Publications by authors named "Mirosław Dziuk"

61 Publications

Evaluation of the usefulness of positron emission tomography with [18F]fluorodeoxylglucose performed to detect non-radioiodine avid recurrence and/or metastasis of differentiated thyroid cancer - a preliminary study.

Nucl Med Rev Cent East Eur 2021 ;24(2):63-69

Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Poland.

Background: About 30% of patients with disseminated differentiated thyroid cancer (DTC) may experience a loss of iodine uptake. It is associated with higher aggressiveness of the tumour and a reduced 10-year survival rate. The diagnosis of non-radioiodine avid DTC metastases remains a diagnostic challenge. A helpful technique for this diagnosis is positron emission tomography with 2-[¹⁸F]fluoro-2-deoxy-D-glucose (PET/CT with [¹⁸F]FDG). On the other hand, there are still discussions about the clinical value of using exogenous thyroid-stimulating hormone (TSH) stimulation before PET/CT with [¹⁸F]FDG. The aim of the study was the assessment of the usefulness of PET/CT with [¹⁸F]FDG under TSH suppression and stimulation of TSH performed in the detection of non-radioiodine avid DTC metastases, as well as determination of the thyroglobulin concentration under suppression and stimulation of TSH, which influences the result of PET/CT with [¹⁸F]FDG in patients with non-radioiodine avid DTC.

Material And Methods: Retrospective analysis of 37 PET/CT with [¹⁸F]FDG performed in patients with DTC diagnosed and treated at the Department of Endocrinology and Isotope Therapy of the Military Institute of Medicine from January 2018 to July 2020. Of these, PET/CT with [¹⁸F]FDG under exogenous rhTSH stimulation was performed in 22 patients and PET/CT with [¹⁸F]FDG under TSH suppression in 15 was performed. In all analyzed patients, the result of diagnostic whole-body scintigraphy (WBS) using 80 MBq ¹³¹I under rhTSH stimulation was negative, and the concentration of thyroglobulin after stimulation (sTg) was greater than 1.0 ng/mL.

Results: In the group of patients examined under TSH suppression, non-radioiodine avid in PET/CT with [¹⁸F]FDG were found in 6 out of 15 patients (40%) and in the group of patients examined under rhTSH stimulation in 10 out of 22 patients (45%). The differences between the groups were not statistically significant. The analysis of the receiver operating characteristic (ROC) curves allowed to determine the cut-off point for the positive result of PET/CT performed under TSH suppression with sTg concentration of 11.03 ng/mL. In the group of studies performed under rhTSH stimulation, the cut-off point for sTg was 6.3 ng/mL. There was no statistically significant difference between the baseline thyroglobulin (natTg) and sTg levels and the positive PET/CT result. The administration of rhTSH before the PET/CT examination also had no statistically significant effect on the maximum standard uptake value (SUVmax) of the dominant lesion identified in the PET/CT.

Conclusions: 1) PET/CT with [¹⁸F]FDG is a useful tool for detection of non-radioiodine avid recurrence and/or metastases of DTC. 2) The concentration of natTg and sTg is highly correlated with a positive result of PET/CT with [¹⁸F]FDG. 3) The concentration of natTg is comparable with sTg in predicting a positive result of PET/CT with [¹⁸F]FDG. 4) The cut-off point for a positive result of PET/CT for natTg was 1.36 ng/mL and for sTg was 7.05 ng/mL.
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http://dx.doi.org/10.5603/NMR.2021.0017DOI Listing
January 2021

A new in vitro model applied Y microspheres to study the effects of low dose beta radiation on colorectal cancer cell line in various oxygenation conditions.

Sci Rep 2021 Feb 24;11(1):4472. Epub 2021 Feb 24.

Laboratory of Molecular Oncology and Innovative Therapies, Military Institute of Medicine, Warsaw, Poland.

We propose a new in vitro model to assess the impact of Y-microspheres derived low-dose beta radiation on colorectal cancer cell line under various oxygenation conditions that mimic the tumor environment. Cancer cells (HCT116) proliferation was assessed using Alamar Blue (AB) assay after 48, 72, and 96 h. FLUKA code assessed changes in cancer cell populations relative to the absorbed dose. In normoxia, mitochondrial activity measured by Alamar Blue after 48-72 h was significantly correlated with the number of microspheres (48 h: r = 0.87 and 72 h: r = 0.89, p < 0.05) and absorbed dose (48 h: r = 0.87 and 72 h: r = 0.7, p < 0.05). In hypoxia, the coefficients were r = 0.43 for both the number of spheres and absorbed dose and r = 0.45, r = 0.47, respectively. Impediment of cancer cell proliferation depended on the absorbed dose. Doses below 70 Gy could reduce colorectal cancer cell proliferation in vitro. Hypoxia induced a higher resistance to radiation than that observed under normoxic conditions. Hypoxia and radiation induced senescence in cultured cells. The new in vitro model is useful for the assessment of Y radioembolization effects at the micro-scale.
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http://dx.doi.org/10.1038/s41598-021-84000-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904911PMC
February 2021

Evaluation of qualitative and quantitative data of Y-90 imaging in SPECT/CT and PET/CT phantom studies.

PLoS One 2021 10;16(2):e0246848. Epub 2021 Feb 10.

National Centre for Nuclear Research, Radioisotope Centre POLATOM, Otwock-Świerk, Poland.

Introduction: We aimed to assess the feasibility of SPECT and PET Y-90 imaging, and to compare these modalities by visualizing hot and cold foci in phantoms for varying isotope concentrations.

Materials And Methods: The data was acquired from the Jaszczak and NEMA phantoms. In the Jaszczak phantom Y-90 concentrations of 0.1 MBq/ml and 0.2 MBq/ml were used, while higher concentrations, up to 1.0 MBq/ml, were simulated by acquisition time extension with respect to the standard clinical protocol of 30 sec/projection for SPECT and 30 min/bed position for PET imaging. For NEMA phantom, the hot foci had concentrations of about 4 MB/ml and the background 0.1 or 0.0 MBq/ml. All of the acquired data was analysed both qualitatively and quantitatively. Qualitative assessment was conducted by six observers asked to identify the number of visible cold or hot foci. Inter-observer agreement was assessed. Quantitative analysis included calculations of contrast and contrast-to-noise ratio (CNR), and comparisons with the qualitative results.

