Bhagwant Rai Mittal

Ultrasonography in detection of single and multiple abnormal parathyroid glands in primary hyperparathyroidism: comparison with radionuclide scintigraphy and surgery

Background  Among the parathyroid imaging techniques, ultrasonography (USG) has the advantage of convenience, easy availability and low cost.

Role of captopril renography in the diagnosis of renovascular hypertension.

Eighty-six hypertensive patients with clinical suspicion of renovascular hypertension (RVH) were evaluated by captopril renal scintigraphy (CRS) and intra-arterial digital subtraction angiography (IADSA) to determine the usefulness of CRS in the diagnosis of RVH and to predict the outcome of revascularization procedures. Technetium 99m-diethlenetriaminepentaacetic acid (DTPA) renal scintigraphy was performed on 2 consecutive days before and after captopril administration. Captopril renal scintigraphy was considered positive if there were changes in the time activity curve according to the criteria specified by the American Society of Hypertension working group. Captopril renal scintigraphy data were compared with presence or absence of anatomic renal artery stenosis (RAS). Of 86 hypertensive patients investigated, 45 had RAS. Aortoarteritis was the cause of RAS in 40 (89%) patients. Revascularization was done in 25 patients, and response to revascularization was compared with that of captopril renography. Compared with IADSA, CRS showed a sensitivity of 82.8% and a specificity of 98.2%. Fourteen patients had bilateral RAS on IADSA. In these patients, CRS was suggestive of bilateral disease in seven patients, unilateral in four, and negative in three. Comparison of CRS with the results of revascularization showed a sensitivity and specificity in detecting curable RAS (RVH) of 95% and 100%, respectively (positive predictive value, 100%; negative predictive value, 85%). In conclusion, we found CRS to be useful in the diagnosis of RVH due to aortoarteritis.

Radioisotope scintigraphy in the diagnosis of hepatic hydrothorax.

Background: Pleural effusion in cirrhotic patients (hepatic hydrothorax) may result from migration of ascitic fluid across defects in the diaphragm. Biochemical analysis of ascitic and pleural fluid provides only indirect information about the nature and origin of the effusion. The present study was performed in order to demonstrate the presence/absence of peritoneo–pleural communication by radioisotope imaging.

Comparison of 18F fluoride PET/CT and 99mTc-MDP bone scan in the detection of skeletal metastases in urinary bladder carcinoma.

Aim The aim of this study was to compare 18F-fluoride PET/CT and 99mTc-MDP bone scintigraphy in the detection of skeletal metastases in urinary bladder carcinoma. Patients and Methods In this prospective study, 48 patients with urinary bladder carcinoma (44 male and 4 female patients, aged 35–80 years) underwent 99mTc-MDP planar and SPECT/CT bone scan (BS) followed by 18F-fluoride PET/CT within 48 hours. Skeletal metastasis diagnosed on each of these techniques was compared against a final diagnosis based on contrast-enhanced CT, MRI, skeletal survey, clinical follow-up, and histological correlation. Results 18F-fluoride PET/CT identified bony metastases and changed the management in 17 of 48 patients (35%). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 99mTc-MDP planar BS were 82.35%, 64.51%, 56%, 86.95%, and 70.83%; of 99mTc-MDP SPECT/CT were 88.23%, 74.19%, 65.21%, 92%, and 79.16%; and of 18F-fluoride PET/CT were 100%, 87.09%, 80.95%, 100%, and 91.66%, respectively. Fair agreement between 99mTc-MDP planar BS and 18F-fluoride PET/CT (&kgr; = 0.42) and excellent agreement between SPECT/CT and 18F-fluoride PET/CT (&kgr; = 0.74) were found. Conclusions 18F-fluoride PET/CT has higher sensitivity, specificity, positive predictive value, negative predictive value, and accuracy in detecting bone metastases in urinary bladder carcinoma than conventional 99mTc-MDP planar BS. SPECT/CT improves all these parameters compared with planar BS and may serve as a cost-effective screening procedure for the detection of skeletal metastases in high-risk patients.

Comparison of 18F-FDG and 68Ga DOTATATE PET/CT in localization of tumor causing oncogenic osteomalacia.

