Bone scan in metabolic bone diseases. Review

Metabolic bone disease encompasses a number of disordersthat tend to present a generalized involvement of the wholeskeleton. The disorders are mostly related to increased boneturnover and increased uptake of radiolabelled diphosphonate.Skeletal uptake of 99mTc-labelled diphosphonate depends primarilyupon osteoblastic activity, and to a lesser extent, skeletalvascularity. A bone scan image therefore presents a functionaldisplay of total skeletal metabolism and has valuable role toplay in the assessment of patients with metabolic bone disorders.However, the bone scan appearances in metabolic bonedisease are often non-specific, and their recognition dependson increased tracer uptake throughout the whole skeleton. Itis the presence of local lesions, as in metastatic disease, thatmakes a bone scan appearance obviously abnormal. In theearly stages, there will be difficulty in evaluating the bone scansfrom many patients with metabolic bone disease. However, inthe more severe cases scan appearances can be quite strikingand virtually diagnostic.Metabolic bone disease encompasses a number of disordersthat tend to present a generalized involvement of the wholeskeleton. The disorders are mostly related to increased boneturnover and increased uptake of radiolabelled diphosphonate.Skeletal uptake of 99mTc-labelled diphosphonate depends primarilyupon osteoblastic activity, and to a lesser extent, skeletalvascularity. A bone scan image therefore presents a functionaldisplay of total skeletal metabolism and has valuable role toplay in the assessment of patients with metabolic bone disorders.However, the bone scan appearances in metabolic bonedisease are often non-specific, and their recognition dependson increased tracer uptake throughout the whole skeleton. Itis the presence of local lesions, as in metastatic disease, thatmakes a bone scan appearance obviously abnormal. In theearly stages, there will be difficulty in evaluating the bone scansfrom many patients with metabolic bone disease. However, inthe more severe cases scan appearances can be quite strikingand virtually diagnostic

Parathyroid gland function after radioiodine (131I) therapy for toxic and non-toxic goitre

Wstęp: Efekt terapeutyczny radiojodu (131I) w wolu łagodnym opiera się na emisji niszczącego tkanki promieniowania beta. Maksymalnyzasięg promieniowania beta 131I w tkance wynosi do 2,4 milimetra. Dlatego, też w zasięgu tego promieniowania mogą się znajdowaćsąsiadujące z tarczycą przytarczyce. Celem pracy była ocena czynności przytarczyc u chorych z wolem nadczynnym i normoczynnympoddanych terapii 131I w okresie do 5 lat od zastosowanego leczenia.Materiał i metody: Badania zostały wykonane u 325 chorych z łagodnym wolem (220 z wolem guzowatym nadczynnym (TNG), 25z wolem guzowatym obojętnym (NTNG) i 80 z chorobą Gravesa-Basedowa (GD) poddanych leczeniu 131I. Aktywność lecznicza 131Idla każdego pacjenta wyliczana była z wzoru Marinellego. W trakcie radiojodoterapii oznaczano stężenia fT3, fT4, TSH, iPTH, Ca2+, Cai fosforanów w surowicy tydzień przed podaniem 131I, i następnie w odstępach dwumiesięcznych przez rok po terapii oraz po 3 i 5 latach.Wyniki: U wszystkich chorych po 2 miesiącach od momentu rozpoczęcia leczenia zaobserwowano znamienny statystycznie wzrost stężeniaiPTH ponad normę (do wartości prawie dwukrotnie powyżej normy u pacjentów z TNG), który utrzymywał się aż do 10 miesiąca,a następnie ulegał normalizacji. Stężenia Ca2+, Ca i fosforanów u wszystkich leczonych pozostawały w zakresie normy w trakcie całegobadania. Stężenia fT3 i fT4 w surowicy po podaniu 131I szybko się normalizowały i pozostawały w zakresie normy do końca badania.Wnioski: Radiojodoterapia łagodnych schorzeń tarczycy prowadzi do powstania przejściowej (trwającej maksymalnie do 10 miesiąca odpodania radiojodu) nadczynności przytarczyc. Stan ten istotnie nie wpływa na stężenia wapnia i fosforanów w surowicy.(Endokrynol Pol 2013; 64 (5): 340–345)Introduction: The therapeutic effect of radioactive iodine (131I) on benign goitre consists of the emission of tissue-destructive beta-radiation. Since the range of beta 131I radiation in tissue can reach 2.4 mm, it can affect the adjacent parathyroid glands. The purpose of this paperis to assess parathyroid function in patients with toxic and non-toxic goitres, up to five years following 131I therapy.Material and methods: The study sample consisted of 325 patients with benign goitres (220 with toxic nodular goitre (TNG), 25 withnon-toxic nodular goitre (NTNG), and 80 with Graves’ disease (GD) treated with 131I. The therapeutic activity of 131I for each patient wascalculated using Marinelli’s formula. The serum levels of fT3, fT4, TSH, iPTH and Ca2+, Ca and phosphates were determined one week before131I administration, as well as every two months up to a year following the therapy, and then after three and five years post-treatment.Results: After two months following the administration of 131I, all the treated patients showed a statistically significant above normal increase in iPTH concentrations (amounting to a value almost twice the norm in patients with TNG), which remained stable up to ten months after treatment, to return to normal level in the following months. In all the patients, Ca2+, Ca, phosphates concentration remained within normal range throughout the course of the study. The concentrations of fT3 and fT4 quickly returned to normal after 131I administration, and remained within normal range until the completion of the study.Conclusion: Radioiodine treatment of benign thyroid disorders results in transient (up to ten months after 131I administration) hyperparathyroidism.The condition does not influence the level of calcium and phosphates concentration in any significant way. (Endokrynol Pol 2013; 64 (5): 340–345

