Recurrent hyperparathyroidism due to parathyroid and pulmonary tumors showing features of parathyroid adenoma.

We report on a case of recurrent primary hyperparathyroidism possibly caused by parathyroid adenocarcinoma metastasizing to the lung. A 46-year-old woman with a history of parathyroid adenoma, which was extirpated 8 years ago, presented with symptoms of primary hyperparathyroidism, and was found to have a parathyroid and a lung nodule in radiographic assessments. Resections of the tumors in the parathyroid gland as well as the lung were required to improve her condition, and in pathology, both tumors demonstrated benign features consistent with adenoma. However, from the perspective of the clinical course and location of the tumors, we deduced that the tumors were malignant despite being identified as benign by conventional pathological examination. The integration of information based on clinical status and imaging studies is essential to evaluate the malignant potential of tumors if a patient with hyperparathyroidism has tumors located both inside and outside of the parathyroid gland.

Primary ovarian leiomyoma with predominant cystic change.

Ovarian leiomyoma is a rare benign tumor, seen mostly in women 20-65 years old. The case of a 51-year-old woman with a large tumor in the pelvic cavity is reported. The dominant feature of the tumor was its cystic component, but an irregular, solid component was recognized along the dorsal margin of the tumor. The latter area showed signal intensity as low as muscle on T2-weighted images and significant contrast enhancement; however, it did not show restricted diffusion, which implied that it was benign. The large tumor was resected because malignancy could not be ruled out, and it was pathologically diagnosed as ovarian leiomyoma with predominant necrosis. When a low-intensity component without malignant features is seen on magnetic resonance imaging, leiomyoma should be included in the differential diagnosis despite its rare occurrence in the ovary.

Selective venous sampling supports localization of adenoma in primary hyperparathyroidism.

BACKGROUND: Selective venous sampling (SVS) is an invasive localization study for persistent or recurrent hyperparathyroidism. PURPOSE: To assess the role of SVS in addition to non-invasive imaging for primary hyperparathyroidism (pHPT). MATERIAL AND METHODS: This study was approved by the institutional review board and included 14 patients who underwent SVS and subsequent parathyroidectomy between January 2014 and April 2017 following a clinical diagnosis of pHPT. All patients underwent pre-SVS non-invasive imaging, including ultrasound, computed tomography (CT), and 99mTc-MIBI scintigraphy, and sensitivity was assessed using the operative and pathological findings. RESULTS: In all but one case, a single parathyroid adenoma was responsible for the pHPT; the remaining case exhibited a chemical response following surgical removal of parathyroid tissue. The sensitivity (%) for ultrasound, CT, 99mTc-MIBI scintigraphy, and SVS was 76.9, 84.6, 69.2, and 76.9, respectively. SVS yielded positive results in four patients with discordant results and one patient with non-detectable results on imaging. In seven patients, a significant increase in the intact parathyroid hormone level was recognized only in the thyroid veins. The procedure time was in the range of 52-183 min (median = 89.5 min). CONCLUSION: The addition of SVS to a non-invasive imaging study would be helpful to locate the responsible lesion of pHPT with discordant or non-detectable results on imaging for initial surgical treatment as well.

Selective venous sampling for primary hyperparathyroidism: how to perform an examination and interpret the results with reference to thyroid vein anatomy.

Primary hyperparathyroidism (pHPT) causes hypercalcemia. The treatment for pHPT is surgical dissection of the hyperfunctioning parathyroid gland. Lower rates of hypocalcemia and recurrent laryngeal nerve injury imply that minimally invasive parathyroidectomy (MIP) is safer than bilateral neck resection. Current trends in MIP use can be inferred only by reference to preoperative localization studies. Noninvasive imaging studies (typically preoperative localization studies) show good detection rates of hyperfunctioning glands; however, there have also been cases of nonlocalization or discordant results. Selective venous sampling (SVS) is an invasive localization method for detecting elevated intact parathyroid hormone in the thyroid and/or internal jugular and brachiocephalic veins. SVS was developed mainly for postoperative patients with persistent or recurrent pHPT; however, SVS could also be useful before initial operations due to its high sensitivity to pHPT. Currently, SVS is generally indicated for recurrent HPT, and for cases with negative imaging study results for HPT or discordant results. Multi-detector row helical CT is useful for imaging the anatomy of the jugular and thyroid veins. Knowledge of the thyroid vein anatomy enables the creation of sampling points in the internal jugular and brachiocephalic veins for catheterization of the thyroid veins and venous anastomoses.

Anatomical variation of thyroid veins on contrast-enhanced multi-detector row computed tomography.