Results: For SPECT data up to two cold foci were discernible, while for PET four foci were visible. We have shown that CNR (with Rose criterion) is a good measure of foci visibility for both modalities. We also found good concordance of qualitative results for the Jaszczak phantom studies between the observers (corresponding Krippendorf's alpha coefficients of 0.76 to 0.84). In the NEMA phantom without background activity all foci were visible in SPECT/CT images. With isotope in the background, 5 of 6 spheres were discernible (CNR of 3.0 for the smallest foci). For PET studies all hot spheres were visible, regardless of the background activity.

Conclusions: PET Y-90 imaging provided better results than Bremsstrahlung based SPECT imaging. This indicates that PET/CT might become the method of choice in Y-90 post radioembolization imaging for visualisation of both necrotic and hot lesions in the liver.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246848PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875374PMC
August 2021

Feasibility of FDG PET in the cardiac inflammation.

Int J Cardiovasc Imaging 2021 Mar 15;37(3):1097-1104. Epub 2020 Oct 15.

Department of Nuclear Medicine, Military Institute of Medicine, 128 Szaserów St, 04-141, Warsaw, Poland.

The aim of the study was to assess the feasibility of FDG PET in cardiac inflammation with a particular focus on the delayed scan. Thirty-five consecutive FDG PET scans of patients with suspected or confirmed cardiac inflammation were retrospectively reviewed. The patients were referred for PET because of endocarditis (n = 16) or sarcoidosis (n = 19). Among them four patients had two consecutive for follow up and treatment control (two patients with sarcoidosis, two with endocarditis). In all of the cases a standard head to mid-thigh scan was performed 45-60 min after FDG injection as well as a delayed heart scan 1 h after the standard imaging was performed. FDG PET confirmed active inflammation in 10 out of 35 scans. Delayed scans in positive cases showed SUVmax value increase, but did not have an impact on the result, neither they did in negative cases-no significant differences between standard and delayed scan were found. Interestingly in 5 out of 14 cases with suspected endocarditis PET revealed the extracardiac inflammation focus, thus changing initial diagnosis. FDG PET also indicated which prosthesis caused inflammation if there were many. In the sarcoidosis group the aim was to confirm or exclude heart involvement (13 scans) or to assess the response to the steroid therapy (6 scans) in patients with previously confirmed sarcoidosis. PET revealed active heart disease in 3 initial scans, and 1 follow up scan. FDG PET is a valuable imaging method for the cardiac inflammation assessment. It adequately localises the active inflammation site. Also, since it is a whole-body scan it may detect the extracardiac inflammation foci, which in some cases may change the initial diagnosis. In our study the delayed scans showed no added value.
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http://dx.doi.org/10.1007/s10554-020-02056-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969535PMC
March 2021

Schnitzler Syndrome in a 27-Year-Old Man: Diagnostic and Therapeutic Dilemma in Adult Auto-Inflammatory Syndromes A Case Report and Literature Review.

Int J Gen Med 2020 25;13:713-719. Epub 2020 Sep 25.

Department of Internal Medicine, Pulmonology, Allergy and Clinical Immunology, Central Clinical Hospital of the Ministry of National Defense, Military Institute of Medicine in Warsaw, Warsaw, Poland.

A 32-year-old-man, with a history of chronic urticaria from the age of 27, diagnosed with an adult-onset Still's disease and received a low dose of glucocorticoids, methotrexate and tocilizumab. Despite the long-term combined treatments, he suffered from chronic urticaria, low-grade fever and bone pain. He was found to have high inflammatory markers, hypogammaglobulinemia, monoclonal IgM - kappa light chain in serum and increased radiotracer uptake in the whole bone scintigraphy. No pathological variants for monogenic autoinflammatory diseases were present in the genome exome sequencing. These investigations confirmed the diagnosis of Schnitzler syndrome, which is an exception before the age of 35. Switching from tocilizumab to interleukin 1 receptor inhibitor, anakinra led to a full clinical response and normalisation of inflammatory markers. Patients with a history of fever and chronic urticaria are routinely tested for monoclonal gammopathy in the context of malignancy, but it should also be considered as a sign of the autoinflammatory syndrome. The Schnitzler syndrome and the adult-onset Still's disease share common features, so the diagnosis requires a thorough investigation to establish an optimal treatment. In the diagnostic algorithm, monoclonal gammopathy is usually considered red flag for malignancy but might be overlooked as a criterion of Schnitzler syndrome, particularly in young adults. We confirm that the interleukin 1 inhibitor should be the first line of therapy in Schnitzler syndrome, and in the presented case we found it more effective than the interleukin 6 blockade. The main goal of this paper is to increase awareness of Schnitzler syndrome among health care professionals. We aim to present features which can be helpful in differential diagnosis.
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http://dx.doi.org/10.2147/IJGM.S265482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532303PMC
September 2020

Ordered subset expectation maximisation vs Bayesian penalised likelihood reconstruction algorithm in 18F-PSMA-1007 PET/CT.

Ann Nucl Med 2020 Mar 4;34(3):192-199. Epub 2020 Jan 4.

Synektik Pharma, Kielce, Poland.

Background: The aim of the study was to compare widely used ordered subset expectation maximisation (OSEM) algorithm with a new Bayesian penalised likelihood (BPL) Q.Clear algorithm in 18F-PSMA-1007 PET/CT.

Methods: We retrospectively assessed 25 18F-PSMA-1007 PET/CT scans with both OSEM and Q.Clear reconstructions available. Each scan was independently reported by two physicians both in OSEM and Q.Clear. SUVmax, SUVmean and tumour-to-background ratio (TBR) of each lesion were measured. Reports were also compared for their final conclusions and the number and localisation of lesions.

