Parathyroid imaging by (18)F-fluorocholine PET/CT in patients with primary hyperparathyroidism and inconclusive conventional methods: clinico-pathological correlations.

(18)F-fluorocholine positron emission tomography/computed tomography (FCH) was performed after inconclusive neck ultrasound and (99)Tc-sestaMIBI SPECT (MIBI) scintigraphy in patients with primary hyperparathyroidism (PHPT) to localize abnormal parathyroid glands before surgery. The results were retrospectively evaluated and compared to postoperative histopathological findings. 13 patients with PHPT were enrolled (mean age 64.3 years, preoperative calcium 2.74 mmol/l and parathyroid hormone 114.6 ng/l). FCH localized hyperfunctioning parathyroid glands in 12 patients of 13 (per patient sensitivity 92 % and positive predictive value (PPV) 100 %). Fourteen parathyroid lesions (11 adenomas, 3 hyperplastic glands) were resected with a mean size of 11.9 mm (per lesion sensitivity 93 % and PPV 81 %). Four adenomas and one hyperplastic gland were composed of only chief cells, whereas five lesions contained both chief and oxyphil cells. In three patients an exclusively oxyphil adenoma was found, surprisingly with negative MIBI scintigraphy in spite of a high mitochondria content in the oxyphil parathyroid cells. 12 of 13 patients had thyroid disease. In our limited study sample, FCH correctly identified parathyroid adenomas and/or hyperplastic glands in 92 % of patients with previously inconclusive conventional imaging. Unlike MIBI, FCH successfully localized small, hyperplastic and multiple hyperfunctioning parathyroid glands, irrespective of their histopathological composition.

[Isolated Perfusion of the Upper Extremity with TNF-α - Double Venous Cannulation]. / Izolovaná perfuze horní koncetiny s TNF-α - dvojitá kanylace zilního systému.

BACKGROUND: The authors present a technical variation of the standard cannulation for cardiopulmonary bypass perfusion during hyperthermic isolated limb perfusion (ILP) procedures in selected patients with unresectable soft tissue sarcoma or malignant melanoma. PATIENTS: Of 55 ILP procedures performed at our institution since the procedure was established in 2009, nine were performed at the upper extremity. Standard single venous cannulation was used in five cases, and extended, double venous cannulation in the last four. The standard technique for brachial vein cannulation in a small compartment of the upper extremity entails a problematic and longer perfusion of the upper extremity. This is due to the lower flow rate in the venous system and relatively large surface area with respect to weight. We present a simple technique based on a "Y" cannulation of the venous system via the deep brachial vein and superficial venous system via the basilic vein, delivering a 20% increase in flow rate in the extracorporeal circulation. Faster heating of the upper extremity and a stable thermal environment throughout upper-extremity ILP are essential for successful treatment. CONCLUSION: Extended technique of venous cannulation for extracorporeal circulation setting, due to their advantages, became standard in the upper limb ILP procedure at our institution.Key words: isolated limb perfusion - malignant melanoma - soft tissue sarcoma - upper limb - extracorporeal circulation The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 8. 1. 2017Accepted: 15. 1. 2017.

Measurement of intact parathormone during operation for primary hyperparathyroidism.

In this prospective study, the role of the intact parathormone (iPHT) levels for the verification of pathologic parathyroid tissue removal during parathyroidectomy, was analyzed in 441 patients diagnosed with primary hyperparathyroidism. The level of intact parathormone was obtained before the initial incision (baseline level) and 10 minutes after the pathologic parathyroid gland removal (control value). In 80 % of cases, the decrease of intact parathormone was more than 50 % of the baseline level. The comparison of preoperative and postoperative intact parathormone levels can also be used as marker of parathyroid hyperplasia or persistent hyperparathyroidism. This method is necessary mainly for performance of focused, miniinvasive approaches as well as in reoperations. This method is of significant benefit in cases of negative preoperative examination methods. The determination of intact parathormone level increases the success of parathyroidectomy (Ref. 26).

[Hyperthermic Isolated Limb Perfusion Combined with Tasonermin - a Perfusion Leakage Monitoring Technique]. / Hypertermická izolovaná perfuze koncetin v kombinaci s tasonerminem - technika monitorování úniku perfuzátu.

