Isabella Bruno

Impact of 111In-DTPA-octreotide SPECT/CT fusion images in the management of neuroendocrine tumours

PurposeSomatostatin receptor scintigraphy with [111In]-diethylene triamine pentaacetate acid (DTPA)-octreotide is an accurate method for detecting neuroendocrine tumours (NETs) but often does not provide clear anatomical localisation of lesions. The aim of this study was to assess the clinical usefulness of anatomical-functional image fusion.Materials and methodsFifty-four patients with known or suspected NET were included in the study. Planar and single-photon-emission computed tomography (SPECT) imaging was performed using a dual-head gamma camera equipped with an integrated X-ray transmission system, and the images were first interpreted alone by two nuclear medicine physicians and then compared with SPECT/CT fusion images together with a radiologist. The improvement provided by SPECT/CT in the interpretation of SPECT data alone and any modification in patientmanagement were recorded.ResultsFusion images improved SPECT interpretation in 23 cases, providing precise anatomical localisation of increased tracer uptake in 20 cases and disease exclusion in sites of physiological uptake in 5. In 10 patients, SPECT/CT allowed definition of the functional significance of lesions detected by diagnostic CT. SPECT/CT data modified clinical management in 14 cases by changing the diagnostic approach in 8 and the therapeutic modality in 6.ConclusionsOur study demonstrates that image fusion is clearly superior to SPECT alone, allowing precise localisation of lesions and reducing false-positive results.RiassuntoObiettivoLa scintigrafia con 111In-DTPA-octreotide rappresenta un metodo accurato per la diagnosi dei tumori neuroendocrini, ma spesso non fornisce una corretta localizzazione anatomica delle lesioni. Scopo di questo studio è valutare l’utilità clinica della fusione di immagini SPECT-TC.Materiali e metodiSono stati inclusi 54 pazienti con tumore neuroendocrino sospetto o noto. Le immagini planari e SPECT, ottenute utilizzando una gamma-camera a doppia testata con integrato sistema trasmissivo TC, sono state interpretate prima separatamente da due medici nucleari e poi confrontate con immagini di fusione insieme ad un radiologo, per valutare i miglioramenti apportati dalla fusione nell’interpretazione delle immagini SPECT e nella gestione del paziente.RisultatiLe immagini di fusione hanno migliorato l’interpretazione SPECT in 23 casi, permettendo una precisa localizzazione anatomica dei siti patologici in 20 casi e l’esclusione di malattia in siti di accumulo fisiologico in 5. In 10 pazienti SPECT/TC ha permesso la definizione funzionale di lesioni evidenziate alla TC diagnostica. SPECT/TC ha modificato il management clinico in 14 pazienti, modificando l’approccio diagnostico in 8 e quello terapeutico in 6.ConclusioniIl nostro studio dimostra che la fusione di immagini è chiaramente superiore alla sola SPECT, permettendo una precisa localizzazione delle lesioni individuate e riducendo i risultati falsi positivi.

USEFULNESS OF THE COMBINATION OF ULTRASONOGRAPHY AND 99MTC-SESTAMIBI SCINTIGRAPHY IN THE PREOPERATIVE EVALUATION OF UREMIC SECONDARY HYPERPARATHYROIDISM

The usefulness of the combination of technetium‐99m‐methoxyisobutylisonitrile (99mTc‐MIBI) parathyroid scintigraphy and ultrasonography to detect parathyroid glands (PTGs) in secondary hyperparathyroidism (SHPT) is still controversial.

Dopaminergic dysfunction and psychiatric symptoms in movement disorders: a 123I-FP-CIT SPECT study.