Results: In both reconstructions the same 87 lesions were reported. Mean SUVmax, SUVmean and TBR were higher for Q.Clear than OSEM (7.01 vs 6.53 [p = 0.052], 4.16 vs 3.84 [p = 0.036] and 20.2 vs 16.8 [p < 0.00001], respectively). Small lesions (< 10 mm) had statistically significant higher SUVmax, SUVmean and TBR in Q.Clear than OSEM (5.37 vs 4.79 [p = 0.032], 3.08 vs 2.70 [p = 0.04] and 15.5 vs 12.5 [p = 0.00214], respectively). For lesions ≥ 10 mm, no significant differences were observed. Findings with higher tracer avidity (SUVmax ≥ 5) tended to have higher SUVmax, SUVmean and TBR values in Q.Clear (11.6 vs 10.3 [p = 0.00278], 7.0 vs 6.7 [p = 0.077] and 33.9 vs 26.7 [p < 0.00001, respectively). Mean background uptake did not differ significantly between Q.Clear and OSEM (0.42 vs 0.39, p = 0.07).

Conclusions: In 18F-PSMA-1007 PET/CT, Q.Clear SUVs and TBR tend to be higher (regardless of lesion localisation), especially for small and highly avid lesions. Increase in SUVs is also higher for lesions with high tracer uptake. Still, Q.Clear does not affect 18F-PSMA-1007 PET/CT specificity and sensitivity.
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http://dx.doi.org/10.1007/s12149-019-01433-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7033087PMC
March 2020

Diagnostic performance of 18F-PSMA-1007 PET/CT in biochemically relapsed patients with prostate cancer with PSA levels ≤ 2.0 ng/ml.

Prostate Cancer Prostatic Dis 2020 06 28;23(2):343-348. Epub 2019 Nov 28.

Synektik Pharma, Kielce, Poland.

Background: The aim of the study was to prospectively evaluate diagnostic performance of 18F-PSMA-1007 PET/CT in patients with prostate cancer (PCa) after radical treatment and low but rising prostate-specific antigen (PSA) levels.

Methods: We prospectively enrolled 40 consecutive patients after radical treatment (80%-radical prostatectomy, 20%-radiation beam therapy) of PCa and low (0.008 to ≤2.0 ng/ml), rising PSA. Skull to mid-thigh PET/CT imaging was performed 95 (±12) min after injection of 295.5 (±14.1) MBq 18F-PSMA-1007. Detection rate was correlated with PSA levels, Gleason score (GS) and T stage ≥ 3. PET/CT results were verified during 10.3 (±4.7) months follow-up to calculate sensitivity, specificity, negative predictive values (NPV) and positive predictive values (PPV).

Results: 18F-PSMA-1007 PET/CT was positive in 24/40 patients, which yielded overall detection rate of 60%. Detection rate was 39%, 55% and 100% for PSA < 0.5, 0.5 to <1.0 and 1.0 to ≤2.0 ng/ml, respectively. PET/CT showed metastases in locoregional lymph nodes in 55% of patients, bones in 36% of patients and local recurrence in 9% of patients. Detection rate was correlated with PSA-a 0.1 ng/ml rise in PSA level increased odds for positive PET/CT by ~30%. PET/CT positivity was independent of GS and T stage. Verification of 40 lesions yielded sensitivity, specificity, PPV and NPV of 100%, 94.4%, 66.7% and 100%, respectively.

Conclusions: 18F-PSMA-1007 PET/CT shows relatively high detection rate in patients with PCa after radical treatment and low, rising PSA levels. Like other PSMA-targeting radiotracers, its detection rate is dependent on PSA levels. 18F-PSMA-1007 also presents excellent sensitivity, specificity and NPV.
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http://dx.doi.org/10.1038/s41391-019-0194-6DOI Listing
June 2020

Head-to-Head Comparison of 18F-Prostate-Specific Membrane Antigen-1007 and 18F-Fluorocholine PET/CT in Biochemically Relapsed Prostate Cancer.

Clin Nucl Med 2019 Dec;44(12):e629-e633

Synektik Pharma, Kielce, Poland.

Purpose Of The Report: The aim of the study was to prospectively compare performance of F-fluorocholine (FCH) and F-prostate-specific membrane antigen (PSMA)-1007 PET/CT in patients with biochemical relapse (BCR) of prostate cancer and low prostate-specific antigen levels.

Methods: We prospectively enrolled 40 BCR patients after radical treatment and prostate-specific antigen levels 2.0 ng/mL or less. F-FCH and F-PSMA-1007 PET/CT imaging was performed within a mean interval of 54 ± 21 days. Scans were done 87 ± 10 and 95 ± 12 minutes after injecting 248 ± 35 and 295 ± 14 MBq of F-FCH and F-PSMA-1007, respectively. Rates of negative, equivocal, and positive scan results were compared per patient. Per lesion, findings were grouped as equivocal or highly suggestive of malignancy and then compared for their number, localization (local relapse, lymph nodes, bones), and SUVmax values.

Results: Positive, equivocal, and negative results were reported in 60%, 27.5%, and 12.5% of F-PSMA-1007 and in 5%, 37.5%, and 57.5% of F-FCH scans, respectively. In 70% of scans, F-PSMA-1007 PET/CT upgraded F-FCH PET/CT results. F-PSMA-1007 scans also showed significantly more lesions (184 vs 63, P = 0.0006). Local relapse, lymph node, and bone lesions accounted, respectively, for 9%, 58%, and 33% of F-PSMA-1007 and 5%, 89%, and 6% F-FCH of PET/CT findings. Highly suspicious lesions accounted for 74% of F-PSMA-1007 and 11% of F-FCH PET/CT findings. In F-PSMA-1007 PET/CT SUVmax values of highly suggestive lesions were significantly higher than in equivocal lesions (median, 3.6 vs 2.5; P < 0.00001).

Conclusions: In early BCR patients F-PSMA-1007 showed a higher detection rate than F-FCH PET/CT. The former also showed more lesions in total, more highly suggestive lesions and less equivocal lesions.
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http://dx.doi.org/10.1097/RLU.0000000000002794DOI Listing
December 2019

Gallbladder Radiation Protection in SIRT-Quantitative Anatomical Study of Hepatic Vasculature.

J Clin Med 2019 Sep 24;8(10). Epub 2019 Sep 24.

Department of Interventional Radiology, Military Institute of Medicine, Szaserów 128, 04-141 Warsaw, Poland.

