Real world analysis of high-cut-off (HCO) hemodialysis with bortezomib-based backbone therapy in patients with multiple myeloma and acute kidney injury.

BACKGROUND: In patients with multiple myeloma (MM) free light chain-induced cast nephropathy is a serious complication associated with poor survival. High-cut-off (HCO) hemodialysis can reduce the amount of serum free light chains (sFLC), but data on its impact on clinical outcome is limited and contradictory. To gain further insights we collected real world data from two major myeloma and nephrology centers in Austria and the Czech Republic. METHODS: Sixty-one patients with MM and acute kidney injury, who were treated between 2011 and 2019 with HCO hemodialysis and bortezomib-based MM therapy, were analyzed. RESULTS: The median number of HCO hemodialysis sessions was 11 (range 1-42). Median glomerular filtration rate at diagnosis was 7 ± 4.2 ml/min/1.73m2. sFLC after the first HCO hemodialysis decreased by 66.5% and by 89.2% at day 18. At 3 and 6 months, 26 (42.6%) and 30 (49.2%) of patients became dialysis-independent. CONCLUSION: The widely used strategy combining HCO hemodialysis and bortezomib-based antimyeloma treatment is dissatisfactory for half of the patients undergoing it and clearly in need of improvement.

The benefit of PET/CT in the diagnosis and treatment of esophageal cancer.

INTRODUCTION: To evaluate the significance of PET/CT for the initial staging of esophageal cancer with emphasis on metastatic lymph node affection and detection of distant metastases. Furthermore, the aim of the work was to analyze the significance of PET/CT examination when evaluating the effect of neoadjuvant therapy. METHODS: A set of 354 patients with esophageal cancer treated at the 1st Department of Surgery, University Hospital Olomouc and Medical Faculty at Palacky University in Olomouc between the years 20062012 were analyzed in a prospective study. The initial PET/CT examination was performed in 349 patients. We analyzed the benefit of this examination in regard to disease staging and based on the result, therapeutic strategy was determined. The initial PET/CT showed varying degrees of disease generalization in 102 patients, these patients were indicated for palliative or symptomatic therapy. In 247 patients, the disease was limited only to the esophagus and /or regional lymph nodes. After considering the patients overall condition and taking into account the wishes of the patient, 188 patients were indicated for neoadjuvant chemoradiotherapy (CRT); 32 patients did not complete this treatment. In 156 patients a follow-up PET/CT scan was performed after an average of 8.4 weeks following completion of neoadjuvant therapy. Based on this examination, a complete response- CR, was observed in 38 patients (24.4%), regression of the tumor in 89 (57.0%), stationary findings were seen in 10 (6.4%), and progression in 19 (12.2%). Ninety-seven patients were indicated for surgical resection; however, esophagectomy was only possible in 85 patients, in the remaining 12 patients only an explorative laparotomy was performed due to disease progression. RESULTS: The initial PET/CT examination performed in 349 patients correctly described the extent of the disease in accordance with the histologically confirmed diagnosis in virtually all patients. A false positive result was seen in only 5 patients (1.43%). When evaluating the effect of neoadjuvant therapy, the patients were divided into groups based on the findings of the follow-up PET/CT after neoadjuvant therapy and their overall survival was evaluated. A significant difference (p=0.0004) in survival was observed between the groups based on the different reactions to neoadjuvant therapy (CR (n=38), regression (n=89), stationary findings (n=10), progression (n=19)) without taking into account the following treatment the patient received after neoadjuvant therapy. Patients who had a better response to neoadjuvant therapy had better survival results. There was also a significant difference in survival between the group of patients who completed neoadjuvant therapy and underwent radical surgical resection (n=85) versus those patients who completed neoadjuvant therapy but did not undergo subsequent surgery (n=59). The operated group had a significantly higher overall survival (p=0.003). The longest mean survival, 38.6 months (median 29.0 months), was achieved by the group of patients who completed neoadjuvant therapy, showed a complete response on the follow-up PET/CT, and underwent surgical resection. However, a significant difference was not observed (p=0.587) between the groups who underwent surgical resection and whose follow-up PET/CT results differed (regression or stationary findings). To date, the number of cases in the individual groups is not great enough to consider the obtained results conclusive, and we will continue to include more patients into the study and continue with the analysis. CONCLUSION: The work documents the significance and benefit of PET/CT in the initial staging of esophageal cancer, especially in detecting metastatic disease- positive lymph nodes as well as distant metastases. PET/CT has great importance in determining therapeutic strategy. Furthermore, the significance of PET/CT in evaluating the effect of neoadjuvant therapy was also studied.Key words: esophageal cancer PET/CT neoadjuvant therapy esophagectomy.

