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   Table of Contents - Current issue
April-June 2019
Volume 18 | Issue 2
Page Nos. 123-225

Online since Friday, April 5, 2019

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The World Association of Radiopharmaceutical and Molecular Therapy position statement on the initial radioiodine therapy for differentiated thyroid carcinoma Highly accessed article p. 123
S Dizdarevic, M Tulchinsky, VR McCready, J Mihailovic, S Vinjamuri, JR Buscombe, ST Lee, S Frangos, M Sathekge, Q Siraj, P Choudhury, H Bom, M Franceschi, A Ugrinska, D Paez, R Hussain, J Mailman, M Luster, I Virgolini, On behalf of the WARMTH Thyroid Group
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Triple-site radiotracer application in breast lymphoscintigraphy and sentinel node discordance Highly accessed article p. 127
John Freebody, Shane Fernando, Monica A Rossleigh
Sentinel lymph node (SLN) biopsy (SLNB) has demonstrated accuracy in the axillary staging of breast cancer patients. Despite variability in selection criteria and technique, an SLN is consistently identified in approximately 96% of cases and in most series predicts the status of remaining axillary LNs in >95% of cases. The false-negative rate of sentinel lymph node biopsy (SLNB) was originally reported as 5%–10% (sensitivity 90%–95%), but improved rates are attainable by experienced surgeons. Radiolocalization with lymphoscintigraphy (LSG) increases SLN identification rates. LSG is a useful tool to establish the abnormal lymphatic drainage patterns and to detect the extra-axillary nodes, particularly internal mammary nodes. Despite controversy regarding the optimal injection method, studies have generally suggested high concordance between the various radiotracer application sites and axillary SLN identification. Discordant SLN identification would have implications for nodal staging as the true SLN might not be identified with individual injection techniques. In the current study, imaging from consecutive patients presenting for breast LSG over a-19 month period was retrospectively reviewed. Radiotracer application was performed with simultaneous injection of peritumoral, subcutaneous, and subareolar regions. This application method provided a mechanism to assess the LSG drainage patterns with a view to assessing injection site concordance and SLN identification rates. Data from 123 breast LSG patients were reviewed. Using our radiotracer technique, the axillary SLN identification rate was 98%. A single axillary node was detected in 110, two axillary nodes were detected in 10, and no axillary node was detected in three patients. Among those 10 patients in whom two axillary nodes were seen, at least two cases of discordant drainage occurred from different injection sites. This study demonstrates that different LSG injection sites can result in the identification of different axillary sentinel nodes although this appears to be a rare event. This finding may be of clinical importance if the true SLN is sought. In addition, the multisite injection technique appears to be an optimal method of axillary SLN identification, with high SLN detection rates.
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Semiquantitative assessment of osteoblastic, osteolytic, and mixed lytic-sclerotic bone lesions on fluorodeoxyglucose positron emission tomography/computed tomography and bone scintigraphy p. 132
Guray Gurkan, Ismet Sarikaya, Ali Sarikaya
Bone scintigraphy is widely used to detect bone metastases, particularly osteoblastic ones, and F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) scan is useful in detecting lytic bone metastases. In routine studies, images are assessed visually. In this retrospective study, we aimed to assess the osteoblastic, osteolytic, and mixed lytic-sclerotic bone lesions semiquantitatively by measuring maximum standardized uptake value (SUVmax) on FDG PET/computed tomography (CT), maximum lesion to normal bone count ratio (ROImax) on bone scintigraphy, and Hounsfield unit (HU) on CT. Bone scintigraphy and FDG PET/CT images of 33 patients with various solid tumors were evaluated. Osteoblastic, osteolytic, and mixed lesions were identified on CT and SUVmax, ROImax, and HU values of these lesions were measured. Statistical analysis was performed to determine if there is a difference in SUVmax, ROImax, and HU values of osteoblastic, osteolytic, and mixed lesions and any correlation between these values. Patients had various solid tumors, mainly lung, breast, and prostate cancers. There were 145 bone lesions (22.8% osteoblastic, 53.1% osteolytic, and 24.1% mixed) on CT. Osteoblastic lesions had a significantly higher value of CT HU as compared to osteolytic and mixed lesions (P < 0.01). There was no significant difference in mean ROImaxand mean SUVmaxvalues of osteolytic and osteoblastic bone lesions. There was no correlation between SUVmaxand ROImax, SUVmaxand HU, and ROImaxand HU values in osteolytic, osteoblastic, and mixed lesions (P > 0.05). Not finding a significant difference in SUVmaxand ROImaxvalues of osteoblastic, osteolytic, and mixed lesions and also lack of correlation between SUVmax, ROImax, and HU values could be due to treatment status of the bone lesions, size of the lesion, nonmetastatic lesions, erroneous measurement of SUVmaxand ROImax, or varying metabolism in bone metastases originating from various malignancies.
