Diagnosis and treatment of Graves’ disease with particular emphasis on appropriate techniques in nuclear medicine. General state of knowledge

Graves’ disease is an autoimmune disease. It accounts for 50–80% of cases of hyperthyroidism. Antibodies against the TSH receptor (TRAb) are responsible for hyperthyroidism (TRAB). The key role in monitoring and diagnosis of Graves’ disease plays the level of hormones of free thyroxine and triiodothyronine. Helpful is an ultrasound of the thyroid scintigraphy which due to its functional character is both a valuable addition to morphological studies as well as plays an important role in the diagnosis and therapy in patients with Graves’ disease. There is no perfect treatment for Graves’ disease. The reason for this is the lack of therapy directed against primary pathogenic mechanisms. Currently available treatments need to be thoroughly discussed during the first visit as the patient’s understanding of the choice of a treatment constitutes a vital role in the success of therapy. Graves’ disease treatment is based on three types of therapies that have been carried out for decades including: pharmacological treatment anti-thyroid drugs, I131 therapy and radical treatment — thyroidectomy. The purpose of the treatment is to control symptoms and patient to return to euthyreosis. Treatment of Graves’ disease is of great importance because if left untreated, it can lead to long-term harmful effects on the heart, bone and mental well-being of patients

Lithium carbonate pre-treatment in 131-I therapy of hyperthyroidism

BACKGROUND: The aim of the present work was to investigate the influence of lithium carbonate on the kinetics of radioiodine in the thyroid gland, and the long-lasting effect of radioiodine therapy pre-treated with lithium carbonate in patients with different types of hyperthyreosis and low baseline 24-h thyroidal radioactive iodine uptake (RAIU). MATERIAL AND METHODS: The examinations were performed in two groups of patients: in a control group with RAIU > 30% and in patients with RAIU < 30%. All groups were comparable with regard to age, sex, duration and type of disease (Graves&#8217; disease, autonomous node, multinodular goitre). The control group was treated (without lithium) according to described protocol. The second group was pre-treated with lithium carbonate in a dose of 1.0 g/day for 6 days before radioiodine and 3 days thereafter. RESULTS: A significant increase in iodide uptake in the thyroid gland was observed during intake of lithium carbonate in 106 out of 128 patients. A decrease of T3, FT3, T4, and FT4 levels and no significant changes in concentration of TSH were observed as an effect of lithium carbonate treatment. Three years of follow-up show that the results of radioiodine therapy with short lasting lithium carbonate intake are better in the first year and are similar in the second and third years in comparison to the control group. CONCLUSIONS: Lithium pre-treatment in hyperthyroid patients with low baseline uptake of radioiodine can increase iodine retention in the thyroid gland independently of the primary disease and permits the use of lower doses of radiation in the therapy. Nuclear Med Rev 2011; 14, 1: 3&#8211;

Myocardial viability assessment in 18FDG PET/CT study (18FDG PET myocardial viability assessment)

Accurate identification of viable myocardium is crucial in patientqualification for medical or surgical treatment. Only personswith confirmed cardiac viability will benefit from revascularizationprocedures. It is also well known, that the amount of viablemyocardium assessed preoperatively is the best indicator oflong term cardiac event free survival after cardiac intervention.There are several diagnostic approaches used in current clinicalpractice for assessment of myocardial viability. Analysis ofwall thickness or myocardial contraction, evaluation of cardiacperfusion or metabolism can be assessed using followingmodalities: Echocardiography, Cardiac Molecular Imagingtechniques (PET, SPECT), Cardiovascular MR or CardiovascularCT. The article describes the methods and problems ofviability assessment in 18FDG PET study. PET imaging hasproved its accuracy and reproducibility for myocardial ischemiaand viability assessment. However this unique in its ability forshowing the particular substrate metabolism technique has unfortunately some disadvantages: currently achieved PETresolution is 0.4 cm. However the combined devices multislicecomputed tomography scanners with PET (PET/CT) are nowwidely used in clinical practice. This combination allows forwider morphologic assessments: coronary calcium scoring andnon-invasive coronary angiography may be added to myocardialperfusion/metabolic imaging if necessary

Computer program for analysis of parathyroid scintigraphy examinations: combination of dual-tracer (subtraction) and double phase single-tracer washout techniques