Value of direct radionuclide cystography in diagnosing vesico-peritoneal fistulae

A 36-year-old female patient underwent a laparoscopic surgery to remove a uterine fibroid. The procedure failed to relieve the pelvic pain, although its nature changed. After a period of observation, the patient was re-admitted to hospital on suspicion of a vesico-uterine fistula to be differentiated with endometriosis. Diagnostic investigations — cystography, cystoscopy, computed tomography and magnetic resonance — did not reveal a fistula. Laparoscopy was performed, with a possible biopsy in order to eliminate endometriosis. The result was negative, but chronic progressive reactive/inflammatory lesions were noticed, possibly indicating the presence of a vesico-peritoneal fistula. Therefore, a direct radionuclide cystography was performed. The scintigraphic images single-photon emission computed tomography (SPECT/CT) showed a radioactive spot, indicative of a vesico-peritoneal fistula. The fistula was treated for three months by catheterisation of the urinary bladder. The follow-up SPECT-CT did not reveal any urine leakage from the bladder. The clinical symptoms disappeared as well

Radiojodoterapia w chorobie Gravesa-Basedowa — czynniki wpływające na skuteczność leczenia w oparciu o analizę retrospektywną

Introduction: Radioiodine (131I) isotope therapy is the method of choice in the treatment of Graves’ disease relapse. The efficiency of this method is dependent on many factors; therefore, the present paper aims to identify the parameters that have a crucial impact on the efficacy of radioiodine therapy for Graves’ disease.Material and methods: The authors performed a retrospective analysis of the medical documentation of 700 Graves’ disease sufferers treated with131I. The patients were divided into three groups depending on the thyroid-absorbed dose of 131I: group I — 100 Gy, II — 150 Gy, and III — 200 Gy. The authors assessed the influence of gender, age, presence of orbitopathy, TRab titres, thyroid mass, iodine uptake after 24 and 48 hours, and the absorbed dose on the treatment efficacy at one year post-131I administration.Results: The volume of thyroid gland (P < 0.002) and the thyroid-absorbed dose (P < 0.001) were the only factors that had a significant impact on the outcome of the treatment. The likelihood of hyperthyroidism persisting (odds ratio: 3.71, 95% confidence interval: 2.4–5.87) was greatest in patients from group I. In group II, with thyroid volume amounting both to 25 mL and to 25–50 mL, the percentage of hyperthyroidism was lowest (1 and 0%). However, with thyroid volume > 50 mL, the percentage of hyperthyroidism was lowest in group III (10%).Conclusions: The absorbed dose of 131I and the volume of the thyroid gland are two parameters that have a significant influence on the efficacy of radioiodine therapy for Graves’ disease. 150 Gy is the optimal dose for glands < 50 mL. A goitre > 50 mL requires an absorbed dose of 200 Gy in order to minimise the risk of recurrent hyperthyroidism. (Endokrynol Pol 2015; 66 (2): 126–131)Wstęp: Metodą z wyboru w leczeniu nawrotów choroby Gravesa-Basedowa jest terapia izotopowa radiojodem (131I). Efektywność tego leczenia zależy od wielu czynników, dlatego też celem pracy było wskazanie parametrów mających decydujący wpływ na skuteczności radiojodoterapii choroby Gravesa-Basedowa.Materiał i metody: Przeanalizowano retrospektywnie dokumentację medyczną 700 pacjentów z chorobą Gravesa leczonych 131I. Ze względu na dawkę pochłoniętą 131I w tarczycy, pacjentów podzielono na trzy grupy (grupa I — 100 Gy, II — 150 Gy, III — 200 Gy). Zbadano zależność płci, wieku, obecności orbitopatii, miana TRAb, masy tarczycy, jodochwytności tarczycy po 24 i 48 godzinach, dawki pochłoniętej na efektywność leczenia, po roku od podania 131I.Wyniki: Objętość tarczycy (P < 0,002), dawka pochłonięta w tarczycy (P < 0,001) miały jedynie istotny wpływ na wyniki terapii. Największe ryzyko utrzymywania się hipertyreozy (iloraz szans [OR] 3,71, 95% przedział ufności [CI] 2,4–5,87) wystąpiło u pacjentów z grupy I. W grupie II przy objętości tarczycy 25ml jak i 25-50ml odsetek hiperytreozy był najmniejszy (1 i 0%). Natomiast przy objętości tarczycy > 50 ml odsetek hipertyreozy był najmniejszy w grupie III (10%).Wnioski: Dawka pochłonięta 131I, objętość tarczycy to parametry mające istotny wpływ na skuteczności radiojodoterapii choroby Gravesa-Basedowa. Optymalną dawką pochłoniętą w tarczycy z objętością < 50 ml jest 150Gy. Wole (> 50 ml) wymaga dawki pochłoniętej 200Gy celem zminimalizowania nawrotu hipertyreozy. (Endokrynol Pol 2015; 66 (2): 126–131

Single, very low dose (0.03 mg) of recombinant human thyrotropin (rhTSH) effectively increases radioiodine uptake in the I-131 treatment of large nontoxic multinodular goiter