OBJECTIVE: The objective of this study was to clarify the anatomical variation of thyroid veins into the systemic vein using contrast-enhanced multi-detector row computed tomography (MDCT). DESIGN AND METHODS: The subjects were 80 patients (34 males and 46 females; mean age, 50.1 years; age range, 15-92 years) with neck diseases who underwent MDCT. The number and location of inflow points of the thyroid veins into the systemic vein, and the length from the junction of bilateral brachiocephalic veins to the orifice of inferior thyroid vein were investigated by reviewing the axial and coronal images. RESULTS: All superior thyroid veins were detected. Right and left middle thyroid veins were identified in 39 and 29 patients, respectively. Right inferior thyroid veins, left inferior thyroid veins, and common trunks were detected in 43, 46, and 39 patients, respectively; in five patients, two left thyroid veins were identified. All left inferior thyroid veins and 34 common trunks flowed into the innominate vein, while right ones had some variations in inflow sites. Mean lengths were 3.01±1.30 cm (range, 0.5-6.19) and 2.04±0.91 cm (0.5-4.4) in the left inferior thyroid vein and common trunk, and 1.96±1.05 cm (0.81-4.8) and 1.65±0.69 cm (0.63-2.94) in the right one flowing into the right internal jugular vein and the innominate vein, respectively. CONCLUSIONS: The numbers and orifices of thyroid veins were identified at high rates on contrast-enhanced MDCT. This strategy can provide anatomical information before selective venous sampling for measurements of parathyroid hormone.

Comparison of the diagnostic performance of H/M ratio between early and delayed phases for Lewy body disease.

OBJECTIVES: The aim of the study was to compare the diagnostic performance of early-phase I-metaiodobenzylguanidine (MIBG) scintigraphy with that of delayed-phase imaging in Lewy body disease (LBD). METHODS: A retrospective cohort study of ¹²³I-MIBG scintigraphy was carried out in 192 patients who were suspected of having LBD. Clinical diagnosis was obtained using the UK Parkinson's Disease Brain Bank Criteria in some cases or the third report of the Dementia with Lewy bodies Consortium in others. The participants consisted of 81 patients with LBD and 111 nondiseased patients. An injection of 111 MBq of ¹²³I-MIBG was used. Planar images were obtained in an early phase and again in a delayed phase and the heart to mediastinum count ratio was calculated for both phases. Diagnostic performance was compared using a receiver-operator characteristic analysis. The cutoff value was chosen to maximize the Youden index. The sensitivity and specificity of each phase were calculated from the optimal cutoff value. RESULTS: The heart to mediastinum ratio of the LBD group (median 1.8 and 1.45 for early and delayed phases, respectively) was significantly lower than that of the nondiseased group (median 2.93 and 3.18 for early and delayed phases, respectively). The area under the receiver-operating characteristic curve was not significantly different between the early and delayed phases (0.871 vs. 0.893; P=0.0914). Sensitivity and specificity were 80.2 and 91% for early-phase imaging (cutoff value at 2.28) and 81.5 and 95.5% (cutoff value at 1.91) for delayed-phase imaging, respectively. CONCLUSION: The diagnostic performance of ¹²³I-MIBG scintigraphy was not significantly different between early-phase and delayed-phase imaging.

Successful natural interferon-ß plus ribavirin therapy in a chronic hepatitis C patient after discontinuation of interferon-α treatment due to arrhythmia and interstitial pneumonia.

A 71-year-old female patient with hepatitis C virus genotype 1 had previously discontinued interferon (IFN)-α plus ribavirin therapy, pegylated IFN-α (pegIFN-α) monotherapy, and natural IFN-α monotherapy because of arrhythmia, interstitial pneumonia, and severe neurovegetative symptoms. She subsequently completed 72 weeks of natural IFN-ß plus ribavirin therapy without remarkable adverse effects and achieved a sustained viral response, suggesting differences in the pharmacological properties and biological effects of IFN-α and IFN-ß. Thus, natural IFN-ß plus ribavirin therapy may be a treatment option for patients with poor tolerance to IFN-α or pegIFN-α treatments.

Pelvic arteriovenous malformation treated by transarterial glue embolisation combining proximal balloon occlusion and devascularisation of multiple feeding arteries.

We present a case of a 70-year-old man with abdominal aortic aneurysm and coincident pelvic arteriovenous malformation (AVM). Before the operation for the aneurysm, we embolised the pelvic AVM that had multiple feeding arteries and an aneurysmal-dilated draining vein. After decreasing the number of the feeding arteries by coil embolisation, an n-butyl-2-cyanoacrylate/lipiodol mixture (1:1) was injected into the prominent feeding artery and nidus with proximal balloon occlusion of the right internal iliac artery to decrease the flow to the nidus. The mixture (1:4-8) was also added for the finer feeding arteries that became apparent after the initial procedure to embolise the rest of the nidus. A follow-up study showed no contrast enhancement of the nidus and aneurysmal draining vein.