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   Table of Contents - Current issue
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January-March 2021
Volume 20 | Issue 1
Page Nos. 1-128

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REVIEW ARTICLES  

Reopening the country: Recommendations for nuclear medicine departments Highly accessed article p. 1
Sanaz Katal, Saif Azam, Emilio Bombardieri, Maria Picchio, Ali Gholamrezanezhad
DOI:10.4103/wjnm.WJNM_73_20  
The best practices for nuclear medicine departments to operate safely during the COVID-19 pandemic have been debated in the literature recently. However, as many governments have started to ease restrictions in activity due to COVID-19, a set of guidelines is needed to resume routine patient care throughout the world. The nonessential or elective procedures which were previously postponed or canceled during the COVID-19 pandemic will gradually restart in the following weeks despite the continued risks. In this paper, we aim to review some of the most effective general precautions to restart the regular nuclear medicine operations safely.
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18F-fluorodeoxyglucose positron emission tomography/ computed tomography imaging review of benign lesions of the thorax Highly accessed article p. 7
Reddy Ravikanth
DOI:10.4103/wjnm.WJNM_85_20  
2-deoxy-2-(Fluorine-18) fluoro-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) has been used exclusively to diagnose malignancies. However, increased18F-FDG uptake is not always limited to malignant lesions. This imaging review demonstrates the physiological18F-FDG uptake of normal structures in the thorax and illustrates many benign pathological lesions with standardized uptake value >2.5. These various conditions can be broadly categorized into three groups: infective lesions, active granulomatous diseases such as sarcoidosis, noninfectious/inflammatory, or proliferative conditions such as radiation pneumonitis, postlung transplant lymphoproliferative disorders, occupational pleuropulmonary complications, and postsurgical conditions, all of which can demonstrate varying degrees of18F-FDG uptake on PET/CT based upon the degree of inflammatory activity. Familiarity of false-positive findings improves the PET/CT evaluation accuracy of benign lesions of the thorax. Radiation exposure and surgical history correlation along with imaging cross check evaluation of radiographs and magnetic resonance images for the anatomic location remains the mainstay of PET/CT characterization of positive findings.
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ORIGINAL ARTICLES Top

Comparison of radioiodine ablation rates between low versus high dose, and according to the surgeon's expertise in the low-risk group of differentiated thyroid cancer p. 17
Ghazal Norouzi, Babak Shafiei, Farzad Hadaegh, Mohsen Qutbi, Isa Neshandar Asli, Esmail Jafari, Hamid Javadi, Majid Assadi
DOI:10.4103/wjnm.WJNM_24_20  
Radioiodine ablation following surgery is the accepted treatment for patients with differentiated thyroid cancer (DTC). Since that surgical volume and radioiodine dose can have impact on treatment outcome, we aimed to evaluate them on the treatment outcome of low-risk DTC patients. Low-risk DTC patients were classified into four groups, including (1) thyroidectomy was performed by thyroid surgeon and low-dose (1850 MBq [30 mCi]) radioiodine was administered (n = 17), (2) thyroidectomy was performed by thyroid surgeon and high-dose (3700 MBq [100 mCi]) radioiodine was administered (n = 10), (3) thyroidectomy was performed by general surgeon and low-dose radioiodine was administered (n = 22), and (4) thyroidectomy was performed by general surgeon and high-dose radioiodine was administered (n = 29). All patients were followed at least for 6 months and also for evaluation of treatment success, neck sonography, thyroid-stimulating hormone-off, thyroglobulin (Tg)-off, and anti-Tg-off tests were performed. Furthermore, two common radioiodine treatment-associated side effects, including dry mouth, and nausea/vomiting were assessed for all patients. Seventy-eight low-risk DTC patients (female: 70 [89.7%]; male: 8 [10.3%]) aged from 18 to 78 years old with mean of 41.96 ± 13.42 years were enrolled in this study. In total, the treatment was successful in 96.2% of patients. There was no significant difference in treatment success among groups (P > 0.05), while there was a significant association among administered activity and side effects. In low dose patients, only one patient complained from dry mouth; however, 11/39 patients who received high dose of iodine complained from dry mouth (P = 0.002). In addition, 9/39 high dose patients suffered from vomiting/nausea, while none of low-dose patients suffered from vomiting/nausea (P = 0.001). In low-risk DTC patients, surgical volume and amounts of radioiodine had no significant impact on treatment results; therefore, low dose radioiodine following thyroidectomy may be preferable to low-risk DTC patients to avoid side effects.