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Diagnostic accuracy of technetium-99m-octreotide in imaging neuroendocrine tumors, Oman hospital experience with literature review p. 137
Naima Al Bulushi, Badriya Al Suqri, Marwa Al Aamri, Aymen Al Hadidi, Hafidh Al Jahdami, Mohammed Al Zadjali, Mimouna Al Risi
The aim of this observational cross-sectional study with retrospective review of the data is to evaluate the efficacy of using technetium-99m-octreotide (Tc-99m-OCT) in imaging neuroendocrine tumors (NETs) in our tertiary care hospital. A total of 58 patients had Tc-99m-OCT were identified in our database, from January 2013 to December 2016. Forty-one patients (age range of 15–75 years) meet our inclusion criteria, namely histopathology proven NETs, Tc-99m-OCT scan, computed tomography (CT), or magnetic resonance imaging (MRI) done in our institute for correlation. Twenty-three patients had true positive Tc-99m-OCT scan. In addition to the primary tumors, the octreotide scan revealed metastasis in the lung, liver, and retroperitoneal lymph nodes. The smallest lesion detected on octreotide scan was a 4-mm pulmonary nodule that was missed on lung window CT scan. The Tc-99m-OCT had 17 true negative, one false negative, and no false positive. The CT and MRI scans had 18 true positive, 17 true negative, 5 false negative, and one false positive. The overall sensitivity, specificity, accuracy, positive, and negative predictive values of Tc-99m-OCT scan were 96%, 100%, 97%, 100%, and 94%, respectively. Whereas those of CT and MRI were 78%, 94%, 85%, 94%, and 77%, respectively. Our diagnostic accuracy of Tc-99m-OCT is high. We recommend that, in addition to the conventional radiological investigations, Tc-99m-OCT scan, or other somatostatin receptor imaging (SSR) is a mandate for better and accurate staging of patients with NETs.
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Prostate-specific antigen and risk of bone metastases in west Africans with prostate cancer p. 143
Yaw Ampem Amoako, Emmanuel Nii Boye Hammond, Awo Assasie-Gyimah, Dennis Odai Laryea, Alfred Ankrah, George Amoah
We aimed to assess the relationship between bone scintigraphy findings and prostate-specific antigen (PSA) and Gleason score in a group of treatment naïve West Africans with prostate cancer. The age, PSA, and Gleason scores of 363 patients with prostate cancer were collected. Patients were risk stratified using the D'Amico criteria. Logistic regression was performed to assess the relationship between bone scan results and PSA and Gleason score. Receiver operating characteristics (ROC) analysis was used to determine the diagnostic reliability of the bone scan findings. Ninety of the 96 patients with metastases had high risk, and only 6 had low-to-intermediate risk disease (P = 0.0001). PSA (odds ratio [OR] 2.4 [95% confidence interval [CI] 1.5–3.8], P = 0.001) and GS (OR 2.2 [95% CI 1.5–3.1], P = 0.001) were independently predictive of the presence of metastases. ROC analysis revealed that PSA predicted the presence of metastases with an area under the curve of 0.72, and using a cut-off value of ≥20 predicted metastases with a sensitivity of 86.5% and specificity of 41.2%. A Gleason score of ≥7 had an 89.6% sensitivity and 34.8% specificity for bone metastases. Using a Gleason cutoff of ≥8, the sensitivity and specificity for predicting bone metastases were 54.2% and 71.5%, respectively. The area under the Gleason score ROC curve was 0.68. PSA and Gleason score are independent predictors of the presence of bone metastases in West Africans with prostate cancer.
