Dagmar Steiner

Visualization of segmental irritation points with scintigraphy

SummaryThe aim of this study was the scintigraphic visualization of points of segmental irritation resulting from reversible articular dysfunction. Because of increased cellular metabolism as a result of muscular hypertonus, scintigraphic visualization of these points should be possible with 99mTc-MIBI. This radiopharmaceutical is localized in cells, depending on the metabolism.In 20 patients we compared manual diagnosis with scintigraphy at the thoracic spine in 22 investigations and at the linea nuchae in one investigation. Manual diagnosis was done within 1 h before or after scintigraphy. Analysis of scintigraphy followed manual diagnosis with a minimal interval of 2 weeks.We were able to compare 401 localizations. Manual diagnosis resulted in 39 points of segmental irritation from which 36 points were also shown in scintigraphy. In 44 cases scintigraphic alteration was shown without correlating points in manual diagnosis. In 318 cases both investigations were negative.Therefore, scintigraphic localization of points of segmental irritation was possible. The higher number of scintigraphic alterations should not be interpreted as false-positive results, but as simultaneous visualization of myofascial trigger points or tender points. Because of that it also should be possible to objectize the diagnosis of myofascial trigger points and fibromyalgia.ZusammenfassungZiel der Studie war die szintigraphische Darstellung segmentaler Irritationspunkte in Folge einer reversiblen Gelenkfunktionsstörung. Da bei diesen Irritationspunkten auf Grund des vorliegenden Muskelhypertonus auch ein erhöhter Zellstoffwechsel vorliegt, sollte der Nachweis mit Tc99m-MIBI, einem stoffwechselabhängigen Radiopharmakon möglich sein.Bei 20 Patienten erfolgten 22 vergleichende Untersuchungen der BWS und eine Untersuchung der Linea nuchae. Die Chirodiagnostik erfolgte mit einem maximalen Abstand von 1 Stunde zur Szintigraphie, ohne Kenntnis des Ergebnisses. Die Auswertung der Szintigraphie erfolgte mit einem Mindestabstand von 2 Wochen zur Chirodiagnostik.Es konnten insgesamt 401 Lokalisationen vergleichend ausgewertet werden. 36 der 39 chirodiagnostisch nachgewiesenen Irritationspunkte fanden sich auch szintigraphisch. In 44 Fällen bestand eine szintigraphische Veränderung ohne chirodiagnostisches Korrelat. In 318 Fällen fand sich ein übereinstimmendes negatives Ergebnis.Somit können segmentale Irritationspunkte szintigraphisch nachgewiesen werden. Bei der größeren Zahl an szintigraphischen Veränderungen ist nicht von einem falsch positiven Ergebnis, sondern von der Darstellung anderer muskulärer Triggerpunkte auszugehen. Die Szintigraphie ermöglicht die Objektivierung muskulärer Triggerpunkte unterschiedlicher Ursache, eventuell sogar die Diagnostik der Fibromyalgie.

Diagnosis of focal nodular hyperplasia with hepatobiliary scintigraphy using a modified SPECT technique.

A 29-year-old woman was examined because of malnutrition and recurrent diarrhea. Her serum glutamate oxaloacetate transaminase and serum gamma glutanyl transferase (SGGT) levels were found to be elevated. The patient denied alcohol abuse, blood transfusion, and foreign travel, and she had never used oral contraceptives. Findings of ultrasonography of the liver were normal. A computed tomographic examination suggested focal nodular hyperplasia (FNH), although adenoma could not be excluded. Hepatobiliary imaging was normal and did not manifest the three typical signs of FNH: hypervascularization, increased tumor uptake, and trapping in later images. Repeated scintigraphy using a modified SPECT technique clearly showed FNH.

Intraindividual homogeneity of 18F-FDG PET/CT parameters in HPV-positive OPSCC

OBJECTIVES 18F-FDG PET/CT is widely used in clinical oncology. Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) represents an emerging disease that differs from HPV-negative OPSCC in clinical behavior and tumour biology. In these tumours, HPV-oncogenes might lead to distinct alterations in metabolic pathways. Therefore, we compared metabolic parameters using 18F-FDG PET/CT in HPV-positive and HPV-negative OPSCC in relation to histopathological findings. MATERIALS Eighty-six patients with OPSCC received pre-therapeutic 18F-FDG PET/CT. Standardised uptake volume (SUV), total lesion glycolysis (TLG) and metabolic tumour volume (MTV) were analysed for the primary tumour. SUVmax was determined for neck lymph nodes. HPV-status was determined; overall survival rates (OS) were estimated. RESULTS 32/86 patients (37.2%) had HPV-related OPSCC. Overall, PET-parameters in primary tumours of both groups did not differ significantly. Comparing early with locally advanced primary tumours, there was a significant increase in 18F-FDG uptake in HPV-negative patients (p<0.001). Positive nodes of HPV-related OPSCC showed significantly higher SUVmax values (p=0.039) compared to HPV-negative OPSCC. Strikingly, there was a higher intraindividual homogeneity of 18F-FDG uptake between primary and respective positive nodes in HPV-related primary OPSCC (p=0.001). SUV-max and -mean values did not correlate with OS in HPV-related OPSCC. CONCLUSION The intraindividual homogeneity of 18F-FDG uptake in HPV-related OPSCC could reflect the more homogenously, HPV-triggered carcinogenesis compared to the mutation-driven carcinogenesis in the HPV-negative OPSCC with heterogenic 18F-FDG uptake.

