Franco Bui

An unexpectedly high rate of pulmonary embolism in patients with superficial thrombophlebitis of the thigh

PURPOSE The rate of objectively proven pulmonary embolism in patients with thrombophlebitis of the greater saphenous vein was studied. METHODS Consecutive ambulant patients with thrombophlebitis of the greater saphenous vein, involving the above-knee segment, underwent a complete venous echo color Doppler examination of the lower limbs, perfusion lung scanning, and chest radiography. A high probability of pulmonary embolism was defined as the presence of two or more large segmental defects, one large and two or more moderate perfusion defects, or four or more moderate perfusion defects, with no corresponding abnormality found by means of chest radiography. RESULTS Of the 21 patients included in the study, findings compatible with a high probability of pulmonary embolism were detected in seven patients (33.3%; 95% CI, 14.6 to 57. 0), although clinical symptoms of pulmonary embolism were present only in one patient. No association was found between the presence of thrombosis at the saphenofemoral junction and the risk for pulmonary embolism. CONCLUSION The rate of pulmonary embolism in patients with thrombophlebitis of the greater saphenous vein is unexpectedly high. This risk is similarly high in patients with thrombosis at the saphenofemoral junction and in patients without thrombosis at the saphenofemoral junction. Our results are consistent with those of other recent investigations and suggest that superficial thrombophlebitis of the thigh is not as benign a disease entity as previously described.

Sensitivity and positive predictive value of CT, MRI and 123I-MIBG scintigraphy in localizing pheochromocytomas: a prospective study.

AimTo establish a standardized non-invasive imaging protocol for patients with pheochromocytoma undergoing surgery. MethodsA series of 32 consecutive patients (16 men, 16 women; median age 43 years, range 15–71 years) with biochemically confirmed pheochromocytoma underwent computed tomography (CT) scanning, magnetic resonance imaging (MRI) and meta-[123I]iodobenzylguanidine (MIBG) whole-body scintigraphy prior to adrenalectomy or excision of extra-adrenal tumour (paraganglioma). ResultsAt final pathology no malignant pheochromocytomas were found. The tumour was right-sided in 16 (50%) patients, left-sided in 13 (41%), extra-adrenal (sympathetic ganglia, upper abdomen) in two (6%) and bilateral in one (3%) patient. Overall, the median greatest diameter (size) of the tumour was 35 mm (range, 15–90 mm). The sensitivity of CT, MRI and MIBG scintigraphy was 90%, 93% and 91%, and the specificity was 93%, 93% and 100%, respectively. The three patients with false negative scintigraphy had an intra-adrenal tumour, ranging from 20 to 50 mm in size. The presence of necrosis within the mass might justify the lack of significant uptake of radiopharmaceutical in two patients, and the small size (15 mm) of the mass in the other. There were two false positive results with both CT and MRI, and no false positive MIBG scintigraphy, which had the highest (100%) positive predictive value. The combination of MRI+MIBG scintigraphy reached 100% sensitivity and positive predictive value. ConclusionOur data suggest that this imaging protocol should be used in all patients with biochemically confirmed pheochromocytoma.

High risk of malignancy in patients with incidentally discovered adrenal masses: accuracy of adrenal imaging and image-guided fine-needle aspiration cytology.