Determining the extent and stage of disease in patients with newly diagnosed non-Hodgkin's lymphoma using 18F-FDG-PET/CT.

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (18F-FDG) combined with computed tomography (CT) represents a three-dimensional imaging method suitable for staging in patients with non-Hodgkin's lymphomas (NHLs). The aim of our prospective multicenter study was to assess the value of initial PET/CT as compared with CT and PET alone for determining the stage and extent of the disease. A total of 122 patients with newly diagnosed NHL were examined using PET/CT. Four patients with resected lymphoma lesion and negative PET/CT were therefore excluded from the study. Of the remaining 118 cases, a total of 117 (99%) were described as 18F-FDG-avid. When compared with PET/CT, CT and PET showed very good sensitivity of lymph node imaging (97% and 100%, respectively); the specificity, however, was significantly lower (66.7% and 94.4%, respectively; p=0.0001). When detecting organ lesions, the sensitivity of CT and PET was lower than that of PET/CT (92.5% and 96.3%, respectively; p=0.0001); specificity was significantly decreased in CT and a little lower in PET (59.5% and 91.9%; p=0.0001). When compared with CT alone, PET/CT changed staging of the disease in 11 patients (9%) and was able to detect a total of 82 discrepancies in 67 of the 117 patients (57%). In conclusion, PET/CT is a new standard in imaging the involvement of lymph nodes and extranodal organs in NHL patients regardless of their histopathological types. Both sensitivity and specificity of the examination are higher than those of CT as well as PET alone.

[18F-FDG PET/CT and 99mTc-MIBI scintigraphy in evaluation of patients with multiple myeloma and monoclonal gammopathy of unknown significance: comparison of methods]. / 8F-FDG PET/CT v diagnostice mnohocetného myelomu a monoklonální gamapatie nejistého významu: srovnání s 99mTc-MIBI scintigrafií.

BACKGROUNDS: Newer imaging modalities, such as 18F-FDG PET/CT and 99mTc-MIBI scintigraphy, have been recently introduced to assess the activity and extent of disease in patients with multiple myeloma (MM) and gammopathy of undetermined significance (MGUS). The aim of our study was to compare the impact of these imaging modalities in the evaluation of MM and MGUS patients. MATERIALS AND METHODS: A total of 101 patients with MM (81 patients) and MGUS (20 patients) were enrolled in the study (21 newly diagnosed and 44 relapsed patients with symptomatic MM, 16 with asymptomatic MM and 20 with MGUS). All patients were without therapy and underwent 18F-FDG PET/CT and 99mTc-MIBI scintigraphy within a maximum interval of 14 days. The scans were classified as normal (N), diffuse (D), and focal or combined (F-FD) pattern. RESULTS: There was no significant difference in the detection of newly diagnosed MM and relapsed patients between the compared methods. 18F-FDG PET/CT performed better than 99mTc-MIBI scintigraphy in the detection of focal lesions (p < 0.039), whereas 99mTc-MIBI scintigraphy was superior in the visualization of diffuse disease (p = 0.042). 18F-FDG PET/CT visualised significantly more focal lesions than 99mTc-MIBI scintigraphy (p = 0.002), both generally in the cohort and when comparing the number of focal lesions per patient. Both the imaging modalities singly or in combination influenced the subsequent clinical management in 17% of patients. In our study, 18F-FDG PET/CT predicted asymptomatic MM and MGUS transformation into more aggressive forms with the necessity to start therapy more often than 99mTc-MIBI scintigraphy. CONCLUSION: 18F-FDG PET/CT appeared to be a better imaging technique than 99mTc-MIBI scintigraphy in the detection of focal lesions in patients with symptomatic MM. 99mTc-MIBI was superior in the visualization of diffuse disease. On the other hand, despite its limited capacity in detecting focal lesions, 99mTc-MIBI scintigraphy still remains the most rapid and inexpensive technique for whole-body evaluation and may be an alternative option when a PET/CT facility is not available.

High-dose therapy and autologous stem cell transplantation in patients with diffuse large B-cell lymphoma in first complete or partial remission.