Radiation synovectomy of the knee joint : Evaluation of bremsstrahlung-detection by using a corpse phantom

AIM Multiple procedures for the quantification of activity leakage in radiation synovectomy of the knee joint have been described in the literature. We compared these procedures considering the real conditions of dispersion and absorption using a corpse phantom. METHODS We simulated different distributions of the activity in the knee joint and a different extra-articular spread into the inguinal lymph nodes. The activity was measured with a gamma-camera. Activity leakage was calculated by measuring the retention in the knee joint only using an anterior view, using the geometric mean of anterior and posterior views, or using the sum of anterior and posterior views. The same procedures were used to quantify the activity leakage by measuring the activity spread into the inguinal lymph nodes. In addition, the influence of scattered rays was evaluated. RESULTS For several procedures we found an excellent association with the real activity leakage, shown by an r(2) between 0.97 and 0.98. When the real value of the leakage is needed, e. g. in dosimetric studies, simultaneously measuring of knee activity and activity in the inguinal lymph nodes in anterior and posterior views and calculation of the geometric mean with exclusion of the scatter rays was found to be the procedure of choice. CONCLUSION When measuring of activity leakage is used for dosimetric calculations, the above-described procedure should be used. When the real value of the leakage is not necessary, e. g. for comparing different therapeutic modalities, several of the procedures can be considered as being equivalent.

Long-term follow-up of meningeal spread of otherwise stage 4S neuroblastoma without treatment

Neuroblastoma (NB) in infants <12 months presenting with metastases limited to skin, liver and bone marrow infiltration <10% are stratified as stage 4 Special (4S) disease.1 Watchful waiting might be pursued in infants who are not critically ill.2 In contrast, NB with metastases to other sites are classified as stage 4 requiring intensive therapy.1,3 The prognostic meaning of rare meningeal lesions in otherwise typical 4S NB is unknown. We report on a four month old male who presented with an asymptomatic subcutaneous mass on his back. NB, Hughes grade II without MYCN amplification or 1p aberration was diagnosed.4 Staging revealed small tumors in both adrenal glands, liver metastases and multiple subcutaneous metastases. Additionally, a subdural lesion in the falx cerebri and an intracranial extracerebral tumor compressing the adjacent left transversal sinus, classified as leptomeningeal metastases, were detected (Fig. 1A). With the typical characteristics of a stage 4S NB, but leptomeningeal metastases of unknown prognostic meaning, we decided after thorough information and consent with the parents to follow the patient closely clinically with short-term restaging without immediate treatment. After 5 months the metastases had regressed considerably. Residual manifestations remained intracranially and subcutaneously. One year after diagnosis all manifestations had completely regressedwith exception of the parieto-occipital lesion. The lesionwas not judged resectable without high risk of disturbed left-hemispheric blood flow with neurological sequelae. Together with the parents, the decision was made to continue the watch and wait strategy. The last 123I-metaiodobenzylguanidine (MIBG) scintigraphy at the age of three years showed attenuating, but persisting uptake in the leptomeningeal lesion. Five years after diagnosis the child is in good clinical condition with normal physical and neurological development. Cranial magnet resonance imaging (MRI) shows the persisting residual 25×10×9 mm lesion occluding the left transversal sinus and encasing the inferior anastomotic vein (Fig. 1B and 1C). Five reports describe infants with otherwise stage 4S NB but leptomeningeal spread. Two of which regressed spontaneously after partial or gross resection of the primary tumor.5,6 Three other infants were cured after low-dose chemotherapy, supplemented by radiotherapy of the falx in one child.7–9 Besides regression, differentiation can be observed in infant neuroblastoma leading to residual masses.10 From the course in our patient, we hypothesize that the residual mass may be a differentiated remnant. The long-term follow-up of our patient with NB stage 4S and persisting leptomeningeal tumor illustrates that meningeal spread of an

Restrictive cardiomyopathy in inherited ATTR amyloidosis (TTR-Ser23Asn) in a patient of German-Italian extraction.

