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   2018| January-March  | Volume 17 | Issue 1  
    Online since January 5, 2018

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Comparison of standardized uptake value ratio calculations in amyloid positron emission tomography brain imaging
Karin Knesaurek, Geoffrey Warnock, Lale Kostakoglu, Cyrill Burger, for Alzheimer's Disease
January-March 2018, 17(1):21-26
DOI:10.4103/wjnm.WJNM_5_17  PMID:29398961
Amyloid positron emission tomography (PET) imaging with florbetapir 18F (18F-AV-45) allows in vivo assessment of cerebral amyloid load and can be used in the evaluation of progression of Alzheimer's disease (AD) and other dementias associated with b-amyloid. However, cortical amyloid deposition can occur in healthy cases, as well as in patients with AD and quantification of cortical amyloid burden can improve the 18F-AV-45 PET imaging evaluations. The quantification is mostly performed by cortical-to-cerebellum standardized uptake value ratio (SUVr). The aim of our study was to compare two methods for SUVr calculations in amyloid florbetapir 18F PET brain imaging. In amyloid florbetapir 18F PET brain imaging study, we imaged 42 cases with the mean age of 72.6 ± 9.9 (mean ± standard deviation). They were imaged on different PET/computed tomography systems with 369.0 ± 34.2 kBq of 18F florbetapir. Data were reconstructed using the vendor's reconstruction software. Corresponding magnetic resonance imaging (MRI) data were retrieved, and matched PET and MRI data were transferred to a common platform. Two methods were used for the calculation of the ratio of cortical-to-cerebellar signal (SUVr). One method was based on the MIM Software Inc., Version 6.4 software and only uses PET data. The second approach used the PMOD Neuro tool (version 3.5). This approach utilizes PET and corresponding MRI data (preferably T1-weighted) for better brain segmentation. For all the 42 cases, the average SUVr values for MIM and PMOD applications were 1.24 ± 0.26 and 1.22 ± 0.25, respectively, with a mean difference of 0.02 ± 0.15. The repeatability coefficient was 0.15 (12.3% of the mean). The Spearman's rank correlation coefficient was very high, r = 0.96. For amyloid-negative cases, the average SUVr values were lower than all group SUVr average values, 0.96 ± 0.07 and 1.00 ± 0.09, for MIM and PMOD applications, respectively. A mean difference was 0.04 ± 0.12, the repeatability coefficient was 0.12 (12.9% of the mean) and the Spearman's rank correlation coefficient was modest, r = 0.55. For amyloid-positive patients, the average SUVr values were higher than the same all grouP values, 1.34 ± 0.16 and 1.35 ± 0.20, respectively, with a mean difference of 0.01 ± 0.16. The repeatability coefficient was 0.16 (11.9% of the mean). The Spearman's rank correlation coefficient was high, r = 0.93. Our results indicated that the SUVr values derived using MIM and PMOD Neuro are effectively interchangeable and well correlated. However, PET template-based quantification (MIM approach) is clinically friendlier and easier to use. MRI template-based quantification (PMOD Neuro) better delineates different regions of the brain, can be used with any tracer, and therefore is more suitable for research.
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Correlation between standardized uptake value of 68Ga-DOTA-NOC positron emission tomography/computed tomography and pathological classification of neuroendocrine tumors
Chalermrat Kaewput, Subapriya Suppiah, Sobhan Vinjamuri
January-March 2018, 17(1):34-40
DOI:10.4103/wjnm.WJNM_16_17  PMID:29398963
The aim of our study was to correlate tumor uptake of 68Ga-DOTA-NOC positron emission tomography/computed tomography (PET/CT) with the pathological grade of neuroendocrine tumors (NETs). 68Ga-DOTA-NOC PET/CT examinations in 41 patients with histopathologically proven NETs were included in the study. Maximum standardized uptake value (SUVmax) and averaged SUV SUVmean of “main tumor lesions” were calculated for quantitative analyses after background subtraction. Uptake on main tumor lesions was compared and correlated with the tumor histological grade based on Ki-67 index and pathological differentiation. Classification was performed into three grades according to Ki-67 levels; low grade: Ki-67 <2, intermediate grade: Ki-67 3–20, and high grade: Ki-67 >20. Pathological differentiation was graded into well- and poorly differentiated groups. The values were compared and evaluated for correlation and agreement between the two parameters was performed. Our study revealed negatively fair agreement between SUVmax of tumor and Ki-67 index (r = −0.241) and negatively poor agreement between SUVmean of tumor and Ki-67 index (r = −0.094). SUVmax of low-grade, intermediate-grade, and high-grade Ki-67 index is 26.18 ± 14.56, 30.71 ± 24.44, and 6.60 ± 4.59, respectively. Meanwhile, SUVmean of low-grade, intermediate-grade, and high-grade Ki-67 is 8.92 ± 7.15, 9.09 ± 5.18, and 3.00 ± 1.38, respectively. As expected, there was statistically significant decreased SUVmax and SUVmean in high-grade tumors (poorly differentiated NETs) as compared with low- and intermediate-grade tumors (well-differentiated NETs). SUV of 68Ga-DOTA-NOC PET/CT is not correlated with histological grade of NETs. However, there was statistically significant decreased tumor uptake of 68Ga-DOTA-NOC in poorly differentiated NETs as compared with the well-differentiated group. As a result of this pilot study, we confirm that the lower tumor uptake of 68Ga-DOTA-NOC may be associated with aggressive behavior and may, therefore, result in poor prognosis.