Background Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome, usually caused by small benign mesenchymal tumors. The localization of these tumors is challenging, however, essential for the management. We compared the utility of 18F-FDG PET/CT and 68Ga DOTATATE PET/CT to detect the site of primary tumor in patients with suspicion of TIO. Patients and Methods Retrospective analysis of 6 patients with hypophosphatemic osteomalacia and suspicion of TIO was performed. 68Ga DOTATATE PET/CT study was performed in all 6 patients to localize the tumor. 18F-FDG PET/CT was performed in 4 of 6 patients. 18F-FDG and 68Ga DOTATATE PET/CT studies were performed within 1 week of each other. Both studies were interpreted blindly without the knowledge of other imaging findings. Results All patients had symptoms of osteomalacia and hypophosphatemia. All except 1 patient had increased level of fibroblast growth factor 23. The lag time (symptoms to PET diagnosis) ranged from 1.5 to 22 years. In 4 patients, where both studies were performed, 18F-FDG and 68Ga DOTATATE PET/CT were able to localize the tumor in 2 and 3 patients. 68Ga DOTATATE PET/CT detected tumor in 5 (83.3%) of 6 patients. Conclusions 68Ga DOTATATE PET/CT performed better than 18F-FDG PET/CT and is useful in the detection of tumors causing oncogenic osteomalacia. Therefore, in clinically suspected cases of hypophosphatemic osteomalacia, 68Ga DOTATATE PET/CT may be performed as first-line imaging investigation to avoid delay in the treatment of this devastating but curable disease. However, further studies with large patient population are warranted to validate our data.

Influence of age and gender on presentation of symptomatic primary hyperparathyroidism.

BACKGROUND The geographical difference in presentation of primary hyperparathyroidism (PHPT) is known. However, there is sparse literature on the influence of age and gender on presentation of PHPT. AIM To analyze the effect of age and gender on presentation of symptomatic primary hyperparathyroidism. SETTING AND DESIGN This is a retrospective analysis of data from the primary hyperparathyroidism registry of a north Indian tertiary care teaching institute. MATERIALS AND METHODS Analysis of 184 histopathologically proven PHPT patients registered between March 1990 and March 2010 from a single centre of north India. PHPT patients were divided into three different age groups i.e. children and adolescents less than 25 years, adults 25-49 years, and ≥ 50 years. Clinical presentations, biochemical parameters and parathyroid weight were compared between different age groups and gender using appropriate statistical methods. RESULTS Mean age of patients was 38.5±13.8 years with female: male ratio of 7:3. Rickets as presenting manifestations were seen in one child and adolescent each. Prevalence of renal stones (P=0.03) and gall stones (P=0.02) was higher in the adult groups compared to the younger and older. There was no difference in bone pain (P=0.7), fracture (P=0.3), osteitis fibrosa cystica (P=0.2), fatigue (P=0.6) and other symptoms among different age groups. There was no difference in serum calcium, phosphate, parathyroid hormone (PTH) and 25 (OH) D levels among different age groups, however, as expected alkaline phosphatase was higher in adolescents compared to adults (P=0.03). Bone pain and muscle aches (P<0.001), fracture (P=0.04), osteitis fibrosa cystica (P=0.01), and gall stones (P=0.03) were more common among women while renal stones (P=0.05) and pancreatitis (P=0.02) were common in men. Serum calcium and phosphate levels were similar in either sex but parathyroid hormone (iPTH) level was higher among women (P=0.02). Parathyroid adenoma weight was higher in older compared to young but did not reach to a level of statistical significance. CONCLUSION Age and gender have substantial influence on presentation of PHPT. Bone pain and rickets were common in children and adolescents while renal stones in adults. Women have more severe disease as musculoskeletal manifestations are common and iPTH levels are also higher compared to men.

Role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in the characterization of pancreatic masses: Experience from tropics

Early detection and differentiation of malignant from benign pancreatic tumors is very essential as mass‐forming pancreatitis is a frequently encountered problem. Positron emission tomography (PET) has a role in establishing the diagnosis of pancreatic carcinoma when the conventional imaging modalities or biopsies are nondiagnostic. In this prospective study, the utility of fluorodeoxyglucose (FDG)‐PET/computed tomography (CT) in the characterization of mass‐forming lesions of the pancreas was reported.

Clinical utility of F-18 FDG PET/CT in recurrent breast carcinoma.

