correspondence
to decipher the biology of CMV in glioblastoma. If valganciclovir is shown to be active in glioblastoma, patients should not be forced to wait until we understand why it works before it is used. Cecilia Söderberg-Nauclér, M.D., Ph.D. Karolinska Institutet Stockholm, Sweden
Inti Peredo, M.D. Giuseppe Stragliotto, M.D., Ph.D. Karolinska University Hospital Stockholm, Sweden Dr. Peredo reports no potential conflict of interest relevant to this letter. Since publication of their letter, the authors report no further potential conflict of interest.
1. Cobbs CS, Harkins L, Samanta M, et al. Human cytomega-
lovirus infection and expression in human malignant glioma. Cancer Res 2002;62:3347-50. 2. Rahbar A, Orrego A, Peredo I, et al. Human cytomegalovirus infection levels in glioblastoma multiforme are of prognostic value for survival. J Clin Virol 2013;57:36-42. 3. Bhattacharjee B, Renzette N, Kowalik TF. Genetic analysis of cytomegalovirus in malignant gliomas. J Virol 2012;86:681524. 4. Ranganathan P, Clark PA, Kuo JS, Salamat MS, Kalejta RF. Significant association of multiple human cytomegalovirus genomic loci with glioblastoma multiforme samples. J Virol 2012;86:854-64. 5. Baryawno N, Rahbar A, Wolmer-Solberg N, et al. Detection of human cytomegalovirus in medulloblastomas reveals a potential therapeutic target. J Clin Invest 2011;121:4043-55. DOI: 10.1056/NEJMc1312413
Visualization of Ectopic Parathyroid Adenomas To the Editor: Ectopic parathyroid adenomas constitute a diagnostic challenge. The precise preoperative localization of these tumors in a patient with primary hyperparathyroidism may enable targeted surgical strategies that limit explorative surgery.1 The preoperative imaging techniques currently in use include ultrasonography, sestamibi scintigraphy, and four-dimensional computed tomography (CT). 11C-methionine positron-emission tomography–CT (PET-CT), a highly sensitive technique for localizing parathyroid adenomas, provides additional information that conventional imaging may not show.2 Simultaneous PET–magnetic resonance imaging (MRI) is a new hybrid method of imaging that permits exact fusion of molecular and high-resolution anatomical imaging that provides excellent soft-tissue contrast.3 This technique appears to have great potential in softtissue analysis of complex anatomical regions in which contrast-enhanced MRI has been superior to CT.4 We present the case of a 60-year-old woman who had undergone thyroidectomy for nontoxic multinodular goiter and simultaneous parathyroidectomy of two of four parathyroid glands for suspected primary hyperparathyroidism. The histomorphologic features revealed one hyperplastic and one normal parathyroid gland. The postoperative level of serum calcium and parathyroid hormone remained elevated. Ultrasonography and technetium-99m–labeled sestamibi
scintigraphy did not show evidence of a parathyroid adenoma in the cervical or mediastinal compartments (Fig. 1A). In addition, the patient underwent 11C-methionine PET-CT and, without further administration of a radiopharmaceutical agent, a 3-tesla simultaneous PET-MRI study. Both forms of imaging showed a metabolically active mass behind the left sternoclavicular joint. Delineation and anatomical attribution of this mass, however, was better with PET-MRI (Fig. 1B) than with PET-CT (Fig. 1C). Surgical resection was performed, and histologic analysis confirmed parathyroid tissue. The serum para-
Figure 1 (following page). Visualization of an Ectopic Parathyroid Adenoma in the Patient with the Use of Scintigraphy, PET-MRI, and PET-CT. Panel A shows a planar technetium-99m–labeled sestamibi scintigraphic scan on the left and an axial technetium-99m–labeled sestamibi single-photon-emission CT scan on the right. Both are negative. Images courtesy of Drs. Christiane Volkheimer, Susanne Schenk, and colleagues, Center for Radiology and Nuclear Medicine am Johannisplatz, Leipzig, Germany. Panel B shows a metabolically active mass (arrows) in the upper anterior mediastinum that is suspicious for ectopic parathyroid tissue. The ectopic parathyroid tissue is detected by means of coronal 11C-methionine PET-MRI (image on the left), axial MRI (image on the top right), and axial 11C-methionine PET-MRI (image on the lower right). Panel C shows detection of this tissue by means of axial CT (left) and axial 11C-methionine PET-CT (right). The arrows indicate the hypermetabolic mass.
