Selective Venous Catheterization Research Articles

Somatostatin receptor imaging in persistent medullary thyroid carcinoma

Somatostatin is secreted from thyroid C-cells and seems to play an important part in the regulation of calcitonin secretion. We therefore evaluated the usefulness of somatostatin receptor scintigraphy in the localization of tumour tissue in patients with persistent medullary thyroid carcinoma. A prospective clinical study. The series consisted of 26 patients with elevated calcitonin levels after total thyroidectomy for histologically proven medullary thyroid carcinoma. Somatostatin receptor scintigraphy using 111In-pentetreotide (Octreoscan) was performed in all patients and the results correlated with histology, ultrasonography, computerized tomography, magnetic resonance imaging, plain radiography, bone scintigraphy and selective venous catheterization. Calcitonin and carcinoembryonic antigen levels were measured. The sensitivity of somatostatin receptor scintigraphy for localization of persistent medullary thyroid carcinoma was 57% in patients with histologically proven disease. The results depended on tumour mass (low sensitivity (33%) in minimal residual disease) and on the location of metastases (insensitive in detecting liver metastases). Somatostatin receptor scintigraphy is of value as an additional diagnostic tool in localizing medullary thyroid carcinoma, especially pulmonary metastases. It is of minor importance in detecting minimal residual disease.

Localization Procedures in Patients With Persistent or Recurrent Hyperparathyroidism

To determine the accuracy of noninvasive and invasive localization studies in patients with persistent or recurrent hyperparathyroidism (HPT). Reoperations based on patients who were treated surgically for recurrent or persistent HPT at the University of California-San Francisco Hospitals from 1982 to 1993. This study evaluated 174 localization studies performed in 152 patients before reoperation (110 women and 42 men). The accuracy of localization studies, including ultrasonography, thallous chloride T1 201-technetium Tc 99m pertechnetate scanning, technetium Tc 99m sestamibi scanning, magnetic resonance imaging, computed tomography, and selective venous catheterization, were evaluated, as were the results of parathyroid reoperations. A total of 174 consecutive reoperations were performed in 152 patients with HPT (persistent, 113; recurrent, 39; mean age, 54 years; range, 21 to 88 years). One hundred thirty-three patients had primary HPT, 15 had secondary HPT, and four had tertiary HPT. Overall, 141 (93%) became normocalcemic, two (1%) became hypocalcemic, and nine (6%) remained hypercalcemic. Abnormal parathyroid glands at reoperation were situated in a normal location in 77 cases (44%), in the mediastinum in 37 cases (22%), in a deep cervical location in 34 cases (19%), or in an intrathyroidal location in 14 cases (8%), or were undescended in four cases (2%); supernumerary glands were found in 26 cases (15%). Some patients had more than one remaining abnormal gland. Selective venous catheterization with a parathyroid hormone assay was done in cases in which the results of noninvasive localization studies were equivocal or negative, and it frequently converted an equivocal result of a localization study to a definitely positive result. There were no complications from the localization studies. At reoperation, permanent hypoparathyroidism that required parathyroid autotransplantation of cryopreserved tissue developed in two patients and two patients had recurrent laryngeal nerve palsies. We currently recommend using ultrasonography and technetium Tc99m sestamibi scanning and magnetic resonance imaging for patients with recurrent or persistent HPT. Selective venous catheterization with a parathyroid hormone assay is done selectively. Localization tests decrease morbidity and improve overall results in these patients.

Postrenal transplant erythrocytosis: Further evidence implicating erythropoietin production by the native kidneys

True erythrocytosis is a relatively common complication of successful renal transplantation. From a group of 17 patients with post-transplant erythrocytosis (PTE), four underwent selective venous catheterization of the native and transplanted kidneys because of arterial hypertension. In three who presented with active PTE at the time the procedure was performed the peripheral blood (PB) concentration of EPO was elevated, and the level of erythropoietin (EPO) in native kidney veins was significantly higher than the PB and allograft EPO levels. Additionally, only one of the three cases had high levels of plasma renin activity (PRA). The fourth patient showed normal levels of EPO and PRA in PB and in venous blood from the native and transplanted kidneys. However, the PTE had subsided 4 months before the performance of the catheterization after he redeveloped terminal renal failure; the loss of a functioning allograft might have blunted the overproduction of EPO by the native kidneys. In conclusion, in patients with PTE, inappropriate EPO production seems to originate from the diseased native kidneys, and there seems to be no correlation between the production of EPO and the PRA.