Improved survival has been observed in poor-risk diffuse large B-cell lymphoma (DLBCL) patients treated with high-dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) in first complete remission. Retrospective studies have suggested that HDT with ASCT can improve survival also in partial responders but some doubts about the advantage of intensive therapy in such patients still remain. We evaluated retrospectively the results of HDT and ASCT in 55 patients with confirmed DLBCL treated between May 1999 and July 2006. Thirty-six patients (65%) showed partial remission (PR) and 19 patients (35%) reached complete remission (CR) after induction treatment with (44%) or without (56%) concomitant rituximab (R) immunotherapy. After HDT and ASCT, 69% of patients fulfilled the criteria of CR, 22% had unconfirmed CR (CRu), 7% remained in PR and 1 patient (2%) relapsed. Twenty patients in PR after the induction treatment reached CR after ASCT, 12 other PR patients achieved CRu. The 5-year event-free survival (EFS) of the 55 transplanted patients was 76% (95% confidence interval /CI/, 63% to 89%) and the 5-year overall survival (OS) was 85% (95% CI, 73% to 97%). The EFS and OS rates differed significantly only between patients younger than 40 years and older groups (p=0.022 and p=0.046, respectively). On univariate analysis of prognostic factors, EFS and OS were not affected by any of the following: age, sex, stage, subtype of DLBCL, initial lactate dehydrogenase, beta-2-microglobulin and serum thymidine kinase levels, International Prognostic Index (IPI) and age-adjusted IPI scores, induction treatment with or without rituximab and type of primary therapeutic response (CR vs PR). These results show that first-line HDT and ASCT for adults up to the age of 65 years with poor-risk DLBCL is a feasible and effective treatment option even in the era of R-chemotherapy in CR as well as for patients in PR.

[Imaging methods in diagnosis and monitoring of multiple myeloma]. / Zobrazovací metody v diagnostice a sledování mnohocetného myelomu.

Imaging methods (IM) are important for both the diagnosis and monitoring of the treatment of multiple myeloma (MM). The report discusses radiological IM as well as methods of nuclear medicine. Hole-body screening using simple X-ray pictures is still used in all newly diagnosed cases of the disease, though its validity is significantly higher in chronic forms and primarily in the diagnostics of vertebral compressions. Computer tomography (CT) ideally scans the destructive changes on the compact bone, but it is not very good in showing bone marrow. It is however, invaluable in targeted biopsy or vertebroplasty. Magnetic resonance imaging (MRI) currently has a decisive role mainly in early diagnostics, thanks to its ability to show early changes in the bone marrow. Of critical importance is also indication for MRI in the imaging of structures of the spinal canal and in evidencing epidural propagation of tumour mass. A disadvantage of the method is its inability to show the effects of the treatment immediately following its administration. Contraindications of MRI are also addressed. Among the methods of nuclear medicine, the most important are hole-body 99mTc-MIBI scintigraphy and full-body FDG-PET/CT examinations. 99mTc-MIBI is a sensitive indicator of the biological activity of the disease. It shows the damage to the skeleton caused by the tumour before anatomic changes appear. It reliably differentiates MM remissions from relapses and can be used to determine the optimal position for biopsy puncture. The method is good for monitoring the course of the disease and forecasting the results of the treatment. Its disadvantage is its limited resolution capacity, therefore focal lesions smaller than 10 mm usually escape scintigraphic detection. Similarly to 99mTc-MIBI scintigraphy, FDG-PET/CT examination shows tumorous affection of the skeleton before structural changes appear. It is a highly effective method especially in detecting skeletal damage and extramedullar exhibitions of the disease. The sensitivity and specificity of FDG-PET/CT examination is increased by simultaneous CT examination which is made possible by new generation hybrid instruments. The method, together with 99mTc-MIBI scintigraphy, is very important in the detection of hypo/non-secretional forms of MM. It provides "real time" information on the response of the tumour to treatment and reliably detects the relapse and the remission. An overview is given of recommended examination algorithms for acute and chronic forms and for the monitoring of the treatment of MM, as well as of the importance of all IM for clinical practice.

Scintigraphy using (99m)Tc-MIBI (sestamibi), a sensitive parameter of activity of multiple myeloma.

