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   2016| September-December  | Volume 15 | Issue 3  
    Online since August 31, 2016

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Radioactive 131Iodine body burden and blood dose estimates in treatment for differentiated thyroid cancer by external probe counting
Ramamoorthy Ravichandran, Naima Al Balushi
September-December 2016, 15(3):153-160
DOI:10.4103/1450-1147.174701  PMID:27651735
Radioactive131 iodine (RAI) body burden is estimated in thyroid cancer patients by a) exposure rate meter and b) external probe counting. A calibration factor of 301 cpm/MBq (d = 16 cm) is used for the probe for estimates of whole body activity. Patients sit in a rotating stool with their center corresponding to the field of view for estimation of whole body RAI. Radioactive counts are obtained for anterio posterior (AP) and postero anterior (PA) geometries. Whole body retention factor is expressed as a ratio against assayed activity administered to the patient on day 1. With exposure rate measurement, for off-thyroxin (hypothyriod) patients, the retention factors were 0.148 ± 0.12 (n = 211) and 0.07 ± 0.08 (n = 68) at 48 h and 72 h, respectively. For recombinant TSH (rhTSH) (euthyroid) group, the retention factors were 0.089 ± 0.06 (n = 24) and 0.05 ± 0.05 (n = 19) at 48 h and 72 h, respectively. By probe counting method, the obtained retention factors were 0.081 ± 0.013 (range: 0.071-0.096) (off-thyroxine group) and 0.039 ± 0.03 (range: 0.008-0.089) for the rhTSH group at 48 h. The 72 h retentions in the off thyroxine (hypothyriod) group and the rhTSH (euthyroid) group were 0.048 ± 0.024 (range: 0.016-0.076) and 0.005, respectively. The radioactive body burdens at 48 h were in the range of 290-315 MBq (7.8-8.5 mCi) for the off-thyroxine group and 44-286 MBq (1.2-7.7 mCi) for the rhTSH group. The calculated residence times in whole body were 21.97 ± 3.8 h (range: 17.1-27.1) for off-thyroxine group and 14.28 ± 2.75 h (range: 9.97-19.46) showing high statistical significance (P < 0.001). The specific blood doses were 0.118 ± 0.025 mGy/MBq (range: 0.083-0.172) for the off-thyroxine group (females n = 23); 0.87 ± 0.028 mGy/MBq (range: 0.057-0.130) (females n = 13), 0.080 ± 0.013 mGy/MBq (range: 0.069-0.098) (males n = 5) and 0.080 ± 0.028 (range: 0.059-0.118 for rhTSH patients (males n = 4). The mean mGy/MBq for blood was higher in females--about 10% for the rhTSH group compared to 40% higher for the off thyroxine (THW) group. The dose to blood was "inversely proportional" to the body weight, both in the off-thyroxine group and the rhTSH group but the dependence was not very strong with rhTSH administration because of less residence time of the radioactive iodine. There was no correlation between administered activity and retained body burden at 48 h or 72 h.
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Gastrointestinal side effects of the radioiodine therapy for the patients with differentiated thyroid carcinoma two days after prescription
Mehran Pashnehsaz, Abbas Takavar, Sina Izadyar, Seyed Salman Zakariaee, Mahmoud Mahmoudi, Reza Paydar, Parham Geramifar
September-December 2016, 15(3):173-178
DOI:10.4103/1450-1147.174703  PMID:27651737
Iodine-131 (I-131) therapy is one of the conventional approaches in the treatment of patients with differentiated thyroid carcinoma (DTC). The radioiodine agents also accumulate in the other organs that cause pain and damage to the patients. Radioiodine therapy is associated with various gastrointestinal (GI) toxicities. In this study, GI side effects of the radioiodine therapy were investigated. GI toxicities of the radioiodine therapy were studied in 137 patients with histologically proven DTC in Jun-Nov 2014. All the patients were treated by radioiodine agents in the research institute of Shariati Hospital, Tehran, Iran. The patients were examined 48 h after prescription (before discharge) and their GI side effects were registered. Correlation of the age, gender, administered dose, administered dose per body weight as the independent factors, and GI side effects were analyzed using the Pearson correlation test with Statistical Package for the Social Sciences (SPSS) version 20. Regression coefficients and linearity of the variable were investigated by MATLAB software. Line fitting was performed using MATLAB curve-fitting toolbox. From the subjects, 38 patients had GI complaints (30.4%). Significant factors influencing GI side effects were dose per body weight and administered doses. There was no significant correlation between age and gender as the independent parameters and GI complaints. The most prevalent GI side effect was nausea that occurs in 26.4% of the patients. From the results, it could be concluded that the GI side effects could be prevented by administering a safe radioiodine dose value less than 5,550 MBq.