Mineralocorticoid excess and inhibition of 11 beta-hydroxysteroid dehydrogenase in patients with ectopic ACTH syndrome.

11 beta-Hydroxysteroid dehydrogenase protects renal mineralocorticoid receptors from cortisol by converting cortisol to inactive cortisone. We hypothesize that 11 beta-dehydrogenase is inhibited by ACTH, providing a mechanism whereby cortisol induces hypokalaemic alkalosis in ectopic ACTH syndrome. The principal sources of plasma cortisone were assessed by selective venous catheterization with measurement of cortisol and cortisone by radioimmunoassays. The effect of ACTH on peripheral plasma cortisol/cortisone ratio was assessed in healthy volunteers during circadian rhythm, insulin induced hypoglycaemia, and infusions with exogenous ACTH or cortisol. In patients with Cushing's syndrome plasma cortisol/cortisone ratios were related to plasma potassium, corticosterone, and 11-deoxycorticosterone concentrations. Catheterization was performed in 24 patients with valvular or ischaemic heart disease. Cushing's syndrome patients included: 15 with pituitary adenoma; two with adrenal adenoma; and nine with ectopic ACTH secretion. Plasma cortisol/cortisone ratios were low in renal vein and high in hepatic vein. In healthy volunteers plasma cortisone increased during cortisol infusion but did not change with increases in endogenous or exogenous ACTH. Plasma cortisol/cortisone ratios were higher in ectopic ACTH syndrome than in other forms of Cushing's syndrome. However, the cortisol/cortisone ratio was no better a predictor of hypokalaemia than the levels of 11-deoxycorticosterone or corticosterone. Peripheral conversion of cortisol to cortisone occurs mainly in the kidney and is inhibited by ACTH. In ectopic ACTH syndrome the characteristic mineralocorticoid excess can be accounted for by a combination of increased secretion of cortisol, corticosterone and of 11-deoxycorticosterone and decreased inactivation of cortisol and corticosterone by 11 beta-dehydrogenase.

Localization of occult persisting medullary thyroid carcinoma before microsurgical reoperation: high sensitivity of selective venous catheterization.

In 14 patients with occult persisting medullary thyroid carcinoma, tumor tissue was removed by microsurgical reoperation in 13 of 14 patients. This resulted in biochemical improvement in all but 1 patient and biochemical cure in 3 patients (21%). The lateral compartment of the neck or the upper mediastinum was involved in all but 1 patient. Before microsurgical reoperation, selective venous catheterization (SVC) for serum sampling along with serum calcitonin (CT) determination was done and compared to other localization methods. Tumor tissue could be localized correctly by SVC in 89% (CT gradient 1.21-2.02), computed tomography in 38%, and ultrasound in 28%. In patients with an elevated CT level after initial surgery and clinically occult disease, SVC is recommended for localization of tumor tissue. The affected side of the neck should be reoperated on with microdissection of the central and lateral compartment of the neck and the upper mediastinum. With this procedure, the cure rate of reoperation in patients with persistent occult MTC can be improved.

Primary amenorrhea in two postpubertal girls with underlying malignancy

We report two adolescent girls diagnosed with 46, XY gonadal dysgenesis and dysgerminomas who initially presented with delayed menarche. The first patient presented with primary amenorrhea and tall stature at age 14 0/12 years. Elevated serum testosterone levels and subsequent selective venous catheterization for localized testosterone levels indicated a gonadal source of the androgens. Examination of the gonads revealed testicular tissue with Leydig cell hyperplasia, and a dysgerminoma. The second patient presented with primary amenorrhea and an abdominal mass at age 15 0/12 years. Fine-needle biopsy of the mass revealed a dysgerminoma. After 4 months of standard chemotherapy, she underwent gonad-ectomy. Findings included fibrotic gonads with a right gonadoblastoma. These two patients illustrate the importance of evaluating abnormal pubertal development. As Y-bearing intraabdominal gonads are associated with significant risk of neoplasia, this diagnosis is critical and must be followed by gonadectomy.