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Benefits of adding coronary calcium score scan to stress myocardial perfusion positron emission tomography imaging p. 149
Ahmed Fathala, Mervat Aboulkheir, Salwa Bukhari, Mohamed M Shoukri, Moheieldin M Abouzied
There have been little and conflicting data regarding the relationship between coronary artery calcification score (CACS) and myocardial ischemia on positron emission tomography myocardial perfusion imaging (PET MPI). The aims of this study were to investigate the relationship between myocardial ischemia on PET MPI and CACS, the frequency and severity of CACS in patients with normal PET MPI, and to determine the optimal CACS cutoff point for abnormal PET. This retrospective study included 363 patients who underwent same-setting stress PET perfusion imaging and CACS scan because of clinically suspected coronary artery disease (CAD). Fifty-five (55%) of the 363 patients had abnormal PET perfusion. There was an association between sex, diabetes mellitus (DM), smoking, and CACS and PET perfusion abnormities with P = 0.003, 0.05, 0.005, and 0.001, respectively. However, there was no association between PET perfusion abnormalities with age, body mass index, hypertension, and hypercholesterolemia. There was association between CACS and age, sex, and DM with P = 0.000, 0.014, and 0.052, respectively, and stepwise increase in the frequency of myocardial ischemia and CACS groups. Receiver-operating characteristic analysis showed that a CACS ≥304 is the optimal cutoff for predicting perfusion abnormalities with sensitivity of 64% and specificity of 69%. In conclusion, the frequency of CAC in patients with normal PET MPI is 49%, it is highly recommended to combine CACS with PET MPI in patients without a history of CAD. PET MPI identifies myocardial ischemia and defines the need for coronary revascularization, but CAC reflects the anatomic burden of coronary atherosclerosis. Combining CACS to PET MPI allows better risk stratification and identifies high-risk patients with PET, and it may change future follow-up recommendations. CACS scan is readily available and easily acquired with modern PET-computed tomography (CT) and single-photon emission CT (SPECT)-CT with modest radiation exposure.
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Predictors of metabolic response in propensity-matched lymphoma patients on interim 18F-fluorodeoxyglucose positron-emission tomography/computed tomography using standardized imaging and reporting protocol: Do we really have one? p. 154
Nosheen Fatima, Maseeh Uz Zaman, Areeba Zaman, Unaiza Zaman, Rabia Tahseen, Sidra Zaman
The purpose of this prospective study was to determine metabolic response predictor(s) in propensity-matched patients having lymphomas who had baseline and interim18fluorodeoxyglucose (FDG) positron-emission tomography/computed tomography (PET/CT) using strict standardized imaging and reporting protocols. This prospective study was conducted at PET/CT section of a JCI-accredited healthcare facility from April 2017 to February 2018. Patients with baseline and interim18FDG PET/CT scans using standardized protocol were selected. Interim scans were performed not earlier than 2nd or later than 4th chemotherapy. During the study period, 97 of 112 consecutive patients with lymphomas (Hodgkin-HL: 32/97 and Non-Hodgkin-NHL: 65/97) were included in the study. Mean age of cohort was 45 ± 19 years (71% male and 29% female) having a mean body mass index (BMI) of 25.57 ± 5.54 Kg/m2 having Stage I (21%), Stage II (18%), Stage III (16%), and Stage IV (45%) disease. Bulky disease was found in 14% and18FDG-avid marrow deposits in 33%. Standardized PET/CT imaging protocol as per EANM guidelines was strictly adopted for baseline and interim studies. %Δ changes in fasting blood sugar,18FDG dose, uptake time, and liver SUV mean were 3.96%, 2.83%, 2.49%, and 12.15%, respectively. Based on Deauville's scoring, cohort was divided into responders having Score 1–3 (49/97) and nonresponders having Score 4–5 (48/97). The demographic analysis found no significant difference between responders and nonresponders for age, gender, BMI, staging, bulky disease or marrow involvement, and study protocol. No significant coefficient or odd ratios were found on multivariate analysis for age, gender, maximum standardized uptake value (SUVmax), size, BMI, NHL, and advance disease (Stage III and IV) in both groups (χ2: 5.12; receiver operating characteristic [95% confidence interval]: 0.616 [0.51–0.713]; P=0.528). Among responders, baseline SUVmaxand tumor size had a direct correlation with a metabolic response on iPET, more pronounced in NHL than HL groups (SUVmax: 13.4 vs. 19.5 and size: 52 vs. 87 mm; P < 0.0001). We conclude that no significant predictor was found for response in propensity-matched patients with lymphomas (both HL and NHL) who had baseline and interim PET/CTs acquired with a standardized protocol. However, NHL responders were found to have higher baseline median SUVmaxand larger lesion size as compared to HL responders. Although, these data are not in concordance with published findings but need to be validated with larger studies using standardized imaging and reporting protocols in propensity-matched patients with lymphomas.