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An extremely rare intersection: Neurolymphomatosis in a patient with burkitt lymphoma detected by 18F-fluorodeoxyglucose positron emission tomography/computed tomography
Ali Ozan Oner, Kursat Okuyucu, Engin Alagoz, Bilal Battal, Nuri Arslan
September-December 2016, 15(3):209-211
DOI:10.4103/1450-1147.172304  PMID:27651745
Neurolymphomatosis (NL) is a rarely seen neurologic involvement of the systematic lymphoma. Its diagnosis is challenging, and requires biopsy. In cases where biopsy is not appropriate, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) may aid in diagnosis. Here, we present a 54-year old male patient diagnosed with Burkitt lymphoma who underwent FDG-PET/CT in order to evaluate the treatment response after chemotherapy and radiotherapy. On viewing PET/CT images of the patient who complained of pain and weakness in his upper extremities after therapy, linear FDG uptake was observed in bilateral cervical 5 (C5), left cervical 6 (C6), bilateral cervical 7 (C7), and right lumbar 4 (L4) nerve roots. Magnetic resonance imaging (MRI) revealed dilation and thickening of nerve roots consisted with FDG uptake observed on PET/CT images. Since biopsy was not performed, histopathological diagnosis could not be established. However, overlapping of clinical, PET/CT, and MRI findings strongly suggested the presence of NL. As is the case of this patient, in cases with non-Hodgkin lymphoma, a combined evaluation of FDG-PET/CT and MRI modalities aid in the establishment of the diagnosis of NL.
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Can neutrophil/lymphocyte ratio be a predictor for bone metastases of solid tumors?
Billur Caliskan, Ayşe Nurdan Korkmaz
September-December 2016, 15(3):196-199
DOI:10.4103/1450-1147.174711  PMID:27651741
Cancer-associated inflammation has been receiving increased attention due to its role in cancer development. It is known that tumors can cause an inflammatory reaction and inflammatory cells play an important role in neoplastic growth. In this study, we aimed to investigate any relationship between bone metastases and the neutrophil-to-lymphocyte ratio (NLR). Patients who were referred for bone scintigraphy to investigate bone metastasis were enrolled in the study. Patients' hematological parameters were obtained from the hospital database retrospectively. Patients with a nonmetastatic bone scan were categorized as Group A (N = 171), patients who had metastatic bone disease without any other organ metastases were categorized as group B (N = 25), and patients who had metastatic bone disease with the other organ metastases were categorized as Group C (N = 48). The median NLR of the patients in Group A was 2.55 (range: 0.38-20.7), in Group B was 2.83 (range: 1.56-31.8), and in Group C was 4.12 (range: 1.79-38). NLR was significantly higher in Group C patients compared to Group A and B patients (P < 0.001). In conclusion, the NLR is significantly associated with the other organ metastases but has no significant correlation with bone metastases.