There is no controversy in the published literature that sensitivity and specificity of parathyroid scintigraphy is superior to other imaging techniques. However no uniform protocol has been established for scintigraphy. In order to analyze parathyroid scintigraphic images in the Department of Nuclear Medicine at the Medical University of Warsaw we have developed a program that allows qualitative and quantitative evaluation of recorded images and motion artifacts correction. This program offers a uniform procedure of analysis of parathyroid imaging results in diagnostic centers, accelerates the analysis of parathyroid tests performed with use of single radioactive tracer, that require the acquisition of consecutive images of the patient, without altering his body position between successive stages of registration. This program allows for automation of previously time consuming procedures and thus saves time and decreases a risk of operator’s errors.There is no controversy in the published literature that sensitivity and specificity of parathyroid scintigraphy is superior to other imaging techniques. However no uniform protocol has been established for scintigraphy. In order to analyze parathyroid scintigraphic images in the Department of Nuclear Medicine at the Medical University of Warsaw we have developed a program that allows qualitative and quantitative evaluation of recorded images and motion artifacts correction. This program offers a uniform procedure of analysis of parathyroid imaging results in diagnostic centers, accelerates the analysis of parathyroid tests performed with use of single radioactive tracer, that require the acquisition of consecutive images of the patient, without altering his body position between successive stages of registration. This program allows for automation of previously time consuming procedures and thus saves time and decreases a risk of operator’s errors

Results of preventive radioiodine therapy in euthyroid patients with history of hyperthyroidism prior to administration of amiodarone with permanent atrial fibrillation — a preliminary study

Wstęp: Terapia radiojodem (RAI) jest standardowym postępowaniem w leczeniu nadczynności tarczycy. Jednakże stosowanie RAI w stanie eutyreozy u pacjentów wymagających przewlekłego podawania amiodaronu (AM), w przypadku braku skuteczności innych leków przeciwarytmicznych, jest kontrowersyjne. Celem pracy była ocena bezpieczeństwa i skuteczności profilaktycznego zastosowania RAI, przed podaniem AM, u pacjentów w eutyreozie z utrwalonym migotaniem przedsionków (PAF), w przeszłości leczonych z powodu nadczynności tarczycy.Materiał i metody: przeprowadzono analizę retrospektywną. Chorych oceniano na początku badania oraz 2, 6, 8 i 12 miesięcy po zastosowaniu RAI. 17 pacjentów z eutyreozą z towarzyszącym PAF zostało zakwalifikowanych do RAI (kobiety/ mężczyźni 3/14; wiek: 65–87, mediana 71 lat). Pacjenci wymagali przewlekłego stosowania AM jako profilaktyki nagłego zgonu sercowego.Wyniki: Każdy pacjent otrzymał dawkę ablacyjną 131I {800 MBq (22 mCi)}. Po podaniu RAI, jak również w okresie obserwacji nie zaobserwowano powikłań. Subkliniczna nadczynność tarczycy wystąpiła w 2 przypadkach (11,8%) po 2 miesiącach od podania RAI i 5 tygodniach od włączenia AM. W tej sytuacji leczenie RAI przeprowadzono ponownie. Trzech pacjentów (17,6%) po 6 miesiącach oraz 2 (11,8%) po 8 miesiącach wymagało podania dodatkowej dawki 131I z powodu nadczynności tarczycy indukowanej AM. Dwunastu pacjentów (70,6%), powróciło do spontanicznego rytmu zatokowego w ciągu dwóch miesięcy. Po 6 i 12 miesiącach leczenia 14 pacjentów (82,4%) wykazało rytm zatokowy w badaniu kontrolnym.Wnioski: Prewencyjne zastosowanie RAI przed włączeniem AM u pacjentów w eutyreozie (w wywiadzie: nadczynność tarczycy) z PAF, gdy terapia innymi lekami antyarytmicznymi okazuje się nieskuteczna, może być rozważana jako metoda z wyboru. Jest to szczególnie ważne w przypadku pacjentów wymagających stałego podawania AM jako leku ratującego życie. (Endokrynol Pol 2014; 65 (4): 270–274)Introduction: Radioiodine (RAI) therapy is a standard procedure in the treatment of hyperthyroidism. However, the use of RAI in euthyroid patients requiring chronic administration of amiodarone (AM) where other antiarrhythmic drugs may lack efficacy is still controversial.Objective: The aim of this study was to assess the safety and efficacy of an AM therapy prior to treatment with radioiodine therapy in euthyroid patients with permanent atrial fibrillation (PAF), who had been treated for hyperthyroidism in the past.Material and methods: This was a retrospective observational study. Patients were assessed at baseline and two, six, eight, and 12 months after RAI therapy. 17 euthyroid patients with PAF were qualified to the RAI (female/male 3/14; age range 65 to 87, median 71). The patients required chronic administration of AM as a prophylaxis against sudden death.Results: Each patient received an ablative dose of 800 MBq (22 mCi) of 131I. At baseline and during follow-up, no side effects of the therapy and no signs of drug intolerance were observed. Subclinical hyperthyroidism occurred in two (11.8%) cases after two months of RAI and five weeks of AM administration. In this situation, RAI therapy was repeated. Three patients (17.6%) after six months, and another two (11.8%) after eight months, required an additional dose of 131I due to amiodarone-induced thyrotoxicosis (AIT). Twelve patients (70.6%) returned to spontaneous sinus rhythm within two months. Fourteen patients (82.4%) had sinus rhythm during follow-up after six and 12 months of treatment.Conclusions: Preventive RAI in euthyroid (but previously hyperthyroid) patients with PAF before administration of AM may be the method of choice. This is particularly important for patients who will require permanent AM administration as a life-saving drug. (Endokrynol Pol 2014; 65 (4): 269–274

