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   Table of Contents - Current issue
January-March 2019
Volume 18 | Issue 1
Page Nos. 1-122

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A message from the new editor-in-chief p. 1
Qaisar Hussain Siraj
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Ensuring effective and sustainable radionuclide delivery and its impact on the development of nuclear medicine in the developing world with special reference to Nigeria Highly accessed article p. 2
T Akintunde Orunmuyi, M Mike Sathekge, R John Buscombe
Recent activities of Boko Haram, a local extremist group in Nigeria, raise concerns about a nuclear terrorist attack. Whereas nuclear medicine (NM) relies on the timely delivery of radioactive sources, a robust security structure that assures public safety is the backbone for its beneficial use. NM radionuclides have short half-lives and carry an insignificant risk for acts of terrorism. Yet, their importation and delivery in Nigeria receive undue scrutiny in a bid to implement a strict nuclear security regime. These actions prevent timely delivery of radionuclides with direct consequences on quality and economic viability of nuclear medicine. There have been no accounts of terrorist acts accomplished with NM radionuclides. Thus, it is important the NM community question the current approach that has contributed to the loss of NM services in Nigeria and proposes a more logical strategy for securing their supply. We also highlight the need for developing local pragmatic solutions when implementing global recommendations in developing countries.
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A tribute to Dr. Saul Hertz: The discovery of the medical uses of radioiodine p. 8
Barbara Hertz
Dr. Saul Hertz was Director of The Massachusetts General Hospital's Thyroid Unit, when he heard about the development of artificial radioactivity. He conceived and brought from bench to bedside the successful use of radioiodine (RAI) to diagnose and treat thyroid diseases. Thus was born the science of theragnostics used today for neuroendorine tumors and prostate cancer. Dr. Hertz's work set the foundation of targeted precision medicine.
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The role of Technetium-99m-Ethambutol scintigraphy in the management of spinal tuberculosis Highly accessed article p. 13
Lisa Herawati Diah, Achmad Hussein Sundawa Kartamihardja
Spines is a common site of extrapulmonary Mycobacterium tuberculosis infection (MTI). Spine destruction due to MTI can mimic other etiologies. Treatment of choice for spinal tuberculosis (STB) is anti-TB drugs while surgery could be needed in other causes. The gold standard for STB diagnosis is histopathology examination from biopsy tissue. Technetium-99m-ethambutol (99mTc-EMB) scintigraphy can be used to detect and localize of TB. The aim of this study was to evaluate the role of 99mTc-EMB scintigraphy in STB management. Retrospective study was carried out from 2006 to 2014. Subject STB were patient STB with suspected of STB and underwent 99mTc-EMB scintigraphy. The histopathologic result was used as gold standard. Whole body planar acquisition was taken at 1 and 3 h postinjection of 370 MBq. Single-photon emission computed tomography/computed tomography acquisition was performed on suspected area. 99mTc-EMB image were analyzed by two nuclear medicine specialis. The 93 subject STB were included in this study. Histopathologic data were available in 40/93 subject STB. Positive and negative 99mTc-EMB scintigraphy were 32 and 8 subject STB. 99mTc-EMB scintigraphy result STB was concordance with the histopathologic finding in 37 subject STB. Sensitivity, specivicity, positive- and negative-predictive value, and accuracy of 99mTc-EMB scintigraphy 90.91%, 71.43%, 93.75%, 62.5%, and 87.5%, respectively. This study showed that patient STB with suspected 99mTc-EMB scintigraphy result could be directly treated with anti-TB. 99mTc-EMB scintigraphy has significant role in the management of STB.