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Detection of primary malignancy and metastases with FDG PET/CT in patients with cholangiocarcinomas: Lesion-based comparison with contrast enhanced CT
Youssef Elias, Aladin T Mariano, Yang Lu
September-December 2016, 15(3):161-166
DOI:10.4103/1450-1147.167605  PMID:27651736
The current National Comprehensive Cancer Network (NCCN) Guidelines consider the role of 2-deoxy-2- 18 F-fluoro-d-glucose positron emission tomography/computer tomography (FDG PET/CT) in the evaluation of cholangiocarcinoma (CCA) as "uncertain," and have recommended contrast enhanced computed tomography (CECT) but not FDG PET/CT as a routine imaging test for CCA workup. We set out to compare the diagnostic performance of FDG PET/CT and CECT in patients with CCA. The retrospective study included patients with CCA who underwent FDG PET/CT and CECT within 2-month interval between 2011 and 2013 in our hospital. Lesion-based comparison was conducted. Final diagnoses were made based on the composite clinical and imaging data with minimal 6-month follow-up. A total of 18 patients with 28-paired tests were included. There is a total of 142 true malignant lesions as revealed by the 6-paired pre-treatment and 22-paired post-treatment tests. On a lesion-based analysis, the sensitivities, specificities, positive predictive values (PPVs), negative predictive values (NPVs), and accuracies of PET/CT and CECT for detection of CCA were 96.5%, 55.5%, 97.2%, 50.0%, 94.1% and 62.2%, 66.7%, 96.7%, 10.0%, 62.5%, respectively. FDG PET/CT detected more intrahepatic malignant and extrahepatic metastases; and had significant higher sensitivity, NPV, and accuracy than CECT, while similar in specificity and PPV. No true positive lesion detected on CECT that was missed on PET/CT, and none of the false negative lesions on PET/CT were detected on CECT. Six patients had paired pretreatment tests, and FDG PET/CT results changed planned management in three patients. Our data suggest that FDG PET/CT detect more primary and metastatic lesions and lead to considerable changes in treatment plan in comparison with CECT.
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Quantitative assessment of radionuclide uptake and positron emission tomography-computed tomography image contrast
Hasford Francis, John Humphrey Amuasi, Kyere Augustine Kwame, Mboyo Di Tamba Vangu
September-December 2016, 15(3):167-172
DOI:10.4103/1450-1147.174702  PMID:27650938
Radionuclide uptake and contrast for positron emission tomography-computed tomography (PET-CT) images have been assessed in this study using NEMA image quality phantom filled with background activity concentration of 5.3 kBq/mL fluorodeoxyglucose (F-18 FDG). Spheres in the phantom were filled in turns with water to mimic cold lesions and FDG of higher activity concentrations to mimic tumor sites. Transaxial image slices were acquired on the PET-CT system and used for the evaluation of mean standard uptake value (SUV mean ) and contrasts for varying sphere sizes at different activity concentrations of 10.6 kBq/mL, 21.2 kBq/mL, and 42.4 kBq/mL. For spheres of same sizes, SUV mean increased with increase in activity concentration. SUV mean was increased by 80.6%, 83.5%, 63.2%, 87.4%, and 63.2% when activity concentrations of spheres with a diameter of 1.3 cm, 1.7 cm, 2.2 cm, 2.8 cm, and 3.7 cm, respectively, were increased from 10.6 kBq/mL to 42.4 kBq/mL. Average percentage contrast between cold spheres (cold lesions) and background activity concentration was estimated to be 89.96% for the spheres. Average contrast for the spheres containing 10.6 kBq/mL, 21.2 kBq/mL, and 42.4 kBq/mL were found to be 110.92%, 134.48%, and 150.52%, respectively. The average background contrast variability was estimated to be 2.97% at 95% confidence interval (P < 0.05).
  2 2,887 279
Failed radiation synovectomy in diseased knee joint with missed tuberculous synovitis
Ashwani Sood, Aman Sharma, Devendra Kumar Chouhan, Kirti Gupta, Rahul Parghane, Jaya Shukla, Bhagwant Rai Mittal
September-December 2016, 15(3):206-208
DOI:10.4103/1450-1147.167606  PMID:27651744
The authors in this case report highlight the poor outcome of radiation synovectomy (RSV) for repeated knee joint effusion in a patient with histopathologically proven nonspecific arthritis. There was partial response initially following RSV but later follow-up showed recurrence in joint effusion with limited and painful mobility of the knee joint. Subsequent surgical synovectomy and histopathological examination showed it to be tubercular in origin. Thus in a country endemic for tuberculosis, an alternative infective etiology should also be kept in mind before subjecting the patient to RSV.