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The New England Journal of Medicine Downloaded from nejm.org at NYU WASHINGTON SQUARE CAMPUS on May 30, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
notices
thyroid hormone level decreased to the normal range within 15 minutes after resection. Taken together, the exact image fusion, the excellent soft-tissue contrast, and the lower radiation exposure of simultaneous PET-MRI suggest that this new form of medical imaging might be superior to PET-CT for the diagnostic localization of an ectopic parathyroid adenoma. Sandra Purz, M.D. Regine Kluge, M.D., Ph.D. Henryk Barthel, M.D., Ph.D. University Hospital of Leipzig Leipzig, Germany [email protected]
Frank Steinert, M.D. Helios Hospital Schkeuditz Schkeuditz, Germany
Patrick Stumpp, M.D. Thomas Kahn, M.D., Ph.D. Osama Sabri, M.D., Ph.D.
• A letter can be signed by no more than three authors. • Financial associations or other possible conflicts of interest must be disclosed. Disclosures will be published with the letters. (For authors of Journal articles who are responding to letters, we will only publish new relevant relationships that have developed since publication of the article.) • Include your full mailing address, telephone number, fax number, and e-mail address with your letter. • All letters must be submitted at authors.NEJM.org. Letters that do not adhere to these instructions will not be considered. We will notify you when we have made a decision about possible publication. Letters regarding a recent Journal article may be shared with the authors of that article. We are unable to provide prepublication proofs. Submission of a letter constitutes permission for the Massachusetts Medical Society, its licensees, and its assignees to use it in the Journal’s various print and electronic publications and in collections, revisions, and any other form or medium.
correction
University Hospital of Leipzig Leipzig, Germany Drs. Purz, Kluge, Barthel, Stumpp, Kahn, and Sabri report receiving funding for the combined PET-MRI system through the German Research Foundation (project no. SA669/9-1). Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
Severe Sepsis and Septic Shock (August 29, 2013;369:840-51). In Table 2 (page 846), the grade given for “Continue fluidchallenge technique as long as there is hemodynamic improvement” (row 6 under Resuscitation) should have been UG, rather than 1C. The article is correct at NEJM.org.
1. Noussios G, Anagnostis P, Natsis K. Ectopic parathyroid
notices
glands and their anatomical, clinical and surgical implications. Exp Clin Endocrinol Diabetes 2012;120:604-10. 2. Caldarella C, Treglia G, Isgrò MA, Giordano A. Diagnostic performance of positron emission tomography using 11C-methionine in patients with suspected parathyroid adenoma: a metaanalysis. Endocrine 2013;43:78-83. 3. Judenhofer MS, Wehrl HF, Newport DF, et al. Simultaneous PET-MRI: a new approach for functional and morphological imaging. Nat Med 2008;14:459-65. 4. Bailey DL, Barthel H, Beyer T, et al. Summary report of the First International Workshop on PET/MR Imaging, March 19-23, 2012, Tübingen, Germany. Mol Imaging Biol 2013;15:361-71. DOI: 10.1056/NEJMc1305558 Correspondence Copyright © 2013 Massachusetts Medical Society.
instructions for letters to the editor
Letters to the Editor are considered for publication, subject to editing and abridgment, provided they do not contain material that has been submitted or published elsewhere. Please note the following: • Letters in reference to a Journal article must not exceed 175 words (excluding references) and must be received within 3 weeks after publication of the article. • Letters not related to a Journal article must not exceed 400 words. • A letter can have no more than five references and one figure or table.
Notices submitted for publication should contain a mailing address and telephone number of a contact person or department. We regret that we are unable to publish all notices received. Notices also appear on the Journal’s website (NEJM.org/medical-conference). The listings can be viewed in their entirety or filtered by specialty, location, or month. First Annual Cleveland Clinic Multispecialty Pathology Symposium The symposium, entitled “A Practical Diagnostic Approach to Surgical Pathology & Cytology,” will be held in Weston, FL, Feb. 1 and 2. Contact Adrianna Brown, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, Florida 33331; or call (954) 6595490; or fax (954) 659-5491; or e-mail [email protected]; or see http://www.clevelandclinicfloridacme.org.
Harvard Medical School/Beth Israel Deaconess Medical Center The following courses will be offered in Boston: “Principles of Critical Care Medicine for Non-Intensive Care Specialists” (March 13–15) and “Nephrology 2014” (March 16–21). They are jointly sponsored by Harvard Medical School Department of Continuing Education and Beth Israel Deaconess Medical Center. Contact Agri Meetings, 21 Robin Hill Rd., Danvers, MA 01923; or call (978) 304-0935; or fax (978) 304-0936; or e-mail [email protected]; or see http://www.criticalmedboston .com or http://www.nephrologyboston.com, respectively.
n engl j med 369;21 nejm.org november 21, 2013
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to decipher the biology of CMV in glioblastoma. If valganciclovir is shown to be active in glioblastoma, patients should not be forced to wait until we understand why it works before it is used. Cecilia Söderberg-Nauclér, M.D., Ph.D. Karolinska Institutet Stockholm, Sweden
Inti Peredo, M.D. Giuseppe Stragliotto, M.D., Ph.D. Karolinska University Hospital Stockholm, Sweden Dr. Peredo reports no potential conflict of interest relevant to this letter. Since publication of their letter, the authors report no further potential conflict of interest.
