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Introduction Hyperthermic isolated limb perfusion (HILP) can be performed as an alternative to amputation for soft tissue sarcomas and melanomas of the extremities. Melphalan and tumor necrosis factor-alpha are used at a dosage that depends on the volume of the limb. Regional tissue volume is traditionally measured for the purposes of HILP using water displacement volumetry (WDV). Although this technique is considered the gold standard, it is time-consuming and complicated to implement, especially in obese and elderly patients. Aim The aim of the present study was to compare the different methods described in the literature for calculating regional tissue volume in the HILP setting, and to validate an open source software. Methods We reviewed the charts of 22 patients (11 males and 11 females) who had non-disseminated melanoma with in-transit metastases or sarcoma of the lower limb. We calculated the volume of the limb using four different methods: WDV, tape measurements and segmentation of computed tomography images using Osirix and Oncentra Masterplan softwares. Results and conclusion The overall comparison provided a concordance correlation coefficient (CCC) of 0.92 for the calculations of whole limb volume. In particular, when Osirix was compared with Oncentra (validated for volume measures and used in radiotherapy), the concordance was near-perfect for the calculation of the whole limb volume (CCC = 0.99). With methods based on CT the user can choose a reliable plane for segmentation purposes. CT-based methods also provides the opportunity to separate the whole limb volume into defined tissue volumes (cortical bone, fat and water).

OBJECTIVE: The study performs a comprehensive analysis of image metrics to objectively support the reduction of injected activity in pediatric oncology (18)F-FDG PET/MR ((18)F-fludeoxyglucose PET/MR) examinations. Contrast-to-Noise Ratio (CNR), Normalized Noise (NN), tumor burden, and standardized uptake value (SUV) parameters stability were investigated to robustly define the acceptable reduced activity level that preserves the clinical utility of images, considering different PET applications. METHODS: 21 PET/MRI examinations performed on a 3-Tesla Biograph mMR scanner were analyzed. Tracer activity reduction was stimulated by decreasing the count statistics of the original list-mode data (3 MBq kg(–1)). In addition to the already studied SUV metrics and subjective scoring on lesion detectability, a thorough analysis of CNR, NN, Metabolic Tumor Volume (MTV), and Total Lesion Glycolysis (TLG) was performed. RESULTS: SUVmax and SUVmean increased more than 5% only in 0.6 MBq kg(–1) reconstructed images (+10% and +9%, respectively), while SUVpeak was almost unaffected (average variations < 2%). The quantified CNR, NN, MTV, and TLG behavior with the decrease of the injected activity clearly defines 1.5 MBq kg(–1) as a threshold of activity after which the quality of the image degrades. Subjective and objective analyses yielded consistent results. All 56 lesions were detected until activity of 1.2 MBq kg(–1), whereas five lesions were missed on the 0.6 MBq kg(–1) image. Perceived image quality (IQ) decreased in Lower Tracer Activity (LTA) images but remained acceptable until 1.5 MBq kg(–1). CONCLUSION: Results about the stability of image metrics beyond the semi-quantitative SUV parameters and subjective analysis, rigorously proves the feasibility of the reduction of injected activity to 1.5 MBqkg(-1) for pediatric patients aged between 7 and 17 years. ADVANCES IN KNOWLEDGE: This is the first report on the quantitative evaluation of the effect of activity reduction on image quality in pediatric PET/MR. The findings offer objective corroboration to the feasibility of a significant dose reduction without consequences on clinical image reading and tumor burden metrics.

Background Positron emission tomography (PET) is a non-invasive imaging method that detects 18F-fluorodeoxyglucose (FDG) uptake in vessel’s walls. Its simultaneous combination with magnetic resonance (MR) would offer not only a more detailed morphological analysis of the vessels but also a reduction of the radiation, simplifying the clinical workflow and being logistically easier for the patient. Objectives To evaluate, for the first time up to now, the usefulness of a fully integrated 18F-FDG PET/MR in a series of large vessels vasculitides (LVV) patients. Methods We performed a controlled non-randomised prospective study. Images were acquired on a fully integrated PET/MR scanner (Siemens Biograph mMR), consisting in a complete MR protocol and FDG-PET whole body imaging. We evaluated vessel’s standard uptake value (SUV) maximum and wall thickness (WT), defined as the mean of 4 measures (at 12, 3, 6 and 9 o’clock) at the inferior margin of D5, D9, D12, L3 and at thickest point (max WT). Results 23 LVV patients were included, 56.5% GCA, 34.8% TAK and 8.7% isolated aortitis, all Caucasian, mostly females (82%). We considered 55 PET scans, 32/55 in LVV group (from min. 1 to max. 3 scans/patient) mainly during follow-up (29/32 scans), and 23/55 in control group. Considering patients with abdominal aorta involvement, we found higher SUV max compared to controls, in all sites, regardless of disease activity. Mean WT resulted higher in patients than controls, but did not significantly differ between PET active or inactive patients (figure 1). Mean WT positively correlated with age in both cohorts, inversely correlated to disease duration in LVV patients, while no correlation with SUV max was observed. Despite clinical assessment was suggestive of remission in 24 (75%) cases before PET/MR acquisition, a normal uptake was present only in 12 (50%) of them. On the contrary, all patient with active disease at clinical examination (8, 25%) had also a positive PET/MR. Cohen’s K coefficient between clinical assessment and imaging was poor (K Cohen=0, 33, 0.11–0.55). Finally, we found no significant correlation between SUV max and acute phase reactants. Demographic and clinical data of LVV patients. Conclusions PET/MR is a safe imaging technique capable of detecting vasculitic inflammation, similar to PET/CT, but with a greater anatomical definition. The low radiological exposure represents a valid alternative to PET/CT for disease monitoring, especially in young women. Disclosure of Interest None declared