  1 2,826 176
Radiation-induced leiomyosarcoma of the oral cavity: A rare occurrence detected on 18F-FDG PET/CT
Fouzia Siraj, Varsha Dalal, Manveen Kaur, Kapil Suri
September-December 2016, 15(3):212-214
DOI:10.4103/1450-1147.172306  PMID:27651746
Radiation-induced sarcomas (RIS) or postirradiation sarcomas have been reported as a rare long-term complication of radiation therapy (RT). The survival benefit offered by radiotherapy has been masked by an increase in the incidence of these sarcomas, thus making radiotherapy a double-edged sword. RIS generally develop with a mean latency period of 10-15 years and encompass different histological types. We report a case of oral leiomyosarcoma with a rather short latency period of 4 years after the radiotherapy of the prior oral squamous cell carcinoma (OSCC) detected on fluorine-18 (18F)-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT). The rarity of occurrence of leiomyosarcoma in the oral cavity is also highlighted.
  1 2,756 194
Evaluation of basal renal Function in treatment-naïve patients with malignancy and comparison with age matched healthy control
Sukanta Barai, Sanjay Gambhir, Suruchi Jain, Neeraj Rastogi
September-December 2016, 15(3):148-152
DOI:10.4103/1450-1147.167602  PMID:27651734
There is a paucity of data regarding the prevalence of renal insufficiency in patients with malignancy at baseline before initiation of therapy. The published studies based on patient with prior exposure to cytotoxic therapy have reported a high prevalence of renal impairment. However, these studies have utilized creatinine-based glomerular filtration rate (GFR) prediction equations to assess the level of renal function. These equations are known to have some serious limitations in reliably predicting GFR. The aim of the study was to accurately document the state of renal function in treatment-naïve cancer patients and compare them against age-matched healthy controls using a reference "creatinine independent" GFR measurement technique. Age-matched comparison of GFR of 1,373 treatment-naïve cancer patients and 1,089 healthy controls were done retrospectively. There was no difference in GFR between cancer and healthy group when analyzed under various age groups, though the overall mean GFR in healthy controls was significantly higher compared to cancer group (80.14 ± 17.63 mL vs 74.43 ± 20.84, P 0≤ 0.01), whereas the mean age in control arm was significantly lower compared to cancer group (44.24 ± 17.63 years vs. 50.70 ± 20.84 years, P ≤ 0.01). Treatment-naïve cancer patients have identical renal function to their healthy age-matched peers. Malignancy per se does not directly lead to the decline in filtration capacity of the kidneys.
  1 3,063 238
Can ultrasound predict malignancy in patient with thyroid cold nodule?
Joko Wiyanto, Achmad Hussein Sundawa Kartamihardja, Trias Nugrahadi
September-December 2016, 15(3):179-183
DOI:10.4103/1450-1147.174704  PMID:27651738
Thyroid nodule is one of the most common endocrine diseases in the world; it occurs in 4-7% of the general population. Depending on the method of discovery, 4-8% nodules are discovered using palpation, 10-41% with ultrasound (US), and 50% through autopsy where only 20% or less of cold thyroid nodules are caused by cancerous lesions. The aim of this study was to assess US as supporting modality for thyroid scintigraphy to predict malignancy in patient with thyroid cold nodules. In a retrospective study between 2009 and 2013, we analyzed 399 subjects with cold thyroid nodule, where 39 subjects (36 women and 3 men) presented with malignant thyroid cold nodule and 19 subjects underwent US. The US showed malignancy parameters in 8 (42.11%) subjects, while the rest of the 11 (57.89%) subject were benign. Out of all the subjects who underwent US in this study, only 8 (42.11%) subjects shown malignancy characteristics in cold thyroid nodule with  papillary thyroid cancer (PTC). That means US parameters of malignant thyroid nodule do not always show up in malignant cold thyroid nodule.
