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   Table of Contents - Current issue
April-June 2021
Volume 20 | Issue 2
Page Nos. 129-214

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Trends in the utilization of nuclear medicine technology in Jamaica: Audit of a private facility Highly accessed article p. 129
Tracia-Gay Kennedy-Dixon, Karlene McDonnough, Marvin Reid, Maxine Gossell-Williams
This study sought to evaluate the types and frequencies of nuclear medicine studies that were carried out at a privately-run nuclear medicine facility in Kingston, Jamaica. Previous studies of this nature have not been done among this population, therefore the researchers sought to gather data which may prove to be useful for the growth of nuclear medicine practice in Jamaica. The study was a nonexperimental, retrospective study which involved an assessment of the records of all nuclear medicine patients who received a radiopharmaceutical during January 01, 2017, to December 31, 2018. The data extracted included age, gender, radiopharmaceutical administered, indication for study, and impression from scan. The total number of nuclear medicine scans that were carried out at the facility for the 2-year period was 3756. Of this number, 1889 (50.3%) were male and 1866 (49.7%) were female, with the age ranging from 3 months to 100 years. The types and frequencies of the most frequently occurring studies conducted were bone (2116, 56.3%), renal (867, 23.1%), thyroid (307, 8.2%), and lung (254, 6.8%). Patients aged 60 years and over accounted for the majority of the bone scans (1353/2116). The age group 26–59 years accounted for most of the scans of the lung (123/254), thyroid (209/307), parathyroid (34/65), and whole body (26/34). Patients under 12 years of age accounted for the majority of the renal (596/867), gastrointestinal (22/26), and hepatobiliary (16/28) scans. The audit of this private facility reflects the documented demand on the International Atomic Energy Agency database for Latin America and the Caribbean, and demonstrates the need for continuity of this specialized service in our population.
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11C-Pittsburgh compound B and 18F-THK 5351 positron emission tomography brain imaging in cognitively normal individuals p. 133
Chanisa Chotipanich, Attapon Jantarato, Anchisa Kunawudhi, Supaporn Kongthai, Chetsadaporn Promteangtrong
Abnormal beta-amyloid plaques and tau protein accumulation are the core pathologic features of Alzheimer's disease. However, the accumulation of these proteins is also common in cognitively normal elderly people. Therefore, this study is aimed to evaluate the amyloid and tau accumulation in the cognitively normal population. A preliminary prospective study was conducted on 24 cognitively normal individuals who underwent Pittsburgh compound B (11C-PiB) and 18F-THK 5351 positron emission tomography (PET)/computed tomography scans. The standardized uptake value ratio (SUVR) was used for quantitative analysis of the two tracers and comparisons between two age groups: ≤60 years and >60 years. Co-registration was applied between the dynamic acquisition PET and T1-weighted magnetic resonance imaging to delineate various cortical regions. P-mod software with the automated anatomical labeling-merged atlas was employed to generate automatic volumes of interest for different brain regions. The posterior cingulate versus precuneus SUVRs of PiB uptake was 1.40 ± 0.07 and 1.38 ± 0.22 versus 1.17 ± 0.07 and 1.14 ± 0.18 in those aged ≤≤60 years and >60 years, respectively, whereas the SUVRs of THK5351 retention at brain stem versus inferior temporal SUVRs were 1.84 ± 0.06 and 1.91 ± 0.18 versus 1.37 ± 0.04 and 1.48 ± 0.21 in the age groups of ≤ 60 years and >60 years, respectively (P = 0.20). Our findings allow the determination of the preliminary optimal cutoff points for SUVRs in amyloid and tau PET studies. Ultimately, these values can be applied to normal databases in clinical use to improve quantitative analysis.
