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   Table of Contents - Current issue
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January-March 2020
Volume 19 | Issue 1
Page Nos. 1-91

Online since Thursday, February 27, 2020

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ORIGINAL ARTICLES  

Assessing oral glucose and intravenous insulin loading protocol in18F-fluorodeoxyglucose positron emission tomography cardiac viability studies Highly accessed article p. 1
Ismet Sarikaya, Prem N Sharma, Ali Sarikaya, Abdelhamid H Elgazzar
DOI:10.4103/wjnm.WJNM_58_18  
Oral glucose and intravenous insulin (G/I) loading protocols are commonly used in18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) cardiac viability studies. Although the amount of insulin to be given per blood glucose range has been well described in guidelines, the amount of glucose to be given is not detailed well. In this retrospective study, we aimed to assess if certain parameters, particularly the amount of glucose and insulin given, may affect18F-FDG uptake in the hibernating myocardium and also determine the problems with this protocol.18F-FDG PET cardiac viability study with G/I loading protocols was performed in 49 patients. Fasting blood glucose (FBG), amount of glucose given, blood glucose level after glucose load, amount of insulin given, and blood glucose level at the time of18F-FDG injection were recorded. Statistical analysis was performed to determine if there is any difference in the above values in PET viable and PET nonviable groups and also in subgroups assessing18F-FDG uptake also in normal myocardium. For G/I loading, we used our local protocol in 43 patients, and other protocols in six.18F-FDG PET showed viability in 31 patients, and it was negative for viability in 18. In 22 patients, mainly in PET viable group, there was varying degree of reduced18F-FDG uptake in normal myocardium. There was no significant difference in FBG, amount of glucose given, blood glucose level after glucose load, amount of insulin given, and blood glucose level at the time of18F-FDG injection in PET viable and PET nonviable groups and also in subgroups. The problems with G/I loading protocol included deciding on the amounts of glucose and insulin given, maximum amount of insulin to be given, handling diabetics, optimal time to measure blood glucose after insulin administration, and interpretation of findings in cases with diffusely reduced18F-FDG uptake. Further improvements in current guidelines are necessary to obtain images in optimal conditions for accurate results.
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Prognostic value of metabolic parameters measured by18F-fluorodeoxyglucose positron emission tomography-computed tomography in surgically resected non-small cell lung cancer patients p. 8
Boon Mathew, Nilendu C Purandare, Ameya Puranik, Sneha Shah, Archi Agrawal, CS Pramesh, George Karimundackal, Sabita Jiwnani, Venkatesh Rangarajan
DOI:10.4103/wjnm.WJNM_26_19  
18F-fluorodeoxyglucose positron emission tomography-computed tomography-derived metabolic parameters can play a role in prognostication. We investigated the prognostic value of various metabolic parameters such as maximum standardized uptake value (SUVmax), mean SUV (SUVmean), whole-body metabolic tumor volume (WBMTV), and whole-body total lesion glycolysis (WBTLG) in surgically resected non-small cell lung cancer (NSCLC) patients. We retrospectively reviewed 153 patients with NSCLC who underwent surgical resection. The SUVmax, SUVmean, WBMTV, and WBTLG of the tumor were measured. Continuous PET parameters were stratified by receiver operating characteristic curve analysis. Prognostic factors were estimated using the Kaplan–Meier method and Cox proportional hazards model. The median follow-up was 36.9 months. Fifty-six patients died and 78 patients had recurrence. On univariate analysis, tumor-node-metastasis (TNM) stage; male sex; no adjuvant treatment; and higher SUVmax, SUVmean, WBMTV, and WBTLG were statistically significant and were associated with poor overall survival (OS). TNM stage; no adjuvant treatment; and higher SUVmax, SUV mean, WBMTV, and WBTLG were statistically significant and were associated with poor disease-free survival (DFS). On multivariate analysis, higher WBTLG (hazard ratio [HR] = 3.08, P = 0.007) for DFS and higher WBTLG (HR = 2.70, P = 0.041) and TNM staging (HR = 1.63, P = 0.035) for OS were statistically significant. Whole-body tumor burden assessment with TLG has independent prognostic value in patients with operated lung cancer. Incorporation of TLG into clinical practice can identify patients benefitted from additional therapy.