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Disseminated skeletal muscle and cardiac metastasis from squamous cell carcinoma of the lung detected with FDG and FLT PET/CT
Tarun Kumar Jain, Sampanna Jung Rayamajhi, Rajender Kumar Basher, Dheeraj Gupta, Venkata Nagarjuna Maturu, Bhagwant Rai Mittal
September-December 2016, 15(3):215-217
DOI:10.4103/1450-1147.167607  PMID:27651747
Lung cancer is one of the leading cancers all over the world. Positron emission tomography (PET) using 18F fluorodeoxyglucose (18F FDG) is useful for staging of the disease and decide the appropriate management. 3Ͳ-deoxy-3Ͳ-18 F-fluorothymidine (18F FLT) is a tracer being extensively evaluated currently and is said to represent tumor proliferation. Common sites of metastases from lung cancer include adrenal glands, bone, and brain. Muscle metastasis and cardiac metastasis are uncommon findings. We report a case of squamous cell carcinoma of the lung with metastases to multiple skeletal muscles and myocardium detected with both FDG and FLT PET/computed tomography (CT).
  - 3,442 436
Laxative related primary hyperphosphatemic tumoral calcinosis identified by bone scintigraphy
Marcus Asokendaran, Nat Patrick Lenzo
September-December 2016, 15(3):200-202
DOI:10.4103/1450-1147.174709  PMID:27651742
We describe a case of a 40-year-old female patient presenting with tumor calcinosis where hypertrophic pulmonary osteoarthropathy (HPOA) was suspected given her extensive history of malignancy. Plain X-rays did not show reveal the typical periarticular calcification but did show appearances consistent with HPOA. Bone scintigraphy with 99m Tc-methylene diphosphonate (MDP) is a sensitive investigation in the detection of hypertrophic osteoarthopathy but did not show findings characteristics of HPOA like bilateral symmetrical increased uptake of the radiopharmaceutical along the cortical margins of the long bones. The final diagnosis of tumor calcinosis was only made after low dose computerized tomography chest showed a moderated sized amorphous calcified cluster in the apical segment of the right upper lobe consistent. In conclusion, bone scintigraphy continues to be a useful investigation for both common and rare conditions like tumor calcinosis. The unusual three phase bone scan finding of diffuse activity throughout both lung fields, which turned to out to be tumoral calcinosis is highlighted in this case.
  - 2,607 177
Use of marrow scintigraphy to confirm compensatory marrow rather than active myeloma
Twyla B Bartel, Tracy L Yarbrough, Lorraine E De Blanche
September-December 2016, 15(3):203-205
DOI:10.4103/1450-1147.172303  PMID:27651743
We present the case of a 40-year-old male with multiple myeloma for whom bone marrow scintigraphy was utilized to help differentiate between active bony myelomatous disease versus treated lesions with compensatory marrow uptake. This case demonstrates technetium (Tc-99m) sulfur colloid imaging as an inexpensive technique to quickly distinguish between active focal bone disease and reactive marrow.
  - 3,063 208
Greetings from the new president of world association of radiopharmaceutical and molecular therapy
Suresh Srivastava
September-December 2016, 15(3):145-147
DOI:10.4103/1450-1147.189525  PMID:27651733
  - 2,997 197
A case of lingual thyroid presenting with severe hematemesis in pregnancy
Manas Kumar Sahoo
September-December 2016, 15(3):218-218
DOI:10.4103/1450-1147.181154  PMID:27651748
  - 2,370 154
Use of marrow scintigraphy to confirm compensatory marrow rather than active myeloma
Manas Kumar Sahoo, Smeeta Gajendra
September-December 2016, 15(3):219-220
DOI:10.4103/1450-1147.189558  PMID:27651749
  - 1,458 134
Is the increased septal perfusion the signal of asymmetrical septal hypertrophy?