Ovarian Hyperandrogenism and Androgen-Producing Tumors

The ovary is an active source of androgen secretion. This is regulated largely by LH but by insulin and other factors as well. Functional states include PCO as well as stromal hyperthecosis, which often mimics a neoplasm. Ovarian neoplasms are often gonadotropin responsive. Both functional and nonfunctional tumors may give rise to elevated androgen levels. Clinical history and the accurate assessment of testosterone measurements aid in the correct diagnosis of an androgen-secreting tumor. Imaging techniques, particularly vaginal ultrasound, are extremely valuable in making the diagnosis. Selective venous catheterization, although useful, should not be the primary diagnostic technique.

Selective venous catheterization in the evaluation of hyperandrogenism

Retrograde bilateral ovarian-adrenal vein catheterization was carried out in 16 patients with plasma testosterone levels exceeding 1.4 ng/ml (4.85 nmol/l). While pelvic ultrasonography and computerized axial tomographic scan failed to locate the androgen-producing ovarian tumors, catheterization led to a diagnosis of occult ovarian tumor in 5 patients, based on the observation of an abnormally-high and unilateral ovarian-peripheral vein testosterone gradient, which was subsequently confirmed histopathologically. In one case, unilateral elevation of the adrenal-peripheral vein testosterone gradient was found, complementing the ultrasonographic finding of an adrenal mass and confirming the diagnosis of a virilizing adrenal tumor. In the other 10 patients, gradient analysis ruled out an androgen-producing tumor, leading to the identification of nontumoral hyperandrogeny, such as a severe form of the polycystic ovary syndrome in the 6 premenopausal patients and of ovarian stromal and hilus cell hyperplasia in the 4 menopausal patients. In conclusion, appropriate indication of selective catheterization may considerably reduce the need for exploratory surgery and may help in selecting the adequate surgical approach.

Management of hyperparathyroid patients with grave hypercalcemia

During recent years the total number of patients undergoing surgery for hyperparathyroidism has markedly increased, but the annual number of cases with substantial hypercalcemia has remained unchanged. Parathyroid carcinoma and water clear cell hyperplasia cause more severe hypercalcemia than other kinds of hyperparathyroidism. Grave hypercalcemia due to hyperparathyroidism is more common among the elderly, but can occur during pregnancy and also among children. Occasionally, a patient with hyperparathyroidism can also have another cause of the hypercalcemia and does not become normocalcemic until adequately treated for both. The suspicion of grave hypercalcemia should arise due to its clinical features. Determination of serum calcium and intact parathyroid hormone concentrations establishes the diagnosis. The basic treatment of grave hypercalcemia is to rehydrate the patient and to restore the sodium losses. To further lower the serum calcium value we have found bisphosphonates to be very effective. The definitive treatment of grave hypercalcemia due to hyperparathyroidism is surgery. As a last resort, frail patients with grave hyperparathyroidism can undergo surgery under local anesthesia. Repeat operations can improve the prognosis of patients with metastatic parathyroid carcinoma. Selective venous catheterization with blood sampling for determination of intact parathyroid hormone can be helpful in localizing recurrent disease.

Diagnosis of a testosterone-secreting adrenal adenoma by selective venous catheterization

Diagnosis of a testosterone-secreting adrenal adenoma by selective venous catheterization

(131I)Meta-iodobenzylguanidine scintigraphy and selective venous catheterization after thyroidectomy for medullary thyroid carcinoma