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Potential application of lutetium-177-labeled prostate-specific membrane antigen-617 radioligand therapy for metastatic castration-resistant prostate cancer in a limited resource environment: Initial clinical experience after 2 years Highly accessed article p. 15
Majid Assadi, Samira Rezaei, Esmail Jafari, Seyed Javad Rekabpour, Mohammad Reza Ravanbod, Farshad Zohrabi, AbdulLatif Amini, Saeid Keshmiri, Habibollah Dadgar, Hojjat Ahmadzadehfar
DOI:10.4103/wjnm.WJNM_20_19  
In recent years, lutetium-177 (177Lu)-labeled prostate-specific membrane antigen (PSMA)-617 has become a promising new therapeutic agent in patients with metastatic castration-resistant prostate cancer (mCRPC). In this study, we report on an early experience of177Lu-PSMA therapy with an evaluation of its efficacy and safety in mCRPC patients. Twenty-one mCRPC patients with a mean age of 70.3 ± 9.6 (54–88)-year-old were treated with one to four therapy cycles (median two cycles) and administered activity of 3.7–29.6 GBq (mean of 15.4 GBq). A prostate-specific antigen (PSA) decline ≥ 50% was considered to be a biochemical response (BCR). To evaluate the clinical response, the Eastern Cooperative Oncology Group (ECOG) status was used. Within 2 weeks before and 1 and 2 months after each therapy cycle, hematology, renal function, liver status, alkaline phosphatase, and PSA were checked. The Common Terminology Criteria for Adverse Events was used for grading adverse events induced by177Lu-PSMA. Furthermore, overall survival (OS) was calculated and analyzed. During the treatment, a BCR was seen in 62% of patients; 19% of patients showed progression and 19% of patients showed stable disease. ECOG status was improved after treatment, and OS was 62.7 weeks. After the treatment, two patients showed Grade II toxicity of white blood cells, Grade I thrombocytopenia was observed in two patients, one patient showed Grade II toxicity in serum creatinine and transient Grade I toxicity in creatinine was seen in two patients. In total, our initial experience demonstrates that177Lu-PSMA therapy has the potential to positively affect the development and maturation of radioligand practices in selected mCRPC patients, even in resource limited, developing country environments. However, some challenges, such as practitioner training, poor initial acceptance by colleagues and financial concerns, particularly in developing nations, still exist.
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Comparison between sentinel lymph node hybrid scintigraphy and blue dye technique in breast cancer patients: An institutional experience Highly accessed article p. 21
Maimoona Siddique, Aamna Hassan, Muhammad Khalid Nawaz, Humayun Bashir, Muhammad Zulqarnain Chaudhry
DOI:10.4103/wjnm.WJNM_23_19  
To compare the detection efficacy of radionuclide lymphoscintigraphy (LS) versus patent blue dye (PBD) technique for hidden sentinel lymph node (SLN) in breast cancer patients and to determine which modality is better for SLN detection. One hundred and thirty-four early stage breast cancer female patients with clinically negative axilla who underwent post technetium-99m nanocolloid injection single photon emission computed tomography (SPECT-CT) for negative SLN on planar imaging were studied prospectively between 2015 and 2017. Following SPECT-CT, patients underwent peroperative gamma probe count detection GP-CD and PBD technique. Visually, blue stained ± hot nodes were surgically removed and subjected to histopathological analysis. The detection rate by individual method was calculated. Kappa statistics were applied to calculate overall agreement between radioisotope and PBD techniques for diagnostic value assessment. One hundred and thirty-four patients underwent SPECT-CT LS and PBD injection. Mean age: 47 ± 7.6 years (range: 26–82 years). Forty-nine (36.6%) had T1 and 85 (63.4%) T2. SPECT-CT LS detected SLN in 105/134 cases (success rate: 78.4%), later GP-CD localized “hot nodes”in additional 20 cases (success rate: 93.3%). The PBD successfully localized SLN in 131/134 (97.8%) cases. Three cases remained negative on both radioisotope and PBD localization, which on subsequent nodal dissection had metastatic disease. All SLNs detected on SPECT-CT showed blue dye uptake. In 112 cases, more than one SLN was surgically removed. Frozen section analysis of excised SLNs showed metastasis in 31%. Overall moderate agreement (k = 0.56) was calculated. No statistically significant difference was seen between isotope detection and PBD. Radionuclide sentinel mapping has good detection rate particularly combined with peroperative GP-CD. The PBD has added value to reduce false-negative rate of SLN mapping and can substitute radionuclide imaging with negative results.
