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   Table of Contents - Current issue
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April-June 2020
Volume 19 | Issue 2
Page Nos. 93-186

Online since Thursday, June 11, 2020

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ORIGINAL ARTICLES  

Quality control and GMP synthesis of68Ga-prostate-specific membrane antigen-11 for detection of low- and high-grade prostate cancer p. 93
Majid Assadi, Habibollah Dadgar
DOI:10.4103/wjnm.WJNM_82_18  
Prostate-specific membrane antigen (PSMA) labeled with68Ga routinely used with higher sensibility and specificity than other radiotracers for detection of low and high grades of prostate cancer using positron emission tomography (PET)-computed tomography.68Ge/68Ga generators are generally used with automated modules for the syntheses of68Ga radiopharmaceuticals. The aim of the current study is to describe the procedures for labeling PSMA with radiotracers and their standard QC tests. The automated synthesis method for68Ga-PSMA-11 was taken and set of a quality control based on chromatographic and spectrometric methods used to determine radiochemical and radionuclide purity of the radiolabeled compound. Meanwhile, high-performance liquid chromatography and rainbow trail Lutheran camp are the best choices after stability tests for assessment of radiochemical purity at the optimized conditions. The clinical utility of the synthesized radiopharmaceuticals was ascertained by performing PET scans in human patients.
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Comparison of68Ga-DOTA-NaI3-Octreotide/tyr3-octreotate positron emission tomography/computed tomography and contrast-enhanced computed tomography in localization of tumors in multiple endocrine neoplasia 1 syndrome p. 99
Virendra A Patil, Manjunath R Goroshi, Hina Shah, Gaurav Malhotra, Priya Hira, Vijaya Sarathi, Vikram R Lele, Swati Jadhav, Anurag Lila, Tushar R Bandgar, Nalini S Shah
DOI:10.4103/wjnm.WJNM_24_19  
The optimum imaging modality for the screening of multiple endocrine neoplasia type 1 (MEN1)-associated tumors is not well established. Here, we compare the performance of contrast-enhanced CT (CECT) versus68Ga DOTA-NOC/TATE PET/CT in MEN1 patients. The retrospective case record study is conducted at a tertiary health-care center. Thirty-four patients, who have undergone both CECT and68Ga DOTA-NOC/TATE PET, were included in the analysis. CECT had higher per-lesion sensitivity than68Ga DOTA-NOC/TATE PET/CT for the detection of parathyroid lesions, (82.6% vs. 24.6%, P < 0.001).68Ga DOTA-NOC/TATE PET/CT had higher per-lesion sensitivity than CECT for the detection of metastases (85% vs. 47.5%, P < 0.001) and gastrinomas (90% vs. 10%, P = 0.003). When combined use of the two imaging modalities is compared to CECT alone (63.7% vs. 93.1%, P = 0.00012) and68Ga-DOTA-NOC/TATE PET/CT alone (74.1% vs. 93.1%, P = 0.0057), it provided significantly higher per-lesion sensitivity for the detection of gastroenteropancreatic neuroendocrine tumors (GEP-NETs).68Ga-DOTA-NOC/TATE PET was more sensitive for the detection of gastrinomas and metastases than CECT, whereas it was less sensitive for the detection of parathyroid lesions than CECT. The combined use of both the imaging modalities significantly increases the sensitivity for detection of GEP-NETs.