Background To evaluate the usefulness of [18F] fluorodeoxyglucose (FDG) positron emission tomography (PET)/magnetic resonance (MR) in large vessels vasculitis (LVV) patients. Methods We performed an observational retrospective study based on our records. Images were acquired on a PET/MR scanner using 18F-FDG-PET whole body imaging. For each PET scan, a qualitative analysis and a semi-quantitative measure using the maximum of the standardized uptake value (SUVMax) were performed. SUVMax measurements normalized to the liver uptake were categorized using a grading scale. Vessel's wall thickness (WT) was measured at five fixed points (inferior margin of T5, T9, T12, L3, thickest area-max WT). Results 23 LVV patients were included, 56.5% giant cells arteritis, 34.8% Takayasu's arteritis and 8.7% isolated aortitis, all Caucasian, mostly females (82%). We considered 32 PET scans for the LVV group (from min. 1 to max. 3 scans/patient) mainly during follow-up (29/32 scans), and 23 PET scans from a control group of non-metastatic malignancies patients. We found higher SUVMax compared to controls, in all sites, irrespective of clinical disease activity. Mean WT resulted higher in patients than in controls but was not correlated to SUVMax. Mean WT positively correlated with age in both cohorts, inversely correlated to disease duration, while no correlation with SUVMax was observed. The concordance between clinically active disease and PET hypermetabolism was poor (K Cohen 0.33). Conclusions PET/MR is a safe imaging technique capable of detecting inflammation in aortic wall. Low radiological exposure of PET/MR should be considered especially in young women receiving follow-up studies.

Introduction In the last 20 years growing attention has been devoted to multimodal imaging. The recent literature is rich of clinical and research studies that have been performed using different imaging modalities on both separate and integrated positron emission tomography (PET) and magnetic resonance (MR) scanners. However, today, hybrid PET/MR systems measure signals related to brain structure, metabolism, neurochemistry, perfusion, and neuronal activity simultaneously, i.e. in the same physiological conditions. A frequently raised question at meeting and symposia is: "Do we really need a hybrid PET/MR system? Are there any advantages over acquiring sequential and separate PET and MR scans?" The present paper is an attempt to answer these questions specifically in relation to PET combined with functional magnetic resonance imaging (fMRI) and arterial spin labeling. Evidence acquisition We searched (last update: June 2017) the databases PubMed, PMC, Google Scholar and Medline. We also included additional studies if they were cited in the selected articles. No language restriction was applied to the search, but the reviewed articles were all in English. Among all the retrieved articles, we selected only those performed using a hybrid PET/MR system. We found a total of 17 papers that were selected and discussed in three main groups according to the main radiopharmaceutical used: 18F-fluorodeoxyglucose (18F-FDG) (N.=8), 15O-water (15O-H2O) (N.=3) and neuroreceptors (N.=6). Evidence synthesis Concerning studies using 18F-FDG, simultaneous PET/fMRI revealed that global aspects of functional organization (e.g. graph properties of functional connections) are partially associated with energy consumption. There are remarkable spatial and functional similarities across modalities, but also discrepant findings. More work is needed on this point. There are only a handful of papers comparing blood flow measurements with PET 15O-H2O and MR arterial spin label (ASL) measures, and they show significant regional CBF differences between these two modalities. However, at least in one study the correlation at the level of gray, white matter, and whole brain is rather good (r=0.94, 0.8, 0.81 respectively). Finally, receptor studies show that simultaneous PET/fMRI could be a useful tool to characterize functional connectivity along with dynamic neuroreceptor adaptation in several physiological (e.g. working memory) or pathological (e.g. pain) conditions, with or without drug administrations. Conclusions The simultaneous acquisition of PET (using a number of radiotracers) and functional MRI (using a number of sequences) offers exciting opportunities that we are just beginning to explore. The results thus far are promising in the evaluation of cerebral metabolism/flow, neuroreceptor adaptation, and network's energetic demand.

In the initial evaluation of patients with suspected dementia and Alzheimer’s disease, there is no consensus on how to perform semiquantification of amyloid in such a way that it: (1) facilitates visual qualitative interpretation, (2) takes the kinetic behaviour of the tracer into consideration particularly with regard to at least partially correcting for blood flow dependence, (3) analyses the amyloid load based on accurate parcellation of cortical and subcortical areas, (4) includes partial volume effect correction (PVEC), (5) includes MRI-derived topographical indexes, (6) enables application to PET/MRI images and PET/CT images with separately acquired MR images, and (7) allows automation. A method with all of these characteristics was retrospectively tested in 86 subjects who underwent amyloid (18F-florbetaben) PET/MRI in a clinical setting (using images acquired 90–110 min after injection, 53 were classified visually as amyloid-negative and 33 as amyloid-positive). Early images after tracer administration were acquired between 0 and 10 min after injection, and later images were acquired between 90 and 110 min after injection. PVEC of the PET data was carried out using the geometric transfer matrix method. Parametric images and some regional output parameters, including two innovative “dual time-point” indexes, were obtained. Subjects classified visually as amyloid-positive showed a sparse tracer uptake in the primary sensory, motor and visual areas in accordance with the isocortical stage of the topographic distribution of the amyloid plaque (Braak stages V/VI). In patients classified visually as amyloid-negative, the method revealed detectable levels of tracer uptake in the basal portions of the frontal and temporal lobes, areas that are known to be sites of early deposition of amyloid plaques that probably represented early accumulation (Braak stage A) that is typical of normal ageing. There was a strong correlation between age and the indexes of the new dual time-point amyloid imaging method in amyloid-negative patients. The method can be considered a valuable tool in both routine clinical practice and in the research setting as it will standardize data regarding amyloid deposition. It could potentially also be used to identify early amyloid plaque deposition in younger subjects in whom treatment could theoretically be more effective.