Assessment of the myocardial FDG-PET image quality with the use of maximal Standardized Uptake Value myocardial to background index. Application of the results in regard to semiquantitative assessment of myocardial viability with cardiac dedicated softwar

BACKGROUND: The objective of this study was to semiquantitatively assess the degree of myocardial fluorodeoxyglucose (FDG) uptake in glucose-loaded myocardial viability positron emission tomography/computed tomography (PET/CT) scans, to calculate the myocardial to background index, and correlate the index with image quality assessed on the basis of visual qualitative assessment. MATERIAL AND METHODS: The myocardial FDG-PET/CT study was carried out in 69 non-diabetic patients, who had known coronary artery disease, by intravenous injection of 250 ± 70 MBq (range: 180–320 MBq) FDG. Images were interpreted visually and patients were divided into three groups according to the grade of myocardial uptake: optimal, suboptimal, and uninterpretable. Semiquantitative analysis was performed by calculating the standardized uptake value (SUVmax) for myocardium and background (blood pool) activity, and expressed as the myocardial to background (M/B) activity ratio. RESULTS: On the basis of visual (qualitative) analysis, 60/69 (86.96%) patients showed optimal quality of FDG cardiac uptake, 3/69 (4.35%) were suboptimal, and uninterpretable FDG PET scan results were found in 6/69 (8.70%) patients. The M/B index was found to be significantly higher in images of optimal vs. suboptimal quality (6.87 ± 3.99 vs. 1.65 ± 0.78 respectively; p &lt; 0.0001). CONCLUSIONS: The index ratio of 2.2, which is consistent with the upper borderline value for visually uninterpretable images, was considered the cut-off value for scans of optimal and non-optimal quality

Wpływ kanabinoidów na układ wydzielania wewnętrznego

Kanabinnoidy stanowią pochodne konopii, najbardziej aktywnym biologicznie wśród nich jest tetrahydrokannabinol (THC). Najczęściej stosowanymi narkotykami są marihuana, haszysz i olej haszyszowy. Te mieszaniny związków wywierają swój efekt poprzez interakcję z receptorami kannabinoidowymi CB1 i CB2. Receptory typu pierwszego (CB1) zlokalizowane są głównie w ośrodkowym układzie nerwowym oraz w tkance tłuszczowej oraz narządach, w tym większości gruczołów wydzielania wewnętrznego. Receptory typu drugiego (CB2) znajdują się głównie w obwodowym układzie nerwowym (obwodowe zakońćzenia nerwowe) oraz na powierzchni komórek ukłądu immunologicznego. Obecnie coraz większą wagę przywiązuje się do roli endogennych ligandów oddziałujących ze wspomnianymi receptorami, jak i roli samych receptorów. Dotychczas udowodniono udział endogennych kannabinoidów w regulacji ilości przyjmowanego pokarmu, homeostazy, mają także istotny wpływ na układ wydzielania wewnętrznego, w tym aktywność przysadki, kory nadnerczy, tarczycy, trzustki i gonad. Wzajemne powiązania pomiędzy układem endokannabinoidowym i aktywnością układu wydzielania wewnętrznego może stanowić punkt uchwytu dla licznych leków, któych skuteczność wykazano w przypadku leczenia niepłodności, otyłości, cukrzycy cz nawet zapobieganiu chorobom układu sercowo-naczyniowego.

