Methotrexate osteopathy demonstrated by Technetium-99m HDP bone scintigraphy

The authors report a case of methotrexate osteopathy as revealed by Tc-99m HDP bone scintigraphy in a patient with rheumatoid arthritis. Methotrexate is used widely in high doses as a chemotherapeutic agent. Lower doses are given in rheumatoid and psoriatric arthritis. Methotrexate affects bone metabolism, resulting in methotrexate osteopathy, characterized by osteoporosis, osseus pain, and even spontaneous (micro)fractures. Radiographic visualization of microfractures is difficult. Tc-99m HDP bone scans have been shown to be very sensitive in the visualization of changes in bone metabolism as a result of methotrexate osteopathy.

186Re-etidronate. Efficacy of palliative radionuclide therapy for painful bone metastases

Pain palliation with bone-seeking radiopharmaceuticals is an effective treatment modality in patients with advanced metastatic bone cancer. Several studies have shown encouraging clinical results of palliative therapy using 186Re-HEDP, with an overall reported response rate of +/-71% for painful osseous metastasized prostate and breast cancer patients. 186Re-HEDP is a very potential isotope with numerous advantageous characteristics for this purpose. Myelosuppressive toxicity is limited and reversible, which makes repetitive treatment safe. However, individual studies are difficult to compare, and are hampered by the numerous and different methods used to assess clinical response. Standardized clinical response assessment using the objective multi-dimensional pain evaluation model should therefore be implemented.

Iodine-131 uptake and turnover rate vary over short intervals in Graves' disease

From a Dutch questionnaire, it was apparent that nearly all institutions used percentage of radioiodine uptake for calculation of the radioiodine dose in Graves' disease. Although there is a general belief that fluctuations in radioiodine uptake may occur, with few exceptions relatively long intervals were accepted between the uptake measurement and the actual therapy dose. With the aim of optimizing the pretherapeutic work-up, we evaluated the stability of iodine uptake over time in patients with Graves' disease who were referred for 131I therapy. 131I uptake was measured in 300 consecutive patients for the calculation of the required 131I therapy dose; data were complete for 291 patients (97%). After discontinuing thyroid medication for 3 days, standardized thyroid probe measurements were performed 5 and 24 h after ingestion of a capsule containing 0.37 MBq 131I-NaI. Measurements were performed at the time of scintigraphic diagnosis (test 1), as well as immediately before 131I therapy (test 2). The time interval between test 1 and test 2 ranged from 2 to 421 (median 40) days. A relative increase or decrease greater than 10% between tests 1 and 2 occurred in 180 of 291 cases (62%) at 5 h and in 158 of 291 patients (54%) at 24 h. These changes were not related to the interval between the tests or to initial uptake values, thyroid mass, gender or age. Rapid turnover of radioiodine (5 h/24 h uptake ratio > 1) was noted in 17% of the patients during test 1 and in 15% during test 2. Rapid turnover was persistent (present in both tests 1 and 2) in only 9%. We conclude that patients with Graves' disease show considerable changes in 131I uptake over relatively short periods of time, and the turnover rate of 131I in this condition is not constant.

The long-term effects of force-transmission in an injured wrist, measured with dual-energy X-ray absorphometry: a case report

PURPOSE

To investigate the feasibility of using a dual-energy X-ray absorphometry (DEXA) scan to predict long-term force-transmission patterns in wrists.

MATERIAL AND METHODS

Both wrists of a man with morbid Kienböck stage IIIa disease of his left wrist (avascular necrosis of the lunate) were examined by a DEXA scan to determine the differences in bone density in the distal radius.

RESULTS

In the distal radius of the injured wrist, a shift in bone density was seen toward the scaphoid fossa, which resembles the shift in force-transmission pattern described in force-transmission studies of the wrist.

CONCLUSIONS

These differences can be interpreted as a result of an altered force-transmission pattern in the injured wrist.

