John P. Wei

Prospective comparison of technetium-99m-sestamibi/iodine-123 radionuclide scan versus high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands in patients with previously unoperated primary hyperparathyroidism

Surgery for primary hyperparathyroidism is successful in 95% of patients, but ectopic glands and anatomic variations in location are causes of surgical failure. The radionuclide imaging agent, technetium (Tc)-99m-sestamibi, in conjunction with subtraction iodine-123 scanning, is a new method of preoperative localization of abnormal parathyroid glands. In a study approved by the Institutional Review Board, 22 patients with primary hyperparathyroidism underwent preoperative evaluation with high-resolution ultrasonography and Tc-99m-sestamibi/I-123 radionuclide scanning for attempted localization of abnormal parathyroid glands. Results of Tc-99m-sestamibi scanning and ultrasound were correlated with surgical and pathologic findings. Of 22 patients, 16 had a solitary parathyroid adenoma, 1 had a double adenoma, and 5 had diffuse parathyroid hyperplasia. The Tc-99m-sestamibi/I-123 radionuclide scan preoperatively identified a solitary adenoma in 14 of 16 patients (sensitivity: 88%). However, when the data were analyzed retrospectively along with surgical and pathologic findings, the Tc-99m-sestamibi scan correctly localized all parathyroid adenomas for a sensitivity of 100%. The one patient with a double adenoma had a localization image consistent with two enlarged glands. All patients with diffuse parathyroid hyperplasia had Tc-99m-sestamibi imaging consistent with diffuse hyperplasia, although delineation of individual enlarged glands was not possible. High-resolution ultrasound identified 11 of 16 parathyroid adenomas (sensitivity: 69%). The patient with a double adenoma had a negative ultrasound. Ultrasound was less accurate in five patients with diffuse hyperplasia: one scan was completely negative, two scans revealed only one enlarged gland, and two scans revealed two enlarged glands. The Tc-99m-sestamibi/I-123 subtraction radionuclide scan is more sensitive than high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands. Tc-99m-sestamibi/I-123 radionuclide scanning may be more useful than ultrasonography to the surgeon in the preoperative localization of abnormal parathyroid glands.

Preoperative imaging of abnormal parathyroid glands in patients with hyperparathyroid disease using combination Tc-99m-pertechnetate and Tc-99m-sestamibi radionuclide scans.

ObjectiveTo evaluate the efficacy of combined Tc-99m-pertechnetate and Tc-99m-sestamibi radonuclide scanning for imaging abnormal parathyroid glands in hyperparathyroid disease in a prospective study. Summary Background DataSummary Background Data methods to localize abnormal parathyroid glands lack accuracy for routine use. Tc-99m-sestamibi used in conjunction with iodine-123 has excellent potential for preoperative imaging in patients with hyperparathyroid disease. An alternative method for parathyroid imaging was studied using Tc-99m-pertechnetate and Tc-99m-sestamibi. MethodsThirty patients with hyperparathyroid disease had Tc-99m-pertechnetate and Tc-99m-sestamibi subtraction radionuclide scanning to visualize abnormal parathyroid glands before surgery. The patients had surgery and pathologic confirmation of all parathyroid glands. ResultsResults 23 patients with primary hyperparathyroidism, 12 of 13 solitary adenomas were visualized. Six of nine patients with diffuse hyperplasia had bilateral uptake consistent with diffuse hyperplasia. Three of nine patients had negative scans. One patient previously operated on for diffuse hyperplasia had only one gland scanned. Seven patients with renal failure-associated hyperparathyroid disease were scanned: five had bilateral uptake of Tc-99m-sestamibi consistent with hyperplasia, and two who had been previously operated on had localization of remaining abnormal parathyroid glands. ConclusionConclusion-99m-pertechnetate combined with Tc-99m-sestamibi subtraction radionuclide scanning is less cumbersome to implement than iodine-123 combined with Tc-99m-sestamibi scanning. It has a high sensitivity for imaging solitary parathyroid adenomas or persistent solitary hyperplastic glands. However it does not have the resolution necessary to delineate all parathyroid glands in diffuse hyperplasia.

Analysis of savings in operative time for primary hyperparathyroidism using localization with technetium 99m sestamibi scan

BACKGROUND The cost effectiveness of preoperative localization in cases of primary hyperpara-thyroidism has not been established. We analyzed the potential savings in operative time after localization with technetium 99m (99mTc) sestamibi scan. METHODS Thirty-three patients had localization of a solitary adenoma with 99mTc-sestamibi. Measurement was made of the time required for adenomectomy, unilateral neck exploration (UNE), unilateral neck exploration and confirmation of one contralateral parathyroid gland (UNEC), or bilateral neck exploration (BNE). RESULTS The total operative time in minutes was 76.4 +/- 18.8 for adenomectomy; 87.5 +/- 20.4 for UNE; 105.6 +/- 25.0 for UNEC; and 117.9 +/- 26.7 for BNE. The time difference was significant between adenomectomy versus UNE, UNEC, and BNE. There were also significant time differences between UNE versus UNEC and BNE. CONCLUSIONS The preoperative localization of a solitary parathyroid adenoma may optimize operative time with UNE, saving approximately 30 minutes.