AIMS AND BACKGROUND The incidental finding of nonfunctioning adrenal masses (incidentalomas) is common, but no reliable criteria in differentiating between benign and malignant adrenal masses have been defined. The aim of this preliminary study was to assess the usefulness of adrenal imaging and image-guided fine-needle aspiration cytology in patients with nonfunctioning adrenal incidentalomas with the aim of excluding or confirming malignancy before surgery. METHODS Forty-two consecutive patients (18 men and 24 women; median age, 54 years; range, 25-75 years) with incidentally discovered adrenal masses of 3 cm or more in the greatest diameter were prospectively enrolled in the study. All patients underwent helical computerized tomography scan and image-guided fine-needle aspiration cytology, 33 (78.6%) underwent magnetic resonance imaging, and 26 (61.9%) underwent norcholesterol scintigraphy before adrenalectomy. RESULTS The revised final pathology showed 30 (71.4%) benign (26 adrenocortical adenomas, of which 3 were atypical, 2 ganglioneuromas, and 2 nonfunctioning benign pheochromocytomas) and 12 (28.6%, 95% CI = 15-42) adrenal malignancies (8 adrenocortical carcinomas and 4 unsuspected adrenal metastases). The definitive diagnosis of adrenocortical carcinoma was made according to Weiss criteria and confirmed on the basis of local invasion at surgery or metastases. The sensitivity, specificity and accuracy were 75%, 67% and 83% for computerized tomography scan, 92%, 95% and 94% for magnetic resonance imaging, 89%, 94% and 92% for norcholesterol scintigraphy, and 92%, 100% and 98% for fine-needle aspiration cytology. The sensitivity and accuracy of image-guided fine-needle aspiration cytology and magnetic resonance imaging together reached 100%. Immediate periprocedural complications of fine-needle aspiration cytology occurred in 2 (4.7%) patients: self-limited pneumothorax (n = 1), and severe pain (n = 1) requiring analgesic therapy. No postprocedural or late complications were observed. CONCLUSIONS With the aim of selecting for surgery patients with a non-functioning adrenal incidentaloma of 3 cm or more in diameter, the combination of magnetic resonance imaging and fine-needle aspiration cytology should be considered the strategy of choice.

Usefulness of CT scan, MRI and radiocholesterol scintigraphy for adrenal imaging in Cushing's syndrome.

The aim of this study was to evaluate the sensitivity and accuracy of computed tomography (CT) scanning, 75Se-selenomethyl-norcholesterol scintigraphy (SNS) and magnetic resonance imaging (MRI) in patients with Cushings syndrome (CS) undergoing adrenalectomy. A series of 67 patients with CS due to benign adrenal disease was reviewed. There were 11 (16.4%) men and 56 (83.6%) women, with an overall median age of 44 years (range 19-69 years). Prior to surgery all patients underwent both CT and SNS, and 58 (86.6%) underwent adrenal MRI. Thirty-five (52.2%) of the patients (group A) had histologically confirmed unilateral adrenal involvement (33 patients with a solitary adrenocortical adenoma, and two with unilateral nodular cortical hyperplasia), while 32 (47.8%) of the patients (group B) had CS caused by bilateral adrenal involvement, including two patients with multinodular adrenal hyperplasia. The sensitivity, specificity and accuracy of adrenal imaging in group A were 97.1%, 100% and 98.5% for SNS, 94.3%, 68.7% (P<0.05, χ2 test) and 82.1% for CT scan, and 92.3%, 60.0% (P<0.05) and 64.3% (P<0.05) for MRI, respectively. In group B the sensitivity, specificity and accuracy were 100%, 97.2% and 98.5% for SNS, 64.5% (P<0.05), 97.2% and 82.1% for CT scan, and 60.0% (P<0.05), 92.3% and 35.7% (P<0.05) for MRI, respectively. In conclusion, SNS represents the most sensitive and specific adrenal imaging study and should be used in all patients with confirmed biochemical diagnosis of CS undergoing adrenalectomy. The sensitivity and specificity of CT scan and MRI are similar, but the latter shows a lower accuracy, especially in patients with bilateral adrenal involvement.

Acromegalic cardiopathy: A left ventricular scintigraphic study

In order to study “acromegalic cardiomyopathy”, cardiac function was examined, using gated radionuclide ventriculography, in 18 acromegalic patients and 21 control subjects with no clinical evidence of cardiac involvement. In these acromegalic subjects, while the Ejection Fraction (EF) did not appear to be significantly different, the Peak Filling Rate (PFR) was reduced while the Time to Peak Filling Rate (TPFR) resulted significantly greater than in control subjects. These findings indicate that chronic growth hormone (GH) hypersecretion, as observed in acromegaly, deteriorate the cardiac ventricular relaxation (diastolic phase) while it has no influence on contractility (systolic phase).

