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Fifty-five patients with Graves' disease (GD) and mild to moderate Graves' ophthalmopathy (GO) underwent near-total thyroidectomy (Tx). In 16 patients this was followed by a standard ablative dose of (131)I because of the hystologic evidence of differentiated thyroid carcinoma. We retrospectively evaluated whether or not GO activity could be affected by thyroid surgery alone or followed by complete ablation of thyroid tissue. Accordingly, on the basis of clinical activity score (CAS) values prior to thyroidectomy, we identified two groups: group A with active GO (CAS > or = 3; n = 31) and group B with inactive GO (CAS < or = 2; n = 24). CAS values were then recorded at 6, 12, and 24 months after surgery/(131)I ablation. Over the course of the follow-up period, GO became inactive in approximately 70% of group A patients (CAS 4.2 +/- 0.8 at baseline, 2.1 +/- 2.0 at 24 months, p < 0.0001) and became active in 37.5% patients from group B. When we examined GO activity according to the type of treatment used (Tx or Tx and (131)I), the prevalence of inactive GO both short- and long-term, was significantly higher in the group of patients who underwent Tx and (131)I ablation. Therefore, this seems to be a more effective means of inducing and maintaining inactive GO.

Objective: This retrospective case series examines 7 infants with large supratentorial arachnoid cysts who underwent cyst-peritoneal shunting and insertion of a Hakim programmable valve. Comparing pre- and postoperative clinical data, neuroradiological and regional cerebral blood flow (rCBF) findings we evaluated the efficacy of the surgical procedure., Methods: Infants, ranging in age from 1 to 55 days (mean age 29.5 days), were assessed pre- and postoperatively by neurological examination, developmental profile and neuroimaging., Results: Post procedure, all patients showed a significant reduction in the cyst/brain ratio on neuroimaging (p<0.001), 6 had a normal developmental profile (p<0.001) and 5 cases showed a significant amelioration of clinical symptoms and neurological signs. Two patients underwent preoperative SPECT scans, which showed hypoperfusion in the area surrounding the cyst; this decreased rCBF also improved post shunting., Conclusions: Large supratentorial arachnoid cysts in infants can be successfully treated with cyst-peritoneal shunting and insertion of a Hakim programmable valve. This is the first study specifically aimed at evaluating the long-term results of these conditions.

The aim of this paper is to give the reader an updated overview of (99m)Tc-MIBI SPET applications in investigating brain tumours. Elements determining MIBI uptake at the level of the brain are first mentioned. (99m)Tc-MIBI SPET features in different malignant and benign brain lesions (low and high grade gliomas, glioblastoma multiforme, metastasis, lymphoma, meningioma, neuroma, radiation necrosis and other rarer brain lesions) are reviewed. The ability of 99mTc-MIBI SPET, alone or in combination with other radiotracers, in the differential diagnosis of brain lesions is discussed. We outline (99m)Tc-MIBI SPET value in determining brain tumours grading and in distinguishing tumour recurrence from radiation necrosis. Clinical applications of 99mTc-MIBI in the management of AIDS patients, where discrimination between lymphoma and several different lesions only on the basis of CT or MRI findings is often impossible, are reported. In addition the relationships among (99m)Tc-MIBI SPET, P-glycoprotein (MDR-1 gene product) expression in brain neoplasms and chemotherapy response are mentioned.

The authors describe their experience in utilizing 'ArcitumoMab' and radioimmunoguided surgery in a group of patients with localized and advanced colorectal cancer. Twenty-one patients were studied who were found to be positive to 'ArcitumoMab'. Immunoscintigraphy was obtained in 95% of cases. Radioimmunoguided surgery was performed in all cases. One case, which was negative at immunoscintigraphy, was found to be positive intraoperatively when radioimmunoguided surgery was performed. Radioimmunoguided surgery, in the authors' view, is a useful technique but needs to be validated in larger samples, particularly in cases of relapse.