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A preliminary study on treatment of human breast cancer xenografts with a cocktail of paclitaxel, doxorubicin, and 131I-anti-epithelial cell adhesion molecule (9C4) Highly accessed article p. 18
Naiim S Ali, John M Akudugu, Roger W Howell
Triple-negative breast cancer often has devastating outcomes and treatment options remain limited. Therefore, different treatment combinations are worthy of testing. The efficacy of a cocktail of paclitaxel, doxorubicin, and 131I-anti-epithelial cell adhesion molecule (EpCAM) (9C4) to treat breast cancer was tested. Efficacy was tested with an MDA-MB-231 human breast cancer xenograft model. Anti-EpCAM (9C4) was demonstrated to bind to MDA-MB-231 human adenocarcinoma cells in vitro. Subsequently, mice-bearing MDA-MB-231× enografts were treated with either 131I-anti-EpCAM (9C4), unlabeled anti-EpCAM (9C4), paclitaxel, doxorubicin, or a cocktail of all of the agents. Tumor volume was measured for up to 70-day postinjection. Exponential regression was performed on tumor growth curves for each of the therapy groups. Statistical comparison of the growth constants λ of the regression models for each of the treatment groups with that of the cold antibody and control groups was done using extra sum-of-square F-tests. Biexponential clearance of 131I-anti-EpCAM (9C4) was observed with biological clearance half-times of 1.14 and 17.6 days for the first and second components, respectively. The mean growth rate of the tumors in animals treated with a cocktail of all of the agents was slower than in those treated with unlabeled anti-EpCAM (9C4) (P = 0.022). These preliminary data suggest that a cocktail of 131I-anti-EpCAM (9C4), paclitaxel, and doxorubicin may be suitable for treating breast cancers with high expression of EpCAM.
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Assessment of the patient satisfaction for nuclear medicine services in Riyadh region p. 25
Ibrahim Elsayed Saad Ahmed, Abd Elrahman Zamzam, Ahmed Abo Hasana
Nuclear medicine is considered mainly as one of the outpatient facilities that provide patients diagnostic services except for the therapy patients who may require isolation for a period away from other patients. For that reason, the patient's services within these units are varied widely and require more patient care techniques. The aim of the present study is to assess the patient satisfaction for the Nuclear Medicine Services in Riyadh region, Kingdom of Saudi Arabia. The study used the survey method for assessment of the patient satisfaction. The purpose of this survey was to gather meaningful opinions, comments, and feedback from patients visiting the nuclear medicine department in different hospitals. Statistical analysis was done for the survey output results to identify the area of strengths and the areas need more improvements. It was concluded that the politeness of the department employees, the privacy of the examination and guaranteed confidentiality of the treatment scored the highest satisfaction mean scores recorded by the patients. On the other hand, multiple appointment options, number of seats available in the waiting room, and cleanliness of the bathrooms had the lowest mean scores.
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Evaluating cardiac hypoxia in hibernating myocardium: Comparison of 99mTc-MIBI/18F-fluorodeoxyglucose and 18F-fluoromisonidazole positron emission tomography-computed tomography in relation to normal, hibernating, and infarct myocardium p. 30
Rajlaxmi Jagtap, Ramesh V Asopa, Sandip Basu
The aim of this prospective study was to explore the feasibility of 18F-fluoromisonidazole (18F-FMISO) cardiac positron emission tomography/computed tomography (PET/CT) in the detection of cardiac hypoxia in patients of ischemic heart disease (IHD) and to compare the uptake pattern with that of 99mTc-MIBI and 18F-fluorodeoxyglucose (18F-FDG). Twenty-six patients suffering from IHD were evaluated in this study. The patients initially underwent 99mTc-MIBI rest/stress myocardial perfusion imaging and 18F-FDG cardiac PET/CT as a part of their routine cardiac imaging. Patients with hibernating myocardium on these scans further underwent 18F-FMISO Cardiac PET/CT. Controls were also considered in the form of patients with scarred and normal myocardium. On visual assessment, increased 18F-FMISO uptake was noted in the hibernating myocardium compared to scarred or normal myocardium. On semiquantification analysis, there was overlap in the uptake values with a range of maximum standardized uptake value (SUVmax) in hibernating, scarred, and normal myocardium being 0.8–2.2 g/dl, 0.7–1.8 g/dl, and 0.7–1.6 g/dl, respectively. On individual patient-specific comparison in subjects harboring both hibernating and scarred myocardium, it was observed that SUVmaxof 18F-FMISO in hibernating myocardium was highest, followed by scarred myocardium and normal myocardium, respectively. The ratio of 18F-FMISO SUVmaxof hibernating to the normal myocardium in these subjects was always more than 1, and never less than the ratio of SUVmaxof scarred to normal myocardium. Thus, in this mixed population study, it was observed that on an individual patient basis, hypoxic myocardium consistently showed higher 18F-FMISO uptake than surrounding scarred and normal myocardium. The ratio of 18F-FMISO SUVmaxof hibernating to normal myocardium was higher than the ratio of scarred to the normal myocardium in all patients. On overall basis, however, there was considerable overlap in the SUV values among hibernating, scarred, and normal myocardium resulting in difficulty in differentiation of these entities with FMISO cardiac PET.18F-FDG cardiac PET/CT remains the standard and superior method to determine hibernating myocardium in patients of IHD due to its superior contrast. The limitation of FMISO is poor signal to noise ratio because of high background uptake from the blood pool. Cardiac PET/CT with superior hypoxia tracers needs to be further examined for imaging cardiac hypoxia.