Technetium-99m methoxyisobutylisonitrile ((99m)Tc-MIBI) has been shown to be useful in identifying several types of tumors, such as breast, brain, thyroid gland, malignant lymphomas and multiple myeloma. In this study, 102 patients with multiple myeloma (MM) and 32 patients with monoclonal gammopathy of undetermined significance (MGUS) had been evaluated for correlation between (99m)Tc-MIBI and biochemical and hematological markers of activity of the disease. Significant statistical correlation was found between summary score (SS) of (99m)Tc-MIBI scintigrams and beta2-microglobulin (p<0.001), monoclonal immunoglobulin level MIG (p<0.001), serum thymidinekinase - sTK (p<0.001), CRP (p<0.05) and cross-linked carboxyterminal telopeptide of type I collagen - ICTP (p<0.05) bone marrow plasmocytosis-BMPc (p<0.001) and hemoglobin Hb (p<0.001). All 32 patients with MGUS had physiological activity of (99m)Tc-MIBI scintigrams. Technetium-99m methoxyisobutylisonitrile is a useful indicator of activity of MM and helps in differentiating between multiple myeloma and monoclonal gammopathy of undetermined significance.

[Validity of bone scintigraphy for the diagnosis of periprosthetic complications in hydroxyapatite-coated total hip arthroplasty]. / Prínos trífázové kostní scintigrafie k diagnostice periprotetických komplikací u protézy s hydroxyapatitovým povrchem.

PURPOSE OF THE STUDY: To evaluate the efficacy and usefulness of 99Tc-MDP bone scans for the diagnosis of complications associated with hydroxyapatite- coated total hip prostheses. MATERIAL AND METHODS: 99Tc-MDP bone scans of 42 hips were taken before revision surgery in 41 patients with ABG 1 prostheses. Of these, 26 patients (27 hips) were included in our study on the basis of the following criteria: at least 23 months between the index surgery and scintigraphic examination and the availability of good quality bone scans. The average patients' age at the time of index and revision operations was 45.3 years (range, 32-57; SD, 6.02) and 50.2 years (36-61; SD, 6.01), respectively. The average time between the index surgery and bone scintigraphy was 50.3 months (23-84; SD, 15.9). Two experienced specialists in nuclear medicine, who were unaware of any clinical conclusions, participated in the study. RESULTS: Pre- and intra-operative findings showed aseptic loosening in three cups (3/27, 11 %) and one stem (1/27, 4 %). Four hips were suspected to have an infection on the basis of the positive results of intra-operative culture. In the diagnosis of aseptic loosening, sensitivity, specificity, accuracy, and positive and negative predictive values of bone scintigraphy were 100 %, 57 %, 62 %, 23 %, and 100 %, respectively, for the ABG I cup and 100 %, 52 %, 54 %, 8 %, and 100 %, respectively, for the ABG I stem. These characteristics were 67 %, 96 %, 93 %, 67 %, and 96 %, respectively, for the ABG I cup, when plain X-ray was used for evaluation of aseptic loosening. Specificity, accuracy and negative predictive value of plain X-ray for ABG I stem aseptic loosening were 100 %, 96 %, and 96 %. Bone scintigraphy gave one false positive result of sepsis; on the other hand, none of the four hips with positive intraoperative culture was diagnosed as septic. DISCUSSION: The fact that 99Tc-MDP bone scintigraphy as a method of diagnosing periprosthetic complications has a high sensitivity and a relatively low specificity has often been discussed in the literature. Currently, there are only a few studies on bone scintigraphy investigations of hydroxyapatite-coated prostheses. Some authors report that a slight increase in peri-prosthetic radionuclide activity may persist for up to 8 years which can explain the problematic accuracy of the technique. CONCLUSIONS: 99Tc-MDP bone scintigraphy is an intermediate useful tool for detecting complications of total hip arthroplasty with hydroxyapatite- coating. A negative bone scan almost always suggested the absence of aseptic loosening. However, the value of a positive result was regarded as controversial for the diagnosis of both aseptic and septic complications.

The accuracy of myocardial perfusion SPECT imaging in the evaluation of coronary artery disease in women and men.