1. Cobbs CS, Harkins L, Samanta M, et al. Human cytomega-
lovirus infection and expression in human malignant glioma. Cancer Res 2002;62:3347-50. 2. Rahbar A, Orrego A, Peredo I, et al. Human cytomegalovirus infection levels in glioblastoma multiforme are of prognostic value for survival. J Clin Virol 2013;57:36-42. 3. Bhattacharjee B, Renzette N, Kowalik TF. Genetic analysis of cytomegalovirus in malignant gliomas. J Virol 2012;86:681524. 4. Ranganathan P, Clark PA, Kuo JS, Salamat MS, Kalejta RF. Significant association of multiple human cytomegalovirus genomic loci with glioblastoma multiforme samples. J Virol 2012;86:854-64. 5. Baryawno N, Rahbar A, Wolmer-Solberg N, et al. Detection of human cytomegalovirus in medulloblastomas reveals a potential therapeutic target. J Clin Invest 2011;121:4043-55. DOI: 10.1056/NEJMc1312413
Visualization of Ectopic Parathyroid Adenomas To the Editor: Ectopic parathyroid adenomas constitute a diagnostic challenge. The precise preoperative localization of these tumors in a patient with primary hyperparathyroidism may enable targeted surgical strategies that limit explorative surgery.1 The preoperative imaging techniques currently in use include ultrasonography, sestamibi scintigraphy, and four-dimensional computed tomography (CT). 11C-methionine positron-emission tomography–CT (PET-CT), a highly sensitive technique for localizing parathyroid adenomas, provides additional information that conventional imaging may not show.2 Simultaneous PET–magnetic resonance imaging (MRI) is a new hybrid method of imaging that permits exact fusion of molecular and high-resolution anatomical imaging that provides excellent soft-tissue contrast.3 This technique appears to have great potential in softtissue analysis of complex anatomical regions in which contrast-enhanced MRI has been superior to CT.4 We present the case of a 60-year-old woman who had undergone thyroidectomy for nontoxic multinodular goiter and simultaneous parathyroidectomy of two of four parathyroid glands for suspected primary hyperparathyroidism. The histomorphologic features revealed one hyperplastic and one normal parathyroid gland. The postoperative level of serum calcium and parathyroid hormone remained elevated. Ultrasonography and technetium-99m–labeled sestamibi
scintigraphy did not show evidence of a parathyroid adenoma in the cervical or mediastinal compartments (Fig. 1A). In addition, the patient underwent 11C-methionine PET-CT and, without further administration of a radiopharmaceutical agent, a 3-tesla simultaneous PET-MRI study. Both forms of imaging showed a metabolically active mass behind the left sternoclavicular joint. Delineation and anatomical attribution of this mass, however, was better with PET-MRI (Fig. 1B) than with PET-CT (Fig. 1C). Surgical resection was performed, and histologic analysis confirmed parathyroid tissue. The serum para-
Figure 1 (following page). Visualization of an Ectopic Parathyroid Adenoma in the Patient with the Use of Scintigraphy, PET-MRI, and PET-CT. Panel A shows a planar technetium-99m–labeled sestamibi scintigraphic scan on the left and an axial technetium-99m–labeled sestamibi single-photon-emission CT scan on the right. Both are negative. Images courtesy of Drs. Christiane Volkheimer, Susanne Schenk, and colleagues, Center for Radiology and Nuclear Medicine am Johannisplatz, Leipzig, Germany. Panel B shows a metabolically active mass (arrows) in the upper anterior mediastinum that is suspicious for ectopic parathyroid tissue. The ectopic parathyroid tissue is detected by means of coronal 11C-methionine PET-MRI (image on the left), axial MRI (image on the top right), and axial 11C-methionine PET-MRI (image on the lower right). Panel C shows detection of this tissue by means of axial CT (left) and axial 11C-methionine PET-CT (right). The arrows indicate the hypermetabolic mass.