Background: The association of hyperparathyroidism (HPT) with thyroid disease has long been known, but the mechanisms underlying such an association have not yet been clarified., Objective: To elucidate the main factors determining this combination of endocrine diseases, in a retrospective multicenter study., Methods: We retrospectively reviewed all patients referred for parathyroid scintigraphy in the period 1990-1999. A total of 487 patients in the age range 17-65 years were selected for the analysis (339 women and 148 men); group A included 241 patients with primary and group B 246 patients with secondary HPT., Results: A total of 124/241 patients in group A (51.5%), but only 92/246 patients in group B (38.2%) had thyroid disorders (notably nodular goiter) associated with HPT (P=0.0035). Thyroid disorders were evenly distributed throughout the entire 17-65 years age range in group A, but 17-40-year-old patients in group B had significantly fewer thyroid disorders than the older patients of the same group (15.5% compared with 43.3%, P<0.002), as expected in a general population. In patients with primary HPT there was no difference in the prevalence of thyroid disease between women and men, whereas the ratio of women to men in secondary HPT patients with thyroid disease was about 3:1., Conclusions: These results demonstrate an increased prevalence of nodular goiter in patients with primary rather than secondary HPT, and are consistent with a possible role of increased endogenous calcium concentrations (a hallmark of primary, but not of secondary, HPT) as a goitrogenic factor in patients with HPT.

The Authors, taking recent literature on tumoral pathology breast studies in to consideration, studied a group of patients with a node or a suspect adenous zone by clinical and instrumental examination with mammoscintigraphy. 22 patients were selected by clinical examination, mammography and ultrasonography. A mammoscintigraphy (Tc 99m Sestamibi) was performed before the surgical operation. The histologic examination revealed 14 cases of breast cancer; 12 of these (86%) resulted positive after scintigraphy, while 2 were false negative. In this study, the scintigraphic exam and its diagnostic accuracy were analyzed, both in relation to anatomical structure of the mammary gland (thick breast, fibrocystic mastopathy, postsurgical scars, etc.) and also in relation to characteristics of the suspected node, the nature of which was not possible to determine from other exams carried out. In conclusion, after comparison between our experience and those reported in literature, we conclude that because of its high specificity and sensibility the mammoscintigraphy exam assumes an important comparative index in obtaining elements for an additional evaluation when other instrumental examinations are dubious.

The authors report a case of multiple system atrophy (MSA) with an onset as a peripheral nerve involvement. Their patient, a 55-year-old man, had a 3-year history of distal weakness and atrophy in upper limbs with dysesthesia in the feet. Other identifiable causes of peripheral neuropathy were ruled out. The authors postulate that peripheral nervous system impairment can anticipate the typical appearance of MSA, and they suggest that, in peripheral neuropathies with autonomic system dysfunction, after excluding main causes of autonomic neuropathy, MSA may need to be suspected.

In this work the authors report a clinical case of Brunner's adenoma, which was responsible for the onset of other pathologies in the upper gastrointestinal tract, such as gastroesophageal reflux (GER), esophagitis and ulcerations of the antral mucosa. The preoperative diagnostic procedure (endoscopy, esophageal manometry, gastric emptying) and the follow-up at 3, 6 and 12 months from the surgery confirmed the relationship between the Brunner's adenoma and the alterations of the lower esophageal sphyncter (LES) tone and the gastric emptying. After a review of the international literature and a short analysis of the physiopathologic alterations, the authors point out the different therapeutical approach, in according to the size and implantation (sessile or peduncolated) of the lesion and to the related pathologies.