BACKGROUND: The purpose of this study is to compare sensitivity, specificity and accuracy of myocardial perfusion SPECT for the detection of coronary artery disease (CAD) in women and men. MATERIAL AND METHODS: 588 patients (455 males and 133 females, 273 after a previous myocardial infarction) underwent stress myocardial perfusion SPECT. The accuracy of myocardial perfusion SPECT was proved by coronary angiography (stenosis > 50% was considered as a CAD). RESULTS: The sensitivity of SPECT was slightly higher, but statistically not significant, in men than in women (94% versus 91%, p > 0.05). The specificity was higher in women than in men (93% versus 82%), but this difference was not statistically significant either (p > 0.05). The accuracy of SPECT was the same for both sexes (92%). In angiographically verified group of patients the selection bias was obvious--patients with CAD dominated (74%) and the fraction of patients with CAD in men's group (83%) was significantly higher than in women's group (50%), p < 0.05. CONCLUSIONS: No significant difference was revealed in the accuracy of myocardial perfusion SPECT in men and women. Our results are in accordance with the prevailing opinion in literature that discovered differences in sensitivity, specificity and diagnostic accuracy are usually not statistically significant or that they can be explained by the selection bias of patients in angiographically verified groups (significantly higher fraction of patients with CAD in men's group).

[Prognostic significance of stress tomographic scintigraphy of myocardial perfusion in diabetic patients]. / Prognostický význam zátezové tomografické scintigrafie myokardiální perfuze u diabetických pacientu.

OBJECTIVE: To assess the prognostic value of SPECT in patients with diabetes (DM) and without DM. METHOD: A total of 366 patients (104 women, 262 men) were examined by T1 +/- 201 or Tc-99m-MIBI SPECT of the myocardium. DM was recorded in 149 patients, 217 patients did not suffer from DM. The SPECT findings were classified as normal and abnormal perfusion (fixed or reversible perfusion defect). A serious cardiac event was defined as sudden cardiac death or non-fatal myocardial infarction. Also angina pectoris requiring revascularization was recorded. RESULTS: During the average investigation period of 24 +/- 7 months we recorded in 147 patients with a normal load perfusion only one non-fatal myocardial infarction and the risk of a serious cardiac event was low: 0.3% per annum in the whole group. A significantly higher incidence of a severe cardiac event, 5.9% per year, was recorded in 219 patients with an abnormal finding on SPECT (10 deaths and 16 non-fatal myocardial infarctions, P < 0.01). On comparison of the frequency of serious cardiac events in groups of patients with and without DM no significant difference was found as regards normal load perfusion of the heart muscle (1.1% vs. 0%, P = NS) even in patients with an abnormal SPECT finding (5.8% vs. 6.1, P = NS). CONCLUSION: SPECT myocardial perfusion makes it possible to stratify the risk in patients with DM similarly as proved previously in non-selected groups. Similarly as in patients without DM normal perfusion in diabetic patients predicts a benign prognosis.

Prognostic value of myocardial perfusion tomographic imaging in patients after percutaneous transluminal coronary angioplasty.

PURPOSE: The authors assessed the prognostic value of stress myocardial perfusion tomographic imaging (SPECT) in patients with recurrent angina or inconclusive results of exercise electrocardiographic tests after successful percutaneous transluminal coronary angioplasty (PTCA). MATERIALS AND METHODS: After PTCA, 70 patients (54 men, 16 women; 41 after myocardial infarction; mean age, 56 +/- 9 years) underwent TI-201 or Tc-99m sestamibi SPECT studies. SPECT patterns were divided into normal (n = 25), fixed defects (n = 15), and reversible or combined fixed plus reversible defects (n = 30). A cardiac event was defined as either cardiac death, nonfatal myocardial infarction, or unstable angina requiring further revascularization. RESULTS: During an average follow-up of 25 +/- 10 months, two patients had severe outcomes (one cardiac death and one nonfatal myocardial infarction), and revascularization was required in 13 patients. In patients with normal SPECT or fixed defects, the annual event rate was low (1.2%), with only one revascularization. In patients with reversible or combined defects, the annual event rate was significantly greater (22.4%; chi square = 17.32, P = 0.00003). CONCLUSIONS: Normal perfusion or fixed defects predict a benign prognosis in patients after successful PTCA. The presence of stress-induced reversible defects appears to be the best predictor of future cardiac events.

Medical radiation exposure of the Czech Republic paediatric population due to diagnostic nuclear medicine.