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Prevalence of hitherto unknown brain meningioma detected on 68Ga-DOTATATE positron-emission tomography/computed tomography in patients with metastatic neuroendocrine tumor and exploring potential of177Lu-DOTATATE peptide receptor radionuclide therapy as single-shot treatment approach targeting both tumors p. 160
Rahul V Parghane, Sanjay Talole, Sandip Basu
There is a relative paucity of data in the literature regarding the prevalence of meningiomas and their detection in the clinical setting of neuroendocrine tumors (NETs). The primary aim of this study was to study incidentally detected meningiomas (on 68Ga-DOTATATE/18F fluorodeoxyglucose positron-emission tomography/computed tomography [18F-FDG PET/CT]) in metastatic NET patients referred for peptide receptor radionuclide therapy (PRRT). The secondary aims of this study were to evaluate the response rate of these incidentally detected meningiomas following PRRT and determine progression-free survival (PFS) in this group of patients. This was a retrospective analysis of 500 metastatic/advanced NET patients who had undergone68Ga-DOTATATE PET/CT and18F-FDG PET/CT before PRRT workup. The case records were searched to identify cases of hitherto unknown meningiomas detected on PET images; subsequently, these patients underwent brain magnetic resonance imaging (MRI) for confirmation of diagnosis. Following177Lu-DOTATATE PRRT, posttreatment functional and structural imaging response evaluation of the meningiomas were undertaken by 68Ga-DOTATATE PET/CT, MRI, or CT brain, respectively, along with clinical neurological evaluation. The patients were designated as responders and nonresponders based on predefined response assessment criteria. The PFS of these incidentally detected meningiomas following PRRT was estimated using the Kaplan–Meier product-limit method. Twelve NET patients were retrospectively identified with abnormal focal brain uptake on 68Ga-DOTATATE PET/CT. Of these, meningiomas were finally diagnosed on brain MRI examination in six patients (M: F =3:3; age range: 30–66 years; and mean age: 45 years), with a prevalence of 1.2%. Standardized uptake value (SUVmax) of meningiomas on 68Ga-DOTATATE and18F-FDG PET/CT ranged from 7.0 to 22.0 (average 17.0) and 10.19–13.70 (mean: 12.10), respectively, and lesion-to-normal brain parenchyma SUVmax ratio ranged from 140 to 400 (mean: 340) and 1.02–1.07 (mean: 1.04), respectively. Of six patients with incidentally detected meningiomas, one patient died within 1 month and five patients received177Lu-DOTATATE PRRT, the number of cycles ranging from two to six (average: 4) and cumulative therapeutic dose ranging from 13.28 to 29.97GBq (average dose: 19.86GBq). Follow-up in these patients ranged from 8 to 36 months (mean: 19.4 months) after the first dose of PRRT. Complete disappearance of neurological symptoms was found in two of five patients (40%), partial response in one of five (20%), and worsening of symptoms in two of five patients (40%). The overall “responder” and “nonresponder” of the meningiomas after PRRT were three patients (60%) and two patients (40%), respectively. Two patients (40%) died of advanced NET at the time of analysis of these data. The observed mean PFS of the meningioma lesions following PRRT was 26.25 months (95% confidence interval, 16.65–35.84 months).No major hematological and renal toxicity were documented in any of these patients. To conclude, 68Ga-DOTATATE PET/CT imaging is an effective technique for the incidental identification of meningioma in NET patients. Considering the limited therapeutic options in the palliative setting of advanced or metastatic NET patients and morbidity associated with the therapeutic procedures, PRRT could be a promising targeted therapeutic approach for such cases of incidentally detected meningiomas, which is also helpful in stabilizing the disease process without any significant toxicity.