Background/purpose: Disturbed peristalsis is reported frequently after successful repair of esophageal atresia (EA). Delayed gastric emptying could be considered a cause of symptoms of gastroesophageal reflux (GER) in patients with repaired EA. The aim of the current study was to evaluate the incidence of and to characterize gastric motility disorders in a long-term follow-up of patients operated on for EA-tracheoesophageal fistula (TEF) by studying gastric emptying with scintigraphic techniques and comparing the results with gastric manometric data., Methods: Eleven patients, between 12 and 23 years of age (median, 17) operated on for EA-TEF between 1975 and 1985, were studied. The scinthigraphic study was undertaken using a standard solid meal. The manometric study was performed using a 2.3-mm probe with 3 solid-state transducers., Results: Dysphagia was present in about 20% of patients. Dyspepsia was recorded in 40% of the patients. A pathological reflux was present in 2 patients. Delayed gastric emptying (T1/2 > 90') was present in 4 patients (36%). Manometric data showed alteration of gastric peristaltic activity in 5 patients (45%)., Conclusions: Delayed gastric emptying is frequent in long-term follow-up of patients operated on for EA-TEF. In these patients antral hypomotility also is recorded manometrically. Abnormal gastric motility can be considered as an important factor predisposing to symptoms of GER. A thorough evaluation of gastric function is recommended in symptomatic patients after EA repair.

Background/aims: Ulcerative colitis (UC) and Crohn's disease (CD) represent the more common forms of idiopathic inflammatory bowel disease. They have a peculiar course, which is characterized by exacerbation and submissions, and a symptomatology that changes in relation to severity and extension of the lesions. The aim of this study is to establish the diagnostic usefulness of 99m Tc human policlonal immunoglobulin (HIG) imaging in patients with inflammatory bowel disease (IBD)., Methodology: During the period between September 1995 and September 1997 we submitted a group of 32 patients affected by UC (n = 22) and CD (n = 10), to Human Immunoglobulin labeled with Technetium 99m (99m Tc-HIG) scintigraphy. The diagnosis of IBD was obtained in all cases by endoscopy with biopsy., Results: Scintigraphic examination with labeled HIG showed an abnormal intestinal fixation (ileal or colic) of the marked immunoglobulins in 17 patients (77.2%) affected by UC and in 8 patients (80%) affected by CD. In 5 (22.7%) and 2 (20%) patients, respectively, the scintigraphic examination revealed a normal distribution of the immunoglobulins without appreciable focal accumulation. Among the patients with a negative scintigraphic examination, only one presented an endoscopic and histologic report that documented UC in an active stage. The histologic and endoscopic findings observed in all cases of CD were similar to that of HIG scintigraphy in 7 of the 8 scintigraphic-positive cases and in 1 of the 2 scintigraphic-negative patients., Conclusions: The authors, on the basis of their results, suggest that this diagnostic strategy may have a significant role in the diagnostic protocol and in the follow-up of chronic inflammatory bowel disease.

Twenty-five patients from a marginally iodine-deficient area with differentiated thyroid cancer who were referred to our unit between 1991 and 1997 had a residual thyroid uptake (RTU) at 24 hours of 5% or more after surgery. None of them underwent reoperation: 8 of 25 had RTU between 5% and 10% and were considered at low risk for both local recurrences and/or distant metastases; 17 of 25 had RTU greater than 10% and up to 30% and refused re-intervention. After detection of their cervical uptake by using a 131I tracer dose of 3.7 MBq (100 microCi), all 25 were treated with 1110 MBq (30 mCi) of 131I. A whole-body scan (WBS) performed 5 days later revealed 131I uptake corresponding to metastatic lymph nodes in the anterior part of the neck in 1 patient and the persistence of only RTU in 24 of 25 patients. RTU and thyroglobulin (Tg) levels were reevaluated 6 months later in all patients and compared to preradioiodine treatment values. RTU, ranging at presentation between 5% and 30%, decreased to below 1% in all but one patient. Serum Tg values, ranging between 1.6 and 108 ng/mL before radioiodine treatment, decreased to below 1.6 ng/mL in all but 4 of them (whose serum Tg was between 2 and 3.4 ng/mL). Our data indicate that 1,110 MBq of 131I can permit complete ablation of 80% of thyroid remnants concentrating up to 30% of radioiodine activity. A relation between this high success rate and iodine deficiency can be hypothesized because an increasing uptake of radioiodine by thyroid remnants could result in overestimation of their size. Therefore, our observations suggest that in iodine deficient areas, a hasty decision to carry out complete thyroidectomy should be avoided, even in the case of thyroid remnants with RTU up to 30%.