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Quantifying the survival benefit of completing all the six cycles of radium-223 therapy in patients with castrate-resistant prostate cancer with predominant bone metastases p. 139
John Buscombe, Daniel Gillett, Nick Bird, Anne Powell, Sarah Heard, Luigi Aloj
A retrospective analysis was performed of epidemiological data assessing the survival of patients who had received radium-223 for castrate-resistant metastatic prostate cancer treated at a regional tertiary referral center over a 5-year period. The patients' age, date of first treatment, and the number of cycles of radium-223 given were obtained from the patients' electronic patient record (EPR). Data on the date of death were provided by national death registrations which update the EPR via a unique national health service number. A total of 187 patients (mean age on the date of first treatment: 73 years; range: 56–93) were treated from April 1, 2014, to June 30, 2019. The median overall survival of the 119 patients (71%) who had died by December 31, 2019, was 15 months. There was no significant age difference between those who had died and survivors (72 vs. 74 years). On a further analysis, it was found that the median overall survival of the 107 patients who had received all the six cycles of radium-223 was 31 months, significantly longer than the median overall survival of only 6 months for those eighty patients who had received less than the full course of six cycles of radium-223 (P = 0.001). Of those who received all the six cycles of treatment, 58 patients had died (58%) and the 1-year survival was 87%. This was compared to the group of patients receiving <6 cycles of radium-223 where 61 patients (76%) had died and the 1-year survival was 30%. Therefore, the hazard ratio of dying before 1 year if the patient did not receive all the six cycles of treatment was 2.9. Where the reason for stopping treatment was recorded on the EPR the most common cause for the cessation of treatment was because of the side effects caused by the treatment itself. Other causes were hospitalization with comorbidities, disease progression, or patient choice. Given the survival advantage of receiving the full course of all the six cycles of treatment, this should be administered if possible and the patients should be managed in such a way as to allow the complete treatment course to be given.
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Evaluation of myocardial perfusion and function in patients with asymptomatic beta-thalassemia major using myocardial gated single-photon-emission computed tomography p. 145
Abdolmajid Omrani, Parivash Rahimzadeh, Ali Aba, Esmail Jafari, Abdullatif Amini, Majid Assadi
This study was conducted to evaluate the cardiac perfusion and function of patients with beta-thalassemia major (TM) using99mTc-MIBI cardiac gated single-photon-emission computed tomography (SPECT) and to compare the obtained indices with echocardiographic and hematological parameters. Patients with TM who were referred for regular blood transfusion and periodic checkup were included in this study. A questionnaire containing demographic and medical data was provided for all patients by an expert pediatrician. All of the patients were on Desferal chelation therapy and none of them had clinical signs of heart failure. Myocardial gated perfusion SPECT, echocardiography, and complete blood tests were performed for each patient. In total, 24 patients including 14 men (58.3%) and 10 women (41.7%) aged 15–36 years with a mean age of 24.3 ± 6.5 years' old were enrolled in this study. Myocardial perfusion scan (MPS) was normal in all patients. The mean value of the measured left ventricular ejection fraction (LVEF) was 58.88 ± 13.45%. There was no significant association between measured LVEF on scan and echocardiography (P > 0.05). In terms of hematological results, there was a significant association between the hemoglobin and ferritin level and the amount of blood transfusion (P = 0.02 and P= 0.00, respectively). According to the results of myocardial perfusion imaging (MPI), cardiac perfusion and LVEF were within normal limits in all asymptomatic patients. In the absence of any perfusion abnormality, the use of MPI in patients with asymptomatic beta-TM is not recommended for diagnosing myocardial ischemia.
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Fluorodeoxyglucose positron-emission tomography-magnetic resonance hybrid imaging: An emerging tool for staging of cancer of the uterine cervix p. 150
Alina Nazir, Robert Matthews, Annapurneswara Rao Chimpiri, Melissa Henretta, Joyce Varughese, Dinko Franceschi
Positron-emission tomography-magnetic resonance imaging (PET-MRI) is an emerging hybrid imaging modality that utilizes the superior soft tissue resolution of MR with the metabolic data from PET. In this study, we sought to assess the clinical value of fluorodeoxyglucose (FDG) PET-MRI with dedicated pelvic PET-MR in the initial staging of cervical cancer. In this institutional-approved study, we identified 23 adult females who underwent FDG PET-MRI on hybrid camera for staging of primary uterine cervical cancer that included a dedicated PET-MR of the pelvis. A nuclear medicine physician and a radiologist reviewed the PET, MRI, and fusion-body and pelvis images alone and then with consensus read characterizing PET and MR abnormal findings. There were 23 patients who underwent FDG PET-MRI for initial staging of cervical cancer with an average age of 52.2 ± 14.0 years. A total of 23 suspected lymph nodes in eight different patients were detected within the pelvis with increased metabolic activity on PET. Both the dedicated pelvis and whole-body PET imaging detected the same corresponding pelvic lymph nodes, although the pelvic PET imaging had better lymph node uptake delineation due to longer acquisition time. Using a 10-mm short-axis criterion, MRI identified only 43.5% of the FDG avid lymph nodes. The average SUVmax on the pelvis PET sequences was higher with SUV 8.9 ± 5.2 compared to the whole-body PET with SUV 7.8 ± 5.4 but was not statistically significant (P > 0.05). Primary cervical cancer was identified in 18 patients on both PET imaging and MRI with dedicated MR pelvis providing better characterization. Based on our results of the patients with cervical cancer evaluated for initial staging, combining dedicated pelvic PET-MRI with whole-body PET/MR provides the most complete status of malignant disease in reference to delineation of primary tumor, involvement of surrounding tissues, and regional lymph nodes.