BACKGROUND: Hyperthermic isolated limb perfusion is used to treat irresectable extremity malignancies. It is based on the following principle - the perfusion of the extremity is isolated from systemic circulation and connected to an extra-corporal circuit via which a very high concentration of a chemotherapeutic agent is administered into the blood compartment of the extremity. In some cases, treatment efficiency can be improved using tasonermin (a TNF-α agent). By itself, tasonermin can cause severe health complications in patients if leakage into systemic circulation results in a level that exceeds the maximally tolerated dose. Therefore, it is important to monitor for leakage during the whole operation. METHOD: Leakage monitoring was performed by a nuclear medicine method based on the measurement of activity of a gamma-emitting radiotracer detected by a scintillation probe located over the heart. An amount of radiotracer that resulted in a basal level of measured signal was first administered into the systemic circuit followed by the administration of a second, one order of magnitude higher amount of radiotracer into the perfusion circuit. Leakage, when it occurred, increased the count rate detected over the heart, and the mathematical relation between leakage level and count rate increase was derived. RESULTS: In our department, the method was tested and optimized during isolated limb perfusion without using a TNF-α agent. Then, accreditation for the use of TNF-α was granted. Since then, the method has been used to monitor leakage in all cases of isolated limb perfusion with TNF-α. All isolated limb perfusion operations with TNF-α passed without complications. The radiation burden was almost negligible for both the patient and medical staff. CONCLUSION: The method described in this report represents a reliable method for perfusion leakage monitoring when using TNF-α in our department.Key words: perfusion - isolated limb - TNF-α - leakage - monitoring - nuclear medicine - radiopharmaceuticalsThe authors declare they have no potential confl icts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 16. 6. 2016Accepted: 21. 6. 2016.

[Videothoracoscopic excision of mediastinal parathyroid adenoma in primary hyperparathyroidism]. / Videothorakoskopické odstranení mediastinálne ulozeného adenomu prístítného telíska pri primární hyperparathyreóze.

INTRODUCTION: Primary hyperparathyroidism is a disease caused by elevated secretion of parathyroid hormone from pathological parathyroid glands. After the diagnosis, the success of its surgical solution depends predominantly on surgical management and experience of the surgeons. A special group is formed by ectopic localizations of pathologically enlarged parathyroid glands in the mediastinum, which require a modified surgical approach. When the adenoma is deep in the mediastinum, sternotomy or thoracotomy is indicated; alternatively, a minimally invasive approach can be used - videothoracoscopic thymectomy. CASE REPORT: We present a case of a patient with normocalcemic recurrent primary hyperparathyroidism. This patient underwent a minimally invasive video-assisted thymectomy after scintigraphic confirmation of parathyroid adenoma in the mediastinum. CONCLUSION: The removal of parathyroid adenoma in the mediastinum using the videothoracoscopic method is safe. Compared to sternotomy, this method improves the postoperative period, reduces the length of stay and provides more comfort to patients. We recommend considering the videothoracoscopic method in cases where the pathologically enlarged parathyroid gland is localized in the inferior and anterior mediastinum. KEY WORDS: primary hyperparathyroidism adenoma of glandula parathyroidea - mediastinum miniinvasive.

Biochemical Testing After Pheochromocytoma Removal: How Early?

Pheochromocytomas are catecholamine-producing tumors with typical clinical presentation. Tumor resection is considered as an appropriate treatment strategy. Due to its unpredictable clinical behavior, biochemical testing is mandatory to confirm the success of tumor removal after surgery. The aim of the study was to investigate the feasibility of a shorter interval of postoperative testing (earlier than the recommended 2-4 weeks according to recently published Guidelines). We investigated 81 patients with pheochromocytoma before and after surgery. Postoperative examination was performed of stable subjects after their transport from the surgical to the internal ward (7.1±2.2 days after surgery). Plasma metanephrines were used for the diagnosis of pheochromocytoma and confirmation of successful tumor removal. All subjects with pheochromocytoma had markedly elevated plasma metanephrines before surgery. No correlation between postoperative interval (the shortest being 3 days) and plasma metanephrine levels was found. Postoperative plasma metanephrine levels did not differ significantly from those taken at the one-year follow-up. In conclusion, we have shown that early postoperative diagnostic workup of subjects with pheochromocytoma is possible and may thus simplify early postoperative management of this clinical condition.

[Ectopic parathyroid glands. Imaging methods and surgical access]. / Ektopická parathyreoidea, zobrazovací metody a chirurgické prístupy.

We discuss the benefits of imaging methods in localizing ectopic parathyroid glands in patients with primary hyperparathyroidism. The ectopic localizations are discussed within the context of the orthotopic norm. In the sample of 123 patients, a 23% rate of ectopic parathyroid glands was detected. Three selected case studies are presented, supporting the benefit of SPECT/CT imaging in terms of surgical access strategy selection.