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The
n e w e ng l a n d j o u r na l
of
m e dic i n e
A
B
C
2068
n engl j med 369;21
nejm.org
november 21, 2013
The New England Journal of Medicine Downloaded from nejm.org at NYU WASHINGTON SQUARE CAMPUS on May 30, 2015. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved.
notices
thyroid hormone level decreased to the normal range within 15 minutes after resection. Taken together, the exact image fusion, the excellent soft-tissue contrast, and the lower radiation exposure of simultaneous PET-MRI suggest that this new form of medical imaging might be superior to PET-CT for the diagnostic localization of an ectopic parathyroid adenoma. Sandra Purz, M.D. Regine Kluge, M.D., Ph.D. Henryk Barthel, M.D., Ph.D. University Hospital of Leipzig Leipzig, Germany [email protected]
Frank Steinert, M.D. Helios Hospital Schkeuditz Schkeuditz, Germany
Patrick Stumpp, M.D. Thomas Kahn, M.D., Ph.D. Osama Sabri, M.D., Ph.D.
• A letter can be signed by no more than three authors. • Financial associations or other possible conflicts of interest must be disclosed. Disclosures will be published with the letters. (For authors of Journal articles who are responding to letters, we will only publish new relevant relationships that have developed since publication of the article.) • Include your full mailing address, telephone number, fax number, and e-mail address with your letter. • All letters must be submitted at authors.NEJM.org. Letters that do not adhere to these instructions will not be considered. We will notify you when we have made a decision about possible publication. Letters regarding a recent Journal article may be shared with the authors of that article. We are unable to provide prepublication proofs. Submission of a letter constitutes permission for the Massachusetts Medical Society, its licensees, and its assignees to use it in the Journal’s various print and electronic publications and in collections, revisions, and any other form or medium.
correction
University Hospital of Leipzig Leipzig, Germany Drs. Purz, Kluge, Barthel, Stumpp, Kahn, and Sabri report receiving funding for the combined PET-MRI system through the German Research Foundation (project no. SA669/9-1). Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
Severe Sepsis and Septic Shock (August 29, 2013;369:840-51). In Table 2 (page 846), the grade given for “Continue fluidchallenge technique as long as there is hemodynamic improvement” (row 6 under Resuscitation) should have been UG, rather than 1C. The article is correct at NEJM.org.
1. Noussios G, Anagnostis P, Natsis K. Ectopic parathyroid
notices
glands and their anatomical, clinical and surgical implications. Exp Clin Endocrinol Diabetes 2012;120:604-10. 2. Caldarella C, Treglia G, Isgrò MA, Giordano A. Diagnostic performance of positron emission tomography using 11C-methionine in patients with suspected parathyroid adenoma: a metaanalysis. Endocrine 2013;43:78-83. 3. Judenhofer MS, Wehrl HF, Newport DF, et al. Simultaneous PET-MRI: a new approach for functional and morphological imaging. Nat Med 2008;14:459-65. 4. Bailey DL, Barthel H, Beyer T, et al. Summary report of the First International Workshop on PET/MR Imaging, March 19-23, 2012, Tübingen, Germany. Mol Imaging Biol 2013;15:361-71. DOI: 10.1056/NEJMc1305558 Correspondence Copyright © 2013 Massachusetts Medical Society.
instructions for letters to the editor
Letters to the Editor are considered for publication, subject to editing and abridgment, provided they do not contain material that has been submitted or published elsewhere. Please note the following: • Letters in reference to a Journal article must not exceed 175 words (excluding references) and must be received within 3 weeks after publication of the article. • Letters not related to a Journal article must not exceed 400 words. • A letter can have no more than five references and one figure or table.
Notices submitted for publication should contain a mailing address and telephone number of a contact person or department. We regret that we are unable to publish all notices received. Notices also appear on the Journal’s website (NEJM.org/medical-conference). The listings can be viewed in their entirety or filtered by specialty, location, or month. First Annual Cleveland Clinic Multispecialty Pathology Symposium The symposium, entitled “A Practical Diagnostic Approach to Surgical Pathology & Cytology,” will be held in Weston, FL, Feb. 1 and 2. Contact Adrianna Brown, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, Florida 33331; or call (954) 6595490; or fax (954) 659-5491; or e-mail [email protected]; or see http://www.clevelandclinicfloridacme.org.
Harvard Medical School/Beth Israel Deaconess Medical Center The following courses will be offered in Boston: “Principles of Critical Care Medicine for Non-Intensive Care Specialists” (March 13–15) and “Nephrology 2014” (March 16–21). They are jointly sponsored by Harvard Medical School Department of Continuing Education and Beth Israel Deaconess Medical Center. Contact Agri Meetings, 21 Robin Hill Rd., Danvers, MA 01923; or call (978) 304-0935; or fax (978) 304-0936; or e-mail [email protected]; or see http://www.criticalmedboston .com or http://www.nephrologyboston.com, respectively.
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