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Hybrid imaging in dementia: A semi-quantitative (18F)-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging approach in clinical practice p. 23
Ana Marija Franceschi, Kiyon Naser-Tavakolian, Michael Clifton, Osama Ahmed, Katarina Stoffers, Lev Bangiyev, Giuseppe Cruciata, Sean Clouston, Dinko Franceschi
DOI:10.4103/wjnm.WJNM_27_20  
Neurodegenerative disorders may demonstrate typical lobar and regional patterns of volume loss with corresponding decreased glucose metabolism. In this retrospective study, we correlated semi-quantitative volumetric changes utilizing NeuroQuant morphometric analysis with decreased fluorodeoxyglucose (FDG) uptake age-matched calculated z-scores utilizing18F-FDG positron emission tomography/magnetic resonance imaging (PET/MRI). Eighty-nine patients (mean age 71.4) with clinical findings suggestive of various subtypes of dementia underwent PET/MR brain imaging. Cases were categorized as follows: Alzheimer's dementia (AD), frontotemporal lobar degeneration (FTLD), dementia with Lewy bodies (DLB), and corticobasal degeneration (CBD). NeuroQuant software provided semi-quantitative assessment of lobar-specific patterns of volume loss compared to age-matched controls. MIMneuro software provided semi-quantitative FDG uptake data, with metabolic z-scores generated in comparison to age-matched controls. Volumetric and metabolic data were then correlated for statistical significance. In 29 AD cases, Pearson correlation coefficient between z-score and lobar volume was 0.3 (P = 0.120) and 0.38 (P < 0.05), for parietal and temporal lobes, respectively. In 34 FTLD cases, it was 0.35 (P = 0.051) and 0.02 (P = 0.916), for frontal and temporal lobes, respectively. In 14 DLB cases, it was 0.42 (P = 0.130), 0.5 (P = 0.067), and 0.22 (P = 0.447) for the occipital lobes, middle occipital gyrus, and parietal lobes, respectively. In 12 CBD cases, it was 0.58 (P < 0.05) for the superior parietal lobule. Semi-quantitative (F18)-FDG PET/MRI analysis demonstrated a positive relationship between volumetric loss and hypometabolism within certain lobar-specific regions, depending on neurodegenerative disorder subtype. Our findings may add diagnostic confidence in the accurate imaging diagnosis of neurodegenerative disease.
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The findings of 18F-fluorodeoxyglucose positron emission tomography–computed tomography scan in patients with hidradenitis suppurativa in Malaysia: A multicenter study p. 32
Chai Har Loo, Alex Cheen Hoe Khoo, Wooi Chiang Tan, Yek Huan Khor, Jyh Jong Tang, Min Moon Tang, Lee Chin Chan
DOI:10.4103/wjnm.WJNM_33_20  
Hidradenitis suppurativa (HS) is known to have association with systemic diseases with chronic inflammation such as psoriasis. We aim to describe the concomitant systemic inflammation in patients with HS using 18F-fluorodeoxyglucose positron emission tomography–computed tomography (18F-FDG PET/CT) scan. This was a case–control study conducted in three tertiary hospitals in Northern Malaysia from January to December 2017, involving HS patients aged 18 years and above. Thirty-two HS patients with age- and sex-matched controls were recruited with a mean age of 31.4 years (range: 18–56). Numerous cutaneous inflammatory foci were detected on FDG-PET/CT scan in clinically unapparent sites (27/32, 84.4%). Approximately 90.6%, 93.8%, and 50.0% of the patients had significantly higher cutaneous uptake over nasal, mandibular, and scalp regions, respectively (P < 0.0001). PET/CT scan did not detect any systemic inflammation unlike those found in psoriasis. Three (9.4%) patients had thyroid nodules with high uptake (maximum standard uptake values ranging from 2.9 to 11.3). Two of them were confirmed to have papillary thyroid carcinoma, while the third patient has inconclusive finding.18F-FDG PET/CT scan may be useful to map disease burden of HS. Nonlesional inflammatory foci on the skin of the nose, mandibular, and scalp are probably significant. The association of thyroid carcinoma in HS warrants further evaluation.