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Usefulness of splenic scintigraphy in differentiating splenosis and malignancy on gallium 68 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid-NaI3-octreotide
Stijn Van Hecke, Tim Van Den Wyngaert, Bart Op De Beeck, Sigrid Stroobants
January-March 2018, 17(1):56-58
DOI:10.4103/wjnm.WJNM_1_17  PMID:29398968
Somatostatin receptor (SSTR) imaging with gallium 68 (Ga-68) 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA)-peptide positron emission tomography/computed tomography (PET/CT) has been introduced in clinical routine for the diagnosis and staging of neuroendocrine tumors (NETs) with high SSTR expression. Although it has high sensitivity for NETs, there are some known diagnostic pitfalls one should be aware of. We present a case of suspected NET where Ga-68 DOTA-NaI3-octreotide (NOC) PET/CT showed several abdominal lesions with high SSTR expression suggesting malignancy. On magnetic resonance imaging, the differential diagnosis of the lesions also included splenosis. Subsequent splenic scintigraphy with technetium-99m phytate showed uptake in all suspicious lesions, and biopsy confirmed the diagnosis of splenosis. Splenic scintigraphy with single-photon emission computed tomography/CT can be a helpful noninvasive diagnostic tool when splenosis is suspected on Ga-68 DOTA-peptide PET/CT.
  2 1,748 203
Awareness of ionizing radiation and its effects among clinicians
Reddy Ravikanth
January-March 2018, 17(1):1-2
DOI:10.4103/wjnm.WJNM_60_17  PMID:29398957
  2 2,044 360
177Lu-DOTATATE peptide receptor radionuclide therapy in patients with borderline low and discordant renal parameters: Treatment feasibility assessment by sequential estimation of triple parameters and filtration fraction
Chinna Naik, Sandip Basu
January-March 2018, 17(1):12-20
DOI:10.4103/wjnm.WJNM_94_16  PMID:29398960
The aim was to assess the effect of standard fixed-dose protocol of 177Lu-DOTATATE peptide receptor radionuclide therapy (PRRT) in patients with borderline low renal function of one parameter (glomerular filtration rate [GFR], effective renal plasma flow [ERPF] or serum creatinine), that was discordant with the remaining parameters and determine the feasibility of this procedure in this group of patients. Renal toxicity of PRRT is a routine issue or concern for such cases. We compared different renal parameters used for pretherapy assessment in patients with borderline low single parameter at baseline and their potential significance with regards to deterioration of renal function subsequently. A retrospective analysis was performed in patients of metastatic neuroendocrine tumors who received therapeutic 177Lu-DOTATATE (using standard fixed-dose protocol) and had borderline compromised renal parameter values (either of GFR/ERPF/serum creatinine). Filtration fraction (FF) was also estimated in each case and all renal parameters were correlated using kappa statistics. The characteristics of cases showing progressive worsening of renal function in the follow-ups were also studied. A total of 15 patients (11 males, 4 females; age range: 32–75 years) were selected among a population of 450 patients. The follow-up duration ranged from 10 to 48 months and administered cumulative activity ranged 9.9–31.3 GBq (2–5 cycles). Based on the parameter characteristics, the study population was divided into following four groups: (a) patients with reduced GFR and maintained ERPF and normal serum creatinine (n = 3); (b) patients with reduced ERPF with maintained GFR and borderline elevated/normal serum creatinine (n = 3); (c) patients with both reduced GFR and ERPF and maintained serum creatinine (n = 1); (d) patients with compromised single kidney function (n = 5). A total of four patients were found who had normal baseline renal function values but showed progressive worsening in the subsequent period. There was no significant change in renal parameters during the follow-up in both Groups a and c. Two patients of Group b demonstrated well-maintained other renal parameters, whereas in 1 patient, there was the evidence of renal toxicity with gradual fall of GFR and ERPF and progressive increase in serum creatinine level. In patients with compromised single kidney function at baseline (Group d), there was overall maintained normal renal parameters, whereas 3 of 5 (60%) showed the increase of FF of the affected kidney. Interestingly, a compensatory hyperfunction was noted in the contralateral kidney. PRRT with 177Lu-DOTATATE is feasible and can be considered in patients with reduced GFR and with maintained ERPF and normal serum creatinine and also in the presence of single compromised parameter if the other two are normal; however, these patients need critical monitoring.
