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   2020| July-September  | Volume 19 | Issue 3  
    Online since September 15, 2020

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Evaluation of estrogen expression of breast cancer using 18F-FES PET CT-A novel technique
Vuthaluru Seenu, Ankit Sharma, Rakesh Kumar, Suhani Suhani, Arun Prashanth, Sandeep Mathur, Rajinder Parshad
July-September 2020, 19(3):233-239
Estrogen receptor (ER) expression in breast cancer is routinely studied on immunohistochemistry (IHC) of tissue obtained from core biopsy or surgical specimen. Sampling error and heterogeneity of tumor may incorrectly label a breast tumor as ER negative, thus denying patient hormonal treatment. Molecular functional ER imaging can assess the in-vivo ER expression of primary tumor and metastases at sites inaccessible for biopsy and also track changes in expression over time. The aim was to study ER expression using 16α-18F-fluoro-17β-estradiol or18F-fluoroestradiol (18F FES) positron emission tomography (PET) computed tomography (CT). Twenty-four biopsy-proven breast cancer patients consenting to participate in the study underwent FES PET CT. Standard uptake value (SUVmean) of maximum of 7 lesions/patient was analyzed, and tumor-to-background ratio was calculated for each lesion. Visual interpretation score was calculated for lesion on FES PET and correlated with the Allred score on IHC of tumor tissue samples for ER expression. The diagnostic indices of FES PET CT were assessed taking IHC as “gold standard.” On FES PET CT, the mean SUV for ER+ tumors was 4.75, whereas the mean SUV for ER − tumors was 1.41. Using receiver operating characteristic curve, tumors with an SUV of ≥ 1.8 on FES PET could be considered as ER+. The overall accuracy of FES PET CT to detect ER expression was 91.66%, with two false negatives noted in this study.18F-FES PET CT appears promising in evaluating ER expression in breast cancer. It is noninvasive and has potential to assess the in-vivo ER expression of the entire primary tumor and metastasis not amenable for biopsy.
  2 999 169
Primary pancreatic lymphoma camouflaged under the umbrella of spectrum of neuroendocrine tumors in somatostatin receptor imaging
Nikita Sampathirao, M Indirani, S Shelley
July-September 2020, 19(3):306-309
Primary pancreatic lymphomas are very rare as compared to other pancreatic neoplasms. However, unlike carcinomas, pancreatic lymphoma is treatable with satisfactory cure rates. Somatostatin receptor (SSTR) positron emission tomography/computed tomography (PET/CT) with68Ga-DOTANOC is a well-established diagnostic modality in the management of neuroendocrine tumors (NETs). Over the years, it has been evident that any neoplasm with SSTR expression shows increased tracer uptake, lymphoma, being the most prominent one. Herein, we report a case of pancreatic mass, suggested as NET on fine-needle aspiration cytology referred to us for staging. Whole-body68Ga-DOTANOC PET/CT scan showed a large pancreatic mass with peripancreatic nodes, level I cervical nodes, cardiac, and left testicular masses which were initially thought to be possibly metastatic from pancreatic NET. However, immunohistochemistry (IHC) of the specimen was suggestive of B-cell Non-Hodgkin's Lymphoma. The present case emphasizes that pancreatic lymphoma is one of the potential differentials for pancreatic masses apart from NET on SSTR imaging. Noteworthy is the fact, that IHC plays a poignant role in the evaluation and is a mandatory tool for the management of tumors. Moreover, the whole imaging picture and clinical scenario ought to be given utmost importance for giving an affirmative diagnosis on imaging. SSTR expression in lymphomas may further obviate a remote fact that peptide receptor radionuclide therapy can be considered as an end of the line treatment for refractory lymphomas.
  1 644 126
Do fasting or high caloric drinks affect the physiological uptake of fluorine-18 prostate-specific membrane antigen-1007 in liver and bowel?