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Is hemi-thyroidectomy adequate in low risk differentiated thyroid cancer? p. 171
Justin Benjamin, Julie Hephzibah, Anish Jacob Cherian, David Mathew, Nylla Shanthly, Regi Oommen
In low-risk differentiated thyroid carcinoma (LRDTC), appropriate surgical procedure in terms of hemi/total thyroidectomy (TT) has been an area of debate. The aim was to determine whether in LRDTC patients, hemithyroidectomy would be an adequate treatment, determine incidence of disease in contralateral lobe and evaluate the effect of radioactive iodine ablation (RAIA). Retrospective study was done from 2008 to 2014 at a single institution. Preoperative ultrasound (USG) and histopathology reports of all LRDTC patients following total/completion thyroidectomy were recorded. Details of postthyroidectomy, thyroid whole body scan, and stimulated serum thyroglobulin (sTg) levels were also documented and results analyzed. A total of 114/562 patients met inclusion criteria. Of these, 25/114 (22%) underwent hemithyroidectomy followed by a completion thyroidectomy while remaining 89/114 (78%) underwent TT initially. Preoperative USG detected single-lobe involvement in 44 patients; however, among them, histopathology revealed bilateral lobe disease in 17 (38.6%). There was a significant fall of sTg level following RAIA as compared to that before RAIA in T1b-T2 (P = 0.009 and 0.012, respectively). Median follow-up was 2 years (range: 1–7 years) with no distant metastasis or deaths recorded till 2017, except for one local recurrence 4 years after RAIA. In conclusion, the role of TT in LRDTC patients is important as 46% of patients were found to have tumor in contralateral lobe as well. Significant fall in sTg levels following RAIA justifies RAIA of remnant lobe even in LRDTC (T > 1a). It facilitates early detection of recurrence when sTg alone is used for follow-up.
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Role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in restaging and prognosis of recurrent melanoma after curative surgery p. 176
Dharmender Malik, Ashwani Sood, Bhagwant Rai Mittal, Rajender Kumar Basher, Anish Bhattacharya, Gurpreet Singh
Malignant melanoma is a highly aggressive tumor and surgical resection is the primary treatment. However, the chances of recurrence are quite high despite complete resection. The aim of study was to evaluate the18F-fluorodeoxyglucose(18F-FDG) positron emission tomography–computed tomography (PET/CT) in detection of recurrent melanoma after curative surgery and its prognostic value. Fifty-four melanoma patients (32 women) with prior primary lesion resection were evaluated with18F-FDG PET/CT for clinically suspicious recurrent disease. The diagnostic accuracy of 18F-FDG PET/CT (visual interpretation as well as semi-quantitative parameter) was determined on the basis of subsequent imaging and clinical follow-up. Melanoma-specific survival and risk of progression (hazard ratio [HR]) were assessed using Kaplan–Meier method and Cox regression analysis.18F-FDG PET/CT detected recurrent diseases in 36 (66%) patients including distant metastases in 13 patients and second synchronous malignancy in 2 patients. Overall, the sensitivity, specificity, positive predictive value, and negative predictive value of 18F-FDG PET/CT were 91.2%, 80.0%, 88.6%, and 84.2%, respectively, with area under the curve of 0.86 (95% confidence interval: 0.74–0.97; P < 0.05). Positive18F-FDG PET/CT study was associated with a significantly shorter overall survival than negative study (30.8 ± 4.6 vs. 64.5 ± 6.9 months, P < 0.05). Apart from positive18F-FDG PET/CT scan, maximum standardized uptake value (SUVmax) >2.7 and combination of both were independently associated with an increased risk of disease progression (HR = 7.72, 21.58, and 11.37, respectively; P < 0.05).18F-FDG PET/CT showed enhanced diagnostic performance in patients with suspicious recurrent malignant melanoma leading to appropriate management. FDG positivity along with SUVmax >2.7 provides important prognostic value in predicting the survival outcomes and assessing the risk of disease progression.