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To evaluate the minimum number of renal scans required to follow pediatric patient postpyeloplasty p. 106
Shashwat Verma, Payal Saxena, Sanjeet Kumar Singh, Sukhanshi Khandpur, Satyawati Deswal, Narvesh Kumar, Anjana Singh
DOI:10.4103/wjnm.WJNM_3_19  
The aim of the study is to evaluate the minimum number of renal scans required to follow pediatric patients postpyeloplasty. We prospectively reviewed the renal scans of 145 children with unilateral pelvi-ureteric junction obstruction who underwent dismembered pyeloplasty. Patients were then divided into four groups based on preoperative split renal function. All patients were followed with renal scan and ultrasound for minimum of 4 years. Renal scan and ultrasound were done after stent removal at 3, 6, and 12 months and then yearly after surgery. Drainage pattern (T1/2) was seen in all groups, except in patients where there was no comment on drainage pattern. Statistical analysis was performed using the Friedman ANOVA and Wilcoxon signed-ranks test as a post hoc test with Bonferroni correction and Kruskal–Wallis test with Mann–Whitney U-test as a post hoc test with Bonferroni correction. On comparison of the pattern of drainage with time in Groups 1–4, it was found that there was no significant difference with time in Group 1. Then, further, using Wilcoxon signed-rank test as post hoc test for Friedman ANOVA, Group 2 showed statistically significant difference in drainage pattern in scans between 6 months and 1 year, Group 3 showed statistically significant difference in drainage pattern in scans between 3 months and 1 year, and Group 4 showed statistically significant difference in drainage pattern in scans done between 3 and 6 months (P < 0.05). Minimum of three renal scans were required for paediatric patients post pyeloplasty at 3 months, 6 months and 1 year in the follow up period.
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18F-fluorodeoxyglucose positron emission tomography/computed tomography in predicting overall survival of oral cavity squamous cell carcinoma: Ongoing controversy p. 111
Stephen Scott, J Kenneth Byrd, Ramon Figueroa, Hadyn Williams, Jie Chen, Jaeeun Lee, Darko Pucar
DOI:10.4103/wjnm.WJNM_36_19  
We aimed to retrospectively determine if initial staging18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) can predict overall survival (OS) in oral cavity squamous cell carcinoma (OCSCC), which is currently a source of ongoing controversy in the literature. Forty-six consecutive patients with nonmetastatic (Stage M0) OCSCC had18F-FDG PET/CT prior to definitive surgical treatment followed by observation or adjuvant treatment at our institution between 2006 and 2012. The median follow-up time was 18 months (range 0.1–76 months). Univariate and multivariate analysis were used to determine the ability of imaging, pathologic, and demographic factors to predict OS.18F-FDG PET/CT parameters were standardized uptake value (SUV) maximum and mean, metabolic tumor volume, and total lesional glycolysis (TLG) of primary tumor and regional nodes. Significant predictors of OS in the multivariate analysis were primary tumor SUV mean, nodal TLG, and age. Two-year OS of patients with primary tumor SUV mean below and above the median of 6.26 was 68% and estimated 28%, respectively. Two-year OS of patients with nodal TLG below and above median of 7.9 was 69% and 34%, respectively. Two-year OS of patients younger and older than median age of 57 was 60% and 43%, respectively. Our results suggest that18F-FDG PET/CT may be a valuable addition to multifactorial models predicting outcome for OCSCC. Thus, continued research aiming to incorporate18F-FDG PET/CT parameters in risk-stratification algorithms for OCSCC is warranted and should be conducted using more standardized prognostic models driven by a specific clinical question.
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Less influence of body mass index on bone mineral density of radius as compared to proximal femur: Possible role in the diagnosis of osteoporosis p. 118
Isa Neshandar Asli, Mahsa Sheikhnezami, Mohsen Qutbi, Faraneh Farsad, Sadaf Neshandar Asli, Shahla Ranji, Maryam Karami
DOI:10.4103/wjnm.WJNM_39_19  
It has been shown that body mass index (BMI) and obesity may affect the mineral density of bones, regionally on weight-bearing bones or systemically through hormones and cytokines. The objective of this study was to evaluate the effect of BMI on bone mineral density (BMD) of the radius. In this cross-sectional study, 260 patients, 233 postmenopausal women and 27 men over 50, were included who underwent a bone densitometry scanning using dual-energy X-ray absorptiometry after obtaining an informed consent. The scanning was performed in three areas (i.e., spine, proximal femur, and radius), then densitometric data (BMD, T- and Z-score) were extracted. Regression analysis was performed to evaluate the effect of independent variables of age, gender, and BMI on the BMD of the above regions. By grouping the patients in two categories (BMI <25 as normal or underweight and BMI >25 as overweight and obese), the discordance in the diagnosis following the inclusion of radius into interpretation (diagnosis based on 2 vs. 3 areas), was assessed by an agreement test. The study is approved by the ethics committee of the university. Of 260 participants in the present study, mean and standard deviation for age were 61.48 ± 8.95 for all patients, 65.81 ± 10.59 for male and 60.98 ± 8.62 for women. An increasing effect of BMI was found to be statistically significant in weight-bearing areas (total femur and femoral neck) and BMI increase was not associated with increased BMD of radius. An agreement test between two diagnoses is used that showed a discordance of 28.5% in diagnosis (diagnosis based on 2 vs. 3 areas) with a kappa coefficient of 0.547 (P = 0.001). In total, 25.4% was minor discordance and 3.1% was major discordance. Based on the results of this study, it is concluded that the BMI is not associated with increased BMD in bones that are not weight bearing, such as radius. Therefore, it may be preferred to include the densitometric data of radius into the diagnosis.