BACKGROUND: The information on the results of the survey of collective effective dose SE to children in the Czech Republic (CR) due to nuclear medicine examinations performed during the one-year period July 1995-June 1996. METHODS: The estimate of SE was based on the annual frequency of nuclear medicine procedures and the type and amount of administered radiopharmaceuticals provided by the General Health Insurance Company covering 75% of the CR population. RESULTS: In the period considered, 15,281 examinations of children younger than 18 years were performed, which represented 7.5% of total nuclear medicine examinations in the CR. The annual SE 43.8 man Sv formed 5.1% of the collective effective dose to all patients examined by nuclear medicine procedures in the CR. The contributions of procedures in various body systems of children to the annual SE: urinary tract 32.8%, bone 30.4%, brain 12.8 %, cardiovascular 6.4%, GIT 6.0%, thyroid 4.4%, lungs 3.0%, other 4.2%. In comparison with a similar survey performed in the CR in 1987 (based on a questionnaire) there was an increase in SE to children younger than 15 years by a factor of 2.8, mainly due to the expansion of kidney and bone investigations. CONCLUSIONS: The mean effective dose per exam to children younger than 15 years was 60% of that for adults, which was in agreement with the requirement that the radiation burden of children should not exceed that of adults. The use of data from the Insurance Company for regular conducting of such surveys appeared to be not as cumbersome and time-consuming as questionnaire surveys.

[Use of radiopharmaceuticals, radiation burden and radiation risks in examination procedures in nuclear medicine]. / Aplikované aktivity radiofarmak, radiacní zátez a radiacní riziko vysetrovacích postupu v nukleární medicíne.

Consistent with the worldwide development of nuclear medicine, in the Czech Republic in 1987 to 1996 partly the spectrum of used radiopharmaceutical preparations and their ratio changed. In the majority of radiopharmaceutical preparations the mean administered activity increased by 20 to 80% and the range of activities administered in different departments diminished somewhat. Adherence to principles of radiation protection of patients is assisted by guidelines of administered activities of radiopharmaceutical preparations laid down in new regulations on radiation protection valid in the CR from the middle of 1997. The radiation burden associated with the majority of examinations in nuclear medicine expressed as the effective dose is comparable with the radiation burden of radiodiagnostic examinations, only after administration of preparations with 131I, 201Tl, 67Ga and 111In it is markedly higher. Based on knowledge of the effective dose it may be concluded that the lifetime extra risk of a fatal tumour due to administration of radiopharmaceutical preparations is by two to three orders lower than the lifetime risk of spontaneous development of fatal tumours. A special feature of radiation risk is its hypothetical character--it is frequently projected into the distant future of human life, contrary to immediate non-radiation risks of some medical procedures and risks in the living environment which frequently are higher. Any examination using ionising radiation can be made only if the expected health benefit for the patient is significantly greater than the radiation risk. Excessive fear of radiation risk should not lead to refusal of justified examinations with possible subsequent serious health damage for the patient.

Hepatic perfusion changes in patients with cirrhosis indices of hepatic arterial blood flow.

PURPOSE: This study used radionuclide angiography to evaluate semiquantitatively the hepatic arterial blood flow changes associated with cirrhosis. METHODS: The parameters of net arterial hepatic perfusion were estimated by analysis of first-pass flow studies in 11 control participants and in 15 patients with cirrhosis (Child-Pugh classification B-C). Hepatic, renal, and splenic time-activity curves were generated, normalized per pixel, and corrected for background. The rate of hepatic arterial blood flow was compared with the reference kidney and spleen perfusion using the hepatorenal and hepatolienal perfusion indices, respectively. These indices were defined as: PI = area under hepatic curve limited by time of the renal (splenic) curve peak/area under renal (splenic) curve to its peak RESULTS: The values of both these perfusion indices are significantly greater in the patients with cirrhosis than in controls (hepatorenal perfusion index, P < 0.01; hepatolienal perfusion index, P < 0.05). The values of the hepatic perfusion index (the ratio of the arterial to the total liver blood flow), which were also calculated, were elevated in the patients with cirrhosis (P < 0.01). CONCLUSIONS: The results confirm that the net hepatic arterial blood flow is increased in patients with cirrhosis. Radionuclide angiography accompanied by calculation of arterial perfusion indices may provide semiquantitative parameters of net hepatic arterial blood flow.

[Myocardial perfusion tomography imaging in patients without prior myocardial infarction--comparison between 201Tl, 99mTc-tetrofosmin and dual-isotope protocol (rest 201Tl/stress 99mTc-tetrofosmin)]. / Tomografické zobrazení myokardiální perfuze u pacientu bez infarktu myokardu--srovnání 201Tl s 99mTc-tetrofosminem a dual-izotopovým protokolem (klid 201Tl/zátez 99mTc-tetrofosmin).