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Intraobserver and interobserver variations in cortical transit time measurement in children with pelviureteric junction obstruction p. 38
Vishesh Jain, Rakesh Kumar, Shamim Ahmed Shamim, Saurabh Arora, Kalaivani Mani, Devendra Kumar Yadav, Prabudh Goel, Anjan Dhua, Sandeep Agarwala
DOI:10.4103/wjnm.WJNM_37_20  
Cortical transit time (CTT) has recently been shown to be a useful parameter in the management of children with pelviureteric junction obstruction (PUJO). The aim of this study was to assess intraobserver and interobserver variations in the qualitative and quantitative assessment of CTT in children with PUJO. A retrospective study was performed, and99mTc-MAG3 renogram images of all children with PUJO performed from January 2016 to December 2017 were retrieved. The images were assessed by three observers at two different time points. CTT was qualified as delayed if CTT was more than 3 min else; it was noted as normal. The intraobserver and interobserver variations in the results of the CTT of the normal kidney and affected kidney both before and after surgery were studied. The kappa statistic was used to compare the interobserver variation of qualitative interpretation of CTT. The Bland–Altman plot was used to evaluate the intraobserver and interobserver variations of the quantitative interpretation of CTT. A total of 5799mTc-MAG3 renal scintigraphies were evaluated. Overall, 114 renal units were evaluated with 51 normal renal units and 63 renal units with PUJO. Of these, 63 renal units with PUJO, 31 renal units had been operated upon, whereas the remaining 32 renal units had no intervention at the time of the study. The kappa statistic in the normal, affected operated, and affected unoperated kidneys was interpreted as almost perfect, substantial to almost perfect, and moderate to substantial level of agreement, respectively. The Bland–Altman plot revealed a large mean difference and wide 95% limits of agreement in affected kidneys (both operated and unoperated). The study concludes that the qualitative CTT interpretation in the affected renal unit which is most commonly used in recent studies is a reliable and reproducible parameter in children with PUJO. The quantitative measurement had wide inter- and intraobserver variation for clinical use.
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Comparison of noise estimation methods used in denoising99mTc-sestamibi parathyroid images using wavelet transform p. 46
Anil Kumar Pandey, Param Dev Sharma, Akshima Sharma, Chandra Sekhar Bal, Rakesh Kumar
DOI:10.4103/wjnm.WJNM_43_20  
The objective of this study was to compare the performance of variance, median absolute deviation, and the square of median absolute deviation methods of noise estimation in denoising of99mTc-sestamibi parathyroid images using wavelet transform. Sixty-eight99mTc-sestamibi parathyroid images including 33 images acquired at zoom 1.0 and 35 acquired at zoom 2.0 were denoised using the wavethresh package in R. The image decomposition and reconstruction method discrete wavelet transform, wavelet filter db4, shrinkage method hard, and thresholding policy universal were used. The noise estimation in the process was made using var, mad and madmad functions, which use variance, mean absolute deviation, and the square of mean absolute deviation, respectively. The quality of denoised images was assessed both qualitatively and quantitatively. A nonparametric two-sample Kolmogorov–Smirnov test was applied to find whether the difference in image quality produced by these three noise estimation methods was significant at 95% confidence. Noise estimation using madmad function produced the best quality denoised image. Further, the quality of the denoised image using madmad function was significantly better than the quality of the denoised image obtained with var or mad function (P = 1). The estimation of noise using madmad functions in wavelet transforms provides the best-denoised image for both zoom 1.0 and zoom 2.099m Tc-sestamibi parathyroid images.