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Differentiated thyroid carcinoma in children: Clinical characteristics and long-term follow-up Highly accessed article p. 28
Muge Tamam, Ercan Uyanik, Nurcan Edís, Mehmet Mulazimoglu, Tevfik Ozpacaci
DOI:10.4103/wjnm.WJNM_15_19  
Differentiated thyroid cancer (DTC) is rare in children, but it still remains the most common endocrine malignancy in children. The aim of this study was to analyze treatment response to radioactive iodine (RAI) therapy, clinical outcomes, recurrences, survival analysis, and long-term follow-up. We retrospectively reviewed the medical records of 43 pediatric patients (≤17 years of age) with DTC diagnosis after thyroidectomy who were treated with RAI. The follow-up protocol consisted of detailed clinical examination, testing of thyroid function, determination of serum thyroglobulin (Tg), and anti-Tg antibodies, and neck ultrasonography application. Forty-three pediatric patients (34 females and 9 males) treated with RAI for DTC in our institute. The median follow-up period was 54 months. The histologic classification was papillary thyroid cancer in 41 patients and the remaining 2 patients had follicular thyroid cancer. After the long-term follow-up, complete remission, partial remission, and recurrent-persistent disease were observed in 37 patients, 3 patients, and 3 patients, respectively. Among the series, 1 death occurred due to multiple metastases. The mortality rate is 2.56%. Total thyroidectomy followed by RAI appears to be the most effective treatment for patients with pediatric DTC in terms of reducing the rate of relapse and improving surveillance for recurrent disease.
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Positron emission tomography–computed tomography-associated incidental neoplasms of the thyroid gland p. 36
K Kamakshi, Arvind Krishnamurthy, V Karthik, Preetha Vinodkumar, R Krishna Kumar, KM Lakshmipathy
DOI:10.4103/wjnm.WJNM_33_19  
With the increasing use of18F-fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (PET-CT) scans in oncology, the finding of thyroid incidentalomas, also popularly described as PET-associated incidental neoplasms (PAINs) of the thyroid gland is not unusual. The18F-FDG PET-CT scans of all patients who underwent imaging for indications other than thyroid malignancy at our tertiary care center between January 1 and December 31, 2017, were retrospectively reviewed for PAINs of the thyroid. A total of 173718F-FDG PET-CT scans were done at our center in the year 2017. 288 thyroid incidentalomas were detected in the said period; the rate of PET-CT-detected thyroid incidentalomas being 16.58%, focal incidentalomas among them being 11.7%. Only 29 out of 204 patients (14.21%) with focal thyroid incidentalomas in our cohort underwent an aspiration cytology and/or ultrasound. The rate of malignancy among the PET detected focal thyroid incidentalomas in the cohort of patients with a proven diagnosis was 10.34%. Our study highlights the challenges in the evaluation and management of PAIN in a tertiary care oncology setting. None of the factors studied including nodule size and standardized uptake value predicted the risk of malignancy. Clinicians specializing in the management of thyroid nodules need to understand the clinical significance of the PAIN, and we hope that our unique experience adds to the limited clinical information available in this regard.