Breast Cancer Detection With 99m-Tc-Sestamibi Scintigraphy, Mammography, and Fine-Needle Aspiration Cytology: Comparative Study in 64 Surgically Treated Patients

Background: In breast cancer, mammography (MG) fails to reveal malignancy in 10% to 15% of patients, and its sensitivity is limited by dense breast tissue. The aim of this study was to evaluate the usefulness of 99m-Tc-sestamibi scintimammography (SMM) in conjunction with MG and fine needle aspiration (FNA) cytology in the detection of low-stage breast cancer.Methods: A total of 64 women (median age 58 years, range 32–86 years), 53 (82.8%) with palpable and 11 (17.2%) with nonpalpable breast mass, underwent SMM; 61 patients had MG and 62 underwent FNA cytology. At histological examination, breast cancer was found in 59 (92.2%) of the women (pTis = 2, pT1a = 2, pT1b = 13, pT1c = 20, pT2 = 22).Results: Of the 61 patients who had MG, 45 (73.8%) showed signs of cancer or abnormalities. Of the 62 patients who had FNA cytology, 55 (88.7%) showed malignancy. In 5 (8.1%) patients, atypical ductal hyperplasia or complex sclerosing lesions were found. MG, SMM, and FNA cytology were 80.4%, 78.0%, and 96.5% sensitive, respectively, and their positive predictive value was 97.8%, 100%, and 100%, respectively. In all patients, cancer was at least detected by one of these three techniques.Conclusions: In women with suspicious MG or abnormal FNA cytology that required further investigations, SMM may be helpful in surgical planning and should be considered in most patients before biopsy as an additional noninvasive procedure.

Angiotensin converting enzyme inhibition worsens the excretory phase of diuretic renography for obstructive hydronephrosis.

PURPOSE A growing body of evidence identifies the renin-angiotensin system as a key factor in the onset and progression of renal damage in chronic partial obstruction, which often represents a complex diagnostic challenge. A prospective study was undertaken to evaluate the role of captopril mercaptoacetyltriglycine-3 (MAG-3) renography as an early diagnostic test of obstruction. We report the results in a subgroup of children who underwent surgical correction for pyeloureteral obstruction. MATERIALS AND METHODS Pyeloplasty was performed in 12 patients, including 10 males, 2 to 72 months old (median age 7) with unilateral hydronephrosis, including normal renal function and blood pressure. Basal and captopril enhanced diuretic renography with 99mtechnetium MAG-3 was performed within 24 hours using the same hydration and diuretic stimulus (0.75 mg./kg. furosemide), and 0.75 mg./kg. captopril was administered orally 60 to 90 minutes before scintigraphy. RESULTS No adverse effects or modifications of the blood pressure were observed after captopril administration. The diuretic response was deeply worsened by angiotensin converting enzyme inhibition in each hydronephrotic kidney even when the basal study was only slightly abnormal (15-minute washout basal -27 +/- 16%, after captopril -9 +/- 13, p <0.005). After surgical correction the diuretic washout during angiotensin inhibition appeared normal in all patients (15-minute washout -56 +/- 14%). Separate renal function and parenchymal transit of MAG-3 were not modified by angiotensin converting enzyme inhibition, preoperatively or postoperatively. CONCLUSIONS Our data confirm the influence of angiotensin on the kidney excretory system in human hydronephrosis and suggest a role for captopril enhanced diuretic renography in the early diagnosis of pyeloureteral obstruction. Further work is needed to evaluate angiotensin converting enzyme inhibition as a protective agent in obstructive nephropathy.

Radionuclide evaluation of lung perfusion after the Fontan procedure.

Lung perfusion was evaluated in 19 patients in whom a Fontan operation had been performed at a mean age of 3.7 years. First pass and equilibrium data were acquired during the lung particle perfusion scan 0.5 to 7.9 years (mean 3.7 years) following the Fontan procedure. Abnormalities of lung perfusion were documented in 8 patients. Minimal underperfusion of small areas of either right or left lung were noted in 4 patients, while the remaining 4 had evidence of major perfusion defects, involving both lungs. The perfusion defects were localized, in the majority of cases, on the side where a palliative procedure had been performed before the Fontan operation: it is of note that all our patients without palliative procedures did not show abnormalities in lung perfusion. Major abnormalities of lung perfusion seemed related to possible intimal thrombosis or emboli due to prolonged polycythemia or to pulmonary vessel distortion due to long-standing shunts.

