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Multiple myeloma (MM) is an incurable plasma cell malignancy of the bone marrow. MM has 3 components: diffuse marrow infiltration, focal bone lesions, and soft-tissue (extramedullary) disease. The hallmark biomarker in blood or urine is a monoclonal immunoglobulin, the monoclonal protein. Waldenstrom macroglobulinemia is a similar disease with secretion of IgM. Staging is classically performed with the 1975 Durie-Salmon system, which includes conventional radiographs. Recently updated, the Durie-Salmon Plus staging system includes CT, MRI, and (18)F-FDG PET/CT. The hallmark radiographic lesion of symptomatic MM is a well-demarcated, focal osteolytic bone lesion. The number of focal bone lesions correlates inversely with outcome. Extramedullary disease is typically an aggressive, poorly differentiated form of MM that confers inferior outcome, with median survival of less than 1 y if present at diagnosis. Achievement of a complete response on (18)F-FDG PET before stem-cell transplantation correlates with a superior outcome.
BACKGROUND - Many patients with sporadic primary hyperparathyroidism (SPHPT) have discordant preoperative Tc-99m-sestamibi (MIBI) and ultrasonography studies prior to focused parathyroidectomy (PTX). This study examines the usefulness of intraoperative parathormone monitoring (IPM) during PTX in patients with discordant preoperative localization studies.
METHODS - A retrospective series of 225 consecutive SPHPT patients with MIBI scans and surgeon performed ultrasonography (SUS) prior to focused parathyroidectomy were studied. All patient operations were reviewed, and how IPM changed operative management was determined. Correct gland localization, presence of multigland disease (MGD), and operative outcome were also examined.
RESULTS - In 225 patients, overall operative success was 97%, and IPM changed operative management in 29% of patients. In 85 patients (38%) with discordant studies, operative success was 93%; IPM changed operative management in 74% of these patients. IPM allowed for 66% (56/85) of these operations to be performed as unilateral neck exploration and confirmed removal of abnormal glands in 7 patients with MGD. In 140 patients (62%) with concordant localization, in which operative success was 99%, IPM changed operative management in only 2% (3/140) of these patients with MGD.
CONCLUSION - Although of marginal benefit in patients with concordant imaging studies, IPM remains essential for performing successful PTX with discordant or incorrect concordant localization.
BACKGROUND - After excision of an abnormal gland, the dynamics of intraoperative parathyroid hormone (PTH) levels signal whether or not more hypersecreting tissue is present. This quantitative assurance of operative success has led to targeted exploration of the hyperfunctioning gland(s). Some have questioned the need for intraoperative PTH monitoring (IPM) in the presence of positive nuclear scanning. The purpose of this study was to examine the accuracy of nuclear scans in correctly localizing and guiding the complete excision of all abnormal gland(s) in patients with sporadic primary hyperparathyroidism (SPHPT) and to demonstrate how IPM changed the operative management in these patients.
STUDY DESIGN - Five hundred nineteen consecutive patients with sporadic primary hyperparathyroidism had technetium 99-m-sestamibi scans (MIBI) as localization studies obtained before undergoing parathyroidectomy guided exclusively by IPM. All patients were either followed for more than 6 months, or their procedures were identified as operative failures. MIBI reports were correlated with operative findings, hormone dynamics, and postoperative outcomes.
RESULTS - Operative success was achieved in 506 of 519 patients (97%). MIBI correctly localized all involved glands in 411 patients (80%). Among the 105 patients (20%) with incorrect or negative scans, IPM changed the operative management in 86 of 105 (82%) by pointing out incomplete resection in patients with a single MIBI incorrect focus (21 of 28) or unrecognized multiglandular disease by scan (13 of 15); avoiding unnecessary exploration in patients with additional incorrect foci (20 of 21); and guiding the surgeon to successful excision or unilateral neck exploration in patients with negative MIBI (32 of 41).
CONCLUSIONS - MIBI as a single adjunct missed 87% of patients with multiglandular disease. Including patients with negative (8%) and incorrect (12%) MIBI, IPM changed the operative management in 17% of patients and led to operative success in 97%. We suggest that IPM should be used to guide parathyroid excision in every patient with sporadic primary hyperparathyroidism.