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Comparison of quantitative analysis to qualitative analysis for interpretation of lower-limb lymphoscintigraphy p. 36
Edward Chege Nganga, Khalid Makhdomi
Qualitative analysis of lymphoscintigrams is subject to wide variability and may miss subtle differences in ilioinguinal uptake between normal and abnormal limbs. This study compared quantitative analysis to qualitative analysis of lower-limb lymphoscintigraphy in diagnosing lymphedema. Fifty-two lymphoscintigrams performed using standardized protocol, 99-metastable technetium nanocolloid intradermal injection at the first interdigital space, were analyzed quantitatively. Fifty-three normal and 51 abnormal limbs were analyzed. For each limb, a region of interest (ROI) was drawn around the injection site, and ilioinguinal nodes on the 1.5 h static images and the counts in these ROIs were recorded. Percentage ilioinguinal nodes uptake was then computed. Analysis of variance (ANOVA) was performed to determine the difference in ilioinguinal uptake between normal and abnormal limbs. Specificity and sensitivity were calculated and the figures were used to plot a receiver operator characteristic (ROC) curve. Thirty-six females and 16 males (104 limbs) were analyzed. ANOVA revealed a significant difference between the mean uptake in normal (19.7%) and abnormal limbs (5.5%) (F = 81, P < 0.001). ROC had a maximal area under the curve of 0.924 (P < 0.001). The significant difference in the means of ilioinguinal uptake between normal and lymphedema limbs infers reduced lymphatic function. Ilioinguinal lymph node uptake is thus a reliable parameter in quantitative analysis of lymphoscintigrams.
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Radioactive iodine (I-131) therapy isolation rooms: Introduction of lead glass window on the wall for patient comfort and better ambience p. 42
Marwa Al Aamri, Ramamoorthy Ravichandran, Naima Al Balushi
For administration of radioactive iodine for the treatment of differentiated cancer thyroid patients, activities ranging between 1.85GBq and 7.0GBq are used. The construction of concrete rooms cleared by national regulatory authorities do not recommend the presence of windows on the walls or advise same lead equivalence of wall for the lead glass if they are put on the walls. To avoid phobia of patients to give consent for I-131 treatment and to stay in isolation rooms, a necessity was felt to introduce glass window on the opposite side wall of entrance door, which had a service corridor with restricted entry, opening toward garden area. Commercially available lead glass used for X-ray computed tomography scanner was fixed on the 0.35 m thick concrete wall in two rooms. The adequacy of protection offered by the lead glass was determined. A I-131 capsule 600 MBq was moved at a distance 50 cm away from the wall inside the room, and transmitted radiation was measured outside the room. An end window pancake type, beta-gamma survey meter was used. The measured values were normalized for 3.7 GBq at 2 m bed position in μSv/h. The obtained maximum exposure rate was 1.48 μSv/h transmitted from the glass window, against 0.44 μSv/h transmitted at full concrete wall level. As the patients provide shielding to the administrated activity, also the activity is progressively decreasing fast with an effective half-life, the stray radiation levels will be decreasing outside, reducing the mean radiation level to 0.74 μSv/h, and increasing the efficacy of protection. The patient's bed position is at lower level by 0.5 m from the lower edge of the lead glass, so that during patient is in bed the stray radiation levels reduce further. As there are no reports about such facility for isolation rooms, this report may be of value in health physics literature.