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18F-fluorodeoxyglucose positron emission tomography/computed tomography in childhood metastatic epithelioid hemangioendothelioma of the liver: Altering the management plan p. 183
Ashwin Singh Parihar, Shelvin Kumar Vadi, Bhagwant Rai Mittal, Harmandeep Singh, Rajender Kumar, Arunanshu Behera
Hepatic epithelioid hemangioendothelioma (EHE) is an uncommon vascular tumor, primarily seen in 20–40 years of age. We report the case of a 14-year-old boy with EHE and distant metastases identified on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT), leading to a change in the management plan.18F-FDG PET/CT proved to be useful in identifying the rare sites of metastasis and planning further treatment.
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Improvement in image quality of Tc-99m-based ventilation/perfusion single-photon emission computed tomography in patients with chronic obstructive pulmonary disease through pretest continuous positive airway pressure treatment p. 185
Jens Peder Dreyer Paludan, Sven Robert Andresen, Jan Abrahamsen, Lars Jelstrup Petersen, Christian Høyer
Ventilation/perfusion single-photon emission computed tomography performed using an aerosol of carbon-coated technetium is frequently used for diagnosing pulmonary embolism. Certain patients may suffer from chronic obstructive pulmonary disease (COPD); for such patients, the formation of mucus clots in airways can cause accumulation of the aerosol in the larger airways. This centralized deposition of the aerosol leads to insufficient activity in peripheral lung segments and subsequently results in ventilation images of substandard or even nondiagnostic quality. Continuous positive airway pressure (CPAP) therapy improves airway dynamics and quality of life for COPD patients. We report for the first time the results for two patients for whom initial ventilation scans were of insufficient quality, but diagnostic-quality images were obtained after CPAP therapy.
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First case of 18F-choline uptake in acoustic schwannoma after stereotactic radiotherapy p. 187
Demetrio Arico, Claudio Giardina, Carmelo Tuscano, Antonio Picone, Vincenzo Militano
A 69-year-old male patient, with bilateral hypoacusia and tinnitus, had a diagnosis of left vestibular schwannoma with synchronous meningioma on the left frontal lobe. After partial surgical resection of the acoustic schwannoma, this was followed by stereotactic radiosurgery on the residual lesion. The patient had a metachronous prostate cancer treated with conformal radiotherapy associated to 6 months of hormone therapy with luteinizing hormone/releasing hormone analog. During follow-up, prostate-specific antigen value increased to 0.27 ng/mL and the patient underwent 18F-methylcholine positron emission tomography/computed tomography (18F-choline PET/CT). The whole-body scan demonstrated a focus of increased uptake at level of the left cerebellopontine angle and at the left frontal lobe, corresponding to the known vestibular schwannoma and meningioma. A subsequent brain contrast-enhanced magnetic resonance imaging (MRI) showed an increased dimension of the left cerebellopontine neuroma and dimensional stability of the left frontal meningioma compared with previous MRI of 6 months earlier. To the best of our knowledge, we describe the first case of a 18F-choline PET/CT demonstrating a relapse of a vestibular schwannoma after stereotactic radiotherapy.
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Jaffe–Campanacci syndrome: Any role for99mTc-methylene diphosphonate bone and99mTc-octreotide scans for evaluation of the disorder? p. 189
Mohsen Qutbi, Sajad Ghanbari, Isa Neshandar Asli, Babak Shafiei
Jaffe–Campanacci syndrome (JCS) is a rare clinical disorder with almost unknown etiology. The main feature of this syndrome is skeletal involvement as nonossifying fibroma which may cause severe morbidity to these patients. X-ray imaging is the widely available modality for evaluation of skeleton, but radionuclide imaging modalities may have a role in workup. Herein, we present a case of JCS evaluated with99mTc-methylene diphosphonate bone and99mTc-octreotide scans for the extent of skeletal involvement. To the best of our knowledge, from over than 30 cases reported in the literature, no evaluation with radionuclide imaging has been done.