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18F-fluorodeoxyglucose positron emission tomography/computed tomography in the diagnosis of suspected paraneoplastic syndromes: A retrospective analysis p. 124
Richard Bresler, William Schroeder Harry, David Z Chow, Ruth Lim
DOI:10.4103/wjnm.WJNM_48_19  
Paraneoplastic syndromes are a rare clinical presentation of tumor thought to affect 0.01% of patients with cancer. Paraneoplastic syndromes present a diagnostic challenge as a wide variety of signs and symptoms may appear. This study examines the use of18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) as a diagnostic imaging tool for detecting tumor in suspected paraneoplastic syndrome cases. This single-center retrospective study included patients with suspected paraneoplastic syndrome who underwent whole-body18F-FDG PET/CT scan between December 2005 and December 2016. Associated clinical data were gathered via electronic chart review. Patient records were reviewed for age, sex, clinical signs and symptoms, ancillary diagnostic procedures, date of diagnosis, and follow-up time. Ninety-nine patients met inclusion criteria for this study. Mean follow-up period was 1.8 years. Cancer prevalence was 12.1%. The18F-FDG PET/CT results are as follows: 10 true positives, 5 false positives, 82 true negatives, and 2 false negatives. The diagnostic values are as follows: sensitivity 83.3%, specificity 94.3%, positive predictive value 66.7%, and negative predictive value (NPV) 97.6%. The high NPV in our study supports the effectiveness of18F-FDG PET/CT to rule out tumor in suspected paraneoplastic syndrome. Future research aims to analyze which patients with suspected paraneoplastic syndrome would benefit most from18F-FDG PET/CT.
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Comparison of predicted postoperative forced expiratory volume in the first second (FEV1) using lung perfusion scintigraphy with observed forced expiratory volume in the first second (FEV1) post lung resection p. 131
Boon Mathew, Sudipta Nag, Archi Agrawal, Priya Ranganathan, Nilendu C Purandare, Sneha Shah, Ameya Puranik, Venkatesh Rangarajan
DOI:10.4103/wjnm.WJNM_59_19  
Lung perfusion scintigraphy is done as a part of preoperative evaluation in lung cancer patients for the prediction of postoperative forced expiratory volume in the first second (FEV1). This study was performed to see the accuracy of prediction of postoperative FEV1 by perfusion scintigraphy for patients undergoing lobectomy/pneumonectomy by comparing it with actual postoperative FEV1 obtained by spirometry 4–6 months after surgery. We retrospectively reviewed 50 surgically resected lung cancer patients who underwent preoperative spirometry, lung perfusion study, and postoperative spirometry. Pearson's correlation coefficient was used to evaluate the relationship between predicted postoperative FEV1 (PPO FEV1) by lung perfusion scintigraphy and postoperative actual FEV1 measured by spirometry. Agreement between the two methods was analyzed with Bland–Altman method. The correlation between the PPO FEV1 and actual postoperative FEV1 was statistically significant (r = 0.847, P = 0.000). The correlation was better for pneumonectomy compared to lobectomy (r = 0.930 [P = 0.000] vs. 0.792 [P = 0.000]). The agreement analysis showed a mean difference of −0.0558 with a standard deviation (SD) of 0.284. The limits of agreement vary over a wide range from −−0.625 to 0.513 L (mean ± 2 SD) for the entire group. For pneumonectomy, the mean difference was −0.0121 and SD 0.169 with limits of agreement varying between −0.30 L and 0.30 L. For lobectomy, the mean difference was −0.0826 and SD 0.336 with limits of agreement varying between −0.755 L and 0.590 L. Postoperative FEV1 predicted using lung perfusion scintigraphy shows good correlation with actual postoperative FEV1 and shows reasonably good agreement in patients undergoing pneumonectomy. The limits of agreement appear to be clinically unacceptable in patients undergoing lobectomy, where single-photon emission computed tomography (SPECT) or SPECT/CT techniques may improve prediction.