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Effect of brown adipose tissue activation on myocardial fluorine-18-fluorodeoxyglucose uptake p. 41
Saud A Alenezi, Shorouk F Dannoon, Naheel S Alnafisi, Saqr M Asa'ad, Medhat M Osman, Abdelhamid H Elgazzar
DOI:10.4103/wjnm.WJNM_16_19  
The aim of this study is to investigate the relationship between brown adipose tissue (BAT) activation and myocardial fluorine-18-fluorodeoxyglucose ([18F] FDG) uptake in terms of intensity and patterns. The patients were divided into two groups as follows: BAT and control groups. The BAT group consists of 34 cases that showed BAT uptake. The control group, with no BAT uptake, included 68 patients who were matched for body mass index, gender, and season. The scans were retrospectively reviewed by two nuclear medicine physicians who visually evaluated the intensity of myocardial [18F] FDG uptake. The myocardial [18F] FDG uptake was visually classified into the following three patterns: diffuse, heterogeneous, and focal. The regions of activated BAT distribution were noted. The mean myocardial [18F] FDG uptake was 2.50 ± 0.75 for the BAT group and 2.13 ± 0.88 for the control group with a statistically significant difference (P = 0.031). The myocardial [18F] FDG uptake pattern was similar in the BAT and control groups with the diffuse pattern being the most common, followed by the heterogeneous and less commonly focal. In the BAT group, the anatomical distribution of BAT was mainly in supraclavicular, paravertebral, and axillary and to a lesser extent in cervical regions. BAT group had a significantly higher intensity of [18F] FDG myocardial uptake compared to that of the control group. The presence of activated BAT did not affect the pattern of myocardial uptake. Knowledge of these findings may help in understanding the variability of myocardial [18F] FDG uptake and consequently in avoiding misinterpretation of cardiac findings in positron-emission tomography/computed tomography studies.
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Detection efficiency of18F-flourodeoxyglucose positron emission tomography/computed tomography for primary tumors in patients with carcinoma of unknown primary p. 47
Nosheen Fatima, Maseeh Uz Zaman, Areeba Zaman, Unaiza Zaman, Sidra Zaman, Rabia Tahseen
DOI:10.4103/wjnm.WJNM_93_18  
Carcinoma of unknown primary (CUP) is defined as biopsy proven tumor metastases that remains unidentified after a thorough diagnostic evaluation. The purpose of this study was to find the detection efficiency of18F-flourodeoxyglucose positron emission tomography/computed tomography (18FDG PET/CT) in patients with CUP. This prospective study was conducted at PET/CT Section of Department of Radiology, Aga Khan University Hospital Karachi, Pakistan from August 2017 to January 2018. Patients with a history of CUP referred for18FDG PET/CT scan for detection of primary sites during the study were recruited.18FDG PET/CT scan was acquired using standardized protocol, and patients with suspected primary sites underwent biopsies. Scan findings and biopsy results were analyzed to find the detection rate, sensitivity, area under curve (AUC), and positive predictive value (PPV). As no biopsy was performed in negative scan, true negative, and specificity could not be calculated. During the study, 46 consecutive patients with CUP were included. Mean age of cohort was 58 ± 17 years (63% male and 37% female) having a mean body mass index of 24.70 ± 4.97 kg/m2. Thirty-four patients (34/46) found to have a hypermetabolic focus suggestive of the primary tumor with known metastatic sites and subjected to biopsy which turned out to be positive in 26/34 patients (true positive). The primary tumor was detected in gastrointestinal and hepatobiliary in 8 (17%), head and neck in 6 (13%), genitourinary 4 (09%), lung 3 (06%), and miscellaneous sites in 5 (11%) patients. Detection rate, sensitivity and PPV of18FDG PET/CT were 57%, 68%, and 76%, respectively. Remaining 12/46 patients with negative18FDG PET/CT for primary focus did not have biopsy. Receiver operating character curve revealed fair diagnostic strength of18FDG PET/CT for detecting unknown primary (AUC 0.667; P = 0.054; standard error = 0.083; confidence interval: 0.504–0.830). We conclude that18FDG PET/CT is an effective tool for detecting primary tumor in patients with CUP and its upfront use could preclude the use of many futile diagnostic procedures. Furthermore, higher resolution scanners and acquiring delayed images in patients with negative study could reduce false-negative results in patients with CUP.