Fifteen patients with medullary carcinoma of the thyroid (MCT), who had persistently elevated levels of serum calcitonin (CT) and carcinoembryonic antigen (CEA) after total thyroidectomy, were studied in order to localize the sites of the recurrent disease. Routine diagnostic examinations, including ultrasonography (US) and computed axial tomography (CAT), were carried out in all the cases. Scintigraphy with radio-iodinated metaiodobenzylguanidine ((131I)-MIBG) was performed in 13 cases; selective venous catheterization (SVC) to reveal a gradient of CT levels was performed in 12 cases. Ten patients underwent both (131I)-MIBG scintigraphy and SVC. US and CAT revealed the sites of recurrent tumor in only 4 out of the total 15 patients. SVC in basal conditions showed the presence of small metastases in 2 cases, and after intravenous stimulus with pentagastrin in 4 others. The MIBG scan showed metastatic foci of sporadic MCT in 2 patients, residual medullary thyroid tissue in 4 others, and a pheochromocytoma in a previously undiagnosed patient with Sipple's syndrome. More particularly, MIBG scan and SVC showed the localization of residual or metastatic tumor in 10 cases. In all 10 cases, results of the MIBG scan and SVC were confirmed as true positive by subsequent surgery and histopathologic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Medullary Carcinoma of the Thyroid: An Update of Diagnostic and Prognostic Factors

Medullary carcinoma of the thyroid gland (MCT) is a disease which shows an early tendency to spread both locally as well as by the blood stream. It is to day possible to make an early diagnosis in patients who have the familial form of the disease as well as perform an organ specific localization regarding possible spread of the disease. Calcitonin is a major product of MCT cells and represent the most used tumour marker for diagnosis and evaluation of prognosis. Basal calcitonin levels are not suited for making neither an accurate diagnostic or prognostic evaluation. Calcitonin provocation test (pentagastrin injections, calcium infusion/injection or a combination) are recommended for both early diagnosis as well as follow-up studies for mapping of the extent of disease. An early diagnosis can be made in kindred of a patient with familial MCT. Selective venous catheterization will in a significant way aid the localization of the disease, and together with calcitonin provocation tests reveal the presence of micro-metastases.

Effect of Endurance Exercise on Cardiac Secretion and Renal Clearance of Atrial Natriuretic Peptide in Normal Humans

Previous work from our laboratory has shown that (i) regular endurance exercise lowers blood pressure (BP), and (ii) acute exercise increases circulating levels of atrial natriuretic peptide (ANP). We hypothesised that increased ANP release may contribute to the antihypertensive effect of regular exercise. Using arterial and selective venous (coronary sinus and renal vein) catheterization and sampling, we measured cardiac secretion and renal clearance of ANP at rest in 7 normal healthy males (mean age 36 years), before and after 4 weeks of training. Body weight and haematocrit remained unchanged. Systolic BP fell by 10 mmHg with training (p = 0.008), diastolic BP fell by 6 mmHg (p = 0.006) and heart rate decreased by 9 beats/minute (p = 0.002), but central venous pressure remained unchanged. Arterial, coronary sinus and renal vein ANP concentrations did not change with training. There was no significant rise in cardiac secretion of ANP with training (sedentary: 42.6 +/- 13.2 ng/ml, trained: 47.4 +/- 17.9 ng/ml, p n.s.). Renal extraction of ANP was 72 +/- 4% before training, and unchanged (66 +/- 5%) after the exercise period. Renal clearance of ANP was also unaltered by training (514.2 +/- 48.4 ml/min before, and 508.9 +/- 74.8 ml/min after training, p n.s.). We conclude that as ANP release is not increased by training, the peptide does not account for the anti-hypertensive effect of endurance exercise. Other humoral and/or neural mechanisms possibly mediate the beneficial haemodynamic effects of training.

Cardiac Secretion and Renal Clearance of Atrial Natriuretic Peptide in Normal Man: Effect of Salt Restriction

1. Previous studies of endogenous atrial natriuretic peptide (ANP) in humans have examined changes in plasma levels, rather than regional secretion and clearance of the peptide. Using arterial and selective venous catheterization and sampling, and measurement of regional organ flow, we measured haemodynamics, cardiac secretion of ANP and renal clearance of ANP in six healthy volunteers at rest, on a normal sodium diet. 2. Salt restriction decreases plasma concentrations of ANP. We assessed the contribution of the heart and kidney to this decrease, by measuring cardiac secretion and renal clearance of ANP at the termination of a low salt diet. 3. Twenty-four hour urinary sodium excretion fell on the low salt diet from 163 to 29 mmol/day [standard error of the difference (SED)+/- 14, P less than 0.001]. Body weight decreased on salt restriction from 76.4 to 75.4 kg (SED +/- 0.33, P less than 0.05). Brachial mean arterial pressure fell by 6% (P less than 0.05), but right atrial pressure was unchanged. Renal vein plasma renin activity increased by 56% with sodium restriction (P less than 0.01), whereas arterial ANP concentrations fell by 39% (P less than 0.05). 4. Coronary sinus ANP levels fell from 417 to 268 pg/ml (SED +/- 74, P less than 0.05), whereas renal vein concentrations were unaltered. There was a 47% decrease in cardiac secretion of ANP in the low salt state (P less than 0.05). Net extraction of ANP across the kidney (about two-thirds) and renal clearance of ANP were unchanged on the low salt diet. Thus decreased plasma ANP with sodium restriction is due to reduced cardiac secretion.