This study was designed to assess quantitatively a safe position of the microcatheter during the SIRT (Selective Internal Radiation Therapy) procedure, in order to minimize the risk of non-target spheres leaking. Retrospective analysis of the distance of the tip of the microcatheter from coiled or patent non-target arteries was measured during Tc-MAA work-up procedure. Frequency of extrahepatic leaking during work-up and SIRT procedures was evaluated. There were 85 patients who underwent 98 work-up procedures. There were 64 radioembolizations. There were 44 gastroduodenal, 51 right gastric, and 54 cystic artery embolizations performed. Extrahepatic Tc-MAA leaking was observed in 33 cases: 16 to gallbladder, four to a gastric wall, nine to the duodenum, one to the intestinal wall, and three to the abdominal wall. Leak in Tc-MAA was also related to the presence of additional arteries ( = 0.009). There were 34 proximal and 31 distal to cystic artery Tc-MAA injections resulting in 12 vs. four leaks, respectively ( = 0.039, RR-2.5). Mean distance of the tip of the microcatheter from the origin of the cystic artery was 20 mm (minimum of 2.1 mm and maximum of 53 mm) proximally and 10 mm (minimum 1 mm and maximum 51 mm) distally (ns). Leaking in Tc-MAA (Tc - labelled macroaggregated albumin) was related to the presence of additional arteries. Regardless of cystic artery embolization, it is 2.5 times safer to inject microspheres distal to its origin, compared to proximal injection. Cystic artery origin relative to the right hepatic artery division usually necessitates embolization of the former.
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http://dx.doi.org/10.3390/jcm8101531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832272PMC
September 2019

Feasibility of myocardial perfusion imaging studies in morbidly obese patients with a cadmium-zinc-telluride cardiac camera.

Nucl Med Rev Cent East Eur 2019 ;22(1):18-22

Military Institute of Medicine, Szaserów 128 Street, 04-141 Warsaw.

Background: A novel cardiac SPECT camera with cadmium-zinc-telluride (CZT) based technology has a fixed array of semiconductor detectors paired with pinhole collimators focused on the heart. Image acquisition in obese patients can be challenging because of much smaller detector field of view compared to conventional gamma cameras. The aim of this study was to evaluate the impact on high body mass on the feasibility of CZT myocardial perfusion imaging (MPI). The additional aim was to investigate the mechanism of the banana-shaped/obesity artifact, as referred to in literature, and to attempt at simulating it on a phantom study.

Material And Methods: Study group consisted of 43 patients with morbid obesity (BMI ≥ 40 kg/m2). All these patients underwent myocardial perfusion imaging on both CZT cardiac camera and general purpose SPECT/CT gamma camera. Control group consisted of all patients who underwent myocardial perfusion imaging on CZT camera throughout one calendar year and whose BMI was lower than 40 kg/m2. In this group, all repeated studies were re-analyzed for estimating the frequency of heart mispositioning in the camera field of view. The number of studies performed was 1180. A static cardiac phantom was used to simulate a banana-shaped artifact. A series of phantom acquisitions during which the phantom position was altered in the camera field of view was performed.

Results: In control group, 3.7% of all cardiac scintigrams required repetition, 18.9% of which were repeated due to wrong heart positioning; median BMI in this group of patients was 36.0. A banana-shaped artifact was observed in one female patient with BMI 36.0. In morbid obesity group, 32.6% of the studies were non-diagnostic with "truncation effect" on Scan Quality Control (QC). Median BMI in patients with diagnostic scans was 42.0, while in patients with not acceptable quality control test it was 45.0 (p < 0.05). Banana-shaped artifacts were observed in 5 non-diagnostic studies. In a phantom study an artifact of banana shape was obtained when gantry was distant from the phantom and target was on the edge of the camera field of view and was slightly truncated.

Conclusions: Problem with heart mispositioning during imaging on the CZT camera affects less than 1% of all performed studies. Morbid obesity is not a contraindication to perform myocardia.
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http://dx.doi.org/10.5603/NMR.2019.0003DOI Listing
April 2020

18F-Prostate-Specific Membrane Antigen 1007 and 18F-FCH PET/CT in Local Recurrence of Prostate Cancer.

Clin Nucl Med 2019 Jun;44(6):e401-e403

From the Affidea Mazovian PET/CT Centre, Warsaw, Poland.

F-prostate-specific membrane antigen (PSMA) 1007 is one of the most promising radiotracers for PET imaging of relapsing prostate cancer. Minimal urinary clearance seems to be its most valuable and outstanding feature. We present images of biochemically relapsed prostate cancer where F-PSMA-1007 PET/CT (performed to verify an ambiguous finding adjacent to the urinary bladder found in F-FCH PET/CT) proved superior to radiocholine and precisely visualized site of local recurrence.
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http://dx.doi.org/10.1097/RLU.0000000000002556DOI Listing
June 2019

The diagnostic efficacy and safety of stress-only supine and prone myocardial perfusion imaging with a dedicated cardiac gamma camera in patients with suspected or known coronary artery disease.

Nucl Med Rev Cent East Eur 2018 ;21(2):104-108

Nuclear Medicine Department, Military Institute of Medicine, Szaserów Street 128, 04-141 Warsaw, Poland.

Background: Myocardial perfusion scintigraphy remains one of the substantial noninvasive diagnostic methods in coronary artery disease. Recent technological advancement allowed to create novel semiconductor, dedicated cardiac gamma camera with better spatial resolution and higher energy resolution, resulting in the reduction of radiation burden and acquisition time. The aim of this study was to evaluate the efficacy and safety of stress-only supine and prone MPS with a cardiac gamma camera in patients with suspected or known coronary artery disease.

Material And Methods: A total number of 203 consecutive patients with suspected or known coronary artery disease, who underwent MPS were enrolled in the study. The patients without perfusion abnormalities on stress supine and prone MPS scans had no rest MPS, in the remaining patients two-day stress-rest imaging was performed. The group of 160 patients with one-year follow up was subjected to final analysis.

Results: Stress-only protocol of myocardial perfusion imaging was performed in 72 patients, 88 patients underwent two-day stress and rest myocardial perfusion scintigraphy. In 46 out of 72 stress-only group of patients, prone study did not affect further proceedings. However, in over 1/3 of cases (26/72), prone scans resulted in abstaining from rest imaging. One year follow-up revealed no sudden cardiac deaths or myocardial infarctions in both (stress-only and stress-rest) groups. Revascularization was performed most often in the double-positive group - patients with significant ischaemia on myocardial perfusion images and chest pain or electrocardiographic changes or both during the stress test. In this double-positive group, all 11 patients had coronary angiography (two of them prior to myocardial perfusion scintigraphy), nine of them had subsequent revascularization.