Introduction. Early signs of response after applying wafers of carmustine-loaded polymers (gliadel) are difficult to assess with imaging because of time-related imaging changes.Tc99m-sestamibi (MIBI) brain single-photon emission tomography (SPET) has reportedly been used to reveal areas of cellularity distinguishing recurrent neoplasm from radionecrosis. Our aim was to explore the role of MIBI SPET in assessing response soon after gliadel application in glioblastoma multiforme (GBM).Methods. We retrospectively reviewed the charts on 28 consecutive patients with a radiological diagnosis of GBM who underwent MIBI SPET/CT before surgery (with intracavitary gliadel placement in 17 patients), soon after surgery, and at 4 months. The area of uptake was selected using a volume of interest that was then mirrored contralaterally to obtain a semiquantitative ratio.Results. After adjusting for ratio at the baseline, the effect of treatment (gliadel versus non-gliadel) was not statistically significant. Soon after surgery, however, 100% of patients treated with gliadel had a decreased ratio, as opposed to 62.5% of patients in the non-gliadel groupP=0.0316. The difference between ratios of patients with radical versus partial resection reached statistical significance by a small marginP=0.0528.Conclusions. These data seem to suggest that the MIBI ratio could be a valuable tool for monitoring the effect of gliadel early after surgery.

Ultrasonography of the abdominal aorta should be performed as part of a complete echocardiographic study. As visualization may be difficult from the epi-mesogastric (E-M) window because of obesity or distension, we evaluated the feasibility of the right flank (RF) as an alternative acoustic window in 100 patients (62 male, 38 female, aged 7-83 years). Compared with the E-M window, our results showed that the right flank was significantly better in imaging of the infrarenal aorta: 89% (RF) vs 75% (E-M) (p < 0.05); right renal artery: 84% vs 71% (p < 0.05); and right renal artery Color Doppler: 84% vs 71% (p < 0.05). The Doppler sonification angle for the right proximal renal artery was 0 degrees-31 degrees (mean 12.7 degrees +/- 4.2 degrees) vs 64 degrees-76 degrees (mean 70.6 degrees +/- 4.1 degrees); for the left proximal renal artery 0 degrees-35 degrees (mean 23.1 degrees +/- 6.6 degrees) vs 62 degrees-73 degrees (mean 68.3 degrees +/- 4.2 degrees). Images obtained from the right flank were often of better quality than those obtained from the abdominal window because of a superior definition of acoustic interfaces and a better performance of Color Doppler sampling. Thus, the right flank could be considered a good alternative window for the echographic study of the abdominal aorta.

PURPOSE A morphofunctional approach to the management of brain tumours has been claimed to increase diagnostic accuracy. Among the proposed single-photon emission tomography (SPET) tracers, (99m)Tc-sestamibi is able to distinguish recurrent tumour from radio-necrosis and to identify early response or resistance to chemotherapy. Major drawbacks of sestamibi, that is, poor morphological resolution and the sites of physiological uptake, could be overcome by dual-modality, integrated systems. The purpose of this study was to investigate the real usefulness of (99m)Tc-sestamibi SPET/computed tomography (CT) and to establish a semiquantitative index. METHODS Charts from 33 consecutive patients selected for surgery, who underwent preoperative SPET/CT and magnetic resonance imaging (MRI), were reviewed. Tumours were confirmed histologically after the surgery in all patients and classified according to WHO recommendations. Semiquantitative indexes were obtained on images (maximum likelihood expectation maximization reconstructed) with and without attenuation correction and visual analysis of SPET versus SPET/CT was performed. RESULTS A significant statistical difference was shown between SPET and SPET/CT in terms of the delineation of medial shift, oedema and the ability to distinguish tumour from the skull-meninges complex and plexus. With regard to semiquantitative indexes, a ratio obtained comparing counts/pixel derived from a region of interest in the tumour area with mirrored region of interest in the contralateral site revealed a sensitivity of 90.9% and specificity of 71.45% in discriminating WHO grade 4 gliomas from a lower grade. CONCLUSION SPET/CT can distinguish tumour from the skull and other sites of physiological uptake better than SPET alone (as confirmed by MRI in all cases) and affords a morphological map. The proposed semiquantitative index also seems promising in identifying higher-grade disease. SPET/CT thus seems a useful additional tool in brain tumour management, especially when MRI is not feasible or PET/CT is not available.

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.

Introduction. It is well known that resolution on a gamma camera varies as a function of distance, scatter and the camera’s characteristics (collimator type, crystal thickness, intrinsic resolution etc). Manufacturers frequently provide only a few pre-calculated resolution values (using a line source in air, 10–15 cm from the collimator surface and without scattering). However, these are typically not obtained in situations resembling a clinical setting. From a diagnostic point of view, it is useful to know the expected resolution of a gamma camera at a given distance from the collimator surface for a particular setting in order to decide whether it is worth scanning patients with “small lesion” or not. When dealing with absolute quantification it is also mandatory to know precisely the expected resolution and its uncertainty in order to make appropriate corrections. Aim. Our aims are: to test a novel mathematical approach, the cubic spline interpolation, for the extraction of the full width at half maximum (FWHM) from the acquisition of a line source (experimental resolution) also considering measurement uncertainty; to compare it with the usually adopted methods such as the gaussian approach; to compare it with the theoretical resolution (analytical resolution) of a gamma camera at different distances; to create a web-based educational program with which to test these theories. Methods. Three mathematical methods (direct calculation, global interpolation using gaussian and local interpolation using splines) for calculating FWHM from a line source (planar scintigraphy) were tested and compared. A NEMA Triple Line Source Phantom was used to obtain static images both in air and with different scattering levels. An advanced, open-source software (MATLAB/Octave and PHP based) was created “ad hoc” to obtain and compare FWHM values and relative uncertainty. Results and Conclusion. Local interpolation using splines proved faster and more reliable than the usually-adopted Gaussian interpolation. The proposed freely available software proved effective in assessing both FWHM and its uncertainty.