  2 2,703 313
Synovectomy using samarium-153 hydroxyapatite in the elbows and ankles of patients with hemophilic arthropathy
José Ulisses Manzzini Calegaro, Davi de Podestá Haje, Julian Machado, Mariana Sayago, Danielle Cicarini de Landa
January-March 2018, 17(1):6-11
DOI:10.4103/wjnm.WJNM_91_16  PMID:29398959
This study aimed to evaluate synovectomy with samarium-153 hydroxyapatite (153Sm-HA) in synovitis of the elbows and ankles of hemophilic patients. The synovectomy was performed using 185 MBq of 153Sm-HA in 166 joints of 82 hemophilic patients, with a mean age of 24.4 years and follow-up of 12 and 42 months, comprising 63 ankles and 84 elbows. Arthropathy was characterized by recurrent joint bleeding. Episodes of hemarthrosis, use of clotting factors, and pain intensity were evaluated before and after treatment. Scintigraphic controls and adverse effects were also considered. Statistical analyses used P ≤ 0,005 as significant. The results pointed that (a) reduction in hemarthrosis was 78% and 68% in elbows and 82% and 72% in ankles; (b) use of clotting factors was 80% and 70% in elbows and 85% and 75% in ankles; (c) pain was 37% and 34% in elbows and 61% and 57% in ankles, after 12 and 42 months, respectively. Three cases of mild reactive synovitis were observed in ankles and four in elbows. There was no joint effusion in any of the cases. In conclusion, the use of 153Sm-HA in elbows and ankles was effective, very safe, minimally invasive and showed consistency over time, is another material to utilize in median hemophilic joints.
  2 2,364 300
Treatment response evaluation using Yttrium-90 in patients with rheumatoid arthritis of knee joint
Jong Min Kim, Wi Song Kim, Yong Pak
January-March 2018, 17(1):3-5
DOI:10.4103/1450-1147.222289  PMID:29398958
For radiosynovectomy, we have measured the retention time of yttrium-90 (90Y) hydroxyapatite (particle size 1–10 μm) within the knee joint space and evaluated the treatment responses in knees with rheumatoid arthritis. Radioactive measurements in the region of knee after injection of 90Y hydroxyapatite into the joint space were made with a single prove system designed to monitor radioactivity and showed retention of 90Y in the knee ranged 76.6% ±5.4% after 4 days of injection. The clinical improvements in rheumatoid arthritis of knee joint with steinbroker Stages I and II were increased as time goes by, the improvement ratio is in 72% at 6th months and 76% at 12th months after injection of 90Y 185 MBq (5 mCi) per joint.
  2 2,109 364
Incidental detection of asymptomatic brain metastases on 18F-fluoride positron emission tomography/computed tomography and 68Ga DOTANOC positron emission tomography/computed tomography in a patient with concomitant breast carcinoma and a pancreatic neuroendocrine tumor
Ruth Brown, Phei Shan Chuah, Emmanouil Panagiotidis, Sobhan Vinjamuri
January-March 2018, 17(1):65-66
DOI:10.4103/wjnm.WJNM_10_17  PMID:29398971
A 54-year-old female treated for locally advanced ductal breast carcinoma was also diagnosed with a pancreatic neuroendocrine tumour. A staging 68Ga DOTANOC positron emission tomography/computed tomography (PET/CT) demonstrated somatostatin receptor-positive foci within the brain parenchyma. A whole body 18F-fluoride PET/CT also demonstrated several foci of low-grade tracer uptake in the brain. Magnetic resonance imaging confirmed several cerebral and cerebellar metastases. This case highlights the need to be aware of each tumor's metastatic profile and the careful attention required for thoroughly evaluating imaging in the presence of multiple pathologies. Furthermore, such incidental findings can have significant treatment and prognostic implications.