PurposePsychiatric symptoms frequently occur in patients with movement disorders. They are not a mere reaction to chronic disability, but most likely due to a combination of psychosocial factors and biochemical dysfunction underlying the movement disorder. We assessed dopamine transporter (DAT) availability by means of 123I-FP-CIT SPECT, and motor and psychiatric features in patients with Parkinson’s disease, primary dystonia and essential tremor, exploring the association between SPECT findings and symptom severity.MethodsEnrolled in the study were 21 patients with Parkinson’s disease, 14 patients with primary dystonia and 15 patients with essential tremor. The severity of depression symptoms was assessed using the Hamilton depression rating scale, anxiety levels using the Hamilton anxiety rating scale and hedonic tone impairment using the Snaith-Hamilton pleasure scale. Specific 123I-FP-CIT binding in the caudate and putamen was calculated based on ROI analysis. The control group included 17 healthy subjects.ResultsAs expected, DAT availability was significantly decreased in patients with Parkinson’s disease, whereas in essential tremor and dystonia patients it did not differ from that observed in the control group. In Parkinson’s disease patients, an inverse correlation between severity of depression symptoms and DAT availability in the left caudate was found (r = −0.63, p = 0.002). In essential tremor patients, levels of anxiety symptoms were inversely correlated with DAT availability in the left caudate (r = −0.69, p = 0.004). In dystonia patients, the severities of both anxiety and depression symptoms were inversely associated with DAT availability in the left putamen (r = −0.71, p = 0.004, and r = −0.75, p = 0.002, respectively). There were no correlations between psychometric scores and 123I-FP-CIT uptake ratios in healthy subjects.ConclusionWe found association between presynaptic dopaminergic function and affective symptoms in different movement disorders. Interestingly, the inverse correlation was present in each group of patients, supporting the fascinating perspective that common subcortical substrates may be involved in both anxiety and depression dimensions and movement disorders.

Cardiac adrenergic nerve function and microvascular dysfunction in patients with cardiac Syndrome X

Objective: To assess whether abnormalities in cardiac uptake of 123I-metaiodobenzylguanidine (MIBG) correlate with coronary microvascular dysfunction in patients with cardiac syndrome X (CSX). Setting: University hospital. Patients: 29 patients (aged 59 (SD 7) years, 11 men) with typical CSX and a matched group of 20 healthy subjects (aged 56 (7) years, 8 men) were studied. Interventions: Planar and single photon emission computed tomography (SPECT) MIBG myocardial scintigraphy was performed in all subjects. Coronary flow response (CFR) to adenosine and to cold pressor test (CPT) in the left anterior descending (LAD) coronary artery was assessed in all CSX patients and in 12 controls by transthoracic Doppler echocardiography. Main outcome measures: Abnormalities in cardiac MIBG scintigraphy were observed in 25 CSX patients (86.2%), but in no healthy control (p<0.001). Compared to controls, CSX patients showed a lower heart/mediastinum (H/M) ratio of MIBG uptake (1.69 (0.24) vs 2.2 (0.3), p<0.001) and a higher cardiac MIBG defect score (25 (22) vs 4 (2), p = 0.002). Both CFR to adenosine (3.31 (1.1) vs 1.94 (0.6), p<0.001) and CFR to CPT (2.35 (0.5) vs 1.63 (0.4), p<0.001) were lower in CSX patients than in controls. In CSX patients, however, no correlation was found between MIBG H/M ratio and CFR to adenosine (r = 0.17; p = 0.38) and to CPT (r = −0.28; p = 0.13), as well as between MIBG uptake score in the LAD territory and CFR to adenosine (r = 0.14; p = 0.47) and to CPT (r = 0.06; p = 0.73). Conclusion: Our data show striking abnormalities in cardiac adrenergic nerve function and in coronary microvascular function in CSX patients. However, no significant relation between the two abnormalities was found. Further studies are needed to clarify the mechanisms and the role of MIBG defects in CSX patients.

Cardiac adrenergic nerve function in patients with cardiac syndrome X.

Background We previously found a severe impairment of cardiac uptake of 123I-metaiodobenzylguanidine (MIBG), an analogue of norepinephrine, on myocardial scintigraphy in a small group of patients with cardiac syndrome X (CSX), suggesting a dysfunction of cardiac adrenergic nerve fibres. In this study, we assessed the consistency of these previous findings in a larger group of these patients. Methods Planar and single-photon emission computed tomography MIBG myocardial scintigraphy was performed in 40 CSX patients (58 ± 7 years, 17 men). Cardiac MIBG uptake was measured by the heart/mediastinum ratio and by a single-photon emission computed tomography regional cardiac MIBG uptake defect score (higher values = lower uptake). As a control group, we studied 20 healthy individuals (56 ± 6 years, nine men). An exercise stress 99mTc-SestaMIBI myocardial scintigraphy was performed in 34 CSX patients (85%). Results Cardiac MIBG defects were observed in 30 patients (75%), with nine (22.5%) showing no cardiac MIBG uptake at all. Compared with controls, CSX patients showed a significantly lower heart/mediastinum ratio (1.70 ± 0.35 vs. 2.1 ± 0.22, P < 0.001) and a higher cardiac MIBG defect score (27 ± 25 vs. 4.4 ± 2.5, P < 0.001). No differences were found in lung MIBG uptake between the two groups. Reversible perfusion defects on stress myocardial scintigraphy were found in 17 out of 34 CSX patients (50%), all of whom also had abnormal cardiac MIBG uptake; cardiac MIBG uptake abnormalities were also present in nine of 17 patients with normal perfusion scintigraphic images. Cardiac MIBG uptake findings were similar in our first 12 patients and in the 28 patients studied subsequently. Conclusion Our data show a relevant impairment of cardiac MIBG uptake in patients with CSX, suggesting that functional abnormalities in cardiac adrenergic nerve function may play a significant role in the mechanisms responsible for the syndrome.