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The diagnostic accuracy of prospective investigative study of acute pulmonary embolism diagnosis criteria for the detection of acute pulmonary thromboembolism in acutely ill patients p. 137
Mehrnaz Asadi Gharabaghi, Fatemeh Sarv, Saeed Farzanehfar, Mehrshad Abbasi
DOI:10.4103/wjnm.WJNM_64_19  
The practical diagnostic performance of Prospective Investigative Study of Acute Pulmonary Embolism Diagnosis (PISAPED) criteria for the detection of acute pulmonary thromboembolism (APTE) in hospitalized patients is not yet well determined. This is the report of the initial results of our recently implemented protocol to employ PISAPED. One hundred and forty-seven pulmonary perfusion scans with 1–3 mCi99mTc-MAA of patients of a single pulmonologist were included. Patients with suspicious perfusion defects underwent single-photon emission computed tomography. Interpretations were done by consensus of two nuclear medicine specialists. Comparisons were done with chest X-ray or chest computed tomography when available. The interpreters had access to the clinical records. The scans were reported based on the PISAPED criteria as negative or positive for APTE or indeterminate. Patients were followed up for 6.2 ± 5.3 months when the final diagnosis confirming or excluding APTE was achieved. Patients aged 55.9 (17.2) years; 78 (53.1%) of them were female and 64 (43.8%) had high Wells' score. The scans were positive, negative, and indeterminate in 17 (11.6%), 126 (85.7%), and 4 (2.7%) patients, respectively. In 6 out of 147 patients, follow-up was not completed and the final diagnosis was not achieved. APTE was finally diagnosed in 21 (14.3%) patients; 12 (57.1%) of them had positive scans. APTE was excluded in 116 (78.9%) patients; 112 (96.5%) of them had negative scans. The accuracy of the test for the diagnosis of APTE was 87.9%. Lung metastasis was the most frequent reason among false-negative cases. The lung perfusion scan using PISAPED criteria could be used with good accuracy in inpatient settings.
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CASE REPORTS Top

“Tumour sink effect” on the diagnostic or posttreatment radioiodine scan due to sequestration into large-volume functioning metastasis of differentiated thyroid carcinoma influencing uptake in smaller metastatic sites or remnant thyroid tissue: An uncommon but possible phenomenon in thyroid cancer practice p. 141
Sandip Basu, Rohit Ranade, Amit Abhyankar
DOI:10.4103/wjnm.WJNM_54_19  
Two patients of differentiated thyroid carcinoma are illustrated demonstrating “sink effect” in posttherapeutic and diagnostic radioiodine (I-131) study: (a) in the first case, it masked the other small-volume metastatic sites (pulmonary and paratracheal nodes) in the posttreatment scan, which were clarified following metastatectomy of the large-volume skeletal metastatic lesion, and (b) in the second, interestingly, it masked the remnant thyroid uptake in the first postoperative diagnostic radioiodine study. In both the situations, large-volume highly functioning skeletal metastasis was the cause for the observed “sink effect” and is presented as learning illustrations to the attending physicians. Although uncommon, this is a possible phenomenon in thyroid cancer practice.