Conclusions: In patients with no significant perfusion abnormalities on stress scans omitting rest study is safe with very good one-year risk prognosis of acute cardiac events and allows to limit the radiation exposure and procedure duration. Additional prone acquisitions are valuable supplements in determining the decision of safe early completion of myocardial perfusion imaging.
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http://dx.doi.org/10.5603/NMR.2018.0028DOI Listing
October 2018

The Predictive Value of SPECT/CT imaging in colorectal liver metastases response after 90Y-radioembolization.

PLoS One 2018 10;13(7):e0200488. Epub 2018 Jul 10.

Nuclear Medicine Department of Military Institute of Medicine, Warsaw, Poland.

Conclusion: The mT/N1 ratio, PAD, and AAD can be used as predictors of tumor response to SIRT treatment, and SPECT/CT imaging can be used for dosimetric assessment of radioembolization.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0200488PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039046PMC
January 2019

The role of FDG-PET in Hodgkin lymphoma.

Contemp Oncol (Pozn) 2017 30;21(2):104-114. Epub 2017 Jun 30.

Affidea Mazovian PET/CT Center, Warsaw, Poland.

18-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) is currently the most valuable imaging technique in Hodgkin lymphoma. Since its first use in lymphomas in the 1990s, it has become the gold standard in the staging and end-of-treatment remission assessment in patients with Hodgkin lymphoma. The possibility of using early (interim) PET during first-line therapy to evaluate chemosensitivity and thus personalize treatment at this stage holds great promise, and much attention is now being directed toward this goal. With high probability, it is believed that in the near future, the result of interim PET-CT would serve as a compass to optimize treatment. Also the role of PET in pre-transplant assessment is currently evolving. Much controversy surrounds the possibility of detecting relapse after completed treatment with the use of PET in surveillance in the absence of symptoms suggestive of recurrence and the results of published studies are rather discouraging because of low positive predictive value. This review presents current knowledge about the role of 18-FDG-PET/CT imaging at each point of management of patients with Hodgkin lymphoma.
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http://dx.doi.org/10.5114/wo.2017.68618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611499PMC
June 2017

Added diagnostic value of respiratory-gated 4D 18F-FDG PET/CT in the detection of liver lesions: a multicenter study.

Eur J Nucl Med Mol Imaging 2018 Jan 19;45(1):102-109. Epub 2017 Aug 19.

Nuclear Medicine, San Gerardo Hospital, Monza, Italy.

Purpose: The aim of the present study was to evaluate the added diagnostic value of respiratory-gated 4D18F-FDG PET/CT in liver lesion detection and characterization in a European multicenter retrospective study.

Methods: Fifty-six oncological patients (29 males and 27 females, mean age, 61.2 ± 11.2 years) from five European centers, submitted to standard 3D-PET/CT and liver 4D-PET/CT were retrospectively evaluated. Based on visual analysis, liver PET/CT findings were scored as positive, negative, or equivocal both in 3D and 4D PET/CT. The impact of 4D-PET/CT on the confidence in classifying liver lesions was assessed. PET/CT findings were compared to histology and clinical follow-up as standard reference and diagnostic accuracy was calculated for both techniques. At semi-quantitative analysis, SUVmax was calculated for each detected lesion in 3D and 4D-PET/CT.

Results: Overall, 72 liver lesions were considered for the analysis. Based on visual analysis in 3D-PET/CT, 32/72 (44.4%) lesions were considered positive, 21/72 (29.2%) negative, and 19/72 (26.4%) equivocal, while in 4D-PET/CT 48/72 (66.7%) lesions were defined positive, 23/72 (31.9%) negative, and 1/72 (1.4%) equivocal. 4D-PET/CT findings increased the confidence in lesion definition in 37/72 lesions (51.4%). Considering 3D equivocal lesions as positive, sensitivity, specificity, and accuracy were 88.9, 70.0, and 83.1%, respectively, while the same figures were 67.7, 90.0, and 73.8% if 3D equivocal findings were included as negative. 4D-PET/CT sensitivity, specificity, and accuracy were 97.8, 90.0, and 95.4%, respectively, considering equivocal lesions as positive and 95.6, 90.0, and 93.8% considering equivocal lesions as negative. The SUVmax of the liver lesions in 4D-PET (mean ± SD, 6.9 ± 3.2) was significantly higher (p < 0.001) than SUVmax in 3D-PET (mean ± SD, 5.2 ± 2.3).

Conclusions: Respiratory-gated PET/CT technique is a valuable clinical tool in diagnosing liver lesions, reducing 3D undetermined findings, improving diagnostic accuracy, and confidence in reporting. 4D-PET/CT also improved the quantification of SUVmax of liver lesions.
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http://dx.doi.org/10.1007/s00259-017-3795-0DOI Listing
January 2018

68Ga-PSMA PET/CT imaging in recurrent prostate cancer: Where are we now?

Cent European J Urol 2017 11;70(1):37-43. Epub 2017 Jan 11.

Department of Nuclear Medicine, Military Institute of Medicine, Warsaw, Poland.

Introduction: Prostate cancer (PCa) is a major health concern worldwide with up to 60% of patients experiencing biochemical relapse after radical treatment. Early diagnosis of PCa recurrence is of high importance for successful salvage therapy. The need for accurate imaging has prompted the introduction of prostate-specific membrane antigen (PSMA)-based radiotracers for positron emission tomography (PET).

Material And Methods: In this review we summarized and discussed the results of the studies analyzing the utility of 68Ga-PSMA PET/CT in patients who experienced a biochemical relapse of prostate cancer.

Results: PSMA-based PET scans have been proved to provide a superior diagnostic performance over other modalities for localization of the site of early PCa recurrence. 68Ga-PSMA has been also shown to have a higher sensitivity and specificity than other established PET radiotracers such as radiocholines.