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F-18 fluorocholine positron emission tomography–computed tomography in initial staging and recurrence evaluation of prostate carcinoma: A prospective comparative study with diffusion-weighted magnetic resonance imaging and whole-body skeletal scintigraphy p. 156
Rakhee Vatsa, Rohit Kumar, Jaya Shukla, Nivedita Rana, Shelvin Kumar Vadi, Anupam Lal, Shrawan Kumar Singh, Bhagwant Rai Mittal
Prostate cancer (PCa) is one of the major causes of death due to cancer in men. Conventional imaging modalities such as magnetic resonance imaging (MRI) provide locoregional status, but fall short in identifying distant metastasis. C-11 choline F-18 fluorocholine (F-18 FCH) has been shown to be useful in imaging of PCa. The present prospective study evaluates and compares the role of F-18 FCH positron emission tomography–computed tomography (PET-CT) with locoregional MRI and whole-body bone scintigraphy in PCa patients for initial staging and recurrence evaluation. This study included a total of 50 patients. Tc-99m skeletal scintigraphy, F-18 FCH PET-CT, and diffusion-weighted MRI of the pelvic region were performed within a span of 2–3 weeks of each other, in random order. For the primary site, core biopsy findings of the lesion were considered as gold standard. The kappa test was used to measure agreement between bone scintigraphy, F-18 FCH, and MRI. For comparing Tc-99m bone scintigraphy, F-18 FCH, and MRI, McNemar's test was applied. F-18 FCH PET-CT and MRI were able to detect primary lesion in all initial staging patients. The sensitivity and specificity of F-18 FCH PET-CT versus MRI were found to be 92.8% versus 89.2% and 100 versus 80%, respectively, for the recurrence at the primary site. A total of 55 bony lesions at distant sites were detected on F-18 FCH PET-CT in comparison to 43 bone lesions on whole-body bone scintigraphy. F-18 FCH PET/CT also detected additional lung lesions in 2 patients and abdominal lymph nodes in 12 patients. F-18 FCH PET-CT could detect primary lesions, local metastasis, bone metastasis, and distant metastasis in a single study and is also a useful modality in recurrence evaluation in PCa patients.