The role of 99mTc-MIBI SPECT/low dose CT with 3D subtraction in patients with secondary hyperparathyroidism due to chronic kidney disease.

OBJECTIVE: The aim of the present work was to assess the incidence of parathyroid glands hyperplasia or adenoma in patients with various stages of chronic renal insufficiency using 99mTc-methoxyisobutylisonitrile (MIBI) SPECT and 3D subtraction technique with 99mTc-pertechnetate (Tc). SUBJECTS AND METHODS: Sixty one patients underwent hybrid SPECT with low-dose CT of the parathyroid glands and thyroid SPECT scintigraphy. Thirty six patients were with chronic kidney disease (CKD) without renal failure (RF) and 25 patients underwent peritoneal dialysis or hemodialysis. In each patient, two SPECT studies were performed - an early and a late one with low dose of CT with MIBI injection. Additional SPECT was performed on another day with Tc. SPECT studies were evaluated visually using volume rendering method and semi-quantitatively by 3D subtraction of Tc SPECT from early MIBI SPECT. RESULTS: From all 61 patients, 40/61 (66%) findings were positive, 7/61 (12%) inconclusive, and 14/61 (23%) negative. Solitary lesions were detected in 22 patients. More than one lesion was found in 18 patients. CONCLUSION: The incidence of secondary hyperparathyroidism was detected in 40/61 patients (66%) with chronic kidney disease using scintigraphy and 16 patients (40%) from them underwent surgery. MIBI SPECT/low dose CT with 3D dual - tracer subtraction (MIBI-Tc) method is an effective tool for preoperative detection of the parathyroid glands hyperplasia or adenoma.

High incidence of cardiovascular complications in pheochromocytoma.

Excess of catecholamines in pheochromocytoma is usually accompanied with classical symptoms and signs. In some cases, severe cardiovascular complications (e. g., heart failure, myocardial infarction) may occur. We performed a retrospective analysis focused on the incidence of cardiovascular complications (classified as follows: arrhythmias, myocardial involvement or ischemia and atherosclerosis, cerebrovascular impairment) before the establishment of diagnosis of pheochromocytoma among 145 subjects treated in our hospital. Cardiovascular complications occurred in 28 subjects, but these subjects did not differ significantly from subjects without complications in age, gender, body mass index, paroxysmal symptoms, symptom duration, tumor dimension, catecholamine secretory phenotype, and incidence of hypertension or diabetes mellitus. Arrhythmias occurred in 15 subjects (2 arrhythmia types in 2 subjects): atrial fibrillation in 9 subjects, supraventricular tachycardia in 3 cases, and ventricular tachycardia in 2 patients. Significant bradycardia was noted in 3 cases. Five subjects presented with heart failure with decreased systolic function (takotsubo-like cardiomyopathy found in 2 cases). One subject suffered from hypertrophic obstructive cardiomyopathy. Seven subjects presented with non-ST-segment elevation myocardial infarction, 2 patients with ST-segment myocardial infarction, and 1 subject underwent coronary artery bypass grafting. Two subjects suffered from significant peripheral atherosclerosis. Among cerebrovascular complications, transient ischemic attack was found in 3 cases, 2 subjects suffered from stroke, and subarachnoidal bleeding occurred in 1 patient. One subject suffered from diffuse neurological impairment due to multiple ischemic white matter lesions. These data show relatively high incidence of cardiovascular complications (19.3%) in subjects with pheochromocytoma. Early diagnosis is mandatory to prevent severe complications in pheochromocytoma.

[Radioiodine 131I therapy of hyperthyroidism on an outpatient basis - safe, effective and economic option]. / Lécba hypertyreózy radiojodem 131I v ambulantním rezimu - bezpecná, úcinná a ekonomická varianta.