Rozpiętość rozkładu objętości erytrocytów — nowy marker zaostrzenia niewydolności krążenia u pacjentów z niedoczynnością tarczycy po leczeniu jodem promieniotwórczym

Introduction: Cardiovascular diseases constitute a major cause of health problems and death in developed countries across the world. The increased value of the index of distribution of red blood cells volume (RDW) may be a prognostic marker in patients diagnosed with chronic heart failure (CHF). Hypothyroid patients present higher RDW values if compared to healthy controls. Taking into consideration that RDW might be both affected by thyroid status and CHF, we decided to determine the effect of concomitant hypothyroidism following radioiodine therapy (RIT) and CHF on hematological parameters. Materials and methods: Patients with toxic nodular goiter and heart failure with concomitant anemia were included. Patients underwent treatment with radioiodine before the planned heart transplant or pacemaker implantation (combined ICD/CRT-D). After RIT patients were divided into the three subgroups: with overt hypothyroidism (TSH ≥ 10µIU/mL, Group I), subclinically hypothyroid patients (TSH 4.3-9.0 µIU/mL, Group II) and with high-normal level of TSH (2.6-4.2 µIU/mL, Group III). Results: Significant correlation between TSH and RDW was observed (r=0.46; P < 0.0001) after RIT, whereas no correlation between serum TSH levels and TIBC and Fe was observed. In Group I significant correlation between TSH and RDW (r= 0.48; P = 0.002) after RIT was observed, whereas in two other subgroups there were no significant correlation. Conclusions: Subclinical hypothyroidism or high-normal levels of TSH did not affect RDW in a significant manner in the studied population. Our results demonstrates that overt hypothyroidism may contribute to deterioration of CHF reflected in changes of RDW value. Wstęp: Choroby sercowo-naczyniowe stanowią główną przyczynę problemów zdrowotnych i zgonów w krajach wysoko uprzemysłowionych na całym świecie. Podwyższona wartość rozpiętości rozkładu objętości erytrocytów (RDW) może stanowić marker prognostyczny u pacjentów z przewlekłą niewydolnością serca (PNS). Pacjenci z niedoczynnością tarczycy mają wyższe wartości RDW w porównaniu z osobami zdrowymi. Biorąc pod uwagę, że RDW może być zmienione zarówno przez stan czynnościowy tarczycy, jak i PNS, autorzy niniejszej pracy postanowili ustalić wpływ współistniejącej niedoczynności tarczycy spowodowanej terapią jodem promieniotwórczym (RIT) i PNS na parametry hematologiczne. Materiały i metody: Włączono pacjentów z wolem guzkowym toksycznym, PNS oraz towarzyszącą niedokrwistością. U pacjentów prze­prowadzono RIT przed planowanym przeszczepieniem serca lub implantacją urządzenia resynchronizującego lub defibrylatora (ICD/CRT-D). Po RIT pacjentów podzielono na 3 podgrupy: z jawną niedoczynnością tarczycy (TSH ≥ 10 μIU/mL — grupa I), z subkliniczną niedoczynnością (TSH 4,3–9,0 μIU/mL — grupa II) oraz z TSH w górnej granicy normy (2,6–4,2 μIU/mL — grupa III). Wyniki: Zaobserwowano istotną korelację między TSH i RDW (r = 0,46; P &lt; 0,0001) po RIT, podczas gdy nie zaobserwowano kore­lacji między stężeniem TSH i stężeniem żelaza oraz TIBC. W grupie I zaobserwowano istotną korelację między TSH i RDW (r = 0,48; P = 0,002) po RIT, jakkolwiek w dwóch pozostałych podgrupach nie zaobserwowano istotnej korelacji. Wnioski: Subkliniczna niedoczynność tarczycy, jak i wartości TSH w górnej granicy normy nie wpływały na RDW w sposób istotny w grupie badanej. Wyniki wskazują, że jawna niedoczynność tarczycy może przyczynić się do zaostrzenia PNS odzwierciedlonej zmianą wartości RDW