The authors compared retrospectively the diagnostic accuracy of three protocols--201Tl stress-redistribution, 2-day 99mTc-tetrofosmin and the dual-isotope protocol (rest 201Tl/stress99m Tc-tetrofosmin)--for the detection of ischaemic heart disease (IHD) in a total of 115 patients without previous myocardial infarction (IM). 201Tl protocol (group A) was used to examine 43 patients, incl. 15 women, mean age 51 years (38-69 years). The 2-day 99m Tc-tetrofosmin protocol was used to examine 39 patients incl. 12 women, mean age 49 years (30-71 years). The dual-isotope protocol was used in 33 patients, incl. 8 women, mean age 52 years (31-69 years). In all patients coronarography was performed, stenosis of the artery >50% was considered significant for IHD. The sensitivity of the dual-isotope protocol was 95% and 96% resp. and 92% in the 2-day tetrofosmin and 201Tl protocol, (p>0.05). The specificity of the dual-isotope protocol was 82% and 89% resp. and 88% in the 201Tl and 2-day tetrofosmin protocol, (p >0.05). The diagnostic accuracy was 91% in the dualisotope and 201Tl protocol and 92% in the 2-day protocol (p>0.05). No significant difference was revealed in the sensitivity, specificity and diagnostic accuracy for the detection of IHD between different protocols in patients without previous IM.

[Correlation of SPECT myocardial stress scintigraphy with coronary angiography]. / Korelace zátezové perfuzní scintigrafie myokardu SPECT s koronarografickými nálezy.

The sensitivity and specificity of a myocardial perfusion single-photon emission tomography (SPECT) for the detection of the coronary artery disease (CAD) was investigated. As a gold standard the coronary angiography was used--the stenosis of the artery by 50% and more was considered as significant for CAD. After performing SPECT studies patients were examined by coronary angiography according to the attending physician's judgement. In the retrospectively created group of 123 subjects (94 males and 29 females, mean age 53 years, range 30-69 years) 55 patients underwent myocardial infarction (MI). The stress was performed using a bicycle ergometer or, in case of patient's inability, an intravenous dipyridamole infusion. Before december 1995 201T1 was used in all patients, after this date only in patients with prior MI with regard to the advantage of this radionuclide for the detection of the ischemic but viable myocardium. Other patients were administered 99mTc-tetrofosmin. In our group of patients we found the high sensitivity of myocardial SPECT of 94.5% 86 (from 91), specificity of 84.4% (27 from 32) corresponding to usually values and the high diagnostic accuracy of 91.9% (113 from 123). Specificity can be impaired by marked attentuation of gamma-rays by overlying soft-tissue structures such as the breast or diaphragm. The artificial imaging of the inferior wall due to the infradiaphragmatic structures represents the most serious problem-there were four false positive findings in our group; further ones in our 99mTc-tetrofosmin studies were avoided by the routine use of the prone position recommended in the literature. The validity of SPECT myocardial perfusion findings should be verified by coronary angiography; however, one must be aware of some questionable points inherent in this comparison.

[Hyperthyroidism caused by TSH producing hypophyseal adenoma]. / Hyperthyreose durch ein TSH-produzierendes Hypophysenadenom.

Thyrotropin (TSH-)producing adenomas of the anterior pituitary gland are the least frequently encountered ones and constitute a very rare cause of hyperthyroidism. The case is presented of a 58 year old male patient with a well-known history of hyperthyroidism over a period of at least 9 years growing goiter. Despite different forms of medical treatment he presented a constant clinical pattern consisting of restlessness and paroxysmal tachycardial atrial fibrillation. Laboratory findings revealed elevated levels of circulating thyroid hormones despite inadequately high levels of TSH. MRI scan revealed an adenoma of the pituitary measuring 9 mm in diameter. After microsurgery, consisting of transphenoidal resection of the tumor, the patient recorded no clinical symptoms. Histological examination revealed positive immunohistochemical staining, with antibodies to TSH, but a negative reaction against the GH, PRL, FSH, LH and ACTH hormone antibodies. Moreover, the levels of circulating hormones (GH, PRL, FSH, LH and ACTH) were normal. TSH-alpha subunits were not elevated. Before the correct diagnosis was reached, this patient was treated for nine years with antithyroid drugs. Five months after the operation the patient showed normal values of circulating thyroid hormones and TSH and thus no thyroid-specific medication was necessary.