Arteriographic ablation of cervical parathyroid adenomas.

In some cases of primary hyperparathyroidism, in particular where neck exploration has been unsuccessful, an alternative to surgical therapy may be desirable. We studied the acute and chronic metabolic effects of attempted angiographic destruction by angiographic contrast infusion of solitary parathyroid adenomas in 18 patients with symptomatic disease. Fourteen patients had failed prior surgery; 4 patients had not undergone prior surgery but were extremely high surgical risks. Cervical adenomas were present in 17 of 18 subjects; mediastinal adenoma in 1 of 18. Sixteen patients underwent selective parathyroid venous catheterization, which facilitated subsequent arteriographic localization. Selective arteriographic localization and attempted angiographic ablation were performed in all subjects with standard contrast, renografin-60. Laboratory studies, including serum calcium and PTH, were frequently performed before and after attempted angiographic parathyroid ablation. In all patients serum calcium fell to normal or subnormal levels within 48 h of attempted ablation. Prolonged follow-up (mean, 35.1 months) revealed that ablation was curative in 12 of 18 (sustained normocalcemia) and partially effective in 1 of 18 patients. For the entire group serum calcium fell from 3.14 +/- 0.07 at presentation to 2.42 +/- 0.07 mmol/L at the end of follow-up (or before surgery in unsuccessful cases; P less than 0.001). In 4 of 5 failed cases hypercalcemia recurred within 2 weeks. All 5 failed cases underwent curative surgery, aided by accurate localization achieved during angiographic procedure. Several transient complications and 1 case of permanent hypoparathyroidism were noted. We conclude that angiographic ablation of cervical parathyroid adenomas can be considered as an extension of diagnostic angiographic procedures in selected cases of primary hyperparathyroidism who have failed prior surgery of possibly in rare cases where surgery is contraindicated.

Preoperative Localization of Androgen-Secreting Tumors

Abstract A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were ovarian, and one adrenal. In an attempt to correctly diagnose the presence of tumor and to accurately localize the lesion to a specific gland, steroid hormones in peripheral, ovarian, and adrenal vein serum were analyzed by radioimmunoassay. Little correlation was made in this series with those levels of testosterone (>2 ng/ml) or dehydroepiandrosterone sulfate (>7000 ng/ml) that have been widely used to predict the presence of such tumors. Peripheral testosterone levels were less than 2 ng/ml in 50% of our patients, and the dehydroepiandrosterone sulfate level was greater than 7000, ng/ml in only a single patient with an ovarian lipoid cell tumor. Pelvic ultrasonography was found to be of limited value in evaluating nonpalpable tumor because of the small size ( 3 ) of the majority of these neoplasms. The use of selective retrograde venous catheterization to demonstrate significant effluent-peripheral vein androgen gradients served to accurately localize androgen-secreting tumors in all six patients in which it was used. Our data emphasize the potential pitfalls that exist in the preoperative evaluation of patients with these fascinating neoplasms and the importance of a high degree of suspicion on the part of the physician caring for these women.

Mediastinal parathyroid tumors.