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Should fluorodeoxyglucose positron emission tomography/computed tomography be the first-line imaging investigation for restaging the laryngeal carcinoma patients? p. 164
Tarun Kumar Jain, Guman Singh, Sumit Goyal, Ajay Yadav, Dinesh Yadav, Nitin Khunteta, Hemant Malhotra
Posttreatment detection of residual/recurrence disease in the head and neck cancers is not an easy task. Treatment induces changes create difficulties in diagnosis on conventional imaging (computed tomography [CT], magnetic resonance imaging) as well as macroscopic inspection (direct laryngoscopy). Hence, we evaluate the diagnostic performance of contract-enhanced F-18 fluorodeoxyglucose positron emission tomography (FDG PET)/CT in restaging of laryngeal carcinoma Postchemotherapy-surgery and/or radiation therapy. We retrospectively analyzed patients of carcinoma larynx (n = 100) who has completed treatment and were referred for FDG PET/CT. Two reviewers performed image analysis to determine recurrence at primary site and/lymph nodes and distant metastases. Receiver operating characteristic (ROC) was used to determine the maximum standardized uptake value (SUVmax) cut off for disease detection. Histopathological examination and clinical or imaging follow-up were taken as gold standard for recurrence. One hundred laryngeal carcinoma patients with mean age of 57.2 years (range of 40–76) were included in the present study. Among the 100 patients, 96 were male and remaining 4 were female. The average interval between completion of treatment and FDG PET/CT scan was 8.5 months (minimum 6 months). Of the 100 patients, FDG PET/CT detected FDG avid lesions in 66 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of FDG PET/CT for residual/recurrence disease detection was 90.3%, 73.7%, 84.8%, 82.3%, and 84.0%, respectively (P < 0.05). In addition, in 10 patients, metachronous primaries were detected (lung-4, thyroid-2, tongue, colon, esophagus, and lymphoma-one each). On ROC curve analysis, SUVmax >6.1 had sensitivity and specificity of 80.6% and 94.7% respectively for detection of recurrent/metastatic disease. FDG PET/CT demonstrates high diagnostic accuracy for detection of residual/recurrent disease in treated laryngeal cancer patients and our findings suggest that this imaging modality should be the first-line diagnostic investigation in this cohort of patients.
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Initial experience with use of infrared assistance for intravenous injection of radiopharmaceuticals p. 172
Ashok Kumar, Meena Negi, Jyoti Khanka, Mohit Dhingra, Ranjeeta Kumari, Vandana Kumar Dhingra, Manoj Kumar Gupta
Radiopharmaceutical injection is challenging as it poses radiation exposure to staff as well as patient. Infrared light-assisted devices have been available since many years and have garnered mixed reviews in the pediatric age group. However, there are no data on outcome of infrared assistance for radiopharmaceutical injection. We compared results of first-attempt intravenous access (in cubital veins) with and without infrared assistance device for injection of radiopharmaceuticals. All adult patients who underwent nuclear scan in the initial weeks of infrared device installation were injected utilizing infrared device assistance. These were compared with those who underwent injection without infrared assistance. Three hundred consecutive patients were studied for success of intravenous injection with and without infrared assistance. Of these, 150 were injected with and 150 without infrared assistance. A success rate of 72%/51.3% was noted with and without infrared assistance, respectively, on the first attempt which was statistically significant. In our initial experience, assistance with infrared device was found to improve the outcome of first-attempt intravenous access for injection of radiopharmaceuticals. This method has potential of improving outcome for radiopharmaceutical injection.
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(18F)-Fluorodeoxyglucose positron emission tomography/magnetic resonance imaging assessment of hypometabolism patterns in clinical phenotypes of suspected corticobasal degeneration p. 176
Ana M Franceschi, Michael Clifton, Kiyon Naser-Tavakolian, Osama Ahmed, Giuseppe Cruciata, Lev Bangiyev, Sean Clouston, Dinko Franceschi
Corticobasal degeneration (CBD) is a rare neurodegenerative disorder presenting with atypical parkinsonian symptoms that characteristically involves the frontoparietal region including the primary sensorimotor cortex, ipsilateral basal ganglia, and thalamus, typically in an asymmetric pattern. We aim to evaluate the metabolic and volumetric abnormalities in patients with clinically suspected CBD phenotypes utilizing hybrid 18F-fluorodeoxyglucose (FDG) positron emission tomography–magnetic resonance (PET/MR) brain imaging. A retrospective analysis was performed on 75 patients (mean age 74 years, 31 males and 44 females) who underwent 18F-FDG PET/MR imaging (MRI) as part of their clinical dementia workup. Images were obtained using an integrated Siemens mMR 3T PET/MRI scanner. Two board-certified neuroradiologists and a nuclear medicine physician evaluated the metabolic and volumetric data of each hemisphere to assess for symmetric or asymmetric involvement of regions of interest in the subset of patients with suspected CBD. Of the 75 patients, 12 were diagnosed with suspected CBD based on a combination of clinical symptoms, neurocognitive testing, and hybrid neuroimaging findings. Ten of 12 patients (87%) demonstrated asymmetrically decreased FDG uptake involving a single cerebral hemisphere and ipsilateral subcortical structures, whereas two of 12 patients (13%) demonstrated striking hypometabolism of the bilateral sensorimotor cortices. Our study highlights two characteristic patterns of hypometabolism in patients with clinical and neuroimaging findings suggestive of the underlying CBD. The first pattern is asymmetric hypometabolism and volume loss, particularly within the frontoparietal and occipital cortices with involvement of ipsilateral subcortical structures, including the basal ganglia and thalamus. The second, more atypical pattern, is symmetric hypometabolism with striking involvement of the bilateral sensorimotor cortices.