INTRODUCTION: Radioiodine 131I therapy of hyperthyroidism on an outpatient basis is widely accepted over the world. In Czech Republic, however, radioiodine therapy is still not enough used, and has been realized on an inpatient basis to date. Our work is the first analysis of the experiences with radioiodine therapy of hyperthyroidism on an outpatient basis in Czech Republic. METHODS: Capsule with 550 MBq of 131I was administered orally in 39 hyperthyroid patients (32 women and 8 men, 21 with autoimmune Graves hyperthyroidism and 18 with toxic thyroid nodules, mean age 66.8 years). In 32 of them we evaluated effectiveness and complications of therapy after 12-42 months. We also compared financial costs of the radioiodine treatment on an outpatient basis with the treatment in hospitalization and with surgery. RESULTS: After the treatment, 9/32 (28 %) patients were euthyroid without thyrostatic/thyroxine treatment, 18/32 (60 %) patients were hypothyroid with thyroxine therapy, 2/32 (6 %) patients significantly decreased doses of thyrostatic drugs. In 2/32 (6 %) patients the treatment was ineffective. The effect of the treatment did not depend on the etiology and severity of hyperthyroidism, but decreased with thyroid volume. Patients with ineffective or only partially effective treatment had median of thyroid volume more than 40 ml. In 1 patient thyroid associated ophthalmopathy was moderately worsened. Other complications were not observed. If we compared financial costs in model with 1 patient, we found that the costs of radioiodine therapy on an outpatient basis (118.7 €) comprise only 16 % of the costs of radioiodine therapy in hospitalization (728 €) and only 25 % of the costs of surgery (475.6 €). CONCLUSION: Radioiodine 131I is effective and safe in the treatment of hyperthyroidism and the therapy on an outpatient basis is much cheaper choice. The therapy with 131I on an outpatient basis is not suitable in patients with thyroid volume more than 40 ml.

[Repeated surgery for parathyroid carcinoma]. / Opakované operace pro karcinom prístítného telíska.

INTRODUCTION: Carcinoma of the parathyroid glands is a rare cause of primary hyperparathyroidism with an incidence of 1%. MATERIAL AND METHODS: This article presents an up-to-date review of the literature illustrated by three clinical cases in the form of case reports. RESULTS: Parathyroid carcinoma is usually not detected before the first operation. Symptoms of carcinoma of the parathyroid glands are similar to those of benign adenoma. Patients with parathyroid carcinoma usually have a higher level of calcium in serum and a higher level of parathormone. Imaging methods such as neck ultrasound and 99mTc sestamibi scan can help localize pathologically enlarged glands, but they are not capable of distinguishing malignant disease. Fine needle aspiration is not recommended due to the possible associated risk of tumour seeding along the needle track. The radical excision of the tumour together with the ipsilateral thyroid gland removal remains the standard of treatment. Local recurrence is frequent. CONCLUSION: Parathyroid carcinoma is a very rare disease and should be managed surgically in a specialized centre.

[Surgical therapy of primary hyperparathyrodism in the context of orthopaedic diagnosis and treatment: our experiences in 441 patients]. / Chirurgická lécba primární hyperparathyreózy v kontextu ortopedické diagnostiky a lécby: nase zkusenosti u 441 pacientu

PURPOSE OF THE STUDY: Primary hyperparathyroidism is an endocrine disorder affecting calcium and phosphate metabolism. It is surgically treated by removing hyperfunctional parathyroid tissue. The aim of the study was to show, based on surgical results, that the introduction of serum calcium screening in orthopaedic therapy is effective. The detection of hypercalcemia and diagnosis of primary hyperparathyroidism allow for a good timing of endocrine surgery in relation to an orthopaedic procedure. MATERIAL AND METHODS: This retrospective study included 441 patients in the age range of 18 to 83 years who underwent parathyroidectomy between 2004 and 2007. Skeletal disorders were diagnosed by clinical, radiographic and densitometric examination; calcium levels were measured after surgery. Bone repair after parathyroidectomy was followed up by the endocrinologist for 1 year. RESULTS: Before surgery, 48 % of the patients had skeletal disorders. Adenoma was found in 87 %, double adenoma in 2 %, hyperplasia in 10 % and parathyroid carcinoma in 0.5 % of the patients. Complications involved transient paresthesia of the recurrent laryngeal nerve (1 %), transient hypocalcemia (0.5 %), transient post-operative arrhythmias (0.5 %), temporary psychological problems (0.7 %) and post-operative bleeding (0.5 %). None of the patients died. Serum calcium levels were as follows: 2.90 ± 0.01 mmol/L pre-operatively; 2.44 ± 0.01 mmol/L on the evening of surgery; 2.30 ±0.01 mmol/L on the 1st day; 2.19 ± 0.01 mmol/L on the 2nd day; and 2.18 ± 0.01 mmol/L on the 3rd post-operative day. On the 3rd post-operative day most of the patients were discharged from the hospital. Normal calcium levels were achieved in 98 % of the surgically treated patients. DISCUSSION AND CONCLUSIONS: The study provides evidence for the efficiency of calcium screening in primary hyperparathyroidism and shows the feasibility of involving endocrine surgery in the course of orthopaedic treatment.