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Tumor volume delineation: A pilot study comparing a digital positron-emission tomography prototype with an analog positron-emission tomography system p. 45
Nghi C Nguyen, Jose Vercher-Conejero, Peter Faulhaber
We evaluated the potential differences of a digital positron-emission tomography (PET) prototype equipped with photon-counting detectors (D-PET, Philips Healthcare, Cleveland, Ohio, USA) in tumor volume delineation compared with the analog Gemini TF PET system (A-PET, Philips). Eleven oncologic patients first underwent clinical fluorodeoxyglucose (FDG) PET/computed tomography (CT) on A-PET. The D-PET ring was then inserted between the PET and CT scanner of A-PET and the patient was scanned for the second time. Two interpreters reviewed the two sets of PET/CT images for image quality and diagnostic confidence. FDG avid lesions were evaluated for volume measured at 35% and 50% of maximum standard uptake value (SUV) thresholds (35% SUV, 50% SUV), and for SUV gradient as a measure of lesion sharpness. Bland–Altman plots were used to assess the agreement between the two PET scans. Qualitative lesion conspicuity, sharpness, and diagnostic confidence were greater at D-PET than that of A-PET with favorable inter-rater agreements. Median lesion size of the 24 measured lesions was 1.6 cm. The lesion volume at D-PET was smaller at both 35% SUV and 50% SUV thresholds compared with that of A-PET, with a mean difference of − 3680.0 mm3 at 35% SUV and − 835.3 mm3 at 50% SUV. SUV gradient was greater at D-PET than at A-PET by 49.2% (95% confidence interval: 34.1%–60.8%). Given the smaller volume definition, coupled with improved conspicuity and sharpness, digital PET may be more robust and accurate in tumor rendering compared with analog PET not only for radiotherapy planning but also in prognostication and systemic treatment monitoring.
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Low-radiation of technetium-99m-sestamibi and single-photon emission computed tomography/computed tomography to diagnose parathyroid lesions p. 52
Michael Vaiman, Mehrzad Cohenpur, Ariel Halevy, Olga Volkov, Ruth Gold, Michael Peer, Haim Golan, Haim Gavriel
We compared preoperative regular activity and low-activity radiology-based predictions with real surgical and pathological findings for parathyroidectomy surgery. The study retrospectively analyzed 54 consecutive cases (2009–2016) for benign tumor removal. Technetium-99m (Tc-99m)-sestamibi was used as a diagnostic radiopharmaceutical for diagnostic dual-phase parathyroid scintigraphy and single-photon emission computed tomography/computed tomography. We assessed images obtained with the radiation activity of 925 megabecquerel (MBq) and images obtained with the activity of 185 MBq. The study compared preoperative evaluation of tumor presence, multiplicity, location, and the type of pathology with actual data that were revealed during the operation and pathological investigation. The agreement between preoperative radiological prediction and actual location, number, and type of the parathyroid lesions was achieved in 98.4% (n = 61/62 lesions). The agreement between 925 MBq-based and 185-MBq based investigations was 100%. The agreement between radiological and pathological findings was 100% for both investigations. Our data suggest that the radioactivity of 185 MBq applied in the evaluation of the parathyroid glands provides results similar to the currently used 925–1110 MBq if used for diagnostic dual-phase parathyroid scintigraphy with Tc-99m-sestamibi. Such radioactivity may reduce the exposure to radiation of the patients and the staff without compromising results of the investigation.