Mediastinal parathyroid tumors are a frequent cause of failed parathyroid operations. I therefore reviewed my experience with 285 consecutive patients treated surgically for hyperparathyroidism from January 1981 to Dec 31, 1986. Two hundred eighty-eight operations were performed on these patients (246 primary, 38 secondary, one error in diagnosis, and 53 reoperations). Mediastinal parathyroid tumors were present in 64 (22%) of the entire group of 285 patients with hyperparathyroidism, and 20 (38%) of 53 patients requiring reoperation for persistent or recurrent hyperparathyroidism. Fifty-two parathyroid tumors were situated in the anterior mediastinum and 12 were found in the posterior mediastinum; 56 of the mediastinal tumors were removed via a cervical approach. In four patients the mediastinal tumor was a fifth histologically documented parathyroid gland. Mediastinal tumors were identified by preoperative localization studies (ultrasonography, three [16%]; thallium-technetium, five of 17 [29%]; computed tomography, eight of 14 [57%]; magnetic resonance imaging, three of seven [43%]; and selective venous catheterization for parathyroid hormone, ten of 11 [91%]). Awareness of the relatively high occurrence of mediastinal tumors (52 anterior, 12 posterior) should decrease the risk of failed parathyroid operations.

Preoperative localization of androgen-secreting tumors: Clinical, endocrinologic, and radiologic evaluation of ten patients

A series of 10 patients with benign androgen-secreting neoplasms is presented. Nine tumors were ovarian, and one adrenal. In an attempt to correctly diagnose the presence of tumor and to accurately localize the lesion to a specific gland, steroid hormones in peripheral, ovarian, and adrenal vein serum were analyzed by radioimmunoassay. Little correlation was made in this series with those levels of testosterone (>2 ng/ml) or dehydroepiandrosterone sulfate (>7000 ng/ml) that have been widely used to predict the presence of such tumors. Peripheral testosterone levels were less than 2 ng/ml in 50% of our patients, and the dehydroepiandrosterone sulfate level was greater than 7000, ng/ml in only a single patient with an ovarian lipoid cell tumor. Pelvic ultrasonography was found to be of limited value in evaluating nonpalpable tumor because of the small size (<2 cm3) of the majority of these neoplasms. The use of selective retrograde venous catheterization to demonstrate significant effluent-peripheral vein androgen gradients served to accurately localize androgen-secreting tumors in all six patients in which it was used. Our data emphasize the potential pitfalls that exist in the preoperative evaluation of patients with these fascinating neoplasms and the importance of a high degree of suspicion on the part of the physician caring for these women.

Primary Hyperparathyroidism: Changing Principles in Evaluation and Surgical Approach

Ashok Shaha, MD, and collaborators, New York, reported their five-year experience with 61 patients who underwent neck exploration for primary hyperparathyroidism. Their presentation was at the 91st annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Chicago. The diagnosis was made on the basis of serum calcium, phosphorus, and parathormone levels, and a 24-hour urinary calcium evaluation. Preoperatively, localization studies were obtained in only ten patients. These studies included ultrasound, thalliumtechnetium subtraction scans, and computed tomographic scan of the neck and mediastinum. More invasive studies, such as arteriography, selective venous catheterization, and digital subtraction angiography, were used only in those patients who underwent secondary explorations. Bilateral neck exploration was performed, and identification of all four parathyroid glands was undertaken. Multiglandular disease occurred in 13% of patients. Frozen section was utilized to distinguish parathyroid gland from thymus, fat, thyroid, or lymph node. Hypoparathyroidism developed in two patients (one permanent)

Virilization due to ovarian hyperthecosis in a postmenopausal woman

A 51-year-old woman presented with hirsutism and virilization of gradual onset. The serum gonadotropin concentrations were in the postmenopausal range, the serum testosterone concentration was markedly elevated (9.8 nmol/l) and the serum estradiol concentration (220 pmol/l) was elevated above the postmenopausal range. A selective venous catheterization study demonstrated raised serum testosterone and androstenedione levels in ovarian veins and suggested the presence of a left ovarian tumor. The raised peripheral estradiol level was shown to be due to ovarian hypersecretion. After bilateral oophorectomy the serum testosterone became normal. Ovarian histology revealed bilateral stromal hyperthecosis. Ovarian hyperthecosis is a rare but important cause of serum testosterone levels in the neoplastic range. This is the third case reported of postmenopausal virilization due to ovarian hyperthecosis and the first report of a selective venous catheterization study in such a patient.