Purpose Although initial studies have shown the utility of fluorine-18 fluorodeoxyglucose (F-18 FDG) PET in the detection and restaging of recurrent breast carcinoma, scarce literature exists on F-18 FDG PET/computed tomography (CT). This retrospective study was carried out to evaluate the role of F-18-FDG PET/CT in recurrent breast carcinoma and its impact on management. Materials and methods Retrospective analysis of data of 111 patients who underwent F-18 FDG PET/CT and were suspected of having recurrent breast carcinoma was carried out. PET/CT imaging was carried out for distant metastases in histologically proven locoregional recurrence in 23 patients, clinically suspicious locoregional recurrence in nine patients, increasing tumour markers in two patients, suspicion of distant metastatic disease in 61 patients or as a part of surveillance in 16 patients. The final diagnosis of recurrence and stage of disease was made after histopathological analysis, correlative imaging and clinical or imaging follow-up of at least 6 months. Results The final diagnosis of recurrent breast carcinoma was made in 76 patients and no evidence of recurrence was found in the remaining 35 patients. Locoregional disease requiring local radiotherapy or surgery was diagnosed in 14 patients and distant metastatic disease was diagnosed in 62 patients. FDG PET/CT was true positive in 75 patients, false positive in six patients, true negative in 35 patients and false negative in one patient, with a sensitivity, specificity, positive predictive value and a negative predictive value of 98.7, 85.3, 92.5 and 97.2%, respectively. FDG PET/CT also accurately restaged 22/23 patients with proven locoregional recurrence with an accuracy of 95.45%. Of 53 patients suspected of having distant metastatic disease on other imaging modalities, true distant metastatic disease was diagnosed in 36 patients and FDG PET/CT identified true metastatic disease in 35/36 patients, accurately ruling out metastases in the remaining 17 patients, and was false negative in one patient. In addition to confirming distant metastatic disease, it revealed more metastatic sites in 22 patients. Overall, F-18 FDG PET/CT had a major impact on management in 41% of the 103 patients being analysed for a major change in treatment. Conclusion F-18 FDG PET/CT is a very sensitive and specific imaging tool in detecting and restaging recurrent breast carcinoma. It can be a very useful imaging tool for restaging locoregional recurrences, and as a one-stop shop imaging technique to confirm suspicious metastatic disease on conventional imaging and to define the total burden of disease.

Large Spontaneous Coronary Artery Dissections A Study of Three Cases, Literature Review, and Possible Therapeutic Strategies

Spontaneous coronary artery dissection is rare, but is now being increasingly recognized as a prominent cause of acute ischemic coronary events occurring usually in relatively young patients, predominantly females. The authors describe the clinical course of 3 patients (1 woman) in whom large spontaneous coronary artery dissections developed. All had diverse clinical presentations; 1 presenting with heart failure, the second with post-myocardial infarction angina, and the third with syncope. The second patient underwent coronary angioplasty with multiple overlapping stents while in the other two, it was the considered opinion to continue aggressive medical therapy. The 1-year follow-up was uneventful in all 3 patients. The risk factors ascertained in our patients were diabetes mellitus, smoking, and hypertension.

A single photon emission computerized tomography (SPECT) study of regional cerebral blood flow in bipolar disorder

Data on functional imaging of bipolar disorder (BD) utilizing single photon emission computerized tomography (SPECT) is limited. This study assessed regional cerebral blood flow (rCBF), using 99mTc-ECD SPECT, among patients with BD, with mania (N=10) or depression (N=10), compared with 10 patients with unipolar depression and 10 normal controls. Regions of interest were analysed using a semi-automatic brain quantification programme. Compared to controls, patients with mania had significantly reduced perfusion mainly in the left frontal area, also in the left anterior cingulate and parietal cortices; those with bipolar depression had significantly lowered rCBF principally in the anterior temporal regions bilaterally, as well as the left parietal area. Patients with unipolar depression had significantly lowered perfusion than controls in most of the regions examined, chiefly in the anterior temporal and frontal cortices bilaterally; they also had lowered perfusion in the right anterior temporal and frontal areas, as well as the right middle temporal area and the right thalamus, compared to patients with mania. Increased severity of psychotic symptoms was associated with reduced rCBF in patients. These results indicate that altered blood flow in the frontal-subcortical systems characterises patients with BD, as well as those with unipolar depression.