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Ovarian cancer unmasked by technetium-99m bone scintigraphy and single-photon emission computed tomography-computed tomography p. 58
Jolien Verschueren, Ivan Huyghe, Tim Van den Wyngaert
We report a case of a 30-year-old female patient with a painless palpable nodule in the chest wall, evaluated for osseous involvement by technetium-99m (Tc-99m) bone scintigraphy. A whole-body scan revealed numerous sites of increased tracer accumulation throughout the thorax, abdomen, and pelvis. Subsequent single-photon emission computed tomography-computed tomography (SPECT-CT) of the abdomen and pelvis showed no abnormal uptake in the bone; however, significant nonosseous tracer accumulation in calcified soft tissue metastases was noted. Pathology confirmed a high-grade ovarian papillary serous adenocarcinoma. Extraosseous uptake of bone-seeking agents in the body is often incidental findings and can be explained by various benign and malignant conditions with soft tissue calcification. In our case report, this unusual finding on bone scintigraphy was highly suggestive for malignancy, initially not considered during the clinical evaluation of the patient. It also illustrates the usefulness of additional hybrid SPECT-CT to precisely localize extraosseous uptake of Tc-99m methylene diphoshonate.
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Sprengel's deformity as congenital scapular asymmetry on bone scintigraphy p. 61
Mohsen Qutbi
Bone scintigraphy is a valuable imaging modality for a diverse range of skeletal abnormalities. Incidental findings and congenital skeletal anomalies are not uncommonly encountered. Therefore, having a substantial knowledge of these findings, even rare ones, is essential for interpreting physicians. Here, we present a case of previously diagnosed malignancy referred for a bone scintigraphy for skeletal metastatic survey, in which Sprengel's deformity as congenital scapular asymmetry and cervicothoracic scoliosis was noted.
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Synchronous bilateral renal cell carcinomas in “Asynchrony of metabolism” p. 63
Hrushikesh Upendra Aurangabadkar, Lalitha Palle, Zakir Ali
Here, we present a case of bilateral synchronous renal cell carcinoma in a 52-year-old male patient, who underwent fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) scan followed by surgical removal of both tumors. On PET scan, left renal mass showed intense FDG uptake while uptake in the right renal mass was minimal. Histopathologically, both tumors were conventional clear cell carcinoma (Fuhrman Grade III). Only the FDG-avid tumor in the left kidney had lymphovascular invasion and necrosis, which are markers of aggressive form of any tumor. FDG PET-CT can act as strong and noninvasive prognostic parameter that could help to identify patients with aggressive disease before treatment.
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Can we differentiate malignant peripheral nerve sheath tumor from benign neurofibroma without invasive sampling p. 66
Fikri Selcuk Simsek, Saadet Akarsu, Yavuz Narin
One of the most important benign tumors in neurofibromatosis type 1 (NF1) is plexiform neurofibroma, and there is a risk of developing malignant peripheral nerve sheath tumor (MPNST) throughout life approximately 10%. However lesion characterization by anatomical imaging methods are not possible. Because of that most of cases goes to biopsy. Using of fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) for lesion characterization can be helpful in NF1 patients. We aimed to present an example of the efficacy of FDG-PET/CT in distinguishing benign neurofibroma from MPNST. A 6-year-old male patient who had NF1 admitted to emergency service due to high fever. Acute upper respiratory tract infection was diagnosed; antipyretic and abundant fluid intake was suggested. When high fever continued, the patient referred to our hospital on detection of axillary lymphadenopathy. Leukocytosis was detected in patient's blood count. Sedimentation was 54 mm/h, C-reactive protein 166 g/L, and lactate dehydrogenase 276U/L. Blood and throat cultures did not show pathogenic bacteria. In serological tests, VZV-IgG, EBV-VCA-IgG, and CMV-IgG were avidite positive; Hepatitis B Ag, Anti-HIV, Anti-HAV IgG and IgM, Anti-HCV, EBV-VCA IgM, and VZV-IgM were negative. Based on these results, cervical and thoracic contrast-enhanced computed tomography was performed on preliminary diagnosis of MPNST. Solid lesions with rounded margins, large one being 49 mm in size, that extend from superior mediastinum to posterior mediastinum, left axillary region, and left part of neck were detected, and they were surrounding the vascular structures. Since neurofibroma, MPNST, and lymphoma could not be distinguished, patient referred to FDG-PET/CT scanning. In FDG-PET/CT, highest lesion maximum standardized uptake value (SUVmax) was 1.5; SUVmaxlesion/SUVmaxliver 1.0, and SUVmax/ SUV mean liver 1.5. Biopsy from mediastinal and axillary region did not have LN structure and was positive for S-100 immunostaining, and patient was diagnosed as benign neurofibroma. We believe that there is no need for biopsy in lesions considered benign based on FDG-PET/CT parameters.