OBJECTIVE: Adrenocortical scintigraphy has demonstrated clinical utility in the morpho-functional characterization of adrenal tumors. The aim of this study was to identify possible relationships between the scintigraphic pattern and endocrine and/or morphological data in a series of adrenocortical carcinomas. DESIGN AND METHODS: Twenty-one patients with adrenocortical carcinoma (11 nonfunctioning and 10 hormone-secreting) were investigated with 75Se-methyl-nor-cholesterol scintigraphy. Clinical, hormonal, radiological, and pathological data were analyzed. RESULTS: The adrenal mass showed no radiocholesterol uptake in 18 cases (11 nonfunctioning and 7 functioning lesions). Contralateral normal adrenal gland was visualized in all patients with nonfunctioning tumors, whereas classic bilateral nonvisualization was observed in the 7 cases with hyperfunctioning masses. Three patients with cortisol-producing carcinomas showed radiotracer uptake by the mass, without visualization of the contralateral gland. At histology, the tumors were shown to be undifferentiated adrenocortical carcinomas; they had an aggressive clinical behavior. CONCLUSIONS: Radiocholesterol scintigraphy has an important role in diagnosing adrenocortical carcinomas, which typically are not visualized. However, 30% of hypersecreting adrenocortical carcinomas show an atypical increased tracer uptake, not predictive of the biochemical and histological features of the tumor.

The aim of this study was to evaluate the usefulness of technetium-99m sestamibi scintimammography (SSM) and combined use of SSM and X-ray mammography (MG) in premenopausal patients with small (≤2 cm) suspicious breast lesions. Eighty-seven premenopausal women (median age 47 years, range 32–52) with breast lesions ranging from 4 to 20 mm in greatest diameter (median 12 mm) and detected by MG, underwent SSM prior to open breast biopsy. A planar camera and single-photon emission tomography (SPET) technique were used in 23 (26.4%) and 64 (73.6%) patients, respectively. At histological examination, 72 (82.8%) breast cancers (pT1a=3, pT1b=27, pT1c=42) and 15 (17.2%) benign masses were found. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of MG and SSM were 80.6% vs 80.6%, 60.0% vs 93.3% (P

Owing to the frequent observation of poverty of movements, facial hypomimia and balance impairment, amyotrophic lateral sclerosis (ALS) variant with predominance of upper motor neuron involvement (UMN-ALS) is prone to be diagnosed with Parkinsonism. A clinical assessment, including the velocity-dependent stretch response test to differentiate between pyramidal and extrapyramidal stiffness; the Unified Parkinson's Disease Rating Scale and the Berg Balance Scale to assess degree of bradykinesia and postural instability; and (123)I-FP-CIT scintigraphy evaluation to investigate the nigrostriatal circuit involvement, were carried out to characterize Parkinson-like features in UMN-ALS patients. Sixteen UMN-ALS patients were included in the study. The velocity-dependent stretch response indicated spasticity in all the muscles tested. The degree of stiffness was found to be related to bradykinesia and postural instability. Eleven patients (70%) showed a reduction in striatal (123)I-FP-CIT uptake found to be related to disease duration and patients' ages but not to scores of the functional scales. Slowness of movements and postural instability noted in our patients could be mostly attributed to spasticity. The lack of any correlation between UPDRS or BBS scores and the degree of nigrostriatal impairment on DaTSCAN seems to disprove nigrostriatal circuit involvement in these extrapyramidal-like features.

The aim of this study was to evaluate the sensitivity, specificity and accuracy of axillary ultrasonography (US) and (99m)Tc-sestamibi scintimammography (SSM) in patients with breast cancer (BC) undergoing curative surgery.A series of 77 consecutive women (median age 54 years, range 36-70) with primary BC underwent both US and SSM from 2 to 15 (median 4) days prior to curative surgery. The results of imaging studies were compared against the final pathology. Breast-conserving surgery with axillary node (AN) dissection was performed in 49 (63.6%) patients, and modified radical mastectomy in 28 (36.4%) patients, according to the tumour staging.Final pathology showed 5 pT1bN0, 1 pT1bN1, 28 pT1cN0, 19 pT1cN1, 7 pT2N0, and 17 pT2N1 BC. Overall, 719 AN were removed of which 106 (14.7%) were metastatized nodes (median 3, range 1-5 per patient). The sensitivity, specificity and accuracy were 67.6%, 80.0%, and 74.0% for US, 78.4%, 85.0%, and 81.8% for SSM, and 91.9%, 92.5%, and 92.2% for US and SSM together, respectively. There was a significant difference (p0.05) in the number of metastatized AN between patients with metastases correctly detected and undetected by both US (3.1+/-1.3 vs. 2.0+/-0.7) and SSM (3.2+/-1.3 vs. 1.7+/-0.7).Although the results of each diagnostic tests are strictly dependent on the number of the metastatized AN, the combination of axillary US and SSM is a sensitive low-cost procedure that should be suggested in all patients with BC, when a preoperative evaluation of the AN status is required.