BACKGROUND - With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy. Nuclear scanning and ultrasonography done by third parties are costly. We investigated whether ultrasonography performed by the operating surgeon (SUS) could be the initial and only preoperative localization study in patients with sporadic primary hyperparathyroidism.
STUDY DESIGN - Two hundred twenty-six patients underwent preoperative SUS and Sestamibi scans before limited parathyroidectomy guided by quick intraoperative parathyroid hormone assay. SUS findings were noted before the surgeon had access to the scan results. Charge for localization by nuclear scan was 1,315 dollars and 204 dollars for SUS. Successful localization was determined by operative findings, intraoperative hormone dynamics, and postoperative calcium levels.
RESULTS - SUS correctly localized all the offending glands in 173 of 226 (77%) successfully treated patients. In 53 patients, SUS showed no parathyroid gland (n = 32), did not recognize multiglandular disease (n = 5), and showed an incorrect location of the abnormal gland (n = 16). In these patients, the technetium-99m-sestamibi scans successfully identified all abnormal tissue in 30 of 53 (57%). Localization using both methods was correct in 203 of 226 (90%) patients. Accuracy of SUS and scans used separately was equal. With use of quick intraoperative parathyroid hormone assay, successful parathyroidectomy was accomplished in 223 of 226 (99%), unilateral exploration in 88%, and overnight stay avoided in 78% of patients.
CONCLUSIONS - With equal accuracy, SUS is more convenient, less expensive, and noninvasive when compared with scans. Sestamibi should be used when the SUS is negative or equivocal. SUS should be the initial localizing test in the treatment of sporadic primary hyperparathyroidism.
With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy (LPX). We investigated whether ultrasonography in the hands of the surgeon (SUS) could improve the localization of abnormal parathyroids when sestamibi scans (MIBI) were negative or equivocal. One hundred eighty patients with sporadic primary hyperparathyroidism (SPHPT) underwent preoperative SUS and MIBI scans before LPX guided by intraoperative parathormone assay. When the sestamibi scans were negative, SUS was used to localize the parathyroid, distinguish parathyroid from thyroid tissue, and to guide the intraoperative jugular venous sampling for differential elevation of parathyroid hormone (PTH). Operative findings, intraoperative hormone dynamics, and postoperative calcium levels determined successful localization. MIBI was negative or equivocal in 36/180 (20%) patients: (1) showed no parathyroid gland in 22 patients, (2) suggested an incorrect location for the abnormal gland in 9, and (3) was insufficient in recognizing multiglandular disease in 5. In these 36 patients, the addition of SUS led to the successful identification of the abnormal tissue in 19/36 (53%). In the remaining 17 patients with negative/equivocal scans, the parathyroid could not be clearly visualized by SUS. In these patients, SUS facilitated LPX by aiding preoperative transcutaneous jugular venous sampling for differentially elevated PTH (n=3) and identifying questionable thyroid nodule versus parathyroid tissue (n=1). Overall, SUS was useful in 23/36 (67%) patients with nonlocalizing MIBI scans, thus improving the rate of localization from 80 per cent to 93 per cent (P < 0.01). Surgeon-performed cervical ultrasonography improved the localization of abnormal parathyroids by MIBI scan, adding to the success of limited parathyroidectomy.
Intraoperative parathyroid hormone (PTH) assay (QPTH) has made possible less invasive operative approaches in the treatment of primary hyperparathyroidism with stated advantages. When compared to the traditional bilateral neck exploration (BNE), only the targeted, hypersecreting gland is excised, leaving in situ non-visualized but normally functioning parathyroids. The QPTH-guided limited parathyroidectomy (LPX) must be able to identify multiglandular disease (MGD), predict a successful outcome, and have a low recurrence rate. In our series, 421 patients who underwent LPX were compared to 340 undergoing BNE; all operative failures and patients followed for 6 months or longer were included. Operative failure occurred if serum calcium and PTH levels were elevated within 6 months of parathyroidectomy. Multiglandular disease was defined in the LPX group as more than one gland excision guided by QPTH or operative failure after removal of a single abnormal gland; in the BNE group it was defined as excision of more than one enlarged gland. Recurrence was defined as elevated calcium and PTH after 6 months of eucalcemia. Operative failure and MGD rates were compared using chi-squared analysis. The method of Kaplan-Meier and the log-rank test were used to compare recurrence rates. Operative success was seen in 97% of LPX patients and in 94% of the BNE group ( p = 0.02). Multiglandular disease was identified in 3% of LPX patients and 10% of BNE patients ( p < 0.001). There was no statistical difference in the overall recurrence rates ( p = 0.23). The QPTH-guided parathyroidectomy identifies MGD and allows an improved success rate with the same low recurrence rate when compared to the results of BNE.