Costal brown tumor detected by dual-phase parathyroid imaging and SPECT-CT in primary hyperparathyroidism.

A 58-year-old male with primary hyperparathyroidism underwent parathyroid scintigraphy to obtain presurgical localization of a suspected parathyroid adenoma. Increased Tc-99m sestamibi uptake was seen on dual-phase imaging in a focal area corresponding to the right inferior parathyroid. An incidental finding was the intense tracer uptake in the left thorax. Immediate SPECT-CT imaging located the uptake area in the third left rib; it was subsequently demonstrated to represent a brown tumor. Brown tumors, skeletal manifestations of hyperparathyroidism, have been incidentally detected by bone scintig- raphy, more rarely by Tc-99m sestamibi parathyroid scintigraphy.

Usefulness of impairment of cardiac adrenergic nerve function to predict outcome in patients with cardiac syndrome X

Patients with cardiac syndrome X (CSX) have an excellent long-term prognosis, but a significant number show worsening angina over time. Previous studies have found a significant impairment of cardiac uptake of iodine-123-meta-iodobenzylguanidine (MIBG) on myocardial scintigraphy, indicating abnormal function of cardiac adrenergic nerve fibers. The aim of this study was to assess whether cardiac MIBG results can predict symptomatic outcome in patients with CSX. Cardiac MIBG scintigraphy was performed in 40 patients with CSX (mean age 58 ± 5 years, 14 men). Cardiac MIBG uptake was measured by the heart/mediastinum uptake ratio and a single photon-emission computed tomographic regional uptake score (higher values reflected lower uptake). Clinical findings, exercise stress test parameters, sestamibi stress myocardial scintigraphy, and C-reactive protein serum levels were also assessed. At an average follow-up of 79 months (range 36 to 144), no patient had died or developed acute myocardial infarction. Cardiac MIBG defect score was significantly lower in patients with worsening versus those without worsening of angina status (13 ± 7 vs 38 ± 28, p = 0.001), in those with versus those without hospital readmission because of recurrent chest pain (15 ± 9 vs 35 ± 29, p = 0.01), and in those who underwent versus those who did not undergo repeat coronary angiography (11 ± 7 vs 36 ± 27, p = 0.001). Significant correlations were found between quality of life (as assessed by the EuroQoL scale) and heart/mediastinum ratio (r = 0.48, p = 0.002) and cardiac MIBG uptake score (r = -0.69, p <0.001). No other clinical or laboratory variable showed a significant association with clinical end points. In conclusion, in patients with CSX, abnormal function of cardiac adrenergic nerve fibers, as assessed by an impairment of cardiac MIBG uptake, identifies those with worse symptomatic clinical outcomes.

Effect of spinal cord stimulation on cardiac adrenergic nerve function in patients with cardiac syndrome x