Summary The complementary role of sestamibi scintimammography (SSM) in patients with breast cancer (BC) is well established. The aim of this study was to establish whether a relationship exists between sestamibi uptake, evaluated as a tumour-to-background ratio (TBR), and the main prognostic factors of BC. SSM with the measurement of TBR was performed preoperatively in 102 women (median age 57 years, range 32–81 years) who underwent curative surgery for primary BC. Final pathology showed 4 (3.9%) with pT1a, 17 (16.7%) with pT1b, 44 (43.1%) with pT1c and 37 (36.3%) with pT2 breast carcinomas. The overall sensitivity of SSM was 80.4%. An ANOVA showed significant ( P 0.01 ) differences between the TBR of patients with G1 vs. G3 tumours, and between the TBR of those with G2 vs. G3 breast carcinomas. Moreover, there was a difference ( P = 0.021 ) between the TBR of patients ( n = 12 , 11.8%) with CEA serum levels >10 ng/ml (2.031±0.420), and those with normal ( n = 90 , 88.2%) CEA values (1.713±0.446), whilst no difference ( P =NS) was found between patients ( n = 27 , 26.5%) with CA 15-3 >30 U/ml (1.893±0.401) and those with normal ( n = 75 , 73.5%) CA 15-3 values (1.699±0.462). There was a mild inverse correlation between TBR and both the oestrogen ( R = 0.25 , P = 0.011 ) and the progesterone receptor ( R = 0.23 , P = 0.02 ) rate. The logistic regression analysis showed that only size and CA 15-3 serum levels represent true independent parameters, but the function was able to predict only 11 out of 21 (52.4%) patients with false-negative SSM. TBR is independent of age and mainly correlates with the size of the tumour. There are no reliable preoperative prognostic factors that are really useful for improving SSM sensitivity in patients with small breast carcinomas.

As observed by other authors, normal adrenal medullary tissue frequently gives an apparently positive meta-iodobenzylguanidine (MIBG) scan in cases studied using 123I-MIBG and less frequently 131I-MIBG. The aim of this study was to assess the usefulness of a scoring system, based on different uptakes of the radiopharmaceutical, to improve the accuracy of 123I-MIBG scintigraphy in patients with either adrenal or extra-adrenal pheochromocytomas. Charts from 67 consecutive patients (29 males and 38 females, median age 48 years, range 14–80 years) with suspected pheochromocytoma (either sporadic or familial: multiple endocrine neoplasia (MEN) 2a, MEN2b, Von Hippel–Lindau, neurofibromatosis type 1) who underwent 123I-MIBG scintigraphy (scans acquired 4–24 h after injection) from 1991 to 2004, were independently reviewed by two experienced nuclear medicine physicians using liver uptake as a reference (scores: 1, uptake absent or less than the liver; 2, equal to the liver; 3, moderately more intense than the liver; 4, markedly more intense than the liver). Interfering medications were discontinued for the appropriate time before MIBG injection. Histological data were obtained for all patients who underwent adrenalectomy. Scintigraphies were classified as positive using the following criteria: extra-adrenal focal uptake, adrenal enlargement together with non-homogeneous uptake and adrenal uptake more intense than the liver (score 3–4). After surgical resection, as confirmed by histological findings and long-term follow-up (range 1–14 years, average 9.25 years), 43 patients were considered true positives using the proposed scoring system, 20 were true negatives, four were false negatives and none was false positive. In conclusion, the proposed scoring system demonstrated high specificity (100%), sensitivity (91.5%) and accuracy (94%) in the management of pheochromocytoma. Positive predictive value and negative predictive value were 100% and 83.3% respectively. Normal adrenal tissue uptake was correctly discriminated from pheochromocytomas in 18 out of 20 patients, with adrenal uptake equal to the liver (grade 2), using the proposed cut-off level.

44 consecutive patients with confirmed primary hyperparathyroidism (HPT) undergoing surgery were prospectively enrolled in the study. There were 13 (29.5%) men and 31 (70.5%) women with an overall median age of 59 years (range 23-78 years). Prior to successful parathyroidectomy both (99)Tc(m)-sestamibi/(99)Tc(m)-pertechnetate subtraction scintigraphy (SS) and helical CT were performed, and the results of imaging studies were compared against intraoperative findings. Final histopathology showed 40 (90.9%) solitary parathyroid (PT) adenomata (median size 18 mm, range 8-40 mm), that were in an ectopic location in 13 (32.5%) patients. Moreover, 3 (6.8%) patients had multiglandular disease (one patient with two PT adenomata, two patients with PT hyperplasia), while one (2.3%) patient had a PT carcinoma. The sensitivity and positive predictive value were 86.0% and 97.4% for SS, 88.1% and 94.9% for CT, and 100% and 97.4% for the combination of SS and CT, respectively. Calcium and parathyroid hormone (PTH) serum levels, and the mean size of the removed PT glands of patients with false negative results were lower than that of those with true positive results, but the difference was not significant. Among patients with solitary PT tumours (N=41) the sensitivity was 88.1% and 90.3% for SS and CT-scan, respectively. In conclusion, our study confirms the usefulness of SS, which should be the initial test for patients undergoing parathyroidectomy. However, the strategy of performing two tests in each patient with primary HPT could be of limited utility when the initial SS is positive.