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Lung cancer metastasis mimicking fingertip osteomyelitis: An 18F-fluorodeoxyglucose positron emission tomography-computed tomography study p. 185
Chiara Cottignoli, Cinzia Romagnolo, Fabio Massimo Fringuelli, Luca Burroni
Lung cancer commonly metastasizes to ipsilateral and contralateral lungs, to mediastinal lymph nodes, to skeletal level, to brain, and to adrenal gland. It is indeed very rare to find skeletal metastases at the extremities, especially at the onset of the disease. We share the case of a 53-year-old man with dyspnea and pain at the level of the first finger of the left hand under antibiotic treatment for suspected osteomyelitis. 18F-fluorodeoxyglucose positron emission tomography–computed tomography showed the presence of a left lung lesion with multiple localizations at muscles and bones.
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Diffuse bone marrow uptake related to granulocyte colony-stimulating factor-producing maxillary sinus carcinoma on 4-borono-2-18F-fluoro-L-phenylalanine positron emission tomography/computed tomography p. 188
Kharisma Perdani Kusumahstuti, Tadashi Watabe, Naoya Kitamura, Tetsuya Yamamoto
Granulocyte colony-stimulating factor (G-CSF) can be produced by tumor cells and is known to promote tumor growth, thereby potentially accelerating disease progression. Squamous cell carcinoma (SCC) at maxillary sinus is aggressive growth with poor prognosis. Maxillary sinus carcinomas are rare and can be clinically silent in the early stages or manifest with the same signs and symptoms of more common illnesses, leading to their delayed diagnosis of disease. Hypermetabolic uptake of 18F-fluorodeoxyglucose (18F-FDG) but not of 4-borono-2-18F-fluoro-L-phenylalanine (18F-FBPA), in the bone marrow of patients with G-CSF-producing tumors without bone marrow involvement during positron emission tomography (PET), has been reported. The present case report describes our first experience of bone marrow uptake in PET/computed tomography examination using18F-FBPA, high uptake seen in the bone marrow of a patient with a G-CSF-secreting SCC of the maxillary sinus that it relapsed following chemoradiation therapy and surgical resection of the tumor.
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A case of hepatic focal nodular hyperplasia mimicking hepatocellular carcinoma identified on gallium-68-prostate-specific membrane antigen positron emission tomography/computed tomography p. 192
Seckin Bilgic, Haluk Burçak Sayman, Muhammet Sait Sager, Kerim Sonmezoglu
Prostate-specific membrane antigen (PSMA) is a glycosylated type-II transmembrane protein highly expressed in individual tumor cells. Lesions with PSMA expression in the liver are commonly reported as prostate cancer metastasis or hepatocellular cancer previously. This is the first case reported as hepatic focal nodular hyperplasia, mimicking hepatocellular carcinoma with imaging features. This patient, having a lesion that has been enlarged from 2.0 cm to 2.5 cm in 3 months, was referred to our department for restaging by gallium-68 PSMA (68Ga-PSMA) positron emission tomography/computed tomography (PET/CT). The CT scan showed a focal segment VI hypodensity, which was significantly PSMA-avid. Consequently, its biopsy resulted as focal nodular hyperplasia in liver. His follow-up 68Ga-PSMA PET/CT ultimately revealed a mass lesion of 8 cm of axial diameter.
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Bilateral renal involvement in diffuse large B-cell lymphoma on fluorodeoxyglucose positron emission tomography/computed tomography p. 195
Yassir Benameur, Adnane Hammani, Kamal Doghmi, Abderrahim Doudouh
Secondary renal involvement in patients with diffuse large B-cell lymphoma (DLBCL) is rare and associated with poor prognosis. We, hereby, described a case of a patient diagnosed with DLBCL, in whom bilateral renal involvement was detected on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). The patient received 4 courses of chemotherapy, and follow-up18F-FDG PET/CT revealed the complete resolution of the diffuse increased renal18F-FDG uptake. Renal lymphoma is uncommon and18F-FDG PET/CT is particularly useful for detecting extranodal involvement in DLBLC.
