5-100 mumol/liter bilirubin concentration. In vivo studies have been performed in 29 subjects. Simultaneous gastric aspirations have allowed a comparison of fiberoptic system measurements both with spectrophotometric analysis and bile acid concentrations of corresponding gastric juice samples. Linear correlations were shown between fiberoptic assessment and both spectrophotometric and bile acid concentration findings (P < 0.01). Simultaneous assessment of reflux with the fiberoptic system and cholescintigraphy has shown a 92.9% concordance as regards the presence or absence of reflux. Present results imply that the fiberoptic system is an important tool for the understanding of the clinical relevance of enterogastric and nonacid gastroesophageal reflux.

[Salivary immunoglobulins in the diagnosis of primary Sjögren's syndrome]

The salivary concentrations of immunoglobulins and total proteins and the salivary flow rate (measured by the method of Deniker et al.) were determined in 29 patients with keratoconjunctivitis sicca and xerostomia and in 11 healthy subjects. According to Fox criteria the group pf 29 patients was divided into two groups: 14 patients with primary Sjögren's syndrome (pSS) and 15 patients with sicca syndrome (SS). The IgA salivary levels were significantly higher in the patients with pSS than in the patients with SS (p < 0.05) and in the healthy subjects (p < 0.001). Moreover the IgG and IgM salivary levels in the first group of patients were higher than in the group of patients suffering from sicca syndrome (p < 0.05) and in the control group (p < 0.02). The salivary flow rate of the patients with pSS and sicca syndrome was lower when compared with the control group (p < 0.005). No significant correlation was found between the salivary flow rate and the immunoglobulins in the three groups of patients. The salivary flow was inversely correlated (p < 0.01) only with the IgA levels in all 40 subjects. The salivary total proteins were significantly elevated in pSS patients when compared with the SS patients (p < 0.04) and with the control group (p < 0.01). The immunoglobulins/total proteins ratios in saliva were significantly higher in the first group than in the other groups (p < 0.005) for the IgG and in the first group than in the SS patients (p < 0.05) for the IgM; no significant differences were noted for the IgA. The bioptic focus scores, graded according Greenspan's criteria, of minor salivary glands of 20 patients with pSS or sicca syndrome were directly correlated with a high significance (p < 0.001) to IgG salivary levels and with a lower significance (p < 0.05) with IgM salivary levels. No significant correlation was found between the bioptic focus scores and the IgA levels. The present results demonstrated a high specificity (100%) and a good sensitivity (86%) of the assessment of salivary IgG for the diagnosis of pSS. The sensitivity of the salivary levels of IgA was higher than that of IgG (93%) but the specificity was low (50%); on the contrary the specificity of the assessment of salivary IgM was good (92%) but the sensitivity was low (60%). This study therefore indicated that the assessment of salivary IgG has a great value for the diagnosis of pSS because IgG levels are related to the amount of lymphoplasmocytic infiltration.(ABSTRACT TRUNCATED AT 400 WORDS)

Suppression of tumorigenesis by the breast cancer cell line MCF-7 following transfer of a normal human chromosome 11

Breast cancer development is associated with several genetic abnormalities. Loss of heterozygosity in the short arm of chromosome 11 has been observed in 30% of tumors. We found homozygosity at five chromosome 11 polymorphic loci in genomic DNA of the MCF-7 breast carcinoma cell line, suggesting a possible loss of one chromosome 11. We have studied the transformed and tumorigenic phenotypes of MCF-7 cells following introduction of a normal human chromosome 11 via microcell fusion. MCF-7/H11 cell hybrids, containing chromosome 11, showed in vitro characteristics similar to the parental cell line. However, tumorigenicity in athymic mice was completely suppressed. Since tumor formation by MCF-7 cells is estrogen dependent, we have analysed the expression of the estrogen receptor and of the estrogen-activated gene pS2. No difference was detected between the parental MCF-7 cells and the derived chromosome 11 cell hybrids, indicating that the mechanism of MCF-7 tumor suppression by chromosome 11-associated functions does not directly involve the estrogen/estrogen receptor molecular pathway.

Merkel cell carcinoma and iodine-131 metaiodobenzylguanidine scan

Two cases of Merkel cell carcinoma, a neuroendocrine neoplasia of the skin, investigated with iodine-131 metaiodobenzylguanidine (131I-mIBG) scintigraphy, are reported. Uptake in the tumor was evident only in 1 case. The possible diagnostic and therapeutic role of 131I-mIBG in patients with this rare neoplasm is discussed.