A series of 112 consecutive patients with primary hyperparathyroidism who underwent both high-resolution neck ultrasonography (US) and 99mTc-sestamibi/99mTc-pertechnetate subtraction scintigraphy (SS) prior to successful parathyroidectomy was reviewed. There were 29 (25.9%) men and 83 (74.1%) women, with a median age of 58 years (range 13-78 years). Patients were divided into two groups, according to the preoperative US findings: group A (87 patients, 77.7%) without thyroid diseases, and group B (25 patients, 22.3%) with either multinodular goitre or a solitary nontoxic thyroid nodule. In group B patients partial or total thyroidectomy was also performed, according to the intraoperative findings and frozen-section examination results. Final histopathology showed 99 (88.4%) solitary parathyroid (PT) adenomas and 3 (2.7%) PT carcinomas, while 10 (8.9%) patients had a multiglandular disease. The sensitivity and positive predictive value (PPV) were (group A vs group B) 79.8% vs 70.8% (P=0.25) and 95.7% vs 94.4% (P=0.58) for US, and 83.3% vs 87.0% (P=0.47) and 95.9% vs 90.9% (P=0.32) for SS respectively. Better but similar (P=not significant) results were obtained in patients with solitary PT tumours: 81.5% vs 77.8% (US) and 85.0 vs 94.1% (SS) sensitivity; 97.1% vs 93.3% (US) and 95.8% vs 88.9% (SS) PPV. Overall, the combination of US and SS was 92.9% sensitive (group A=93.1%, group B=92.0%; P=0.55), and the PPV reached 100% in each group. In conclusion, in patients with primary hyperparathyroidism the results of both US and SS are independent of coexistent thyroid disease, especially in patients with solitary PT tumours.

The aim of this study was to evaluate the sensitivity and positive predictive value (PPV) of dexamethasone-suppression norcholesterol scintigraphy (NCS), computed tomography (CT) scanning and magnetic resonance imaging (MRI) in patients with primary aldosteronism (PA) who had undergone unilateral adrenalectomy. A series of 49 patients with confirmed PA was reviewed. There were 18 (36.7%) men and 31 (63.3%) women, with a median age of 47 years (range, 23-66 years). NCS was performed in all patients, and 46 (93.9%) and 31 (63.2%) underwent CT scan and MRI, respectively. Final pathology showed an aldosterone-producing adenoma in 45 (91.8%) patients, unilateral nodular cortical hyperplasia (NCH) in two (4.1%) and unilateral microscopic cortical hyperplasia (MCH) in two (4.1%). No aldosterone-producing carcinoma or bilateral adenomas were found. The greatest diameter of the removed adrenal tumour was in the range 8-40 mm (median, 14 mm). The PPV of adrenal imaging was 97.6% for NCS, 85.0% for CT scan (P=0.04) and 83.3% for MRI (P=0.03), and the sensitivity was 85.4%, 85.0% and 74.1%, respectively (P=NS). The age and the main biochemical parameters did not differ significantly (P=NS) between patients with true positive and false negative results of the imaging procedures. NCS accurately depicted all patients with NCH and MCH, whilst CT scan and MRI failed to diagnose such unilateral adrenal gland hyperfunction in two and three patients, respectively. The overall sensitivity of combined NCS and CT scan was 100%. In conclusion, in patients with PA, both NCS and CT scan are necessary to confirm the exclusive unilateral adrenal hyperfunction and, subsequently, to establish the appropriate treatment.

The purpose of this study was to analyse whether the use of Tc sestamibi scintimammography improves the positive predictive value of X-ray mammography. A series of 73 women (median age 51 years, range 35-79 years) with non-palpable, mammographically suspicious, breast lesions was reviewed. There were 41 (56.2%) pre-menopausal, and 32 (43.8%) post-menopausal women. All patients underwent sestamibi scintimammography prior to open breast biopsy. Definitive histology showed breast cancer (pT1a=1 (1.9%), pT1b=47 (90.4%), pT1c=4 (7.7%)) in 52 (71.2%) patients, and benign breast lesions in 21 (28.8%). Patients with cancer were significantly older (P0.01), while the greatest dimension (size) of the excised lesion did not differ (8.47+/-1.51 vs 8.30+/-1.53 mm; P =0.66) between the two groups. Overall, the positive predictive values of mammography and sestamibi scintimammography were 71.2% and 95.7%, respectively (P =0.004). Patients with false positive mammography were significantly younger than those in whom cancer was diagnosed correctly (45.35+/-7.56 vs 53.96+/-10.60 years; P =0.001), while age did not affect the sensitivity of sestamibi scintimammography, which reached 100% in patients with breast lesionsor =8 mm in size. In this subgroup the positive predictive value of mammography, sestamibi scintimammography, and mammography+sestamibi scintimammography together were 63.4%, 95.1% (P =0.001), and 97.6%, respectively, and the majority of the patients with benign lesions (13 of 15 (86.7%)) could have avoided biopsy. It is concluded that the use of Tc sestamibi scintimammography in conjunction with mammography may potentially reduce unnecessary surgical procedures, and should be performed in all patients with mammographically suspicious breast lesions of 8 mm or greater in size.

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 Cushing's 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

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.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.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, p0.005). 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.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.