Relationship between parathyroid gland scintigraphy and its histopathology, oxyphil cell content and volume: a retrospective study

BACKGROUND: Mechanisms that are responsible for positive 99mTc-MIBI uptake in parathyroid glands are not clearly understood, some authors suggest there is a correlation between 99mTc MIBI accumulation and oxyphil cell content or parathyroid gland volume. The aim of our work was to assess the relationship between the pathological structure of parathyroids, their volume, oxyphil cell content and parathyroid 99mTc-MIBI retention. MATERIAL AND METHODS: A total of 62 hyperfunctioning parathyroid glands in 46 patients were retrospectively analyzed. Preoperative 99mTc-MIBI scintigraphy was performed according to the double-phase and subtraction protocol. After surgery all glands were evaluated histologically, oxyphil cell content was assessed and volume of each excised gland was calculated. RESULTS: Scintigraphy was positive in 41 of 62 parathyroid glands (66%). The median volume of positive glands was larger than that of negative glands (1.33 ml vs 0.7 ml, p = 0.015). Of the parathyroid lesions, there were 14 (22.6%) cases of nodular hyperplasia, 23 (37.1%) cases of diffuse hyperplasia, and 25 (40.3%) cases of adenomas. A high (≥ 25%) oxyphil cell content was found in 16 glands (25.8%) and a low ( &lt; 25%) oxyphil cell content in 46 (74.2%) glands. Histopathology of parathyroid glands was related to the scintigraphy result (p = 0.002), but not to the 99mTc-MIBI uptake pattern (p = 0.868). The overall result of scintigraphy was not related to the oxyphil cell content (p = 0.797). 99mTc-MIBI uptake pattern wasn’t related to the oxyphil cell content (p = 0.833). In general, parathyroid lesions with low oxyphil cell content were larger than parathyroid glands with high oxyphil cell content (1.33 ml vs 0.5 ml, respectively; p = 0.01). The median volume of parathyroids containing a high number of oxyphil cells and having a prolonged 99mTc-MIBI retention was larger than those without prolonged 99mTc-MIBI retention (1.62 ml vs 0.3 ml, respectively; p = 0.008). The median volume of parathyroids with low oxyphil cells content and showing prolonged 99mTc-MIBI retention was larger than those without prolonged 99mTc-MIBI retention (1.95 ml vs 1.07 ml, respectively; p = 0.014). CONCLUSIONS: Our findings suggest that a positive scintigraphy result depends on parathyroid histopathology and gland volume and does not depend on the presence of oxyphil cells. Prolonged 99mTc-retention is not related to the parathyroid gland histopathology and the presence of oxyphil cells but to the gland volume

Zastosowanie metod medycyny nuklearnej w ocenie ośrodkowego układu nerwowego

Współczesna medycyna korzysta z licznych technik obrazowania centralnego układu nerwowego, najpopularniejsze badania to tomografia komputerowa i rezonans magnetyczny. W niektórych przypadkach klasyczne techniki nie dostarczają nam wszystkich istotnych informacji – w takiej sytuacji często zastosowanie mają metody medycyny nuklearnej. Medycyna nuklearna zajmuje się diagnozowaniem i leczeniem schorzeń przy pomocy izotopów promieniotwórczych wykorzystując głównie mechanizmy fizjologii ciała i organów, uwidaczniając patologię dotyczącą choroby. Metody medycyny nuklearnej można wykorzystywać w diagnostyce i terapii. Do podstawowych technik obrazowych w medycynie nuklearnej należą: ––Technika pojedynczego fotonu (SPECT-CT - obrazy 3D oraz technika planarna 2D), ––Pozytonowa Tomografia Emisyjna (PET-CT – w większości przypadków są to obrazy 3D)