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18F-fluorodeoxyglucose positron emission tomography/computed tomography in extensive bland portal vein thrombosis from retroperitoneal adenocarcinoma p. 192
Guillaume Chausse, Gad Abikhzer, Stephan Probst, Jerome Laufer
A 73-year-old woman undergoing hormone therapy for previously treated localized breast cancer presented at oncology follow-up 4 years after mastectomy/radiation therapy with weight loss, night sweats, and abdominal pain. Contrast computed tomography (CT) abdomen revealed a soft-tissue mass posterior to the pancreas, several enlarged retroperitoneal lymph nodes, and a dilated portal vein. On 18F-fluorodeoxyglucose positron emission tomography/CT, metabolic activity extended along the portal vein, outlining most of the liver venous system. This “tree-like” appearance was diagnostic of recent portal vein thrombosis by vascular compression from the retroperitoneal mass. Biopsy of the mass later confirmed undifferentiated adenocarcinoma without breast cancer marker expression.
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Role of [18F] Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography/Computed Tomography in the Diagnosis of Tonsillar Carcinoma in a Patient with Multiple Primary Carcinomas p. 194
Patrick Earl Amparado Fernando, Eduardo Erasto Santiago Ongkeko
Tonsillar carcinoma is not easily diagnosed on [18F] fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan; normal, inflamed, and infected tonsils also exhibit increased tracer uptake. We present a case of a 68-year-old male with colon and prostate carcinomas who was referred for a PET/CT scan. He presented with right cervical lymphadenopathy which, on fine-needle biopsy, was found to have atypical cells suspicious for malignancy. On PET/CT, the right cervical lymph nodes appeared hypermetabolic; subsequent excision biopsy revealed metastatic poorly differentiated carcinoma. Increased metabolic activity was also seen in the tonsils, the right more than the left, which was initially ascribed to be inflammatory or physiologic. On magnetic resonance imaging follow-up, however, a more prominent and more enhancing right palatine tonsil was observed, which on histopathology was consistent with squamous cell carcinoma. Determining the maximum standard uptake value ratio between the two tonsils could have been helpful in differentiating squamous cell tonsillar carcinoma from benign asymmetric FDG uptake in this case. On a background of enlarged cervical lymph nodes and known primary carcinomas, uptake in the tonsils should be thoroughly assessed before interpreting it as an inflammatory or physiologic variant, especially if there is asymmetry in FDG uptake.
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Evaluation of recurrent parathyroid carcinoma: A new imaging tool in uncommon entity p. 198
N. T. K. Thanseer, Ashwin Singh Parihar, Ashwani Sood, Sanjay Kumar Bhadada, Divya Dahiya, Priyanka Singh, Bhagwant Rai Mittal
Parathyroid carcinoma (PTC) is a rare endocrine tumor and uncommon cause for primary hyperparathyroidism.18F-fluorocholine (FCH) positron emission tomography and computed tomography (PET/CT) has shown promising results in the detection of parathyroid adenoma, though its role in PTC is undefined due to the paucity of incidence. The authors in this case report discuss the possible complimentary role of FCH PET/CT with18F-fluorodeoxyglucose PET/CT in the evaluation of the management of suspected recurrence, since this rare entity has high loco-regional and distant recurrence of the disease.
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A new role for fluorine-18-fluorodeoxyglucose positron-emission tomography/computed tomography in Erdheim-Chester disease p. 201
Ciska-Anne Van Keerberghen, Antoine Harrouk, Luca Leone
Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis, with multisystem manifestation such as bone pain, being the most common presenting symptom, cardiovascular or central nervous system involvement, interstitial lung disease, skin and orbital lesions, adrenal enlargement, retroperitoneal fibrosis and renal impairment as well fever, and weight loss. The disease is challenging to diagnose due to its rarity and mimicry of other infiltrative processes. Technetium-99 m bone scintigraphy showing pathological bone activity in the long bones is highly suggestive of ECD. However, not all patients have bone complaints. Till now, fluorine-18-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) was especially used after histological diagnosis to determine disease activity and extent, as well as the evaluation of treatment response. With this case, we suggest an additional role for18F-FDG PET/CT earlier on in the diagnosis workup as follows: detecting a possible biopsy site to establish the diagnosis of ECD especially in a clinical context without bone pain.
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Preface p. 204

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International Symposium On Radiopharmaceutical Therapy helsinki,18-20 November 2018 p. 205

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