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Resumen Antecedentes Demostrar la exactitud diagnostica de un abordaje integrado del diagnostico de las adenopatias mediastinicas mediante aspiracion por puncion transbronquial (TBNA) ciega y tomografia computarizada de emision fotonica unica con 99m Tc-2-metoxi-isobutil-isonitrilo ( 99m Tc-MIBI-SPECT). Metodos Se incluyo prospectivamente en el estudio a 61 pacientes consecutivos con adenopatias mediastinicas a los que se practico una TBNA y una 99m Tc-MIBI-SPECT. En el caso de que la TBNA fuera negativa se realizaba una mediastinoscopia. Resultados Se obtuvieron muestras de 83 adenopatias (73 malignas y 10 benignas). La sensibilidad, la especificidad, el valor predictivo positivo (VPP) y el valor predictivo negativo (VPN) de la TBNA fueron del 74, del 100%, del 100 y del 34%, respectivamente, y las de la 99m Tc-MIBI-SPECT fueron del 96, del 80, del 97 y del 73%, respectivamente. La combinacion de TBNA y 99m Tc-MIBI-SPECT alcanzo una sensibilidad, especificidad, VPP y VPN del 97, del 100, del 100 y del 83%, respectivamente. La TBNA sola evito la mediastinoscopia en el 65% de los casos, mientras que un abordaje integrado podria haber obviado la mediastinoscopia en el 76% de los casos. Conclusiones La 99m Tc-MIBI-SPECT mejoro la sensibilidad y el VPN de la TBNA, reduciendo la necesidad de realizar mediastinoscopias.

OBJECTIVES The aim of this study was to evaluate: 1) the effects of insulin administration on left ventricular ejection fraction (LVEF) during exercise, and 2) the eventual impairment of the cardiovascular response to insulin in noninsulin dependent diabetes mellitus. BACKGROUND Insulin influences the cardiovascular system, but its effect on left ventricular function has yet to be established. METHODS The effects of normal saline (test A) and insulin-glucose (insulin = 1.7 mU·kg−1·min−1; glucose = 6 mg·kg−1·min−1) (test B) infusions on systolic and diastolic functions at rest and during dynamic exercise were examined by radionuclide ventriculography. Twenty-two noninsulin-dependent diabetic patients and 22 gender, age and body mass index matched healthy subjects were investigated. RESULTS Both groups had normal scintigraphic parameters at rest and during dynamic exercise. Rest- and stress-LVEF as well as rest- and stress-peak filling rate were significantly (p CONCLUSIONS In both normal and diabetic humans, insulin induces a very important rise in LVEF after submaximal work. However, the rise is significantly lower in diabetic than in nondiabetic subjects. The increase in exercise-LVEF on insulin is likely due to an enhancement of ventricular contractility. Insulin resistance could justify the lower angioscintigraphic indexes in diabetic subjects.

Background: To demonstrate the diagnostic accuracy of an integrated approach of blind trans-bronchial needle aspiration (TBNA) and Tc-99m-2-methoxy-isobutyl-isonitrile single photon emission computed tomography (Tc-99m-MIBI-SPECT) in diagnosing mediastinal lymph adenopathy.Methods: Sixty one consecutive patients with mediastinal lymph adenopathy undergoing both TBNA and Tc-99m-MIBI-SPECT were prospectively enrolled. Mediastinoscopy was attended in case of negative TBNA.Results: Eighty three adenopathies were sampled (73 malignant and 10 benign). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of TBNA was 74%, 100%, 100%, and 34%, respectively; and of Tc-99m-MIBI-SPECT was 96%, 80%, 97%, and 73%, respectively. Combining TBNA and Tc-99m-MIBI-SPECT results sensitivity, specificity, PPV, NPV of 97%, 100%, 100%, and 83%, respectively, was obtained. TBNA alone avoided medistianoscopy in 65% of cases, while an integrated approach could haveConclusions: Tc-99m-MIBI-SPECT improved the sensitivity and the NPV of TBNA, reducing the need of mediastinoscopy. (C) 2013 SEPAR. Published by Elsevier Espana, S.L. All rights reserved.

Adenocarcinoma arising from a mediastinal cyst was detected by exercise technetium-99m hexakis-2-methoxyisobutylisonitrile 99mTc-MIBI scintigraphy in a 65-year-old woman with known coronary disease. This guided further investigations and resection of the tumor which stained positive for P-glycoprotein. Three years earlier, myocardial scintigraphy was negative, probably due to down-expression of P-glycoprotein because the cells were in the early stages of carcinogenesis. After completing malignant transformation, the high P-glycoprotein expression resulted in MIBI uptake on the second myocardial scintigraphy.