Background. In patients with cardiac syndrome X (CSX) who present with refractory angina episodes, spinal cord stimulation (SCS) has beneficial effects. The mechanisms of SCS, however, remain speculative. We assessed the effects of SCS on cardiac sympathetic function in these patients.Methods and Results. We studied 11 CSX patients treated by SCS for refractory angina (mean age, 60±9 years; 5 men and 6 women), both during SCS therapy (SCS-ON) and after withdrawal of SCS therapy (SCS-OFF), using a randomized crossover design. Planar and single photon emission computed tomography iodine 123 metaiodobenzylguanidine (MIBG) myocardial scintigraphy and technetium 99m sestamibi (MIBI) bicycle exercise stress testing were performed at the end of each period. Compared with 10 healthy control subjects, CSX patients showed a lower heart-mediastinum ratio for MIBG uptake (2.19±0.3 vs 1.69±0.3,P=.001) and a higher cardiac MIBG uptake score (4.0±2.5 vs 19.7±27,P=.08). There were no differences in CSX patients during the SCS-ON and SCS-OFF phases of the study in heart-mediastinum ratio (1.74±0.3 vs 1.69±0.3,P=.13), cardiac washout rate of MIBG (42.9%±14% vs 43.3%±14%,P=.08), or MIBG defect score (18.7±25 vs 19.7±27,P=.22). Reversible perfusion defects during the SCS-OFF phase were detected in 8 patients; an improvement in perfusion defects was observed in 2 patients (25%) during the SCS-ON phase.Conclusions. Our data confirm the presence of abnormal cardiac adrenergic nerve function in CSX patients. SCS was unable to result in significant improvement of cardiac MIBG uptake abnormalities, suggesting that its therapeutic effects are unlikely to be mediated by modulation of cardiac adrenergic nerve activity.

Safety and efficacy of G-CSF in patients with ischemic heart failure: The CORNER (Cell Option for Recovery in the Non-Eligible patients for Revascularization) study

BACKGROUND Demonstration that the heart is not a post-mitotic organ has led to clinical trials trying to obtain myocardial repair even in patients with heart failure. AIM OF THE STUDY To evaluate as a less invasive method for promoting cardiac repair. METHODS Thirteen patients with ischemic heart failure in NYHA and/or CCS classes ≥ 3 unsuitable for revascularization received G-CSF, as a compassionate use, in addition to optimal medical therapy. Symptoms and cardiac perfusion by gated-SPECT were assessed at baseline and at 4 month follow up. RESULTS G-CSF was generally well tolerated. NYHA and CCS classes improved significantly from 3 (IR 2.5-3) to 2 (IR 1-2.5) (p = 0.012) and from 3 (IR 1-3) to 1 (IR 1-2) (p = 0.033). Heart failure severity symptoms according to the Minnesota Living with Heart Failure Questionnaire scores exhibited a non significant improvement from 52 ± 27 to 39 ± 26 (p = 0.15). At the Seattle Angina Questionnaire scores (ranging from 0 to 100, higher scores indicating better status), physical limitation improved from 39 ± 31 to 64 ± 29 (p = 0.03), angina stability from 42 ± 29 to 64 ± 28 (p = 0.05), angina frequency from 53 ± 33 to 73 ± 26 (p = 0.04), treatment satisfaction from 67 ± 29 to 83 ± 21 (p = 0.07), disease perception from 37 ± 29 to 66 ± 26 (p = 0.007). Quality of life assessed by a Visual Analogue Scale improved from 33 ± 24 to 64 ± 20 mm (p = 0.003). Stress and differential regional perfusion scores improved significantly from 1.78 ± 1.38 to 1.66 ± 1.38 (p = 0.05) and from 0.35 ± 0.68 to 0.23 ± 0.53 (p = 0.02) respectively. CONCLUSIONS In patients with ischemic heart failure unsuitable for revascularization, G-CSF is associated to a significant improvement of symptoms, possibly reducing stress-induced ischemia.

Myocardial Perfusion Single-Photon Emission Tomography (SPET) and Positron Emission Tomography–Computed Tomography (PET-CT) Imaging for Congenitally Corrected Transposition of Great Arteries

Congenitally corrected transposition of great arteries (ccTGA) consists of both atrioventricular and ventriculo-arterial discordance. In patients with ccTGA, the pulmonary artery arises from the left ventricle, whereas the aorta arises from the right ventricle. The burden of the systemic blood pressure on the right ventricle involves an increased risk of coronary artery disease (CAD) and, as a long-term consequence, myocardial hypertrophy and gradual failure. This report describes the case of an adult patient affected by ccTGA who was referred for an episode of atypical chest pain while at rest. First-line diagnostic examinations were inconclusive. Myocardial perfusion single-photon emission tomography (SPET) was performed to exclude CAD, but the congenital abnormalities of the patient’s heart made interpretation of the images particularly difficult. A perfusion positron emission tomography–computed tomography (PET-CT) scan with 13N-ammonia then was suggested, which unmasked an unexpected artifact. The case report demonstrates that hybrid imaging techniques such as SPET-CT and PET-CT should be used systematically when CAD is suspected for patients with abnormal anatomy of the heart, including ccTGA.