99m-Technetium sestamibi localized solitary parathyroid adenoma as an indication for limited unilateral surgical exploration

BACKGROUND Because of its successful localization of solitary adenomas, 99m-Technetium sestamibi (MIBI) may challenge the standard operation for primary hyperparathyroidism. METHODS Thirty-five consecutive patients underwent preoperative MIBI localization to optimize a surgical approach. Single-site localization in 21 patients directed a limited unilateral neck exploration (UNE) with adenomectomy and ipsilateral gland biopsy. Fourteen patients who did not localize underwent bilateral neck exploration (BNE). Conversion to a bilateral operation was required in 1 UNE patient because no adenoma was found on that side. RESULTS There were no significant differences in preoperative and postoperative serological markers between the two groups. However, the total operative time for UNE (49 +/- 21 minutes) was significantly less than for BNE (103 +/- 45 minutes; P <0.001). CONCLUSIONS Preoperative MIBI scan-directed limited unilateral neck operation may be used reliably for primary hyperparathyroidism due to a single adenoma, and thereby reduce operative time, extent of surgical dissection, and risk.

Prospective hospital-based survey of attitudes of Southern women toward surgical treatment of breast cancer.

AbstractBackground: Breast-conserving surgery is equivalent to total mastectomy in the treatment of breast cancer. The Southern part of the United States has a low rate of breast conservation. Methods: We surveyed 300 women: 100 hospital personnel, 100 cancer clinic patients, and 100 non-cancer clinic patients. The women were asked about their attitudes toward breast cancer, surgery preferences, and factors that might influence their decisions. Results: One hundred eighty-nine chose mastectomy as the best operation, 106 women chose lumpectomy, and five women were undecided. There was no difference in mean age, racial distribution, education level, income level, percentage of women who considered themselves Southern women, concerns about breast cancer, recent mammograms, previous breast surgery, previous breast cancer treatment, or acquaintances with breast cancer between the mastectomy and the lumpectomy groups. Women interested in saving the breast were more likely to pick lumpectomy (35 vs. 84%,p=0.001). A fear of cancer recurrence played a role in the decision (88 vs. 40%,p=0.001). Fear of radiation therapy (76 vs. 57%,p=0.002) and of the side effects (80 vs. 63%,p=0.005) was a significant factor. Conclusions: The choice of surgery for breast cancer is an individual process between a woman and her surgeon. Attitudes and fears regarding cancer recurrence and radiation therapy may make women select mastectomy over lumpectomy.

Characterization of the neoplastic potential of solitary solid thyroid lesions with Tc-99m-Pertechnetate and Tc-99m-sestamibi scanning

AbstractBackground: Radionuclide scans that use Tc-99m-pertechnetate or I-123 currently lack the specificity to assess the malignant potential of solitary solid lesions of the thyroid gland. Tc-99m-sestamibi scanning was used to determine the neoplastic potential of thyroid lesions. Methods: Patients with lesions of the thyroid underwent Tc-99m-sestamibi imaging to assess the neoplastic potential of their thyroid lesions, identified as solitary and cold by radionuclide imaging with Tc-99m-pertechnetate. Tc-99m-sestamibi uptake was correlated with fine-needle aspiration cytology or surgical pathology. Results: Twenty-seven patients were evaluated using Tc-99m-pertechnetate and Tc-99m-sestamibi scans: 14 had right thyroid lesions, and 13 had left thyroid lesions. Of 27 patients, 10 had a positive Tc-99m-sestamibi scan: one Hürthle cell adenoma, one papillary carcinoma, six follicular adenomas, and two nodular goiters. Of 27 patients, 17 had a negative Tc-99m-sestamibi scan: one follicular carcinoma, one papillary carcinoma, two follicular adenomas, one Hürthle cell adenoma, one metastatic adenocarcinoma, one medullary carcinoma, four nodular goiters, and six colloid nodules. Positive Tc-99m-sestamibi scan identified neoplasms with a sensitivity of 53%, a specificity of 83%, and a positive predictive value of 80%. Conclusions: Tc-99m-sestamibi scanning lacks sufficient sensitivity for diagnosis of solitary thyroid nodules. Future work may define a role for its use in recurrent or metastatic thyroid neoplasms.

Novel antibody drug products

Recent developments in protein and genetic engineering methods have allowed the production of antibody-derived molecules that have important potential as therapeutic agents. Although monoclonal antibodies of murine origin have been used for therapeutic purposes, limitations due to anti-antibody responses and suboptimal effectiveness for some indications, such as tumor cell killing, have led to the development of human monoclonal antibodies, chimeric and complementarity determining-region grafted antibodies, immunotoxins, and other engineered products. These novel antibodies are being tested for the treatment and prevention of infectious diseases and for the diagnosis and treatment of cancers, as well as for indications considered nontraditional for antibodies (e.g., as antithrombotics or inhibitors of neutrophil adherence). The availability of antibody drug products raises a number of issues for clinicians. Among these are new patterns of adverse effects, immunogenicity (development of anti-antibody response), important questions regarding administration and dosage, and substantial cost implications.

Acute abdominal pain in the presence of hemi-corporeal neurosensory deficits

Acute abdominal conditions may be extremely difficult to diagnose in patients with spinal cord neurologic deficits. Syringomyelia, and the surgical treatment of it, can cause an unusual distribution of neurosensory defects involving primarily pain and temperature sensation, and this can mask occult intraabdominal pathology. We report a case of acute abdominal pain in a patient previously treated with a syringo-pleural shunt for correction of a cervical syringomyelia and the difficulties in diagnosis that this presents.

Upper gastrointestinal hemorrhage from a mallory-weiss tear associated with an occult richter's hernia and small bowel obstruction: To see the forest as well as the trees in the emergency department

Mallory-Weiss tears are a common cause of upper gastrointestinal bleeding and are often associated with vomiting from heavy alcohol ingestion. Other causes of severe emesis can induce a Mallory-Weiss tear, and it may be important to diagnose these conditions so that appropriate therapy can be instituted. We report an unusual condition presenting with a Mallory-Weiss tear, a small bowel obstruction resulting from an occult Richters hernia, which was not suspected or diagnosed at initial presentation.