Objective: To evaluate the usefulness of (99m)Tc-2-Methoxy-Isobutyl-Isonitrile Single Photon Emission Computed Tomography (MIBI-SPECT) for assessing anterior mediastinal mass, and distinguishing the grade of malignancy of thymic epithelial tumors to offer guidance for decision making. Methods: From January 2006 to November 2009, 31 consecutive patients with an anterior mediastinal mass at CT were enrolled. All patients underwent (99m)Tc-MIBI-SPECT before invasive diagnostic procedures and/or surgical resection. The uptake of the mediastinal tumor (T) was compared with the normal tissue (N) and the T/N ratio was calculated to define the metabolic activity of the lesions. Patients were divided into six groups according histologic patterns, which were then correlated to the T/N value: benign tumor (BT), lymphoma (LYM), other malignant tumor (OMT), and low-risk thymoma (LRT) including types A, AB, and B1, high-risk thymoma (HRT) including types B2 and B3, and thymic carcinoma (TC). Results: There were five BT, eight LRT (four = A, two = AB, and two = B1), four HRT (three = B2 and one = B3), four thymic carcinoma, six LYM and four OMT. The T/N value of BT, LRT, HRT, CT, LYM, and OMT was 1.3 +/- 0.3, 1.3 +/- 0.2, 1.8 +/- 0.3, 2.7 +/- 0.5, 2.8 +/- 0.1, and 2.9 +/- 0.2, respectively. The T/N ratio of BT and of LRT was significantly lower than that of HRT, of CT, of LYM, and of OMT (p < 0.05), while there is no significant difference of MIBI uptake between BT and LRT. MIBI uptake in HRT was significantly lower than that in TC, LYM, and OMT (p < 0.05), whereas no significant difference was found between the different types of malignant lesions (TC, LYM, and OMT). Regarding thymoma, the degree of MIBI accumulation significantly increased as the World Health Organization (WHO) classification shifted from type A to type B and to TC. Yet, the T/N value of stages I and II was significantly lower than that of stages III and IV. The size of the lesion and the presence of myasthenia were not correlated with MIBI uptake. Conclusion: (99m)Tc-MIBI-SPECT seems to be useful in the evaluation of malignancy in anterior mediastinal mass, and is significantly correlated with the WHO classification and the Masaoka stage. Thus, this technique may add further information to morphological studies for decision making. (C) 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B. V. All rights reserved.

OBJECTIVE Studies have suggested that insulin resistance plays a role in cognitive impairment in individuals with type 2 diabetes. We aimed to determine whether an improvement in insulin resistance could explain cognitive performance variations over 36 weeks in older individuals with mild cognitive impairment (MCI) and type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 97 older individuals (mean ± SD age 76 ± 6 years) who had recently ( RESULTS At baseline, no significant differences were found between groups in clinical or neuropsychological parameters. Mean ± SD values in the entire population were as follows: A1C 7.5 ± 0.5%, fasting plasma glucose (FPG) 8.6 ± 1.3 mmol/l, fasting plasma insulin (FPI) 148 ± 74 pmol/l, MMSE 24.9 ± 2.4, TMT-A 61.6 ± 42.0, TMT-B 162.8 ± 78.7, the difference between TMT-B and TMT-A [DIFFBA] 101.2 ± 58.1, and RAVLT 24.3 ± 2.1. At follow-up, ANOVA models tested changes in metabolic control parameters (FPI, FPG, and A1C). Such parameters improved in the metformin and metformin/rosiglitazone groups (Ptrend < 0.05 in both groups). ANCOVA repeated models showed that results for the metformin/rosiglitazone group remained stable for all neuropsychological tests, and results for the diet group remained stable for the MMSE and TMT-A and declined for the TMT-B (Ptrend = 0.024), executive efficiency (DIFFBA) (Ptrend = 0.026), and RAVLT memory test (Ptrend = 0.011). Results for the metformin group remained stable for the MMSE and TMTs but declined for the RAVLT (Ptrend = 0.011). With use of linear mixed-effects models, the interaction term, FPI × time, correlated with cognitive stability on the RAVLT in the metformin/rosiglitazone group (β = −1.899; P = 0.009). CONCLUSIONS Rosiglitazone may protect against cognitive decline in older individuals with type 2 diabetes and MCI.