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18F-fluorodeoxyglucose positron emission tomography/computed tomography as a metabolic marker for functional assessment of spinal tuberculosis after early decompression surgery p. 198
Kasturi Rangan, Amrin Israrahmed, Ajay Singh Suraj, Sanjay Gambhir
Tuberculosis (TB) of the spine is the most important extra pulmonary form of TB. The lytic destructive variant of spinal TB can destroy the intervertebral discs, vertebral body, collapse, kyphotic deformity, and spinal cord compression. Complicated Pott's disease if not managed early can lead to neurological deficits, so there is a need for early surgical decompression, compliant anti-tubercular therapy, and response evaluation tool. We present two cases of multilevel dorsal spinal TB diagnosed on magnetic resonance imaging spine and baseline 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) scan. They underwent early decompression with internal fixation and were followed up for 18 months with serial 18F-FDG PET/CT at 3rd and 18th month, respectively. One patient showed an early complete metabolic response and excellent functional recovery. Another patient showed progressive disease (drug-resistant status) and delayed functional recovery. 18F-FDG PET/CT has an excellent role in assessing response to therapy and thus helps to achieve therapeutic endpoint.
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Hot-clot artifact in the lung parenchyma on 18F-fluorodeoxyglucose positron emission tomography/computed tomography mimicking malignancy with a homolateral non-small cell lung cancer p. 202
Yacine El Yaagoubi, Caroline Prunier-Aesch, Laurent Philippe, Philippe Laplaige
18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (CT) is an important tool widely used in the oncology to stage and restage various malignancies. Intense focal FDG uptake in the lung parenchyma associated with the absence of anatomical lesion detected on CT can be explained by a lung microembolism, known as hot-clot artifact. We report, to the best of our knowledge, the first case describing a single hot-clot artifact located in the same lung as a histologically proven non-small cell lung cancer.
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A case of dermatopathic lymphadenitis mimicking lymphoma on 18F-fluorodeoxyglucose positron emission tomography/computed tomography imaging p. 205
Koon Kiu Ng, Yan Ho Hui, Boom Ting Kung, Ting Kun Au Yong
This case report illustrates a rare case of dermatopathic lymphadenitis with interval 18F-fluorodeoxyglucose positron emission tomography/computed tomography performed. The clinical presentation, imaging, and histological findings are described. We discuss the diagnostic challenges in this case.
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Malignant perivascular epithelioid cell tumor of the ileum on 18F-fluorodeoxyglucose positron emission tomography/computed tomography with pathological correlation p. 208
Jeeban Paul Das, Jad Bou-Ayache, Marc J Gollub, Christopher C Riedl, Gary A Ulaner
A 75-year-old woman presented with a 1-month history of abdominal pain. Contrast-enhanced computed tomography (CT) demonstrated a large solid mass in the left lower abdominal quadrant, suspicious for malignancy. Staging with 18F-fluorodeoxyglucose (FDG) positron emission tomography/CT imaging demonstrated intense FDG uptake in the mass with no evidence of metastatic disease. Complete surgical resection was performed, and histopathological analysis confirmed a malignant perivascular epithelioid cell tumor of the ileum.
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A rare case of pituitary metastasis from breast cancer detected on fluorodeoxyglucose positron emission tomography/computed tomography that presented as insipid diabetes p. 211
Omar Ait Sahel, Yassir Benameur, Salah Oueriagli Nabih, Abdelhamid Biyi, Abderrahim Doudouh
Pituitary metastases are rare, are generally asymptomatic, and often remain undiagnosed. Breast cancer is the most common primary cancer metastasizing to hypophysis in women. However, it is difficult to clinically and radiologically differentiate pituitary metastases from pituitary adenomas. We report a case of pituitary metastases diagnosed on magnetic resonance imaging and positron emission tomography/computed tomography, which was the prime manifestation of a breast cancer in a 46-year-old female. This cancer was revealed by insipid diabetes.
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