Conclusions: The early studies show promising results and support the use of 68Ga-PSMA for PCa restaging. However, the number of studies concerning the utility of 68Ga-PSMA PET in the context of secondary PCa staging is limited and there is still a considerable scope for further research in this field.
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http://dx.doi.org/10.5173/ceju.2017.947DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407340PMC
January 2017

Utility of single-photon emission tomography/computed tomography for sentinel lymph node localization in breast cancer patients.

Nucl Med Commun 2017 Jun;38(6):493-499

Department of Nuclear Medicine, Military Institute of Medicine, Warsaw, Poland.

Objectives: Sentinel lymph node (SLN) mapping is currently a routine technique in breast cancer management and preoperative scintigraphic imaging plays a crucial role in the process of SLN detection. The guidelines recommend performing planar acquisition and optional single-photon emission tomography/computed tomography (SPECT/CT) imaging. The aim of this study was to verify whether routine performing of SPECT/CT in addition to planar imaging increases the sensitivity of SLN detection in patients with early-stage breast cancer. The secondary aims were to compare radionuclide SLN imaging with intraoperative SLN detection and identify clinical and histopathological factors affecting the SLN detection rate.

Materials And Methods: A total of 153 early-stage breast cancer patients underwent lymph node scintigraphy in the years 2007-2013. Breast cancer patients with staging T1-2N0M0 were included. Planar and SPECT/CT lymphoscintigraphy were performed on the day before the surgery. The data on presence or absence of SLN, their number and localization were recorded for both methods and compared with each other as well as with intraoperative blue dye staining and histopathological findings.

Results: SPECT/CT identified SLN in 119/153 and planar scintigraphy in 114/153 patients. Identification rates were 77.7 and 74.5%, respectively. Intraoperative lymph node assessment identified SLN in 76/126 cases with an identification rate of 60.3%. Identification rates for second echelon lymph node were 34.6% for hybrid imaging and 21.2% for planar scintigraphy. Statistical analysis did not yield a significant difference in diagnostic accuracy between these methods; however, the Wilcoxon signed-rank test showed that SPECT/CT significantly increases SLN identification rate compared with planar scintigraphy and intraoperative detection. Histopathological examination of excised SLN showed that 22 nodes were metastatic. SPECT/CT visualized all of these, whereas planar imaging and intraoperative lymph node detection procedure visualized 19 and 18, respectively. No clinical and histopathological factors affecting SLN detection rate were identified.

Conclusion: Hybrid SPECT/CT lymphatic mapping yields a high SLN detection rate in patients with early-stage breast cancer and provides lymph node localization details. It identifies more SLN than planar imaging and intraoperative SLN detection. However, its limited superiority over the remaining two methods does not support its routine use for SLN localization. We suggest using SPECT/CT for SLN detection in case of equivocal planar imaging results.
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http://dx.doi.org/10.1097/MNM.0000000000000676DOI Listing
June 2017

Electrocardiographic and scintigraphic evaluation of patients with subclinical hyperthyroidism during workout.

Endocrine 2016 Aug 9;53(2):512-9. Epub 2016 Feb 9.

Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, 49 Przybyszewskiego St, 60-355, Poznan, Poland.

Subclinical hyperthyroidism (sHT) was found to be associated with elevated heart rate, blood pressure and increased risk of extrasystoles. However, the full clinical relevance of morphological and functional implications of sHT on the cardiovascular system is still a matter of debate. The aim of the study was to prospectively assess the influence of endogenous sHT on exercise capacity and cardiac function during workout with the use of exercise electrocardiography (ExECG) and perfusion scintigraphy. The studied group consisted of 44 consecutively recruited patients diagnosed with sHT. In all patients, ExECG, followed by post-exercise myocardial perfusion imaging, was performed. Both ExECG and scintigraphy were performed twice-in the state of sHT and after euthyroidism was restored. An average time period of exercise test was significantly longer in the state of euthyroidism than in sHT. An average oxygen consumption during exercise test was also higher after euthyroidism was achieved when compared to sHT. The end-diastolic and end-systolic volume indexes, stroke volume index and cardiac index were significantly larger in patients with sHT if compared values achieved after euthyroidism restoration. Stroke volume index was negatively correlated with TSH, and positively with free thyroid hormones values in the state of sHT, before euthyroidism was achieved. Cardiac index was positively correlated with free thyroid hormones levels. The obtained results indicate worse physical capacity in subjects with sHT and improvement of several parameters assessed during ExECG and perfusion scintiscan after therapy. Observed changes might reflect the mechanism of the deleterious effect exerted by sHT on the heart.
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http://dx.doi.org/10.1007/s12020-016-0877-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949289PMC
August 2016

Veteran player tips the scale - V/Q SPECT-CT proves decisive in blunt chest trauma. Case report and brief literature review.

Nucl Med Rev Cent East Eur 2016 ;19(1):51-3

Nuclear Medicine Department, Military Institute of Medicine, Warsaw, Poland.

A 29-year-old patient after blunt chest trauma with right lung atelectasis and pulmonary empyema was referred for lung ventilation and perfusion scintigraphy before right-sided pneumonectomy. Radionuclide imaging revealed severely reduced perfusion and lack of ventilation in the collapsed right lung. Additionally, it showed a matching lobar perfusion-ventilation defect in the lower left lobe, which, apart from consolidation area in posterior basal segment, appeared normal in computed tomography. A normal perfusion and ventilation pattern was observed in the upper left lobe. Since it was found to be the only functioning lobe, pneumonectomy was excluded from possible treatment options.
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http://dx.doi.org/10.5603/NMR.2016.0010DOI Listing
October 2016

Incidentally recognised thyroid focal uptake of 99mTc-sestamibi during stress myocardial perfusion scintigraphy.

Endokrynol Pol 2015 ;66(6):521-5

Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw.

Introduction: 99mTc-sestamibi, a radiopharmaceutical widely used in the assessment of myocardial perfusion, can be used as an indicator of thyroid disease due to its oncophilic character. The aim of this study was to establish the usefulness of performing additional examinations of radiotracer uptake in the thyroid gland during standard stress scintigraphy with sestamibi in order to identify thyroid diseases.

Material And Methods: After a retrospective evaluation of 330 consecutive myocardial perfusion scintigraphies performed in our hospital during one year, 41 patients with a focal accumulation of 99mTc-sestamibi in the thyroid were enrolled in the study. The patients underwent clinical examinations, including thyroid ultrasonography and TSH, fT4, fT3, aTPO, TRAB, calcitonin, and CEA levels. Based on the thyroid ultrasounds, 21 patients were referred for fine-needle aspiration biopsy of the thyroid.