Diabetic cardiomyopathy is a ventricular dysfunction in the absence of coronary artery disease, valvular or hypertensive heart disease. The mechanisms underlying diabetic cardiomyopathy may involve metabolic disturbances, myocardial fibrosis, small vessel disease, microcirculation abnormalities, cardiac autonomic neuropathy and insulin resistance. Diagnostic problems emerge because no specific disease pattern characterizes the disease and because there may be coexistence in diabetes of coronary artery disease and hypertension as independent but compounding causes of biochemical, anatomical and functional alterations impairing cardiac function. In this paper we will review the role of nuclear imaging today, concentrating on the diagnostic capabilities of radionuclide ventriculography, to study the effect of insulin resistance and, more extensively, gated-single photon emission computed tomography with Tc-99m labelled agents. A broad analysis will be dedicated to: 1) positron emission tomography using perfusion agents, with the potential to quantify resting and stress blood flow and coronary flow reserve; 2) radionuclide procedures evaluating aerobic and anaerobic cardiac metabolism; and 3) cardiac neurotransmission imaging, studying the autonomic neuropathy.

Background To quantitatively evaluate radiation-induced impaired oesophageal transit with oesophageal transit scintigraphy and to assess the relationships between acute oesophagitis symptoms and dysmotility. Methods Between January 1996 and November 1998, 11 patients affected by non-small-cell carcinoma of the lung not directly involving the oesophagus, requiring adjuvant external beam radiotherapy (RT) to the mediastinum were enrolled. Oesophageal transit scans with liquid and semisolid bolus were performed at three pre-defined times: before (T0) and during radiation at 10 Gy (T1) and 30 Gy (T2). Two parameters were obtained for evaluation: 1) mean transit time (MTT); and 2) ratio between peak activity and residual activity at 40 seconds (ER-40s). Acute radiation toxicity was scored according to the joint EORTC-RTOG criteria. Mean values with standard deviation were calculated for all parameters. Analysis of variance (ANOVA) tests and paired t-Tests for all values were performed. Results An increase in the ER-40s from T0 to T1 or T2 was seen in 9 of 11 patients (82%). The mean ER-40s value for all patients increased from 0.8306 (T0) to 0.8612 (T1) and 0.8658 (T2). These differences were statistically significant (p < 0.05) in two paired t-Tests at T0 versus T2 time: overall mean ER-40s and upright ER-40s (p = 0.041 and p = 0.032, respectively). Seven patients (63%) showed a slight increase in the mean MTT value during irradiation but no statistically significant differences in MTT parameters were found between T0, T1 and T2 (p > 0.05). Conclusion Using oesophageal scintigraphy we were able to detect early alterations of oesophageal transit during the third week of thoracic RT.

Selective deep lobe parotidectomy is a demanding technique, but it preserves healthy glandular tissue, improves cosmetic results and minimises the incidence of Frey's syndrome. We have evaluated postoperative function of the superficial lobe of the parotid after selective resection of the deep lobe. Fourteen patients who each had a mass involving the deep lobe of the parotid were selected from 127 patients with tumours of the parotid gland who were seen and treated between January 2001 and March 2004. Of the 14, 12 matched the study criteria. The preoperative diagnosis was made using both computed tomography (CT) and ultrasound or fine needle aspiration cytology, and the diagnosis was confirmed by histological analysis. All cases were treated by the same surgeon. At 6 months follow-up all patients had a House-Brackmann test, iodine starch test, and scintigraphy of both parotid glands. After scintigraphy the maximum uptake value and function of the gland were evaluated with the concentration index (CI) and the CI percentage ratio. The concentration function of the gland in the resected side of the study group had a mean (S.D.) CI index of 5.5 (3.6) and a CI percentage ratio of 84%. Selective deep lobe parotidectomy has the following advantages: it minimises the impact of treatment on the facial contour, it does not increase postoperative morbidity and it preserves the function of the gland.