Staging of lymph nodes with FDG dual-headed PET in patients with non-small-cell lung cancer

Accurate assessment of mediastinal lymph node involvement in patients with non-small-cell lung cancer (NSCLC) is necessary to select patients for direct surgical treatment. The aims of the present study were to assess the feasibility of staging NSCLC with FDG using a dual-headed positron emission tomographic (PET) camera and to compare this non-invasive technique with computed tomography (CT) and lymph node sampling, since both modalities are currently used for staging NSCLC. Thirty-three patients (29 men and 4 women, mean age 60 years) with newly diagnosed NSCLC were studied. In all patients, CT, FDG dual-headed PET and mediastinoscopy were performed within 4 weeks. The results of mediastinoscopy were used to select patients for thoracotomy. For both the assessment of individual lymph node involvement and the patient-based classification, the results of FDG dual-headed PET and CT were compared using the McNemar test. Thirty-one of 187 lymph nodes studied contained tumour metastases. FDG dual-headed PET showed a significantly higher sensitivity (P < 0.001) and specificity (P < 0.001) than CT. FDG dual-headed PET and CT correctly staged 27 and 20 patients, respectively. Due to the significantly higher negative predictive value of FDG dual-headed PET versus CT (P = 0.012), it was a better non-invasive diagnostic tool for selecting patients for surgery. In seven of eight patients, additional intrapulmonary sites of increased uptake were found, which revealed malignancy on histological examination. CT was false-negative in three of these patients. In one patients, increased FDG uptake was caused by an infection. In conclusion, it is possible to stage mediastinal lymph nodes in patients with NSCLC using a dual-headed PET camera. The high negative predictive value of FDG dual-headed PET suggests that mediastinoscopy may be omitted in patients with NSCLC.

Undetectable serum thyroglobulin in a patient with metastatic follicular thyroid cancer

The case of a 54-year-old woman with metastatic follicular thyroid cancer and undetectable serum thyroglobulin is presented. Many years after the patient had a subtotal thyroidectomy for a large goiter that had no clear evidence of malignancy, metastatic bone disease developed. When the bone metastases were detected and during the follow-up period, serum thyroglobulin values remained undetectable, but radioiodine uptake in the metastases was abundant. This case indicates that the combination of 1-131 scintigraphy and serum thyroglobulin values is superior to the measurement of serum thyroglobulin alone in detecting well-differentiated, metastatic thyroid cancer.

[Palliative treatment of bone metastases with bone-seeking radionuclides]

The skeleton is a common site for metastases in patients with prostate and breast cancer. Beside analgesic therapy and external beam radiotherapy, the use of bone-seeking radiopharmaceuticals gives pain relief. Analogues of these pharmaceuticals are also applied in skeletal scintigraphy. They accumulate at the site of high osteoblast activity and in this way they exert a local favourable influence on metastases through their radiation (beta particles or conversion electrons). The bone-seeking radiopharmaceuticals include strontium-89 chloride and rhenium-186 hydroxyethylidenediphosphonate. The main adverse reaction that has been observed is myelosuppression.

Reverse discordant scintigraphy in diffuse goiter

Both Tc-99m pertechnetate and radioactive iodine (I-123 NaI or I-131 NaI) are useful in thyroid scintigraphy. These radiopharmaceuticals yield similar functional information in most patients. Occasionally, however, discordant results have been reported in the literature (warm or hot on the pertechnetate image and cold on the radioiodide image). Most of these reports have concerned the solitary thyroid nodule. A case is presented here with diffusely decreased Tc-99m pertechnetate uptake and normal I-131 NaI uptake in a patient with a diffuse goiter and subclinical hyperthyroidism, so-called reverse discordant behavior.

Pulmonary embolism after thrombolysis of hemodialysis grafts

The aim of this study was to determine the incidence of pulmonary embolization occurring after mechanical or pharmacomechanical percutaneous intravascular thrombolysis in 23 patients with occluded hemodialysis grafts. In all patients, pulmonary perfusion scintigraphy was performed before and immediately after thrombolysis. In eight (35%) of the patients, there was evidence of pulmonary embolism resulting from the interventional procedure; however, in only one was there clinical symptoms. It is concluded that there is substantial risk of pulmonary embolism in patients undergoing percutaneous intravascular thrombolysis for an occluded hemodialysis graft.

Treatment of metastatic bone pain using the bone seeking radiopharmaceutical Re-186-HEDP

Recent advances in radionuclide therapy offer a new approach for the management of metastatic bone pain. This paper reports the results of dosage escalation studies with 186Re-HEDP as a bone-seeking radiopharmaceutical in patients with bone metastases originating from breast or prostate cancer with regard to toxicity, pharmacokinetics and bone marrow dosimetry and the palliating effect on bone pain. Thrombocytopenia proved to be the dose limiting factor and 186Re-HEDP showed a considerable efficacy in end-stage patients with metastatic bone pain.