BACKGROUND: Radioiodine therapy (RIT) in patients with large nontoxic multinodular goiter (MNG) recently becomes more common method in comparison to surgery (especially in elderly patients and with contraindications because of severe chronic diseases other systems). Repeatedly low thyroid radioactive iodine uptake (RAIU) decreases effectiveness of RIT or makes it impossible. The recombinant human thyrotropin can increase RAIU and improve the results of RIT. The aim of the study was to assess the influence of a single very low dose (0.03 mg) of rhTSH on RAIU and thyroid function in euthyroid (MNG-EU) and subclinical hyperthyroid (MNG-SC) patients with a large multinodular goiter. MATERIAL AND METHODS: 40 patients (14 male, 26 female, age 57–80 yr) with large non-toxic MNG over 80 grams and with baseline RAIU < 40% were included into the double-blind randomized study and divided into two groups: rhTSH-group and control group. First group received the single intramuscular injection of 0.03 mg rhTSH and the second received placebo. The RAIU were measured 24 and 48 hours after the rhTSH and then all the patients were administered therapeutic doses of I-131. TSH and free thyroxine levels were measured at 1st and 2nd day after the injection of rhTSH and later, at 4 and 8 weeks after the RIT. RESULTS: The mean RAIU increased significantly from 30.44 ± 7.4% to 77.22 ± 8.7% (p < 0.001). There were no statistically significant differences in RAIU between euthyroid (MNG-EU) and subclinically hyperthyroid (MNG-SC) patients. The peak of serum TSH was noticed 24 hours after rhTSH injection and in MNG-EU patients it has remained within normal range, similarly as fT4. In the MNG-SC group the administration of rhTSH resulted in a significant increase in the TSH values after 24 hours, whose mean level slightly exceeded the upper limit of the normal range with normalization at 48 hours. 8 weeks after the RIT, the TSH and fT4 levels did not exceed the normal range and did not differ in a statistically significant way. Conclusions: Even the single very low dose of rhTSH increases the values of RAIU in significant way, in euthyroid and subclinically hyperthyroid patients. The administration of rhTSH is well-tolerated. Neoadjuvant administration of a low dose (0.03 mg) of rhTSH before I-131 seems to be an optimal method of management which may increase the effectiveness of RIT and decrease the exposure of the patients to absorbed doses of ionizing radiation.BACKGROUND: Radioiodine therapy (RIT) in patients with large nontoxic multinodular goiter (MNG) recently becomes more common method in comparison to surgery (especially in elderly patients and with contraindications because of severe chronic diseases other systems). Repeatedly low thyroid radioactive iodine uptake (RAIU) decreases effectiveness of RIT or makes it impossible. The recombinant human thyrotropin can increase RAIU and improve the results of RIT. The aim of the study was to assess the influence of a single very low dose (0.03 mg) of rhTSH on RAIU and thyroid function in euthyroid (MNG-EU) and subclinical hyperthyroid (MNG-SC) patients with a large multinodular goiter. MATERIAL AND METHODS: 40 patients (14 male, 26 female, age 57–80 yr) with large non-toxic MNG over 80 grams and with baseline RAIU < 40% were included into the double-blind randomized study and divided into two groups: rhTSH-group and control group. First group received the single intramuscular injection of 0.03 mg rhTSH and the second received placebo. The RAIU were measured 24 and 48 hours after the rhTSH and then all the patients were administered therapeutic doses of I-131. TSH and free thyroxine levels were measured at 1st and 2nd day after the injection of rhTSH and later, at 4 and 8 weeks after the RIT. RESULTS: The mean RAIU increased significantly from 30.44 ± 7.4% to 77.22 ± 8.7% (p < 0.001). There were no statistically significant differences in RAIU between euthyroid (MNG-EU) and subclinically hyperthyroid (MNG-SC) patients. The peak of serum TSH was noticed 24 hours after rhTSH injection and in MNG-EU patients it has remained within normal range, similarly as fT4. In the MNG-SC group the administration of rhTSH resulted in a significant increase in the TSH values after 24 hours, whose mean level slightly exceeded the upper limit of the normal range with normalization at 48 hours. 8 weeks after the RIT, the TSH and fT4 levels did not exceed the normal range and did not differ in a statistically significant way. Conclusions: Even the single very low dose of rhTSH increases the values of RAIU in significant way, in euthyroid and subclinically hyperthyroid patients. The administration of rhTSH is well-tolerated. Neoadjuvant administration of a low dose (0.03 mg) of rhTSH before I-131 seems to be an optimal method of management which may increase the effectiveness of RIT and decrease the exposure of the patients to absorbed doses of ionizing radiation

The usefulness of an 18F-FDG-PET/MR examination in a patient with rectal and breast cancer. A case report