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Outcomes following I-131 treatment with cumulative dose exceeding or equal to 600 mCi in differentiated thyroid carcinoma patients p. 54
Chalermrat Kaewput, Pawana Pusuwan
DOI:10.4103/wjnm.WJNM_49_20  
To evaluate treatment outcomes following radioactive iodine (RAI) treatment with a cumulative dose of ≥≥600 mCi in differentiated thyroid carcinoma (DTC) patients, a retrospective review of medical records was done in 176 DTC patients with a cumulative dose of ≥600 mCi from January 1993 to December 2013. All patients were followed up for at least 2 years after receiving 600 mCi of I-131 treatment. Remission criteria were no clinical and imaging evidence of disease and low serum thyroglobulin levels during thyroid-stimulating hormone suppression of <0.2 ng/ml or of <1 ng/ml after stimulation in the absence of interfering antibodies. A total of 176 patients were included in the study: 137 – papillary thyroid cancer, 29 – follicular thyroid cancer, 9 – mixed papillary and follicular thyroid cancer, and 1 – Hurthle cell carcinoma. Most of the patients (118, 67%) had locoregional metastasis, whereas 48 patients (27%) had distant metastases at presentation. The median cumulative dose was 900 mCi (range: 600–2200 mCi). The mean follow-up period was 82.84 ± 42.41 months. Only 16 patients (9.1%) met remission criteria at the end of treatment. The rest of patients (160, 90.9%) were not remitted: stable disease in 94 (53.4%), at least 1 metastasis without I-131 uptake in 34 (19.3%), progressive disease in 21 (11.9%), and death during the whole follow-up period in 11 (6.3%). Two patients (1.1%) developed second primary malignancy. Eighteen cases were suspected of bone marrow suppression (14 cases [7.9%] had anemia and 5 cases [2.8%] had neutropenia). Seven patients (3.9%) developed permanent salivary gland dysfunction. Although the complications after receiving RAI treatment with a cumulative dose of ≥≥600 mCi were low and not severe, the patients with remission were in <10%. Our study suggests that the decision to administer further treatments should be made on an individual basis because beneficial effects may be controversial.
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Analysis of amyloid and tau deposition in Alzheimer's disease using11C-Pittsburgh compound B and18F-THK 5351 positron emission tomography imaging p. 61
Chotipanich Chanisa, Nivorn Monchaya, Kunawudhi Anchisa, Promteangtrong Chetsadaporn, Jantarato Attapon
DOI:10.4103/wjnm.WJNM_50_20  
This study aims to determine the deposition of11C-Pittsburgh compound B (11C-PiB) and18F-THK 5351 using a normal database of the optimal cut-off-points for standardized uptake value ratios (SUVRs) in Alzheimer's disease (AD) patients. Sixteen AD patients and 24 cognitively normal individuals were enrolled in this study. The optimal cutoff points for the SUVR from the normal database were used for quantitative analysis. P-mod software with the Automated Anatomical Labeling merged atlas was employed to generate automatic volumes of interest to identify different brain regions, and the SUVRs of AD patients were compared with those of the age-matched normal controls. The correlation between PiB and THK5351 deposition at matching brain regions was identified. The mean regional11C-PiB SUVRs of the AD patients were significantly higher than the healthy controls (P < 0.05). The11C-PiB SUVR cut-offs were 1.46–1.81, with sensitivity ranging from 81.25% to 93.75% and specificity of 100%. The mean SUVRs of18F-THK 5351 in various regions were also significantly higher in the AD patients than in the healthy controls (P < 0.05). The inferior temporal gyrus yielded an optimum SUVR cut-off-points of 1.5 with 80% sensitivity and 83.33% specificity. The correlation of PiB and THK5351 SUVR was reported at precuneus, parietal, and occipital brain areas, with spearman's rho of 0.67, 0.66, and 0.72, respectively. Our findings allow determination of the SUVRs of11C-PiB and18F-THK-5351 amyloid and tau positron emission tomography tracers for clinical use, according to the normal database of the optimal cut-off-points for SUVRs in AD patients.