Results: An abnormal accumulation of radiotracer in the thyroid was found in 41(12.4%) of 330 patients who underwent stress cardiac scintigraphy. Thirteen (31.7%) of those patients had multinodular euthyroid goitres, 12 (29.2%) had a single thyroid nodule (including two autonomous nodules), 11 (26.8%) had autoimmune thyroid disease, and one (2.4%) had papillary thyroid carcinoma. In 12 (29.2%) with thyroid tracer uptake there was no thyroid pathology.

Conclusions: Additional evaluation of radiotracer uptake in the thyroid during standard myocardial perfusion scintigraphy is a valuable tool in the detection of thyroid diseases. The additional or parallel evaluation of radiotracer uptake in the thyroid should be considered during every myocardial scintigraphy.
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http://dx.doi.org/10.5603/EP.2015.0064DOI Listing
February 2017

The Utility of Hybrid SPECT/CT Lung Perfusion Scintigraphy in Pulmonary Embolism Diagnosis.

Respiration 2015 30;90(5):393-401. Epub 2015 Sep 30.

Department of Nuclear Medicine, Military Institute of Medicine, Warsaw, Poland.

Background: Pulmonary embolism (PE) is diagnosed either by ventilation/perfusion (V/Q) scintigraphy or pulmonary CT angiography. One of the imaging methods used in nuclear medicine is hybrid SPECT/CT scintigraphy.

Objectives: The aim of this study was to evaluate the utility of SPECT/CT(Q) scintigraphy in the diagnosis of PE and to compare SPECT/CT(Q) with planar(Q) and SPECT(Q) methods.

Methods: The study group consisted of 109 consecutive patients suspected of having PE referred for performing lung scintigraphy. The inclusion criteria were: performance of perfusion planar, SPECT and SPECT/CT scans; availability of clinical data covering a 6-month follow-up period, and D-dimer level testing. The number of eligible patients was 84. PE was reported in patients with at least 1 segmental or 2 subsegmental perfusion defects without parenchymal abnormalities on CT scans. PE was excluded when there was a normal perfusion pattern or perfusion defects were caused by lung parenchymal abnormalities or were not arranged in accordance with the pulmonary vasculature.

Results: Twenty-six patients (31%) had a final diagnosis of PE. The sensitivity and specificity values of each method were as follows: planar(Q) 73 and 43%, SPECT(Q) 88 and 47% and SPECT/CT(Q) 100 and 83%. SPECT/CT(Q) yielded a significantly higher diagnostic accuracy than planar(Q) (p < 0.001) and SPECT(Q) (p < 0.001) scans.

Conclusions: We conclude that hybrid SPECT/CT(Q) imaging has a high diagnostic efficacy in the diagnosis of PE. Lung perfusion scintigraphy performed with a hybrid SPECT/CT device has a significantly higher sensitivity and specificity than scanning performed with the planar or SPECT technique.
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http://dx.doi.org/10.1159/000439543DOI Listing
September 2016

Long bone metastases as predictors of survival in patients with metastatic renal cancer.

Nucl Med Rev Cent East Eur 2015 ;18(2):89-91

Department of Nuclear Medicine, Military Institute of Medicine, Warsaw, Poland.

Background: The aim of this study was to assess the prevalence of long bone metastases in renal cancer patients and to evaluate their utility as predictors of survival in this group.

Material And Methods: This retrospective study included 20 patients with metastatic renal cancer and bone metastases. The patients were referred for regular bone scintigraphy in order to assess disease spread in the skeleton. The patients were divided into two groups: those with 1) metastases in the skeleton (including long bones) and those with 2) metastases in the axial skeleton only.

Results: Bone scintigraphy imaging was performed regularly up to 81 months from the first positive bone scan. During that time 11 deaths (8 among patients with long bone lesions) were recorded. Kaplan-Meyer curves showed that patients with long bone metastases tend to have lower survival probability in comparison to the ones with metastases in other bones.

Conclusions: Bone metastases localization seems to influence survival in patients with renal cancer. Long bone-involving spread of the disease is associated with worse survival probability than the spread to the other bones.
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http://dx.doi.org/10.5603/NMR.2015.0021DOI Listing
May 2016

New diagnostic pathways urgently needed. Protocol of PET Guidance I pilot study: positron emission tomography in suspected cardiac implantable electronic device-related infection.

Kardiol Pol 2016 23;74(1):47-52. Epub 2015 Jun 23.

Institute of Cardiology, Warsaw.

Background: Cardiovascular implantable electronic device (CIED) infection is a complication of increasing incidence. We present a protocol of an observational case control clinical trial "Positron Emission Tomography Combined With Computed Tomography (PET CT) in Suspected Cardiac Implantable Electronic Device Infection, a Pilot Study - PET Guidance I" (NCT02196753).

Aim: The aim of this observational clinical trial is to assess and standardise diagnostic algorithms for CIED infections (lead-dependent infective endocarditis, generator pocket infection, fever of unknown origin) with PET CT in Poland.

Methods And Results: Study group will consist of 20 patients with initial diagnosis of CIED-related infection paired with a control group of 20 patients with implanted CIEDs, who underwent PET CT due to other non-infectious indications and have no data for infectious process in follow-up. All patients included in the study will undergo standard diagnostic pro-cess. Conventional/standard diagnostic and therapeutic process will consist of: medical interview, physical examination, laboratory tests, blood cultures; imaging studies: echocardiography: transthoracic (TTE), and, if there are no contraindications transoesophageal, computed tomography scan for pulmonary embolism if indicated; if there are abnormalities in other systems, decisions concerning further diagnostics will be made at the physician's discretion. As well as standard diagnostic procedures, patients will undergo whole body PET CT scan to localise infection or inflammation. Diagnosis and therapeutic decision will be obtained from the Study Committee. Follow-up will be held within six months with control visits at three and six months. During each follow-up visit, all patients will undergo laboratory tests, two blood cultures collected 1 h apart, and TTE. In case of actual clinical suspicion of infective endocarditis or local generator pocket infection, patients will be referred for further diagnostics. Endpoints for the results assessment - primary endpoints are to standardise PET CT in the diagnostic process: sensitivity, specificity, positive predictive value, and negative predictive value of the diagnosis made by PET CT; secondary endpoints are: assessment of usefulness of PET CT for detection of remote infective complications (metastatic abscesses, infected pulmonary emboli), incidence of particular localisations of infection, influence of PET CT on therapeutic decision: confirmation or change of decision based on PET CT, safety and complications of diagnostic process of CIED-related infections with PET CT.