Recently, we have gained access to innovative radiological and metabolic examination methods. One of these methods is PET/MRI with fluorodeoxyglucose (18F-FDG) tracer. Performing this innovative examination in a 69-year-old woman with diagnosed rectal cancer brought additional benefits. The use of PET/MRI resulted in precise clinical staging, the detection of a synchronous early-stage right breast cancer, and in the optimisation of treatment of both cancers. To date, diagnostic guidelines concerning rectal and breast cancers do not recommend the use of functional imaging for routine imaging.Recently, we have gained access to innovative radiological and metabolic examination methods. One of these methods is PET/MRI with fluorodeoxyglucose (18F-FDG) tracer. Performing this innovative examination in a 69-year-old woman with diagnosed rectal cancer brought additional benefits. The use of PET/MRI resulted in precise clinical staging, the detection of a synchronous early-stage right breast cancer, and in the optimisation of treatment of both cancers. To date, diagnostic guidelines concerning rectal and breast cancers do not recommend the use of functional imaging for routine imaging

Przydatność hybrydowego badania 18F-FDG-PET/MR u chorej na raka odbytnicy i piersi. Opis przypadku

W ostatnim czasie istnieje dostęp do innowacyjnych obrazowych badań radiologicznych i metabolicznych. Jedną z takich możliwości jest wykorzystanie hybrydy PET/MR z użyciem znacznika — fluorodeoksyglukozy (18F-FDG). Wykonanie tego badania w opisywanym przypadku 69-letniej chorej z rozpoznaniem raka odbytnicy przyniosło dodatkowe korzyści w postaci precyzyjnego określenia stadium zawansowania raka odbytnicy, wykrycia synchronicznego wczesnego raka piersi prawej oraz zoptymalizowania planu leczenia pacjentki z powodu obu tych nowotworów. Jak dotąd, wytyczne diagnostyki chorych na raka odbytnicy lub piersi nie zalecają stosowania badań metabolicznych w rutynowym postępowaniu

Rozbudowa układu stymulującego serce wymaga szczegółowej diagnostyki oraz precyzyjnej kwalifikacji

53 y.o. female patient after DDD pacemaker implantation in March 2021 due to symptomatic paroxysmal 3rd degree atrioventricular block, with heart failure with mildly reduced left ventricular ejection fraction (HFmrEF) in stable ambulatory III NYHA class. In ECHO examination before pacemaker implantation, LVEF was 60%. In subsequent ECHO examinations, a reduction of LVEF to 40% was observed. Exercise cardiac scintigraphy (February 2022) revealed irreversible perfusion loss in the apex area, apical segments of the anterior wall, septum and inferior-posterior wall (the area corresponded to about 21% of the left ventricle), LVEF at rest was 42%, and 43% during exercise. Coronary angiography (July 2022) revealed non-significant atherosclerotic lesions. Extensive, consisted with the ESC GDs pharmacological treatment of heart failure was implemented. The patient was admitted electively for the qualification for eventual upgrading of an implantable device to the resynchronization therapy. ECHO examination confirmed mildly reduced LVEF, asynchrony of LV wall contraction, without significant valvular defect, EF 41%. Laboratory tests showed slightly