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Initial clinical evaluation of indigenous90Y-DOTATATE in sequential duo-PRRT approach (177Lu-DOTATATE and90Y-DOTATATE) in neuroendocrine tumors with large bulky disease: Observation on tolerability,90Y-DOTATATE post- PRRT imaging characteristics (bremsstrahlung and PETCT) and early adverse effects p. 73
Rahul V Parghane, Arpit Mitra, Trupti Upadhye Bannore, Sutapa Rakshit, Sharmila Banerjee, Sandip Basu
DOI:10.4103/wjnm.WJNM_52_20  
177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) alone has lesser potential in the clinical setting of neuroendocrine tumor (NET) with large bulky disease and nonhomogeneous somatostatin receptors (SSTR) distribution, owing to lower energy (Eβmax 0.497 MeV) and a shorter particle penetration range (maximum 2–4 mm) of177Lu. In large bulky NETs,90Yttrium (90Y) has the theoretical advantages because of a longer beta particle penetration range (a maximum soft tissue penetration of 11 mm). Therefore, a combination of177Lu and90Y is a theoretically sound concept that can result in better response in metastatic NET with large-bulky lesion and non-homogeneous SSTR distribution. The aim of the study was to determine the feasibility of combining90Y-DOTATATE with177Lu-DOTATATE PRRT as sequential duo-PRRT in metastatic NET with (≥5 cm) including the post90Y-DOTATATE-PRRT imaging and also to determine early toxicity of the duo-PRRT approach. A total of 9 patients received combination of177Lu-DOTATATE with90Y-DOTATATE (indigenously prepared and approved) through sequential duo-PRRT approach. These 9 NET patients were included and analyzed in this study. All 9 patients had undergone post-PRRT90Y-DOTATATE imaging, including a whole-body planar bremsstrahlung imaging followed by regional single-photon emission computed tomography (SPECT)-computed tomography (CT) imaging and also a regional positron emission tomography–computed tomography imaging. Grading of90Y-DOTATATE and177Lu-DOTATATE uptake was done on post-PRRT imaging by both modalities. The size of the lesions ranged from 5.5 cm to 16 cm with average size of 10 cm before sequential duo-PRRT was decided. Sequential duo-PRRT was administered because of stable, unresponsive disease following177Lu-DOTATATE in 5 patients (55.6%), progressive disease after177Lu-DOTATATE in 2 patients (22.2%), and with neoadjuvant intent in 2 patients (22.2%). The total cumulative dose of177Lu-DOTATATE before duo-pRRT ranged from 11.84 GBq to 37 GBq per patient and average administered dose of 27.21 GBq per patient in this study. Out of 9 patients, 8 patients received single cycle of90Y-DOTATATE (ranging from 2.66 GBq to 3.4 GBq per patient with average administered dose of 3.12 GBq per patient). One patient received two cycles of90Y-DOTATATE (total dose of 6.2 GBq). Out of 9 patients, 8 patients showed excellent tracer concentration in lesions on post-PRRT90Y-DOTATATE imaging and the remaining 1 patient showed fairly adequate90Y-DOTATATE tracer uptake in lesion on visual analysis. There was matched90Y-DOTATATE uptake with68Ga-DOTATATE and also with177LuDOTATATE in all 9 patients. The sequential duo-PRRT was well tolerated by all patients. Two patients (22.2%) developed mild nausea, one patient (11.1%) developed transient mild-grade hemoglobin toxicity, and one patient (11.1%) developed mild-grade gastrointestinal symptoms (loose motion and abdominal pain). No nephrotoxicity, hepatotoxicity, and other hematological toxicity was observed. The combination of the indigenous90Y-DOTATATE with177Lu-DOTATATE PRRT in NET as sequential duo-PRRT was well tolerated, feasible and safe in stable, unresponsive/progressive disease following single isotope177Lu-DOTATATE therapy and also in neoadjuvant PRRT setting with large bulky lesion (≥≥5cm). Post-PRRT90Y-DOTATATE imaging showed excellent90Y-DOTATATE uptake in nearly all NET patients. Mild-grade early adverse effects were easily manageable and controllable in this sequential duo-PRRT approach.