Different rates of thyrotropin suppression after total body scan in patients with thyroid cancer: effect of regular doses of thyroxine and triiodothyronine

The relative rates of T4 and T3 in inducing TSH suppression when therapy is re-started after Total Body Scan (TBS), in patients with differentiated thyroid cancer, were evaluated in two groups of 9 patients, each. The doses adopted were those usually considered to be TSH suppressive in chronic administration (T4 = 3.4 ± 0.3 µg/day/kg bw; T3 = 1.1 ± 0.04 µg/day/kg bw). At time 0, TSH levels were elevated in all patients, ranging from 58 to 147 µU/ml; T3 and T4 were below the limit of detectability. After the beginning of the therapy decrease of TSH levels and inhibition of TSH response to TRH was very gradual. It was slower in patients on T4: at day 14 basal TSH level was 23.6 ± 26.7 µU/ml (mean ± SD) and 30 min after 200 µg TRH iv mean TSH level was 99 ± 40 µU/ml; at day 30 mean basal TSH was 1.5 ± 1.2 µU/ml and, after TRH, 5.8 ± 6.9 µU/ml, than in patients on T3: at day 14 mean basal TSH level was 1.8 ± 1.0 µU/ml and after TRH 10 ± 13.9 µU/ml; at day 30 mean basal TSH was 1.0 ± 0.5 µU/ml and after TRH was 2.7 ± 1.4 µU/ml. In patients taking T3, serum levels of T3 rose to normal limits very quickly (at day 3 mean serum T3 level was 159 ± 30 ng/100 ml) and afterwards remained slightly above normal range (at day 7 it was 213 ± 41 ng/100 ml). In patients taking T4, the rise of serum levels of both T3 and T4 was much slower and gradual: at day 3 mean T3 level was 53 ± 15 ng/100 ml; at day 7 it was 99 ± 25 ng/100 ml; at day 14 it was 144 ± 26 ng/100ml; at day 3 mean T4 levels was 2.0 ± 0.6 µg/100ml; at day 7 it was 6.6 ± 1.5 µg/100 ml; at day 14 it was 9.9 ± 1.9 µg/100 ml. These data show that T4 in the usual suppressive dose is not suitable to achieve TSH suppression as quickly as would be necessary in patients with differentiated thyroid cancer when therapy is re-started after TBS. Treatment with T3, 1.1 µg/day/kg bw, induces TSH suppression more quickly. Therefore, it seems advisable in such patients to start suppressive treatment with T3 and to shift to T4 after a month, in order to avoid any unnecessary stimulation by TSH of eventual residual tumor.

Peptide Receptor Radionuclide Therapy in a Case of Multiple Spinal Canal and Cranial Paragangliomas

Case Report In 2000, a 32-year-old man was admitted to the hospital with lower back pain. Gadolinium-enhanced lumbar (L1-S1) magnetic resonance imaging (MRI) revealed a clearly delimited, ovoid, expansive, intradural mass with a strong contrast enhancement behind the L4 vertebral body, occupying the vertebral foramina, mildly scalloping the vertebral body. MRI findings were interpreted as caudal ependymoma. After radical surgery, the symptoms vanished. The tumor mass measured 3 2.5 2 cm and had a yellowish brown cut surface with hemorrhagic and cystic foci. The specimens were fixed in 10% buffered formalin and embedded in paraffin. Sections (3 m thick) were stainedwithhematoxylinandeosin(Fig1A; 10),Grimelius Masson trichrome (Bio-Optica, Milano, Italy), and periodic acid-Schiff (PAS; Merck, Darmstadt, Germany). Immunohistochemical analyses were carried out by using synaptophysin (Fig 1B; 10; positive stain), CD56 (Fig 1C; 20; positive stain), avidin-biotin complex method for low-molecular-weight cytokeratin (Fig 1D; 10; punctiform expression of anticytokeratin marker [CAM 5.2]), somatostatin, serotonin, neuronspecific enolase, Leu-7, inhibin, and S-100 protein. A positive SDHB immunohistochemistry (Fig 1E; 10) was also reported. At light microscopy, the tumors presented as solid proliferation of round cells with eosinophilic cytoplasm and regular, monomorphic, oval central nuclei in an alveolar arrangement (Zellballen pattern) surrounded by thin capillaries and a flattened layer of sustentacular cells. Pleomorphism, mitotic figures, and bizarre nuclear forms were occasionally seen. Positive expression of chromogranin A and synaptophysin and the presence of chief (type 1) cells were consistent with the neuroendocrine nature of the tumor. Few sustentacular cells were positive for S-100 protein, and immunoreactivity for glial