Aims: To evaluate the usefulness of 99m-Tc-sestamibi scintimammography (SSM) in the detection of T1-2, N0-1, M0 breast cancer (BC) and axillary node (AN) metastases. Patients and methods: A series of 239 women (median age 55 years) who had already been selected for breast biopsy underwent both mammography (MG) and SSM before surgery. The final diagnosis confirmed in 207 (86.6%) patients, and benign breast lesions in 32 (13.4%). Results: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MG and SSM in BC detection were 88.9% vs 87.9%, 62.5% vs 93.8% (P

Objective To evaluate the usefulness of the combination of Tc-sestamibi/Tc-pertechnetate subtraction scintigraphy (SS) and high-resolution neck ultrasonography (US) in patients with primary hyperparathyroidism (pHPT) undergoing parathyroidectomy. Design and Methods Ninety-one patients with proved pHPT were studied, excluding patients with persistent or recurrent disease. There were 65 (71.4%) women and 26 (28.6%) men, with a median age of 59 years (range 18-78 years). All patients underwent both SS and US prior to surgery, and the results were compared with operative and histological findings. The intraoperative quick-parathyroid hormone assay was available for 52 (57.1%) patients. When multiglandular disease was found, both SS and US were considered truly positive only when at least two enlarged parathyroid (PT) glands had been localized. Results Eighty-three (91.2%) solitary PT adenomas and three (3.3%) carcinomas were found. Moreover, two (2.2%) patients had a double adenoma and three (3.3%) patients had diffuse PT hyperplasia. The overall sensitivity of combined SS+US was 94.5% (86.8% and 80.4% for SS and US respectively). There was a significant (P Conclusions When the preoperative localization of the PT glands is chosen, the combination of SS and US represents a reliable noninvasive localization technique and should be considered for use in each patient with pHPT undergoing surgery.

The antihypertensive and renal haemodynamic effects of 5 mg/day tertatolol (T), a new nonselective and long-acting beta-adrenoceptor blocker, and 80 mg/day nadolol (N) in hypertensive patients with mild renal impairment have been compared in a randomized double-blind trial. Before and after 30 days of active treatment glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were determined by use of a simultaneous i.v. bolus of 99mTc-DTPA and 131I-hippuran. Both T and N significantly decreased blood pressure and heart rate, and induced an insignificant increase in GFR and ERPF. There were no differences between the effect of the treatments on blood pressure and heart rate. Despite the persistent fall in BP and HR, renal function was maintained during both T or N treatment, suggesting that both drugs may act by a direct intrarenal vasodilator mechanism.

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.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).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.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.

To evaluate the effectiveness of single proton emission tomography (SPECT) with 99mTc-HMPAO in the diagnosis of brain death (BD).Prospective study in comatose and brain-dead patients.Neurologic ICU.Fifty comatose patients (age range: 10 days-75 years) were submitted to SPECT study. In 21 of them (42%) reversible factors (e.g., influence of drugs affecting the central nervous system) were present. Thirty-eight patients were clinically brain-dead, while the remaining 12 were tested both in pre-terminal conditions and after the clinical onset of BD.Brain SPECT following i.v. injection of 99mTc-HMPAO (300-1100 MBq), using a 4-headed gamma-camera (20 min, 360 degrees, 88 images).All patients tested in pre-terminal conditions showed preserved brain perfusion. Two of them had flat EEGs despite the absence of any reversible cause of coma; three patients survived, but remained in persistent vegetative states. SPECT confirmed the diagnosis of BD in 45 out of 47 patients (95.7%), clearly showing the arrest of brain perfusion (picture of "empty skull"); in two clinically brain-dead children (aged 10 days and 12 months, respectively) weak perfusion of the basal ganglia, thalamus and/or brain stem was still present, precluding the diagnosis of BD; both of them died a few days later.Our results confirm the reliability of SPECT in the diagnosis of BD. A problem arises about its effectiveness in brain-dead children, but this seems to be a matter of definition of BD and cerebral viability, rather than a limit of SPECT.

In the long-term follow-up of patients after repair of tetralogy of Fallot, monitoring right ventricular function is mandatory. The echocardiographic subtraction method proposed by Tomita seems to be easily applicable to a pediatric age population and accurate enough to be included in the longitudinal surveillance of such a group of patients.

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).

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.

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.

The reaction by which thyroxine (T 4 ) undergoes monodeiodination in the nonphenolic ring to form 3,3′,5′-triiodothyronine (reverse-T 3 ) has been studied in rat liver. In whole homogenate the conversion of T 4 to rT 3 is obscured by rapid degradation of the product, whereas in cytosol accumulation of rT 3 is linear for 60 min of incubation. In the cytosol system, the rate of rT 3 formation is maximal at pH 8.2, is thiol-dependent, is inactivated by heat, but is not inhibited by anaerobiosis or absence of light. Propylthiouracil is a potent inhibitor of the reaction. The higher pH-optimum of the rT 3 -forming system compared to that of T 4 -to-T 3 conversion indicates that the former reaction is mediated by an enzyme which is distinct from that controlling 3,5,3′-triiodothyronine (T 3 ) formation.

The rate of TSH suppression in patients with differentiated thyroid cancer, when therapy is re-started after total body scan, was investigated adopting an optimal saturation regimen, either with T4 or with T3. The first group of 6 patients received T4 as follows: from day 1 to 7 = 22, 11, 6, 4, 3.5, 3.2, 3.2 micrograms/day/kg body weight (b w) and continued with 3.2; the second group of 8 patients received T3 as follows: 2.4, 1.8, 1.4, 1.2, 1.1, 1.1 micrograms/day/kg BW and continued with 1.1. At time 0, TSH levels were high in all patients (range 80-180 microU/ml); T3 and T4 levels were below the limit of detectability. After the beginning of the therapy, the decrease of TSH levels and the inhibition of TSH response to TRH occurred faster in patients taking T3 than in patients taking T4. In the former, at day 7, mean basal TSH level was 1.9 +/- 0.5 microU/ml and 30 min after 200 micrograms TRH iv mean TSH level was 9.9 +/- 4.4 microU/ml; at day 10 they were 1.4 +/- 0.5 and 2.7 +/- 0.8 microU/ml respectively. In the latter, at day 7, mean basal TSH level was 4.6 +/- 3.9 microU/ml and 30 min after TRH mean TSH level was 42.2 +/- 34.2 microU/ml. Only at day 20 they were 0.8 +/- 0.2 and 1.2 +/- 0.9 microU/ml respectively. In patients taking T3 by saturation regimen, serum levels of T3 rose rapidly to supranormal values (at day 3, mean serum T3 level was 297 +/- 62 ng/100 ml), reached a peak at day 5 (340 +/- 62 ng/100 ml) and decreased thereafter, always remaining however above normal limits.(ABSTRACT TRUNCATED AT 250 WORDS)