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Synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget's disease in a case of newly diagnosed prostatic carcinoma p. 144
Robert Devita, Kaushik Chagarlamudi, Arash Kardan
DOI:10.4103/wjnm.WJNM_63_19  
Tc-99m methylene diphosphonate bone scintigraphy (bone scan) is a highly sensitive technique for the evaluation of osseous pathology. However, the nonspecificity of the method can present diagnostic challenges in differentiating benign from malignant processes. Often, Paget's disease and osseous metastasis can coexist in elderly patients. Therefore, it is important to accurately distinguish the two pathologies, as each has a different prognosis and impacts clinical management. Obtaining the appropriate clinical diagnosis often involves a combination of laboratory, radiographic, and clinical data. We present a case of newly diagnosed prostatic carcinoma presenting with synchronous osseous metastasis, degenerative changes, and incidental multifocal Paget's disease.
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Occult tumour-induced osteomalacia causing lesion detected by FDG-PET/CT scan p. 147
Nitin Gupta, Natasha Singh
DOI:10.4103/wjnm.WJNM_68_19  
Oncogenic osteomalacia is a rare condition, with overproduction of fibroblast growth factor 23, leading to hypophosphatemia, phosphaturia. If it is associated with benign mesenchymal tumor, then resection of tumor is curable. Thus, detection and localization of the lesion are of utmost importance. We report a case, where18F-FDG PET/CT scan was useful in detection of such occult lesion.
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An unusual case of hyperparathyroidism, presenting as multiple skeletal lesions p. 149
Nitin Gupta, Ankur Pruthi, Ritu Verma, Anisha Manocha
DOI:10.4103/wjnm.WJNM_69_19  
We report the case of a 43-year-old male patient, who presented with severe osteoporosis and pain at multiple sites and a chest X-ray suggestive of few cystic lesions in bilateral ribs. Subsequently, the patient was referred for bone scan, in view of the suspicion of polyostotic fibrous dysplasia or neoplastic lesions. Bone scan showed homogenously increased tracer uptake in the axial and appendicular skeletal system, suggestive of metabolic superscan. Computed tomography neck localized right inferior parathyroid adenoma and expansile lytic skeletal lesions suggestive of brown tumors were also seen. This case highlights the importance of bone scan, helping in the differential diagnosis of multiple skeletal lesions.
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Isolated single lobe hyperplasia of the thyroid gland, presenting as anterior mediastinal mass, detected on positron emission tomography-computed tomography scan p. 152
Nitin Gupta, Dharmender Malik, Ritu Verma, Sunila Jain
DOI:10.4103/wjnm.WJNM_70_19  
We report a case who presented with facial swelling and breathlessness. Recent chest X-ray was suggestive of soft-tissue in the mediastinum. In view of the suspicion of mass being neoplastic, the patient was referred for positron emission tomography-computed tomography (PET-CT) scan. Whole-body fluorodeoxyglucose (FDG) PET-CT scan revealed a mildly FDG-avid large lobulated soft-tissue mass in the anterior mediastinum, seen to arising from right lobe of the thyroid gland, extending into the right hemithorax. Histopathological examination of the mass was compatible with adenomatous hyperplasia of the thyroid. Here, we report an unusual case of isolated single lobe hyperplasia of the thyroid gland, masquerading as an anterior mediastinal mass.
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Late recurrence of a papillary thyroid carcinoma 37 years after hemithyroidectomy: Solitary, left cervical lymph node metastasis evident on fluorodeoxyglucose positron-emission tomography/computed tomography images revealing nodular uptake p. 155
Hiroaki Kunogi, Yutaka Naoi, Toshiharu Matsumoto, Yutaka Ozaki
DOI:10.4103/wjnm.WJNM_72_19  
In patients with well-differentiated papillary thyroid carcinoma (PTC), late recurrence is very rare. It is unusual that18F-fluorodeoxyglucose positron-emission tomography/computed tomography (PET/CT) shows hypermetabolic lesions in patients with well-differentiated PTC metastases. We demonstrate an exceptional case exhibiting a first relapse 37 years after hemithyroidectomy to treat PTC. Recurrent metastasis of a PTC should be considered as a differential diagnosis even if the elapsed time from the initial treatment is great. A left cervical lymphadenopathy, which exceptionally exhibited a hypermetabolic lesion on PET/CT, should be considered a metastatically well-differentiated PTC.