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CASE REPORTS Top

Unusual presentation of a curve-shaped Meckel's diverticulum detected on technetium-99m Meckel's scintigraphy p. 52
Dharmalingam Anitha, Pawar U Shwetal, Shetye S Suruchi, Ghorpade K Mangala
DOI:10.4103/wjnm.WJNM_27_19  
Complicated Meckel's diverticulum (MD) in pediatric age group may not present with classic symptoms or signs. The routine modalities of investigations for the detection of MD are ultrasonography (US), computerized tomography, and air enema. However, these may miss the diagnosis in cases of atypical patterns of presentation. In such situations, the radionuclide Meckel scan helps to narrow down the diagnosis. The objective of this case report was to present an unusual presentation of MD where the diagnosis was established by a radionuclide scan against other methods which were equivocal. An 8-year-old boy was admitted with features of intestinal obstruction.99mTc-pertechnetate Meckel's scintigraphy showed localization of tracer in ectopic gastric mucosa. The surgical exploration after the Meckel's scan revealed a curve-shaped MD localized 50 cm proximal to the ileocecal valve. The surgery was completed after a diverticulectomy, and the patient was relived of symptoms. MD scintigraphy can help detect ectopic gastric mucosa in cases of unusual presentation by considering the atypical presentation, variation in shape, and location on Meckel's scan and improve the disease management.
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Multiple scalp metastases from pulmonary adenocarcinoma seen on fluorodeoxyglucose positron-emission tomography/computed tomography p. 56
Abderrahim Doudouh, Salah Nabih Oueriagli, Omar Ait Sahel, Yassir Benameur
DOI:10.4103/wjnm.WJNM_31_19  
Scalp metastasis from a primary visceral malignancy is an uncommon clinical entity. Here, we report a case of scalp metastases from lung cancer seen on fluorodeoxyglucose positron-emission tomography-computed tomography.
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Intravenous blood pool activity masquerading as gastrointestinal hemorrhage p. 59
Scott A Fleming, Andrew M Keenan
DOI:10.4103/wjnm.WJNM_28_19  
Radiolabeled red blood cell (RBC) scintigraphy is a common study to detect and localize gastrointestinal hemorrhage. There are many potential entities that may result in false-positive RBC scintigraphy. Here, we present a case of enlarged feeding vessels of omental carcinomatosis which scintigraphically might be mistaken as intraluminal bowel activity and thus active hemorrhage. This case highlights the importance of reviewing correlative imaging in patients with a large neoplastic burden.
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Failure of iodine uptake in microscopic pulmonary metastases after recombinant human thyroid-stimulating hormone stimulation p. 61
Courtney Lawhn-Heath, Robert R Flavell, Eunice Y Chuang, Chienying Liu
DOI:10.4103/wjnm.WJNM_29_19  
Elevated thyroid stimulating hormone (TSH) is required when preparing for radioactive iodine therapy in patients with differentiated thyroid cancer. Recombinant human TSH (rhTSH: Thyrogen; Genzyme Corporation, Cambridge, MA) avoids hypothyroidism and has been commonly used in place of thyroid hormone withdrawal (THW) in this process. We describe a 31-year-old woman with sclerosing variant of papillary thyroid cancer with multiple lymph node metastases and elevated postoperative thyroglobulin suggesting the presence of distant metastases, who was found to have miliary pulmonary metastases on the posttherapy I-131 scan after THW, but not visible on the post therapy scan after rhTSH preparation.