elevated N-terminal fragment (pro) of B-type natriuretic peptide (NT-proBNP) (238 pg/mL). A careful analysis of the patient's condition, the results of the diagnostics and laboratory tests did not provide a consistent clinical presentation, which prompted an in-depth diagnostic imaging of the lungs. An angio CT scan showed adnexal lesions in both lungs, which may suggest sarcoidosis, an inflammatory process or metastatic lesions. The patient was referred for urgent pulmonary diagnostics. In the described patient, both chronic right ventricular pacing and cardiac sarcoidosis may have been the causes of the myocardial perfusion loss followed by the decreased LVEF. The progressive development of electrophysiology has resulted in the availability of cardiac pacing device implantation services, but some clinical situations require in-depth diagnosis and very careful analysis, especially before pacing system expansion.Opis przypadku dotyczy pacjentki lat 53, po przebytej w marcu 2021 roku implantacji stymulatora serca typu DDD z powodu napadowego bloku przedsionkowo-komorowego III stopnia z zespołami MAS, z niewydolnością serca z łagodnie obniżoną frakcją wyrzutową lewej komory (LVEF, left ventricle ejectionfraction) serca (HFmrEF, heart failure with mildly reduced ejection fraction), z ponad rocznym wywiadem duszności wysiłkowej w III stadium według NYHA. W badaniu echokardiograficznym (ECHO) przed implantacją stymulatora serca LVEF wynosiła 60%. W kolejnych badaniach ECHO notowano obniżenie LVEF do 40%. W scyntygrafii wysiłkowej serca (luty 2022) stwierdzono nieodwracalny ubytek perfuzji w obrębie koniuszka, a także przykoniuszkowych segmentów ściany przedniej, przegrody i ściany dolno-przegrodowej (obszar odpowiadał ok. 21% powierzchni lewej komory). W spoczynku LVEF wynosiła 42% a podczas wysiłku 43%. W koronarografii (lipiec 2022) stwierdzono obecność przyściennych zmian miażdżycowych w tętnicach wieńcowych. Wdrożono pełne leczenie farmakologiczne niewydolności serca. Chora została przyjęta planowo w celu kwalifikacji do rozbudowy układu stymulującego serce do terapii resynchoronizującej. W badaniu ECHO potwierdzono łagodnie obniżoną LVEF do 41%, asynchronię skurczu ścian lewej komory, bez cech istotnej wady zastawkowej. W badaniach laboratoryjnych stwierdzono nieznacznie podwyższone stężenie N-końcowego fragmentu (pro) peptydu natriuretycznego typu B (NT-proBNP) (238 pg/ml). Dokładana analiza stanu pacjentki, wyników przeprowadzonej diagnostyki oraz badań laboratoryjnych nie stanowiła spójnego obrazu klinicznego, co skłoniło do pogłębienia diagnostyki obrazowejpłuc. Angio-TK wykazało przywnękowe zmiany w obu płucach, mogące sugerować sarkoidozę, proces zapalny lub zmiany przerzutowe. Pacjentka została skierowana na pilną diagnostykę pulmonologiczną. U opisywanej chorej, zarówno przewlekła prawokomorowa stymulacja serca, jak i sarkoidoza serca mogły być przyczynami ubytku perfuzji mięśnia sercowego oraz obniżenia LVEF. Postępujący rozwój elektrofizjologii spowodował poprawę dostępności do implantacji urządzeń do stymulacji serca, ale niektóre sytuacje kliniczne wymagają pogłębionej diagnostyki oraz bardziej wnikliwej analizy, szczególnie przed rozszerzeniem układu stymulującego