Semra Ozdemir, Yusuf Ziya Tan, Emine Gazi
September-December 2016, 15(3):184-189
DOI:10.4103/1450-1147.174706  PMID:27651739
In this study, we have compared scintigraphic and echocardiographic data in order to investigate whether increased septal perfusion represents asymmetrical septal hypertrophy (ASH), which is a symptom followed in the scintigraphy of myocardial perfusion. The study consists of a total of 186 patients (120 females and 66 males with an average age of 59.45 ± 11.54 years) who had normal myocardial perfusion scintigraphy and echocardiography examinations. Statistical comparison of septal wall thickness measurements obtained from echocardiography and septal-to-lateral wall ratios (S/L ratio) was performed scintigraphically. Left ventricular mass values were obtained as both scintigraphic and echocardiographic data and their correlations were evaluated in order to assess the presence of left ventricular hypertrophy (LVH). In statistical analyses, the values of interventricular septal thickness in diastole (IVSd), left ventricle posterior wall thickness in diastole (LVPWd), left ventricle mass (LVM), and left ventricle mass index (LVMI) were found to be significantly higher in group 2 (S/L ratio >1) compared to group 1 (S/L ratio <1). In addition, S/L ratio is significantly correlated with echocardiographic IVSd, LVPWd, LVM, LVMI, and scintigraphic LVM (rest) values. Furthermore, echocardiographic LVM and LVMI values were significantly correlated with LVM and LVMI values obtained from scintigraphy. It should be known that increased S/L ratio that can be monitored during scintigraphic studies can be an indicator of septal hypertrophy and/or LVH, however, further examination and close follow-ups should be performed in necessary cases.
  - 2,799 183
Comparison of hemodynamic effects and negative predictive value of normal adenosine gated myocardial perfusion scan with or without caffeine abstinence
Maseeh uz Zaman, Nosheen Fatima, Areeba Zaman, Unaiza Zaman, Rabia Tahseen
September-December 2016, 15(3):190-195
DOI:10.4103/1450-1147.176887  PMID:27651740
For vasodilator stress, myocardial perfusion imaging (MPI) with at least 12-h caffeine abstinence is recommended, as it attenuates cardiovascular hyperemic response of adenosine and dipyridamole. However, many published conflicting results have shown no significant effect upon perfusion abnormalities in MPI performed without caffeine abstinence. The aim of this study was to compare the hemodynamic changes and negative predictive value (NPV) of normal MPIs with adenosine stress performed with or without caffeine abstinence. This was a prospective study that accrued 50 patients from May 2013 till September 2013 and followed till November 2014. These patients had a normal adenosine-gated MPI (GMPI) with technetium-99m methoxy isobutyl isonitrile ( 99m Tc-MIBI) after 12-h caffeine abstinence (no-caffeine). Next day, all patients had a repeat adenosine stress within 60 min after ingestion of a cup of coffee (about 80 mg of caffeine) followed by no MPI in 30 patients due to concern about radiation dose (prior-caffeine adenosine-no MPI; group A). Twenty patients opted for a repeat MPI (prior-caffeine adenosine-MPI; group B). Adenosine-induced hemodynamic response and NPV of the normal MPI with no-caffeine and prior-caffeine protocols were compared. The mean age of the study cohort was 57 ± 9 years with a male-to-female ratio of 76:24% and mean body mass index (BMI) of 26.915 ± 4.121 kg/m 2 . Prevalence of hypertension, diabetes, dyslipidemia, and positive family history were 76%, 20%, 22%, and 17%, respectively. Comparison of group A with group B revealed no significant difference in demographic parameters, hemodynamic or electrocardiography (ECG) parameters, or left ventricular (LV) function parameters during adenosine intervention with prior-caffeine and no-caffeine protocols. During the follow-up, no fatal myocardial infarction (MI) was reported but 6 nonfatal MIs were reported based upon the history of short hospitalization for chest pain but without biochemical or ECG criteria for infarction (3/30 in group A and 3/20 group B). Event-free survival (EFS) for fatal MI was 100% for both the groups while EFS for nonfatal MI was 90% for group A and 85% for group B (nonsignificant P values). Kaplan-Meier survival plot also depicted nonsignificant EFS for nonfatal MI. This study did not find any significant attenuation effect upon adenosine-induced hemodynamic response and similar NPV of a normal GMPI in patients with or without caffeine abstinence. We assume that better designed prospective studies are required to validate findings of our study and provide justification for revision of guidelines about caffeine abstinence.
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