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Rapid progression of carcinoma en cuirasse breast dermal metastases on18F-fludeoxyglucose positron emission tomography–computed tomography p. 65
Colin Raymond Young, Mallini Harigopal, Darko Pucar
DOI:10.4103/wjnm.WJNM_37_19  
Cancer in the dermis of the breast has a poor prognosis. The breast dermis can become malignantly involved primarily in inflammatory breast cancer, through the direct extension of locally advanced breast cancer, or metastatically from an underlying breast mass or a distant primary malignancy (e.g., gastric adenocarcinoma). Breast dermal metastases have the shortest median survival among them. Breast dermal metastases are classified into eight clinicohistopathologic groups, one of which is carcinoma en cuirasse. We present a case of a 52-year-old female with a history of invasive ductal carcinoma, Stage IIIC (pT2N3a), treated with lumpectomy, axillary node dissection, and chemoradiation therapy that recurred as carcinoma en cuirasse breast dermal metastases. Through18F-fludeoxyglucose positron emission tomography–computed tomography (18F-FDG PET-CT) and clinical images, the case illustrates the rapid progression and devastating consequences of carcinoma en cuirasse breast dermal metastases over a 4-month period despite optimal therapy. Furthermore, the case emphasizes the sensitivity of18F-FDG PET-CT to detect pathology in the breast dermis. Finally, the case highlights the crucial role that nuclear medicine physicians play in helping clinical colleagues differentiate between the various breast dermal malignant manifestations and benign mastitis, a common confounder in postradiation patients.
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Incidental breast lesion detected by technetium-99m sestamibi scintigraphy in a patient with primary hyperparathyroidism p. 69
Sakditad Saowapa, Wichana Chamroonrat, Ronnarat Suvikapakornkul, Chutintorn Sriphrapradang
DOI:10.4103/wjnm.WJNM_5_19  
Nuclear scintigraphy is functional imaging and can be combined with anatomical imaging to improve diagnostic yield. Detection of parathyroid lesion by technetium-99m methoxyisobutylisonitrile (Tc-99m MIBI) can facilitate an appropriate operative approach in a patients with primary hyperparathyroidism. Tc-99m MIBI is concentrated in highly cellular or metabolically active tissues, which have abundant mitochondria. False-positive scintigraphic findings could be from head-and-neck carcinomas, thyroid neoplasm, and multinodular goiter. In addition, multiple organs outside of the neck region, such as lung and breast, can take up the Tc-99m MIBI. Herein, we report the occurrence of abnormal focal uptake in the breast region during the preoperative localization of parathyroid adenoma and later discovered breast carcinoma.
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Head-to-head comparison of [18F]-fluorodeoxyglucose and [18F]-fluorocholine positron emission tomography/computed tomography in three patients with rare gestational trophoblastic neoplasms: A case series p. 72
Tanyaluck Thientunyakit, Thonnapong Thongpraparn, Tossaporn Siriprapa, Juri G Gelovani
DOI:10.4103/wjnm.WJNM_91_18  
We report the efficacy of dual positron emission tomography/computed tomography (PET/CT) imaging with [18F]-2'-fluoro-2'-deoxy-D-glucose ([18F]-FDG) and [18F]-fluorocholine ([18F]-FCH) in patients with gestational trophoblastic neoplasia (GTN) for primary diagnosis and staging of this rare pregnancy-related disorder. Whole-body PET/CT with [18F]-FDG and [18F]-FCH was performed in three patients with GTN in 2 consecutive days. Each detectable lesion was characterized by visual and quantitative analyses. As compared to CT alone, PET/CT with [18F]-FDG and [18F]-FCH PET/CT revealed more hypermetabolic metastatic lesions in the body, but not in the brain. The standard uptake value of [18F]-FDG was generally higher than [18F]-FCH in all detectable tumor lesions. In conclusion, both [18F]-FDG and [18F]-FCH PET/CT can be used for diagnosis and staging for GTN, based on their sensitivity for small extracerebral metastatic lesions. Additional studies are warranted to determine whether the PET/CT imaging with [18F]-FDG and [18F]-FCH can serve as a biomarker of GTN aggressiveness, for prediction of treatment response.