BACKGROUND - We hypothesized that imaging of regional myocardial function (RF) and perfusion (PER) will add incremental value for both diagnosis and short-term prognosis to routine demographic, clinical, and electrocardiographic findings in patients presenting to the emergency department (ED) with chest pain and without ST-segment elevation on the electrocardiogram.
METHODS - We compared contrast echocardiography (CE) with gated single-photon emission computed tomography (SPECT) for this purpose. Both CE and SPECT readings included separate and composite assessments of both RF and PER. Adverse events in the first 48 hours after ED presentation included acute myocardial infarction, emergent revascularization, and cardiac-related death.
RESULTS - Concordance between CE and SPECT was 77% (73% to 82%) for all territories, with a higher concordance for the anterior wall of 84% (78% to 89%). Of the 203 patients recruited for the study, 38 (19%) had a cardiac event within 48 hours of ED presentation: 21 had acute myocardial infarction, 16 underwent an urgent revascularization procedure, and 1 died. In multivariate logistic regression models, the number of abnormal segments on CE and SPECT were significant predictors (P <.05) of cardiac events. The composite scores on CE provided 17% incremental information (P =.009, n = 203) and gated SPECT provided 23.5% additional information (P =.020, n = 163) for predicting cardiac events compared with routine demographic, clinical, and electrocardiographic variables. RF and composite evaluation was superior on SPECT compared with CE, whereas PER alone was not.
CONCLUSIONS - Cardiac imaging of RF and PER at the time of ED presentation offers substantially greater diagnostic and prognostic information for early cardiac events in patients presenting to the ED with chest pain and no ST elevation than does the routine demographic, clinical, and electrocardiographic assessment.
OBJECTIVES - This work was undertaken to define the intrinsic cardiac risk of the patient population referred for dobutamine stress perfusion imaging and to determine whether dobutamine technetium-99m ((99m)Tc)-sestamibi single-photon emission computed tomography (SPECT) imaging is capable of risk stratification in this population.
BACKGROUND - In animal models, dobutamine attenuates the myocardial uptake of (99m)Tc-sestamibi resulting in underestimation of coronary stenoses. Therefore, we hypothesized that the prognostic value of dobutamine stress (99m)Tc-sestamibi SPECT myocardial perfusion imaging might be impaired, owing to reduced detection of coronary stenoses.
METHODS - We reviewed the clinical outcome of 308 patients (166 women, 142 men) who underwent dobutamine stress SPECT (99m)Tc-sestamibi imaging at our institution from September 1992 through December 1996.
RESULTS - During an average follow-up of 1.9 +/- 1.1 years, there were 33 hard cardiac events (18 myocardial infarctions [MI] and 15 cardiac deaths) corresponding to an annual cardiac event rate of 5.8%/year, which is significantly higher than the event rate for patients referred for exercise SPECT imaging at our institution (2.2%/year). Event rates were higher after an abnormal dobutamine (99m)Tc-sestamibi SPECT study (10.0%/year) than after a normal study (2.3%/year) (p < 0.01), even after adjusting for clinical variables. In the subgroup (n = 29) with dobutamine-induced ST-segment depression and abnormal SPECT imaging, the prognosis was poor, with annual cardiac death and nonfatal MI rates of 7.9% and 13.2%, respectively.
CONCLUSIONS - Patients referred for dobutamine perfusion imaging are a high-risk population, and dobutamine stress (99m)Tc-sestamibi SPECT imaging is capable of risk stratification in these patients.