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Visual versus semiquantitative analysis of F-18 fluorodeoxyglucose-positron emission tomography brain images in patients with dementia p. 82
Ismet Sarikaya, Walaa A Kamel, Khattab Khaled Ateyah, Nooraessa Bin Essa, Samira AlTailji, Ali Sarikaya
DOI:10.4103/wjnm.WJNM_53_18  
Various studies have reported to the superiority of semiquantitative (SQ) analysis over visual analysis in detecting metabolic changes in the brain. In this study, we aimed to determine the limitations of SQ analysis programs and the current status of F-18 fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan in dementia. F-18 FDG-PET/computed tomography (CT) brain images of 39 patients with a history of dementia were analyzed both visually and semiquantitatively. Using the visually markedly abnormal F-18 FDG-PET images as standard, we wanted to test the accuracy of two commercially available SQ analysis programs. SQ analysis results were classified as matching, partially matching and nonmatching with visually markedly abnormal studies. On visual analysis, F-18 FDG-PET showed marked regional hypometabolism in 19 patients, mild abnormalities in 8 and was normal in 12 patients. SQ analysis-1 results matched with visual analysis in 8 patients (42.1%) and partially matched in 11. SQ analysis-2 findings matched with visual analysis in 11 patients (57.8%) and partially matched in 7 and did not match in 1. Marked regional hypometabolism was either on the left side of the brain or was more significant on the left than the right in 63% of patients. Preservation of metabolism in sensorimotor cortex was seen in various dementia subtypes. Reviewing images in color scale and maximum intensity projection (MIP) image was helpful in demonstrating and displaying regional abnormalities, respectively. SQ analysis provides less accurate results as compared to visual analysis by experts. Due to suboptimal image registration and selection of brain areas, SQ analysis provides inaccurate results, particularly in small areas and areas in close proximity. Image registration and selection of areas with SQ programs should be checked carefully before reporting the results.
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CASE REPORTS Top

18F-fluorodeoxyglucose positron emission tomography/ computed tomography of giant cell arteritis with lower extremity involvement in association with polymyalgia rheumatica p. 90
Ananya Panda, Gregory A Wiseman, Matthew J Koster, Kenneth J Warrington, Geoffrey B Johnson
DOI:10.4103/wjnm.WJNM_102_20  
An 80-year-old man presented with new-onset pain in the shoulders and lower extremities and elevated serum inflammatory markers. A clinical diagnosis of polymyalgia rheumatica (PMR) was made, but there was a suboptimal response to glucocorticoid therapy, prompting further evaluation.18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) revealed intense FDG uptake in the arteries of the bilateral lower extremities, head, and neck, but sparing the aorta, suggestive of an uncommon pattern of giant cell arteritis (GCA). There were also imaging signs consistent with PMR, including FDG uptake in the synovium of large joints. This case highlights the uncommon manifestation of GCA with lower extremity involvement and sparing of the aorta. The combination of FDG PET imaging features and elevated serum markers obviated the need for invasive biopsy. One might also conclude that standard FDG PET/CT imaging protocols covering orbits/vertex to thighs incompletely evaluate the extent of arterial distribution of GCA.
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Xanthogranulomatous cholecystitis mimicking gallbladder cancer on18F-fluorodeoxyglucose positron emission tomography/computed tomography scan p. 93
Nitin Gupta, Ritu Verma, Ethel Shangne Belho, Shashi Dhawan
DOI:10.4103/wjnm.WJNM_118_20  
The abnormal thickening of the gallbladder (GB) wall can be caused by a malignant condition like gallbladder carcinoma or by benign lesions such as chronic cholecystitis or xanthogranulomatous cholecystitis (XGC). Mural thickening is a common finding between them as fluorodeoxyglucose (FDG) can be taken up by inflammatory cells also. Here, we present a patient with irregular thickening of the GB wall which was suspected to of GB carcinoma since FDG positron emission tomography/computed tomography scan showed increased tracer uptake in the lesion. However, after surgery the histopathological report was suggestive of XGC.
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Localizing a metabolic focus during a functional seizure with fluorodeoxyglucose positron emission tomography-computed tomography p. 96
Siroos Mirzaei, Barbara Preitler, Thomas Wenzel
DOI:10.4103/wjnm.WJNM_22_20  
Traumatic brain injuries can lead to long-term mental seizures that are difficult to differentiate from dissociative psychogenic symptoms, respectively, psychogenic nonepileptic seizures. Recent articles have drawn attention to the need of differentiation of psychological and brain trauma-related symptoms in survivors of violence. This case study reflects a diagnostic step in a 20-year-male who reported to have been subjected to torture, including blunt force to the head 2 years before examination. He suffers from episodical headaches followed by mental bouts of aggression and restlessness. We performed a brain18F-fluorodeoxyglucose positron emission tomography (PET)-computed tomography to identify a cerebral correlate of the psychogenic seizures. The examination yielded a hypermetabolic focus in the frontal superior parasagittal region. Psychogenic seizures can frequently be observed as culture-specific “idioms of distress” and can challenge diagnostic evaluation, especially in the victims of violence with an additional history of blunt brain trauma. The advances in molecular imaging such as PET can be expected to play a crucial role in forensic and clinical assessment in the increasing number of such patients.