The role of a procedure depends not only on its own capabilities but also on a cost/effective comparison with alternative techniques giving similar information. Starting from the definition of emergency as a sudden unexpected occurrence demanding immediate action, the role of nuclear medicine (NM) is difficult to identify if it is not possible to respond 24 h a day, 365 days a year, to clinical demands. To justify a 24 h NM service it is necessary to reaffirm the role in diagnosis of pulmonary embolism in the spiral CT era, to spread knowledge of the capabilities of nuclear cardiology in reliably diagnosing myocardial infarction (better defining admission and discharge to/from the emergency department), to increase the number of indications. Radionuclide techniques could be used as first line, alternative, complementary procedures in a diagnostic tree taking into account not only the diagnosis but also the connections with prognosis and therapy in evaluating cerebral pathologies, acute inflammation/infection, transplants, bleeding, trauma, skeletal, hepatobiliary, renal and endocrine emergencies, acute scrotal pain.

Aims We designed this study in order to determine the effect of insulin on cardiac function in overweight and obese subjects during exercise. Methods and results The cardiac function of 62 normal glucose tolerant subjects, aged 30–40 and divided into normal weight (group 1, n ¼ 22, BMI 20–24.9 kg/m 2 ), overweight (group 2, n ¼ 20, BMI 25–29.9 kg/m 2 ), and obesity (group 3, n ¼ 20, BMI 30–35 kg/m 2 ) was evaluated at rest and during dynamic exercise through angiocardioscintigraphy, when on hyperinsulinaemic euglycaemic clamp (test A) and when on normal saline infusion (test B). Left ventricular function at rest was statistically greater (P , 0.05) in both tests in overweight and obese subjects compared with normal weight controls, with no statistical difference (P ¼ 0.057) within groups between insulin and normal saline infusion. During exercise, cardiac function improved in all the subjects in both tests. The increase was lower in overweight and obese patients, even if statistically significant only in obese vs. control subjects in both tests (P , 0.05). Insulin sensitivity showed a significant correlation (P � 0.001) with left ventricular ejection fraction (LVEF) at rest and with change in LVEF during clamp. Conclusion Our findings suggest a metabolic pathogenesis for the impaired LV function in obesity.

Molti studi hanno dimostrato la affidabilità della tecnica del linfonodo sentinella (SN) nella valutazione del parametro N nel cancro mammario tanto da indurre a limitare la dissezione ascellare alla biopsia del solo SN (SNB) in caso questo sia negativo. Dopo un periodo di messa a punto della tecnica di identificazione, biopsia ed esame istologico del SN (ottobre 97- gennaio 98) sempre seguita dalla dissezione completa dei tre livelli dell’ascella (ALND), abbiamo intrapreso uno studio per valutare la affidabilità di una dissezione limitata al solo I livello dell’ascella (FLND) in donne con T

We describe the unusual case of a Caucasian woman who had a diagnosis of medullary thyroid cancer and papillary microcarcinoma 5 years after a diagnosis of Graves’ disease. The patient came to our observation for recurrence of hyperthyroidism. An ultrasound scan revealed diffuse thyroid enlargement with a nodule, recently increased in size. The serum CT and carcinoembrional antigen were elevated, and the fine-needle aspiration cytology with immunocytochemical analysis for CT was suggestive for medullary thyroid carcinoma. The nodular lesion showed intense 111In-pentetreotide uptake, whereas total body scintigraphy with the same tracer and with Thallium- 201, 99mTc (V) dimercaptosuccinic acid was negative for lymph node and distant metastasis. The histological examination of thyroidectomy specimens confirmed the diagnosis of medullary thyroid cancer, showing a lymphocytic intratumoral infiltration. The histological analysis of the controlateral lobe showed an occult papillary microcarcinoma. Medullary thyroid carcinoma and papillary microcarcinoma showed intense staining with policlonal anti-RET antibodies, although genetic analysis was negative for RET mutations most frequently involved in familial and sporadic medullary thyroid carcinomas. Possible implications about the coexistence of the 3 thyroid diseases are discussed.

The diagnostic use of radiolabeled octreotide has shown that somatostatin receptor scintigraphy can be successfully used in various neoplasms with a strictly neuroendocrine derivation, because of a good correlation between in vitro receptor expression and in vivo uptake. Moreover, 111In-Octreotide uptake has been demonstrated in various pathologies owing to the receptorial expression on cell elements such as lymphocytes, fibroblasts and endothelium. Although main diagnostic role is in neuroendocrine tumours, octreotide can be also used to obtain an immunological imaging in other fields. The presence of type 2 receptors on activated lymphocytes has stimulated the use of somatostatin in both the treatment and diagnosis of disease activity in patients with Graves' ophthalmopathy. Somatostatin analogs have been successfully used for the treatment and imaging of various tumours of thymic origin. Our research group has evaluated the possible clinical role of octreotide scintigraphy in paediatric patients with thymic hyperplasia after chemotherapy for lymphoma. Even if not routinely applicable, these approaches offer interesting diagnostic, prognostic and therapeutic prospects.