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Primary ovarian carcinoid and dotanoc positron emission tomography-computed tomography scan p. 69
Nitin Gupta, Pankaj Dougall, Shruti Mahawar
Primary ovarian carcinoids are very rare tumors, representing only <1% of all carcinoid tumors and <0.1% of all ovarian neoplasm. Here, we present a case report where DOTANOC positron emission tomography-computed tomography scan helped in diagnosis and management of rare entity.
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A case of crossed cerebellar diaschisis on follow-up positron emission tomography/computed tomography with (18F) fluoro-D-glucose after treatment for glioblastoma p. 71
Dimitrios Priftakis, Phivi Rondogianni, Ioannis Datseris
Crossed cerebellar diaschisis (CCD) represents the reduction of blood flow, metabolism, and oxygen consumption in the cerebellar hemisphere contralateral to a cerebral focal lesion. This phenomenon is the result of remote metabolic effects of cerebral lesions and it has been described since the first attempts for functional imaging of the brain, almost 40 years ago. Nevertheless, its clinical significance remains uncertain and new ways to use imaging of CCD for prognosis or assessment of novel therapies are being investigated. In this report, we present treatment for glioblastoma as a cause of CCD imaged on positron emission tomography/computed tomography with (18F) fluoro-D-glucose in our department.
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The importance of appropriate reporting and investigation of incidental findings on computed tomography attenuation correction images during myocardial perfusion scintigraphy p. 74
Francis T Delaney, Emma L Gray, Joseph C Lee
We present a case of lung cancer incidentally detected as a pulmonary nodule on computed tomography attenuation correction (CTAC) images during myocardial perfusion scintigraphy (MPS). Unfortunately, the incidental lesion was not fully investigated following MPS report and had developed into metastatic lung carcinoma when diagnosed over 1 year later, with failure of subsequent emergent chemotherapy. The disease appeared to be localized when initially detected during MPS. This case highlights the importance and potential clinical value of routine review of CTAC images in MPS with appropriate reporting and further investigation of suspicious incidental findings. In addition, the importance of effective communication between nuclear medicine department and treating team is clear to ensure suspicious incidental findings are given sufficient credence and thoroughly investigated promptly to avoid adverse clinical outcomes.
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Role of fluoroethyl tyrosine positron emission tomography-computed tomography scan in differentiating ewing's sarcoma from osteomyelitis p. 77
Hitesh Aggarwal, Maria D'souza, Puja Panwar, Neeru Jyotsna, Tauheed Alvi, Yachna Solanki, Tarakant Kumar, Rajnish Sharma
Ewing's sarcoma is a kind of undifferentiated reticulocytic sarcoma, which was first reported in 1921 by James Ewing. It is difficult to differentiate Ewing's sarcoma from osteomyelitis on computed tomography (CT) and X-ray and hence cytological confirmation is needed. Fluorodeoxy glucose being a nonspecific tracer cannot differentiate between malignant and inflammatory lesions. However, it is found that Ewing's sarcoma has increased LAT1 transporter expression at the cell surface. This property has been utilized to specifically target the tumor cells and differentiate them from inflammatory lesions. 18F-fluoroethyl tyrosine (FET) is a radiotracer which shows increased uptake in tumors having LAT1 expression and no uptake in inflammatory lesions. Thus, FET positron emission tomography-computed tomography can serve as a useful tool in diagnosing recurrence or residual Ewing's sarcoma from infective pathology. Besides, it is also helpful in monitoring response to therapy.
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Academic Proceedings - 18th Biennial Congress of the South African Society of Nuclear Medicine (SASNM) 10th – 12th August 2018 p. 81
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