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Solitary late metastasis of primary renal cell carcinoid tumor to the extraocular muscles imaged with indium-111 octreotide p. 99
Philip Jude Dempsey, Martin J O'Connell, Ferdia Bolster
DOI:10.4103/wjnm.WJNM_28_20  
A 75-year-old male presented with right eye pain and proptosis. His history was significant for renal cell carcinoma treated with left nephrectomy 2 years previously. Computed tomography (CT) imaging demonstrated a 1.6-cm enhancing lesion in the right retrobulbar space. Surgical biopsy revealed a low-grade metastatic carcinoid tumor. At retrospective review, the primary renal lesion from 2 years prior was rediagnosed as consistent with a renal carcinoid tumor. Indium-111 octreotide single photon emission CT/CT imaging demonstrated a solitary metastasis within the right extraocular muscles. The patient subsequently developed additional metastases within the remaining right kidney and lung.
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Graves' disease: A rare fate of Hashimoto's thyroiditis p. 102
Rahul Jadhav, Mohammad Alberawi, Khushboo Gupta
DOI:10.4103/wjnm.WJNM_34_20  
Hashimoto's thyroiditis is a known autoimmune disorder that leads to chronic inflammation of the thyroid gland, with a gradual decline in function and eventual hypothyroidism. Conversion of Hashimoto's thyroiditis to Graves' disease is unusual clinically and has been occasionally reported in the literature. Awareness of such a rare phenomenon is important for the physicians evaluating patients with autoimmune thyroid disorders. Close investigation of the patient's symptoms and biochemical status is crucial in the implementation of appropriate treatment.
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Breast uptake on a myocardial perfusion scan p. 105
Cristina Cuaresma Morales, Angelin Fragante Apostol
DOI:10.4103/wjnm.WJNM_35_20  
A 42-year-old female underwent a myocardial perfusion scan (MPS) for the evaluation of coronary artery disease. Raw and cine loop images hinted at abnormal tracer accumulation in the chest. Review of short-axis slices and low-dose computed tomography images taken for attenuation correction and their subsequent fusion confirmed the presence of focal tracer uptake localized to nodular breast masses. This case demonstrates that despite MPS not being optimized to detect breast pathologies, careful inspection of unprocessed images and the application of available software for fusion can help detect concurrent pathology.
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Clinically occult image revelations of fluorodeoxyglucose positron emission tomography/computed tomography in a peculiar case of sinonasal myeloid sarcoma p. 109
Shema Mathew, Indirani Muthukrishnan, Shelley Simon
DOI:10.4103/wjnm.WJNM_36_20  
Myeloid sarcoma (MS) is a sparse association of acute myeloid leukemia (AML) with poor overall survival. Sinonasal involvement in MS is rarer and meagerly studied. Recent prospective studies have underlined the importance of positron emission tomography/computed tomography (PET/CT) in disease assessment and relapse detection in extramedullary (EM) AML. Herein, we report a case of MS with sinonasal, orbital, dural, breast, pleural extent of disease with sacral neural foraminal compression. Initial histopathologic and clinicoradiologic features had pointed toward lymphoma. Immunohistochemistry (IHC) on the contrary revealed MS. Although the role of IHC in asserting the diagnosis of MS is remarkable, PET/CT surpasses other modalities in early detection of EM sites of involvement, overall assessment of disease burden, targeting therapy, prognostication, and relapse recognition. Inclusion of PET/CT as a baseline imaging modality can be beneficial in tailoring patient management to improve survival and overall quality of life.