The authors report their experience on 22 neonates (14 males and 8 females) with primary megaureter. In 18 patients a prenatal diagnosis was available, in the other four the diagnosis was suspected during a neonatal ultrasound screening. The dilatation involved the right ureter 7 times and the left 13 times, in 2 patients it was bilateral. Intravenous urography documented a type I ureteral dilatation in 2 renal units (8.3%), a type II in 9 (37.5%) and a type III dilatation in 13 (54.2%). Radionuclide scan (Tc99m DTPA) demonstrated in all the renal units with megaureter a stable function. From diuretic renal scan, non-obstruction appeared in 19 (83%), obstruction in 2 (8.5%) and an equivocal result in the remaining 2. Antibiotic prophylaxis was administered to all patients. Follow-up period ranged from 18 to 54 months. The 2 obstructed megaureter were surgically treated. Other 2 patients with type III dilatation and non-obstructing megaureter underwent surgery at 18 and 24 months of age respectively. The remaining 17 patients were all conservatively treated. The 2 patients with type I dilatation resolved spontaneously. Of 9 patients with type II megaureter the dilatation resolved in 6 patients and 3 patients had a good reduction. In the remaining 8 patients with type III megaureter, the dilatation resolved in 5 cases and 3 patients had only a fair reduction. The renal function (> 40%) remained stable in all the patients.

Mutism is an infrequent and transitory complication observed following posterior fossa surgery. Patients become mute in the immediate postoperative period, with restoration of speech within a few weeks in the absence of additional neurological alterations. The anatomical structures thought to be involved are the connections between the cerebellar dentate nucleus, the ventrolateral nucleus of the contralateral thalamus and the supplementary motor area. In an attempt to understand the pathophysiology of this syndrome, and to depict the perfusion of different brain areas semiquantitatively, in two children who had become mute after posterior fossa surgery we performed a Tc99M-HM-PAO SPECT study during the period of mutism and again when normal speech had returned. In one patient, who had a left cerebellar astrocytoma, the SPECT study showed a marked reduction of cerebral perfusion in the right fronto-parietal region, and in the other, who had a medulloblastoma, a left fronto-temporo-parietal perfusion alteration was observed. When the patients regained normal speech, the follow-up SPECT studies revealed normalization of the cerebral perfusion. This study demonstrates the occurrence of a focal dysfunction of cerebral perfusion in children with cerebellar mutism after posterior fossa surgery. These observations are useful in extending our understanding of the pathophysiology of this postoperative clinical syndrome.

Unlabelled: The authors evaluated the ability of rHuEPO (recombinant human erythropoietin) in performing a vasoactive calcium-mediated action. Forty healthy volunteers were evaluated for the muscle blood flow at rest (RBF) and after reactive hyperemia by Xenon 133 clearance. Pre-treatments with several calcium antagonists were used., Results: The i.v. infusion of rHuEPO brought about a reduction of the RBF and MBF (maximal blood flow). This reduction was maintained with nifedipine or verapamil. Gallopamil and ketanserine prevented the reduction of blood flow induced by rHuEPO. CONCLUSIONS. The rHuEPO has a vasoconstrictive action in vivo since gallopamil and ketanserine, drugs able to prevent intracellular mobilisation of the Ca++, can block the rHuEPO induced vasoconstriction. The action exerted by rHuEPO could be due not an increased flow of the Ca++ from the extracellular department but to a mobilisation from Ca++ deposits.