Improvement of hypertension after parathyroidectomy of patients suffering from primary hyperparathyroidism.

Background. Primary hyperparathyroidism (PHPT) is one of the most common endocrine conditions and is accompanied by hypertension and increased cardiovascular mortality. The purpose of this study was to evaluate the effect of parathyroidectomy on systolic and diastolic blood pressure (BP) in hypertensive patients with PHPT and whether hypertension occurs more frequently in PHPT than in control group. Methods. A total of 1020 patients with proved PHPT who underwent surgery were compared with with 1020 age, sex, BMI, and smoking status matched controls. We evaluated changes in serum calcium, parathyroid hormone (PTH), uric acid, and BP before and 6 months after surgery. Results. Parathyroidectomy corrected PHPT and resulted in a substantial fall in both mean systolic (150 ± 3.8 to 138 ± 3.6 mmHg) and mean diastolic pressures (97 ± 3 to 88 ± 2.8 mmHg) of the hypertensive subjects; P < .01. In these patients, PTH, calcium, and uric acid normalized. 726 patients from 1020 with PHPT (69.8%) were found to be hypertensive whilst only 489 (47.8%) from 1020 of our control group. Conclusion. Parathyroidectomy in hypertensive patients reduces systolic and diastolic BP. PHPT is accompanied by a variety of metabolic complications, which are a risk factor for hypertension, and parathyroidectomy can improve these metabolic complications.

[Therapy of thyroid carcinoma using radioiodine]. / Terapie karcinomu stítné zlázy pomocí radiojodu.

The paper is submitted as one of the recommendations for diagnostic and therapeutic care in nuclear medicine meant in particular for the clinical need of physicians indication treatment of thyroid carcinoma with iodide. The author presents a brief review of principles, indications, the procedure proper, clinical interpretation and possible risks and contraindications, incl. the clinical and socioeconomic impact.

[Palliative therapy of bone metastases using radiopharmaceuticals. Recommendations for diagnostic and therapeutic care in nuclear medicine]. / Paliativní terapie kostních metastáz pomocí radiofarmak. Doporucení diagnostické a lécebné péce v nukleární medicíne.

The paper is presented as one of recommendations of diagnostic and therapeutic care in the field of nuclear medicine intended especially for the clinical needs of physicians indicating palliative treatment of metastases into bones using radiopharmaceuticals. It provides a brief review of principles, indications, the very performance of interventions, clinical interpretations, possible risks and contraindications including the clinical and social-economic meaning.

[Scintigraphic diagnosis of abscesses and other inflammatory processes using indium 111In labeled leukocytes]. / Scintigrafická diagnostika abscesu a jiných zánetlivých procesu indiem 111In znacenými leukocyty.

Autologous polymorphonuclear leucocytes are injected after separation and labelling with 111In oxine to the patient with a suspect inflammatory process and after 24 hours their localization is assessed by standard scintigraphic examination by a scintillation camera. The authors examined in a prospective investigation 33 patients--the sensitivity of the method was in that group 80%, the specificity 100%, the diagnostic accuracy 94%. The authors discuss the possibilities of application of the method in intraperitoneal abscesses and in some inflammations with another localization. They evaluate the contribution of the method in the diagnosis of inflammatory processes, as compared with the possibilities offered by computed tomography and ultrasound.

[Role of cerclage in the prevention of abortion and premature labor]. / Die Rolle der Zerklage bei der Verhütung der Fehlgeburt und der Frühgeburt

In the course of the analysis of the results of 175 cerclage-operations carried out during the last 5 years, the authors intended to answer the question: whether the operation is reasonable on the basis of a prophylactic indication. As indication of this kind has been considered for example the following: when in the case-history of the patient one or more spontaneous abortions have occured after the third month of gravidity--with insufficient symptoms, when the mother's birth was a full-term confinement after cerclage-operation, finally, when the insufficiency of the cervical os had been diagnosed before getting pregnant. At symptoms of incipient abortion the aim of the medical treatment was therapeutic. The prophylactic operation was performed between the 16-18th week of the pregnancy, while the therapeutic one between the 20th and 30th week. In the first group 97,2 per cent was the rate of the viable children, while in the second one: 67,2 per cent. The well-foundedness of the prophylactic indication is proved by the fact that the number of full-term confinements has been quinetupled, compared with the pre-operation state. In our opinion in case of typical anamnesis the cerclage-operation is to be performed earlier than in the practice up till now, before opening the cervical os, and the infection of the amnion.