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Oligometastasis to testis in prostate cancer: Role of gallium-68 prostate-specific membrane antigen positron-emission tomography computed tomography p. 113
Manoj Gupta, Partha Sarathi Choudhury, Sudhir Rawal, Amitabh Singh
DOI:10.4103/wjnm.WJNM_39_20  
Accurate staging and restaging with early detection of recurrent site is the key for planning treatment in patients of prostate cancer. Recently, gallium-68 prostate-specific membrane antigen positron-emission tomography computed tomography (68Ga-PSMA PET/CT) has emerged as a better tool for this. Few uncommon sites of early metastasis can also be identified in addition to the other common sites. Herein, we present three cases of early metastasis to testis in prostate cancer identified on68Ga-PSMA PET/CT scan.
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Multicentric primary diffuse large B-cell lymphoma in genitourinary tract detected on18F-fluorodeoxyglucose positron emission tomography with computed tomography: An uncommon presentation of a common malignancy p. 117
Asra Patel, Indirani Muthukrishnan, Ann Kurian, Jaykanth Amalchandra, Nikita Sampathirao, Shelley Simon
DOI:10.4103/wjnm.WJNM_45_20  
Primary extranodal lymphomas (ENLs) are lymphomas with no or minor nodal involvement and a dominant extranodal component originating from any organ. Primary ENL originating in the genitourinary tract is extremely rare. Diffuse large B-cell lymphoma (DLBCL) is the most frequent histological subtype in primary genitourinary lymphoma. Lymphomatous involvement of genitourinary system organs is common in the setting of disseminated disease. Herein, we present a unique case of primary multicentric extranodal DLBCL of the urogenital system involving ureter, seminal vesicle, and penis detected on18fluro-deoxyglucose positron emission tomography with computed tomography, and to the best of our knowledge, it is the first case report with multiorgan involvement within a single (urogenital) organ system in a patient without disseminated disease, i.e., with no other nodal or extranodal organ system involvement.
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Fibromatosis with aggressive demeanor: Benign impersonator of malignancy p. 121
J Naveen Kumar, M Indirani, Nikita Sampathirao, S Shelley
DOI:10.4103/wjnm.WJNM_55_20  
Fibromatosis or desmoid fibromatosis is a rare benign neoplasm and develops commonly in the abdominal wall, abdominal cavity, or extra-abdominal sites. The mainstay of treatment is surgery. Chemotherapy and radiotherapy are preferred in cases of inoperable/relapse or a multifocal disease. Hereby, we report a case of fibromatosis arising in the left popliteal fossa, proven by histopathology and immunohistochemistry. Local excision of the mass was performed. The patient was asymptomatic for 6 months, after which she complained of difficulty in walking. Clinical evaluation elicited recurrence in the surgical bed. In spite of the surgical excision with tumor-free margins, recurrence was seen within a span of 6 months.18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) was done to rule out multifocal disease and to define the extent of relapse. Although magnetic resonance imaging provides an excellent soft-tissue resolution to delineate the disease,18F-FDG PET/CT is an important and supplementary tool which aids in the management of fibromatosis.
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Grade 3 metastatic neuroendocrine neoplasms of two unusual primary sites with contrasting differentiation characteristics: Dual tracer positron emission tomography and computed tomography imaging (18F-fluorodeoxyglucose and68Ga-DOTATATE) correlates and their treatment implications p. 125
Sarvesh Loharkar, Sandip Basu
DOI:10.4103/wjnm.WJNM_67_20  
The correlates of dual tracer positron emission tomography and computed tomography (PET-CT) (18F-fluorodeoxyglucose [18F-FDG] and68Ga-DOTATATE) in patients of Grade 3 neuroendocrine neoplasms (NENs) are presented. The first, a patient of gall bladder NEN, operated, with histopathology suggestive of high-grade well-differentiated neuroendocrine tumors with MiB-1 labeling index of 35%, showed uptake with both18F-FDG and68Ga-DOTATATE, including an uptake equivalent to Krenning score of 3–4 on68Ga-DOTATATE PET-CT; in the second, a patient of esophageal NEN, Grade 3 with poor differentiation features, with MiB-1 labeling index of 70%, thereby qualifying for Grade 3 neuroendocrine carcinoma, the FDG uptake was high with minimal uptake on68Ga-DOTATATE PET-CT. The illustrations reiterate the impression that relative uptake of68Ga-DOTATATE/FDG in the NEN lesions forms a valuable parameter for assessing the dynamic tumor biology in continuum and thus personalizing the treatment strategies.
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