99mTc-labeled red blood cell (RBC) scanning is considered a highly specific technique for the study of hepatic hemangiomas. However, planar imaging displays poor sensitivity for the identification of small lesions. The authors consider a survey group of 119 patients, of whom 66 with a presumed diagnosis of hepatic hemangioma, for a total of 77 lesions ranging from 0.8 to 15 cm in diameter. The study was conducted with three-phase planar imaging and single photon emission computed tomography (SPECT). The results, which confirm a high specificity of 99mTc-RBC scanning (100%) in the study of hepatic hemangiomas, show that SPECT significantly improves the detection of these lesions (71%) compared to the delayed static study (52%), with the largest gain for lesions between 2-3.5 cm (83% versus 51%). However, also SPECT has difficulty in detecting lesions of less than 2 cm. With regard to three-phase imaging, the authors point out that the pattern considered characteristic for hepatic hemangiomas (perfusion blood-pool mismatch) is infrequent (13%).

Delayed gastric emptying has been assumed to play an important role in the pathogenesis of gastroesophageal reflux (GER), even though this relationship has not been definitely established. Eleven patients with symptomatic GER were studied by esophageal manometry, endoscopy, gastroesophageal scintiscanning and gastric emptying of a mixed meal. Nine healthy subjects served as controls. Gastric emptying of solids (evaluated both as emptying half-time and emptying index) in GER patients was significantly slower than in controls. In comparison with a "normal" range previously established in 50 healthy subjects, only 2 of 11 (18.2 p. 100) of GER patients had a normal emptying rate. In addition, a significant correlation was found between the emptying half-time and the degree of esophageal lesions. These results suggest that impaired motor function of the gastric antrum could influence the natural history of GER disease and especially the appearance of esophagitis. The lack of esophageal lesions in the only two patients with "normal" emptying strongly supports this hypothesis.

99mTechnetium pyrophosphate (99mTc PYP) muscular scanning was carried out in 28 patients affected by neuromuscular diseases. To express the muscle tracer retention quantitatively, the soft tissue to bone uptake ratio was calculated in the thigh and in the lower leg. Significantly increased ratio values were found in all the patients with polymyositis and in most patients with different types of muscular dystrophy, while high values were seen in a few subjects with myasthenia gravis and with neurogenic disorders. These findings are compared with those of previous studies, and the factors playing a role in determining some discrepant observations are discussed. The use of 99mTc muscular scanning in the investigation of patients with suspected inflammatory myopathy is suggested.

Quantitative gastric emptying essay by a single radio-nuclide technique (Tc99m), utilizing a fluid/solid meal, were performed in 2 groups of age-matched children: (a) 15 males with non-endocrine obesity; (b) 6 males and 3 females affected by gastroesophageal reflux, arbitrarily used as controls. Mean (+/- SD) gastric emptying rates, expressed as emptying half-time (T/2 in min) in the group a and b were superimposable (102.0 +/- 60.6 vs 97.3 +/- 43.1). Our data do not support the existence of an abnormally rapid gastric emptying rate in obesity, at least in pediatric age. This finding is even more striking if one considers that our control group was at high risk for delayed gastric emptying.

Surgical operations characterised by the creation of a bilio-intestinal anastomosis are becoming an increasingly frequent procedure in bile tract surgery. Just as frequent and well known are the immediate and longer-term postoperative sequelae. Thus, one of the problems which has always interested surgeons and investigators is how best to monitor the functional efficiency of the anastomosis. Traditional x-ray methods, including highly invasive examinations such as PTC and ERCP, as well as the harmless ultrasound procedures do not provide an adequate picture of the functional efficiency of such anastomoses, the only wholly valid and efficacious method being sequential scintigraphy with 99mTc-Hida. On the basis of these principles, the authors describe their experience in this field, stressing the validity of the method, which enables surgeons to study the morphology and, above all, the functional efficiency of bilio-intestinal anastomoses.