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Neurolymphomatosis – Rare presentation in non-Hodgkin's lymphoma: The role of18F-fluorodeoxyglucose positron-emission tomography and computerized tomography imaging p. 159
Nosheen Fatima, Maseeh Uz Zaman, Areeba Zaman, Sidra Uz Zaman
DOI:10.4103/wjnm.WJNM_22_19  
Neurolymphomatosis (NLS) is infiltration of lymphoma cells into the peripheral or cranial nervous system and is a rare manifestation of non-Hodgkin lymphoma (NHL). Nerve biopsy is considered as the gold standard for diagnosis but not a preferred choice, and magnetic resonance imaging has lower reported sensitivity.18F-Fluorodeoxyglucose (18FDG) positron-emission tomography and computerized tomography (PET/CT) has a higher sensitivity for diagnosing and assessing the neurological and nonneurological metabolic tumor volume and response evaluation to therapy. We present the case of a lady, known to have NHL in remission. She presented with a short history of severe pain and weakness of the right lower limb. Baseline and interim18FDG PET/CT played a crucial role in diagnosing and assessing the extent of NLS and nonneurological disease burden and also in evaluation of response to treatment.
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Extrapancreatic insulinoma p. 162
Robin Garg, Saba Memon, Virendra Patil, Tushar Bandgar
DOI:10.4103/wjnm.WJNM_41_19  
A 38-year-old female presented with recurrent episodes of hypoglycemia for 5 years. On 72-h fast test, critical sample biochemistry was suggestive of endogenous hyperinsulinemic hypoglycemia. Both constrast-enhanced computed tomography and68Ga-DOTATATE positron emission tomography/computerized tomography (PET/CT) revealed no pancreatic lesion but showed a jejunal lesion suggestive of neuroendocrine tumor (NET) but not confirmatory of insulinoma.68Ga-Exendin-4 PET/CT showed intense uptake in the proximal jejunum, and this being a specific scan for insulinoma, confirmed it as an ectopic insulinoma. The patient attained normoglycemia after excision of this NET confirming it to be a case of ectopic insulinoma located in the jejunum. Although most insulinomas are located in the pancreas, rarely ectopic cases have been described in the spleen, perisplenic tissue, duodenohepatic ligament, adjacent to the ligament of Treitz, duodenum, and the jejunum. Functional scanning with68Ga-Exendin-4 PET/CT scan aids the localization of ectopic insulinoma.
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Radiosynovectomy is a safe and an efficient alternative in the treatment of chronic, recurrent knee hemarthrosis p. 165
Ioannis Iakovou, Dimitrios Kotrotsios, Konstantinos Michailos, Christos Sachpekidis
DOI:10.4103/wjnm.WJNM_43_19  
Chronic recurrent hemarthrosis, defined as repeated intra-articular hemorrhage, can lead to a disabling arthropathy. We herein report on a 26-year-old patient presenting with recurrent, postoperative, serious knee hemarthrosis refractory to conventional treatment, including systemic and intra-articular steroid injections as well as chemical synovectomy with osmic acid. The patient was finally treated with a twice performed knee radiosynovectomy with yttrium-90 and showed an extraordinary good clinical outcome with a symptom-free period of 4 years. In cases of refractory hemarthrosis, radiosynovectomy should have a place in the therapeutic armamentarium of the treating physician, as a minimally invasive, safe, and efficient therapeutic tool.
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Temporal muscle uptake causing an unusual focal artifact on three-dimensional stereotactic surface projections statistical maps of (18F) fluorodeoxyglucose brain positron emission tomography in a patient with Alzheimer's disease p. 168
Tanyaluck Thientunyakit, Satoshi Minoshima
DOI:10.4103/wjnm.WJNM_97_18  
(18F) fluorodeoxyglucose brain positron emission tomography and statistical mapping analysis, such as three-dimensional stereotactic surface projections, have been used widely for the evaluation of dementia patients. We present an unusual focal artifact on the statistical maps resulting from intense temporal muscle uptake in a patient with Alzheimer's disease. Various degrees of physiologic uptake can be seen in head and neck muscles. However, it is unusual to see a focal artifact on the statistical maps due to temporal muscle uptake. This case illustrates the importance of quality control of imaging processing when atypical findings are seen on statistical maps.