  1 1,689 211
Unilateral primary adrenal lymphoma: Uncommon presentation of a rare disease evaluated using 18f-fluorodeoxyglucose positron emission tomography/computed tomography
Renjith Kalathoorakathu Radhakrishnan, Bhagwant Rai Mittal, Arun Kumar Reddy Gorla, Pankaj Malhotra, Amanjit Bal, Subhash Varma
January-March 2018, 17(1):46-48
DOI:10.4103/1450-1147.222288  PMID:29398965
Primary adrenal lymphoma (PAL) is a relatively rare disease entity with only fewer than 200 cases reported till date. PAL frequently presents with bilateral adrenal involvement and shows male preponderance. We here present a case of PAL in a 65-year-old female with a relatively uncommon unilateral adrenal involvement. The present case depicts that 18F-fluorodeoxyglucose positron emission tomography/computed tomography had decisive role in the treatment management of this patient suggesting its potential utility in the management of this rare disease.
  1 1,522 188
99m-Technetium sestamibi uptake in a gastric schwannoma
Mohamed Shawgi, Tamir Ali, Matthew Scott, George Petrides
January-March 2018, 17(1):49-51
DOI:10.4103/1450-1147.222292  PMID:29398966
We report the case of a 74-year-old woman with primary hyperparathyroidism who underwent 99m-technetium-sestamibi single photon emission computed tomography-computed tomography for preoperative localization of parathyroid adenoma. Unexpected focal sestamibi uptake was observed at a 5 cm submucosal tumor arising from the greater curve of the stomach. The patient underwent partial gastrectomy and the histological and immunohistochemical findings were consistent with the diagnosis of gastric schwannoma.
  1 1,591 211
Active herpes zoster infection involving lumbosacral dermatome, an unusual site of manifestation and incidental finding in fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan
Deepa Singh, Rajender Kumar, Gaurav Prakash, Anish Bhattacharya, Bhagwant Rai Mittal
January-March 2018, 17(1):52-55
DOI:10.4103/wjnm.WJNM_104_16  PMID:29398967
Herpes zoster virus reactivation in the lumbosacral dermatomal distribution is an unusual site of manifestation and atypical in presentation than its usual sites in thoracolumbar (D3–L2) and facial (V1) dermatomes. Here, we are reporting a patient of marginal zone lymphoma who on fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography scan performed for chemotherapy response evaluation showed hypermetabolic cutaneous and subcutaneous lesions in the right vulva and posteromedial aspect of the right thigh along with ipsilateral pelvic lymph nodes involvement as an incidental finding. Subsequently, FDG active lesions were considered to be as herpes zoster virus reactivation rather than the recurrence of lymphoma and treated with antiviral drug.
  - 1,892 207
Alveolar soft part sarcoma presenting as hypervascular adrenal metastasis
Manjunath Goroshi, Anurag R Lila, Tushar Bandgar, Nalini S Shah
January-March 2018, 17(1):62-64
DOI:10.4103/wjnm.WJNM_8_17  PMID:29398970
Hypervascular adrenal masses include pheochromocytoma, metastases caused by clear renal cell carcinoma/hepatocellular carcinoma. Alveolar soft part sarcoma (ASPS) causing hypervascular metastases is not described in the literature. Here, we describe the first case of ASPS presenting as hypervascular metastasis. Our case was a 23-year-old male incidentally detected right adrenal mass during the evaluation of pain in the abdomen. On computed tomography (CT), adrenal mass showed bright enhancement in early arterial phase (unenhanced Hounsfield unit [HU]-45.3; arterial phase HU-158.2). 18- flurodeoxyglucose positron emission tomography/CT showed multiple lesions and was confirmed histologically to be due to ASPS.