Current therapeutic approaches in neuroendocrine tumours include surgery, radiotherapy and polychemotherapy. Different metabolic patterns of neuroendocrine tumours allow the use of a wide range of diagnostic options in nuclear medicine, due to the presence of a wide spectrum of radiotracers electively concentrating in these neoplasms. Nuclear medicine, and in particular 111In Octreotide (OCT) scintigraphy, 123I Methaiodobenzylguanidine (MIBG) and pentavalent 99mTc-DMSA (V-DMSA), together with biohumoral markers, are currently able to locate tumours also not detectable using traditional diagnostic techniques. Somatostatin analogs, such as octreotide have become increasingly important over the years in the treatment of patients with neuroendocrine tumours. At present the therapeutic use of somatostatin analogs can be schematised as 1) pharmacological treatment (with cold octreotide); 2) surgical treatment (radioguided surgery); 3) radiometabolic treatment (with marked octreotide). The development of new synthetic molecules and new radiocompounds will probably open up interesting scenarios in the near future.

The study evaluates the role of radio-guided surgery (RGS) with 111In-octreotide in the treatment of lung neoplasms. RGS with octreotide appears to be useful in surgery, above all during the intraoperative staging of the tumour; it can define with greater precision the extent of the resections extended towards the lung wall and ensure a radical approach in minimal lung resections.

Radioimmunoguided surgery (RIGS) can be a valid option in the management of lung cancer as well as neoplasms in other anatomic sites.We evaluated the usefulness of radioimmunoguided surgery (RIGS) in the staging of primitive non small cell lung cancer. Intraoperatively, this technique can define the lymph nodes involvement and thus, the radicality of the resection. In the first stage of our study, we looked for the epitope TAG 72 in 45 patients with primary non small cell lung cancer. The epitope was found by immunochemistry in only 6 cases. The only one operable patient was injected with monoclonal antibody B 72.3, that was 125I-labelled.At the operation, the monoclonal antibody showed no selectivity for neoplastic cells. Neoplastic tissue and healthy tissue showed a similar detection of the monoclonal antibody both intraoperatively and at the histochemical study. Because of the problems related with this method--e.g. technical difficulties, excessive wasting of time and lack of imaging--we modified our strategy. In this second stage of our study we used fragments of murine anti-CEA monoclonal antibody F023C5. The protocol was performed in 11 patients with squamous cell lung cancer. In one patient operated on for an excavated cancer(not well-defined at the immunoscintigraphy) intraoperative detection was negative while the ex vivo counts were significant: the neoplastic tissue showed a radioactivity twice higher than healthy tissue. Furthermore, the RIGS found a small intraparenchimal lymph node that was seen neither by CT nor by immunoscintigraphy.Our data are still preliminary, but with improvement of the technique and the use of more specific monoclonal antibodies the RIGS could become a helpful method, able to improve the radicality of surgery for lung cancer.

Eight patients, two male and six female, aged between 24 and 48 years, with Graves’ disease and severe ophthalmopathy were included in the study. A standardized A-scan echography was performed to evaluate the reflectivity of the extraocular muscles (EOMs); a planar scintigraphy (PS) and/or a single photon emission computed tomography (SPECT) were also performed at various times after endovenous injection of 111 MBq In-111 OCT, a somatostatin analogue.

The uptake of Tc-99m tetrofosmin (TF) is reported in a case of parathyroid adenoma. A 65-year-old woman was studied on different days with TF, Tc-99m sestamibi (MIBI) and Tl-201 chloride (Tl). TF and MIBI injections were preceded by oral administration of potassium perchlorate. Clear identification of the adenoma was observed in all scans. No further information was obtained using a subtraction technique with Tc-99m pertechnetate. Regarding the thyroid/parathyroid ratio, different kinetics between TF and MIBI appear to be demonstrated. In particular, thyroid washout was observed with MIBI but not with TF.

Septic sacroiliitis in childhood is a relatively rare condition. We describe a case of septic sacroiliitis occurring in an 11-year-old girl in whom the diagnosis was suspected on clinical findings and bone scan. Immunoscintigraphy with 99mTc-labelled antigranulocyte antibodies further supported the hypothesis for a septic origin of the disease. The clinical evolution clinched the diagnosis.