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Reactive changes with microfilaria in a suspected metastatic axillary lymph node on positron emission tomography–computed tomography in breast malignancy: An interesting finding p. 171
Anuja Anand, Aarti Tyagi, Shubham Jain, Pankaj Dougall
DOI:10.4103/wjnm.WJNM_98_18  
Positron emission tomography–computed tomography (PET-CT) has evolved as an important diagnostic tool in the diagnosis and management of breast carcinoma. PET/CT can help in staging as well as detecting metastases to mediastinal, axillary, and internal mammary nodes. However, PET-CT is not useful in differentiating between inflammation and malignancy.
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Calcified peritoneal metastasis due to advanced ovarian cancer: Incidental finding in bone scan and single-photon emission computed tomography-computed tomography p. 174
Hadeer Yousef Elhamady
DOI:10.4103/wjnm.WJNM_99_18  
We present the case of a 51-year-old female complaining of persistent abdominal pain that started 5 months ago with recent bone pain. Abdomen-pelvic computed tomography (CT) showed a large pelvic mass raising the possibility of a malignant neoplasm. Bone scan was done to rule out bone metastases and showed extraskeletal abdominal tracer uptake with the single-photon emission CT/CT imaging showing the uptake to correspond to multiple calcified peritoneal deposits.
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LETTERS TO EDITOR Top

Obsessional pursuit for high-impact factor p. 177
Deepak Juyal, Benu Dhawan, Vijay Thawani
DOI:10.4103/wjnm.WJNM_95_19  
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Clinical significance of thyroid incidentalomas detected on fluorodeoxyglucose positron emission tomography scan (PETomas): Its original description and now p. 179
Jacques How, Roger Tabah, Elliot J Mitmaker
DOI:10.4103/wjnm.WJNM_2_20  
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INTERESTING CASES Top

Diagnostic value of the rim sign on hepatobiliary scintigraphy p. 180
Shekhar Vinod Shikare
DOI:10.4103/wjnm.WJNM_79_19  
The most commonly accepted pathophysiologic mechanism for the appearance of the “hot rim” sign is inflammatory changes from the gallbladder spreading to and affecting the surrounding liver. The “hot rim” sign has clinical relevance, because it is associated with a high incidence of perforated or gangrenous cholecystitis. The presence of these above-mentioned conditions increases the likelihood of complications and warrants urgent surgical evaluation. We present present the findings of on hepatobiliary scintigraphy and adjunct single-photon emission computed tomography/computed tomography-fused imaging in a case of acalculous cholecystitis, which has been confirmed on histopathology (marked degree of acute gangrenous cholecystitis).
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Contribution of radiobiphosphonates bone scan in multifocal tuberculous osteomyelitis p. 184
Salah Oueriagli Nabih, Omar Ait Sahel, Yassir Benameur, Abderrahim Doudouh
DOI:10.4103/wjnm.WJNM_20_20  
We share the case of a 86-year-old male patient, followed up for recent left hip pain. Interrogation revealed a fever, nocturnal shivering, and bone pains. Standard radiographs and computed tomography centered on both shoulders and pelvis showed osteoarthritis of the left hip and multiple lytic lesions in both humeral heads and clavicles, suggestive of chronic infectious, metabolic, or secondary disease. Bone scan with radiobiphosphonates showed intense and diffuse uptake in the clavicles, the two humeral heads, and at the cervical and dorsal spine. Biopsy of the left humeral head confirmed the diagnosis of tuberculous osteomyelitis, showing an aspect of caseo-follicular tuberculosis. Bone scan with radiobiphosphonates can be used in our context to search other localizations falling within the framework of a polystotic form, and also to guide nonrisk biopsy in such group of patients.
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