Amyloidosis occurs when certain soluble proteins are transformed into amyloid fibrils in the extracellular space. Most common are the light-chain amyloidoses; less common is the AA-amyloidosis, which follows chronic inflammatory diseases, and the amyloidoses of transthyretin (TTR) origin. We report on a women of Italian-German origin with the mutation TTR (Ser23Asn). Whole body scintigraphy using TC99m-DPD showed end stage hereditary amyloidosis caused by ATTR with predominant tracer retention in the myocardium. Myocardial biopsies revealed the presence of amyloid by Congo red staining. Further immunohistochemical analysis showed ATTR amyloidosis. DNA sequencing revealed a point mutation of the transthyretin gene leading to a single amino acid substitution. The only effective treatment in patients with manifest cardiac ATTR amyloidosis is combined heart and liver transplantation. Our patient was placed on a list for this procedure, but unfortunately she died during the standby procedure due to urosepsis.

Neubewertung der Diureseradionuklidnephrographie bei Ureterabgangsstenosen

ZusammenfassungFragestellung: Die dynamische Radionuklidnephrographie (99mTc-MAG3) stellt die wichtigste Untersuchungsmethode zur Klärung einer oberen Harnwegobstruktion dar. Untersucht wurde, ob die Methode, unter standardisierten Bedingungen (i.v.-Hydratisierung, Furosemidgabe und Sedierung) angewandt, eine strenge Operationsindikation erlaubt und sich als Verlaufsbeobachtung eignet. Dabei wurde insbesondere geprüft, ob bei minimalem Abfall der Traceraktivität (10–25%) und guter Nierenfunktion ein konservatives Vorgehen möglich ist. Methode: Bei 55 Kindern mit ausgeprägter Hydronephrose (>12 mm Dilatation des Nierenbeckens und der Kelche in der Sonographie) wurde eine Radionuklidnephrographie veranlaßt. Die Untersuchung erfolgte nach i.v. 4stündiger Hydratisierung mit 30–40 ml/kg KG. Ergebnisse: Bei 24 Kindern war ein Abfluß von mehr als 50% und bei 13 von mehr als 25% der Aktivität nachweisbar. Bei 3 Patienten war nur eine geringe Ausscheidung (10–25%) zu dokumentieren, die sich bei einer Kontrollradionuklidnephrographie nach 8 Wochen bei allen Patienten eindrucksvoll besserte. Von 15 Kindern mit fehlendem Tracerabfall wurden 6 Monate nach erfolgreicher Korrektur der Ureterabgangsstenose bei 13 Kindern mehr als 50% der Traceraktivität ausgeschieden, bei den beiden anderen mehr als 30%. Schlußfolgerungen: Die standardisierte Radionuklidnephrographie ermöglicht eine wichtige funktionelle Aussage über die urodynamische Relevanz der Harntransportstörung. Ein geringer Auswascheffekt (10–25%) erlaubt bei Säuglingen mit normaler Nierenfunktion primär ein konservatives Vorgehen, und ein Tracerabfall <50% darf nicht länger als Maß für eine urodynamisch bedeutsame Obstruktion mit der Konsequenz einer operativen Korrektur angesehen werden.SummaryBackground: The dynamic radionuclide nephrography (Tc99m-MAG3) is an important method in the evaluation of obstruction of the upper urinary tract. The aim of the present study was to assess whether radionuclid nephrography under standardized conditions with adequate hydration and Furosemid induced diuresis can reliably detect a significant obstruction at the pelvi-ureteric junction. We therefore tested whether minimal tracer washout (10–25%) in the presence of normal renal function could justity a non-operative managment. Methods: 55 children with sonographically diagnosed hydronephrosis (dilation of the renal pelvis of more than 12 mm and calical dilation) had dynamic radionuclide nephrography after intravenous hydratisation (30–40 ml/kg bw). Results: 24 children showed a washout above 50%, 13 of more than 25%. Three patients had only a minimal washout (10–25%), which improved impressively as demonstrated in a control nephrography 2 months later in all of them. 15 children without any significant washout underwent corrective surgery: Six months after operation 13 of them showed a washout above 50%, the two remorning or more than 30%. Conclusion: Standardized radionuclide nephrography allows an important functional assessment of the urodynamic relevance of the pelvi-ureteric junction obstruction. With minimal tracer washout (10–25%) in the presence of normal renal function (>40% divided renal function) primary conservative management seems justified. A washout below 50% no longer can be accepted as on indication of urodynamicly important obstruction necessitating operative corrective surgery.