The Role of the CYP11B2 Promoter Polymorphism in the Diagnosis of Primary Aldosteronism

Background: nowadays, primary aldosteronism (PA) is suggested to be the most frequent cause of secondary hypertension and it reaches 10% of whole hypertensive population. The CYP11B2 promoter polymorphism might cause aldosterone overproduction. The aim of this study was to establish whether the polymorphism CYP11B2 promoter has a significant impact on diagnostic of PA. Material and Methods: study group consisted of 239 hypertensive patients previously diagnosed with adrenal incidentaloma. For diagnose of PA were performed: screening test–aldosterone-renin ratio (ARR) and saline suppression test (SIT) as a confirmatory test. Genotyping was carried out by the real time PCR method. The significance of differences between the groups was evaluated through Student’s t-test. Results: our study revealed that genotype TT had plasma aldosterone concentration (PAC), ARR and SIT significantly higher in comparison with CC patients. The mean PAC in CC was 12.71 ng/dL vs. 20.55 ng/dL in TT patients (p = 0.037), which consequently gave a higher ARR in TT patients (119 vs. 44, p = 0.034). Mean aldosterone concentration in SIT was 2.40 ng/dL in CC patients and 9.99 ng/dL in TT patients (p = 0.046). Patients with CC genotype required less hypotensive drugs in comparison with TT genotype (p = 0.044). PA was recognized in 16 patients. Nine patients had TC genotype, six TT, and one with CC genotype. Conclusion: our study revealed predisposing TT genotype to PA. Additionally, patients with TT genotype, regardless of the PA presence, had more severe hypertension. The determination of the CYP11B2 promoter polymorphism seems to be useful in the diagnosis of PA, especially in cases where it is difficult to properly prepare patients for hormonal tests or even results of the hormonal test are incoherent