Forty-six patients whose thyroid glands had been ablated for thyroid carcinoma, maintained on replacement treatment with triiodothyronine (T3), have been followed by means of serial determinations of pituitary thyrotropin (TSH) levels and of the TSH response to thyrotropin-releasing hormone (TRH), in order to verify the actual dose required to suppress TSH secretion. The treatment was begun with a dose of T3 roughly related to body weight (about 1 mug/kg/day). The daily dose was sequentially adjusted according to the measured TSH levels. The dose of T3 which reduced serum TSH within the normal limits varied from 40 to 120 mug daily. More precisely, it was as low as 40-50 mug daily in five patients and as high as 90-120 mug daily in three patients. The dose, which was given according to their body weights, varied from 0.75 to 1.12 mug/kg/day. TRH administration produced a marked increase of TSH levels in those patients whose TSH was elevated, and varying responses (from no response to a response three times the normal one) in those patients whose TSH was within the normal limits. In the latter group of patients, an increase of the T3 dosage inhibited the TSH response to TRH. These data suggest that, even though 1 mug/kg/day is an adequate T3 dose for the great majority of patients, the extent of TSH suppression is not surely predictable, but must be evaluated case by case by means of serial determinations of TSH levels and of the TSH response to TRH.

In a group of 113 patients who had undergone thyroid ablation for differentiated thyroid carcinoma, serum levels of TSH were measured 12 and 17 days, after discontinuation of triiodothyronine (T3) treatment. On both occasions a wide scattering of TSH levels was found. In patients without metastases, TSH levels varied between 23 and 330 μU/ml (mean ± SD 142 ± 81 μU/ml) at day 12 and between 50 and 380 μU/ml (mean ± SD 212 ± 95 μU/ml) at day 17. In patients with metastases, TSH levels varied between 35 and 315 μU/ml (mean ± SD 145 ± 64 μU/ml) at day 12 and between 45 and 330μU/ml (mean ± SD 179 ± 74 μU7ml) at day 17. No significant difference between TSH levels of patients with and without metastases was found at day 12, while the difference was significant at day 17. In both groups of patients the increase of TSH levels from day 12 to day 17 was statistically significant. In most patients the reduction or disappearance of metastases by 131I treatment was followed by a significant increase of serum TSH at d...

Measurements of serum triiodothyronine (T3) concentrations were made in 46 patients who had thyroid ablation for thyroid cancer and who were receiving T3 three times a day as suppressive treatment. In all patients thyrotropin (TSH) suppression was confirmed by the inhibition of TSH response to thyrotropin releasing hormone (TRH). The suppressive dose of T3 varied from 40 to 100 micrograms/day (mean +/- SD 72.39 +/- 13.07 micrograms/day). Related to body weight the dose varied from 0.95 to 1.35 micrograms/kg/day (mean +/- SD 1.13 +/- 0.13 micrograms/kg/day). In ten hospitalized patients serum T3 levels were measured at hourly intervals from 08:00 to 23:00. Before the first dose of T3, serum T3 levels were 153 +/- 43 mg/100 ml; after T3 the levels increased promptly reaching after 4 h a peak of 264 +/- 90 ng/100 ml. Afterwards T3 levels showed a similar peak after each dose: 262 +/- 77 and 266 +/- 78 ng/100 ml, slightly decreasing in the intervals between the doses: 227 +/- 63 and 255 +/- 69 ng/100 ml. After the last peak T3 levels showed a slow decline during the night. TSH response to TRH was completely inhibited both at 08:00 and at 16:00. In 36 outpatients T3 levels were measured twice a day and T3 levels were found similar to the ones of the first group. In these patients also TSH response to TRH evaluated at 08:00 was completely inhibited. No important side effect was noted in both groups of patients.

Incidentally discovered adrenal masses (incidentalomas) are relatively frequent and unsuspected incidentalomas (AI) of more than 1 cm in size may be found in 1-5% of patients who have undergone abdominal or chest computed tomography (CT)-scan for unrelated reasons. Once an AI is detected, the two major questions are whether the patient has biochemical evidence of adrenal hyperfunction, and whether the mass is an adrenal metastasis or a malignant adrenal tumour. In most cases (90%) AI are non-functioning, with a low (10%) risk of being malignant, and an estimated cumulative risk of malignant transformation of less than 1:1000. However, all patients with non-functioning AI usually undergo several imaging studies, but the impact of imaging techniques and image-guided fine-needle aspiration cytology (FNAC) on the cost-effectiveness in the management of patients is not well established. A single test for disease probabilities is not always more cost-effective than two-test approaches and it has been shown that the cumulative sensitivity and accuracy of both FNAC + magnetic resonance imaging (MRI) and FNAC + norcholesterol adrenal scintigraphy reach 100%, at a similar cost-to-accuracy ratio (7.5 vs. 7.0), whilst the strategy CT-scan + MRI together is less sensitive at a lower cost-to-accuracy ratio. In conclusion, the significance of AI, as well as the optimal management approach to treatment, is still under discussion. However, image-guided FNAC in conjunction with MRI as the exclusive imaging test has the major role and cost-effectiveness in the management of patients with AL, and should be considered the strategy of choice in distinguishing between benign and malignant non-functioning adrenal masses of more than 2 cm in diameter.