Conclusions: Evaluation of PET CT use for device-related infections in a case control study may be conclusive and improve diagnostic pathway.
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http://dx.doi.org/10.5603/KP.a2015.0113DOI Listing
February 2017

Brain metastases in patient with prostate cancer found in 18F-choline PET/CT.

Nucl Med Rev Cent East Eur 2015 ;18(1):39-41

Department of Nuclear Medicine Military Institute of Medicine.

Brain metastases are a rare complication of prostate cancer. They are usually diagnosed in an end-stage disease when the tumor has already spread to the other organs and tissues. We present a case of a male with castration-resistant prostate cancer with bone metastases visualized in ¹⁸F-fluorocholine PET/CT scan.
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http://dx.doi.org/10.5603/NMR.2015.0010DOI Listing
September 2015

Nuclear medicine training and practice in Poland.

Eur J Nucl Med Mol Imaging 2014 Oct;41(10):1995-9

Department of Nuclear Medicine, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland,

In Poland, nuclear medicine (NM) has been an independent specialty since 1988. At the end of 2013, the syllabus for postgraduate specialization in NM has been modified to be in close accordance with the syllabus approved by the European Union of Medical Specialists and is expected to be enforced before the end of 2014. The National Consultant in Nuclear Medicine is responsible for the specialization program in NM. The Medical Center of Postgraduate Training is the administrative body which accepts the specialization programs, supervises the training, organizes the examinations, and awards the specialist title. Specialization in NM for physicians lasts for five years. It consists of 36 months of training in a native nuclear medicine department, 12 months of internship in radiology, 3 months in cardiology, 3 months in endocrinology, 3 months in oncology, and 3 months in two other departments of NM. If a NM trainee is a specialist of a clinical discipline and/or is after a long residency in NM departments, the specialization in NM can be shortened to three years. During the training, there are obligatory courses to be attended which include the elements of anatomy imaging in USG, CT, and MR. Currently, there are about 170 active NM specialists working for 38.5 million inhabitants in Poland. For other professionals working in NM departments, it is possible to get the title of a medical physics specialist after completing 3.5 years of training (for those with a master's in physics, technical physics or biomedical engineering) or the title of a radiopharmacy specialist after completing 3 years of training (for those with a master's in chemistry or biology). At present, the specialization program in NM for nurses is being developed by the Medical Centre of Postgraduate Education. Continuing education and professional development are obligatory for all physicians and governed by the Polish Medical Chamber. The Polish Society of Nuclear Medicine (PTMN) organizes regular postgraduate training for physicians working in NM. Educational programs are comprehensive, covering both diagnostics and current forms of radioisotope therapy. They are aimed not only at physicians specialized/specializing in NM, but also at other medical professionals employed in radionuclide departments as well as physicians of other specialties.
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http://dx.doi.org/10.1007/s00259-014-2853-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159576PMC
October 2014

[Refractory hypercalcemia in patient with lung cancer].

Pol Merkur Lekarski 2014 Apr;36(214):261-4

Hypercalcemia is a common complication of malignancy which recognition is usually delayed. Severe hypercalcemia can lead to death. Mechanisms of hypercalcemia of malignancy include excessive production of parathyroid hormone related protein (PTHrP), local osteolysis, absorptive hypercalcemia due to overproduction of calcitriol and ectopic parathormone (PTH) production. Volume expansion with normal saline solution, loop diuretics and intravenous bisphosphonates are mainstays of therapy for hypercalcemia. As an adjunctive therapy calcitonin and corticosteroids are used. In refractory cases gallium nitrate and denosumab can be an option. In patients with severe acute kidney disease hemodialysis with a low-calcium bath is an alternative treatment. In this paper we present a case of severe, refractory hypercalcemia in 53-years old patient with squamous cell carcinoma of the lung and multiple metastases to bones. Despite intensive treatment, that included also intravenous bisphosphonates, patient relapsed on therapy and didn't respond to subsequent doses. Patient received subcutaneous denosumab with good hypocalcemic effect. In this paper we present pathogenesis and treatment of hypercalcemia, including advantages and limitations of denosumab.
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April 2014

Economical aspect of PET/CT-guided diagnosis of suspected infective endocarditis in a patient with implantable cardioverter-defibrillator.

Heart Lung 2014 Jul-Aug;43(4):341-3. Epub 2014 May 22.

II Department of Coronary Artery Disease, Institute of Cardiology, Spartanska 1, 02-637 Warsaw, Poland.

We present a case report of potential reduction of hospitalization costs due to utilization of PET/CT in a diagnostic work-up of a patient with an implantable cardioverter-defibrillator and suspicion of infective endocarditis. The PET/CT scan would have shorten hospital stay, prevented clinical complications and reduced the cost of hospitalization by 45%.
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http://dx.doi.org/10.1016/j.hrtlng.2014.04.002DOI Listing
August 2014

[A novel way to induce coronary hyperaemia].

Postepy Hig Med Dosw (Online) 2013 Sep 10;67:933-7. Epub 2013 Sep 10.

Klinika Kardiologii i Chorób Wewnętrznych Wojskowego Instytutu Medycznego w Warszawie.

Coronary angiography and measurement of fractional flow reserve (FFR) are used for anatomical and functional assessment of coronary stenoses. The achievement of maximal coronary hyperaemia is crucial for an accurate calculation of FFR. Although adenosine and papaverine have been well validated, their mechanisms of action as well as methods of administration have some limitations. New and better agents to induce hyperaemia are therefore still being sought. Currently regadenoson, a selective adenosine A2A receptor agonist, seems to possess the characteristics of the almost ‹ideal› hyperaemic stimulus.
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http://dx.doi.org/10.5604/17322693.1066058DOI Listing
September 2013
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