  - 1,523 179
Bronchopulmonary sequestration as a cause of mismatched perfusion defect on single-photon emission computed tomography ventilation-perfusion scan
Michael A.S Kreltszheim, Nick I Brown, Joseph C Lee
January-March 2018, 17(1):59-61
DOI:10.4103/wjnm.WJNM_3_17  PMID:29398969
We present a 46-year-old female with pleuritic chest pain on a background of pulmonary embolism diagnosed on a single-photon emission computed tomography (SPECT) ventilation-perfusion (V/Q) imaging 3 years earlier. A SPECT V/Q scan detected a mismatched perfusion defect in the posterior basal segment of the right lower lobe, essentially unchanged from a defect identified 3 years earlier. Given the atypical finding, the patient went on to have a computed tomographic pulmonary angiogram. It revealed an intralobar bronchopulmonary sequestration as the cause of the right lower lobe mismatched perfusion defect. With growing awareness of radiation safety, the number of V/Q imaging studies being undertaken to investigate suspected pulmonary emboli, especially in young female patients, has increased. This case report serves as a timely reminder of the potential pitfalls associated with V/Q scan image interpretation.
  - 1,649 191
Stimulated serum thyroglobulin levels versus unstimulated serum thyroglobulin in the follow-up of patients with papillary thyroid carcinoma
Saumya Sara Sunny, Julie Hephzibah, David Mathew, Joseph Dian Bondu, Nylla Shanthly, Regi Oommen
January-March 2018, 17(1):41-45
DOI:10.4103/wjnm.WJNM_20_17  PMID:29398964
Serum thyroglobulin (Tg) and thyroid whole-body radioiodine scintigraphy (TWBS) are used in the follow-up of patients with papillary thyroid carcinoma (PTC) after total thyroidectomy. Symptoms of hypothyroidism are frequent as patients discontinue levothyroxine 1 month before visit, favoring the use of unstimulated serum Tg (uSTg) only. This study was done to determine the reliability of stimulated serum Tg levels (sSTg) over uSTg. A total of 650 patients with PTC came for follow-up between June 2011 and 2016. In those who had levels of uSTg and sSTg months measured within an interval of median of 3 months (range from 1 to 8 months), risk stratification was done as per the American Thyroid Association guidelines 2015. Intervention was based on a cutoff value of sSTg >10 ng/ml in our institution and the same was used for data analysis. Out of 650 patients, 106 had paired Tg values. Low-, intermediate-, and high-risk groups comprised 40, 31, and 35 patients, respectively. The sSTg >10 ng/ml with uSTg <10 ng/ml in the same patient was noted in 22.5% (9/40) of the low-risk, 41.9% (13/31) of the intermediate-risk, and 14.2% (5/35) of the high-risk groups. The levels were corroborated with tumor burden as determined by additional clinical, ultrasonography neck, and TWBS findings. Our study highlights the superiority of sSTg over uSTg in the follow-up of PTC patients. Follow-up with uSTg alone may result in underestimating the tumor burden.
  - 2,598 360
Detection of lower limb deep vein thrombosis: Comparison between radionuclide venography and venous ultrasonography
Daris Theerakulpisut, Nantaporn Wongsurawat, Charoonsak Somboonporn
January-March 2018, 17(1):27-33
DOI:10.4103/wjnm.WJNM_13_17  PMID:29398962
Deep vein thrombosis (DVT) is a serious medical condition that needs prompt diagnosis and treatment. The invasive gold standard contrast venography has largely been replaced by venous ultrasonography which is currently the imaging modality of choice for DVT diagnosis. Radionuclide venography (RNV) is an alternative test for DVT, but a few studies have directly compared RNV with venous ultrasonography. This study aims to determine the agreement between RNV and venous ultrasonography for diagnosis of DVT and to determine the predictive value of different RNV findings for the prediction of DVT as detected by venous ultrasonography. Imaging results from patients who underwent both RNV and venous ultrasonography for suspected DVT no more than 1 week apart were reviewed. Results from both modalities were compared to determine inter-modality agreement. A total of 121 venous segments from 102 lower limbs of 75 patients could be compared. The prevalence of DVT as detected by venous ultrasonography was 39%. RNV and venous ultrasonography had moderate agreement (73.6% agreement, κ =0.48, P < 0.0001). The absence of radiotracer activity from a deep venous segment had a positive predictive value (PPV) of 100% for DVT. Other findings such as isolated great saphenous vein activity had a lower PPV. The negative predictive value of RNV is 97.5% with only one patient out of forty with normal RNV found to have DVT by venous ultrasonography, which suggests that DVT can virtually be excluded in patients with normal RNV.
  - 2,777 463