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68Ga-DOTATATE positron emission tomography/computed tomography to detect the recurrence of phosphaturic mesenhcymal tumor-induced osteomalacia p. 78
Manav I Bhalla, Kennedy M Wirtz, Eric S Fair, Daniel J Bucklan
DOI:10.4103/wjnm.WJNM_92_18  
68Ga-DOTATATE positron emission tomography/computed tomography (PET/CT) has shown superiority over111Indium-octreotide scanning for the detection of phosphaturic mesenchymal tumors (PMTs). We report a case of tumor-induced osteomalacia resulting from PMT which, although initially clinically suspected, was not localized on octreotide scintigraphy performed several years prior. Subsequent surgical excision of a presumed benign osseous lesion a few years later revealed the diagnosis on pathology. Imaging assessment using68Ga-DOTATATE PET/CT following recent clinical suspicion for recurrence revealed an intense tracer-avid lesion at the primary tumor site. DOTATATE imaging plays an important role in localizing tumors with high somatostatin receptor expression, such as neuroendocrine tumors (pheochromocytoma, paraganglioma, and neuroblastoma), meningioma, and mesenchymal tumors, causing oncogenic osteomalacia.
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Acute urinary obstruction during99mTc-ethylenedicysteine diuretic renal scintigraphy acquisition: Is furosemide the culprit? p. 82
Shelvin Kumar Vadi, Anish Bhattacharya, Ashwani Sood, Bhagwant Rai Mittal
DOI:10.4103/wjnm.WJNM_30_19  
99mTc-ethylenedicysteine (99mTc-EC) diuretic renal scintigraphy is an established, safe, and noninvasive study to evaluate relative renal function and drainage. We present a known case of bilateral renal stone disease who presented with acute urinary obstruction detected intraprocedurally on99mTc-EC diuretic renography. He was managed subsequently with emergency double J stenting. The development of acute obstruction intraprocedurally in this patient may be resultant of forced diuresis caused by furosemide, dislodging the renal stones in the distal ureters. In the setting of renal calculi, cautious use of furosemide with watchful monitoring may be needed to see for the development of obstruction and manage accordingly.
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Positron emission tomography-magnetic resonance liver parenchyma attenuation correction artifact in secondary hemochromatosis p. 85
Robert Matthews, Michael Joseph Salerno, Paul Vaska, Halley Hindman
DOI:10.4103/wjnm.WJNM_10_19  
Positron emission tomography-magnetic resonance (PET-MR) hybrid imaging is a relatively new imaging modality combining the superb MR contrast capabilities among different soft-tissue structures with the high sensitivity of PET functional imaging. With the development of any new technology, a variety of limitations will be encountered including the introduction of new types of artifacts. In this case report, we present a restaging PET-MR scan for multiple myeloma that showed severely decreased fluorodeoxyglucose activity in the liver on the PET attenuated corrected images. Careful analysis showed the cause of the decreased activity to be the improper density assignment on the mu map caused by iron deposition within the liver. Follow-up imaging showed reversal of the phenomena following improvement of liver disease.
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INTERESTING CASES Top

Unexpected rare metastases of renal cell carcinoma p. 89
Alex Cheen Hoe Khoo, Yew Teik Cheong
DOI:10.4103/wjnm.WJNM_14_19  
Renal cell carcinomas (RCCs) commonly metastasize to the lungs and bones and rarely to the parathyroid, maxillary sinus, and adrenals. It is indeed very rare to have these all these metastases occurring simultaneously in an individual. We share a case of 67-year-old woman provisionally treated for parathyroid carcinoma but subsequently found to actually have metastatic RCC to the left maxillary sinus, parathyroid, lungs, and adrenals on18F-fluorodeoxyglucose positron emission tomography–computed tomography.
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