Kambiz Rahbar, Ali Afshar-Oromieh, Robert Seifert, Stefan Wagner, Michael Schäfers, Martin Bögemann, Matthias Weckesser
July-September 2020, 19(3):220-223
Recently introduced fluorine-18 prostate-specific membrane antigen-1007 (18F-PSMA-1007) for imaging prostate cancer has an intense physiologic liver uptake and biliary excretion. The aim of the present study was to evaluate the effect of different dietary conditions on this physiological uptake. Forty consecutive prostate cancer patients were scanned with18F-PSMA-1007 positron emission tomography/computed tomography at different dietary conditions. In addition to a blinded read scoring, tracer uptake intensities (standardized uptake values [SUVs]) were measured in the liver and small bowel. There was no significant difference in liver and small-bowel uptake between different patient groups. Wilcoxon signed-rank tests revealed no significant difference of the median mean SUV of the liver or maximum SUV of the horizontal part of the duodenum between different dietary conditions groups. A dietary preparation of patients by fasting or the attempt to clear liver activity by high caloric drinks does not have a significant effect on tracer uptake in the liver or in the small bowel.
  1 1,548 301
Clinical efficacy of177Lu-DOTATATE peptide receptor radionuclide therapy in thyroglobulin-elevated negative iodine scintigraphy: A “not-so-promising” result compared to GEP-NETs
Sandip Basu, Rahul V Parghane, Chinna Naik
July-September 2020, 19(3):205-210
This study aimed at assessing the performance of177Lu-DOTATATE-based peptide receptor radionuclide therapy (PRRT) in de-differentiated thyroid carcinoma thyroglobulin-elevated negative iodine scintigraphy (TENIS) in terms of clinical efficacy and outcome. This is a retrospective analysis of patients of TENIS who had undergone PRRT in a tertiary care setting. The selected patients were analyzed for the following parameters: (i) the patient characteristics, (ii) the metastatic burden, (iii) study of PRRT cycles and activity, (iv) response assessment (undertaken by three-parameter scale: symptomatic including Karnofsky/Lansky Performance scoring, biochemical and scan features) employing predefined criteria (detailed in methods), and (v) Grade III/IV hematological or renal toxicity. According to the qualitative uptake of the tracer in somatostatin receptor (SSTR)-based imaging (with either99mTc-HYNIC-TOC/68Ga-DOTATATE), the lesions were divided into the following four categories: Grade 0: no uptake, Grade I: uptake less than the liver but more than background, Grade II: uptake equal to the liver, and Grade III: uptake more than the liver. A total of eight patients of TENIS who had undergone177Lu-DOTATATE were retrieved. Among those eight patients, the follow-up duration (from the time of the 1st PRRT cycle) at the time of analysis ranged from 7 to 52 months, with an average of 34 months. At the time of assessment, two (25%) out of the eight patients had expired due to extensive metastatic disease and 6 (75%) were alive. On symptomatic response, complete disappearance of symptoms was found in one patient (12.5%), whereas three patients (37.5%) showed partial improvement in symptoms after PRRT and four patients (50%) showed worsening of and appearance of new symptoms. On biochemical response, reduction in serum thyroglobulin (TG) was found in three patients (37.5%) after PRRT and increase in serum TG was noticed in the rest of five patients (62.5%). Imaging response showed stable scan in two patients (25%) and progressive disease (PD) in six patients (75%), following a progression-free survival ranging from 7 to 16 months, when they were considered for tyrosine kinase inhibitors in view of PD. There was no obvious evidence of Grade III/IV hematological or renal toxicity in any of the patients, suggesting that the therapy in this group of patients is well tolerated. In addition, we also observed that most patients of TENIS showed low-grade uptake on SSTR-based imaging (Grade II as per our semi-quantitative scale), with only one patient showing Grade III uptake.177Lu-DOTATATE PRRT demonstrates modest response in SSTR-positive metastatic TENIS patients: (i) low SSTR expression and tracer avidity, and correspondingly lesser degree of targeting by the therapeutic agent and (ii) the fact that most of the TENIS patients usually have fluorodeoxyglucose (FDG)-avid disease, where high FDG avidity is commensurate with aggressive biology and could be the reason for the relatively less response documented. Larger prospective data need to be accrued in this domain in view of its well tolerability and nonavailability of better efficacious and less toxic treatment at present; however, this needs to be tried in receptor-positive cases with high-grade uptake (Score III/IV) for a definitive conclusion.
  1 1,486 230
Determination of the optimal cut-off value of serum prostate-specific antigen in the prediction of skeletal metastases on technetium-99m whole-body bone scan by receiver operating characteristic curve analysis
P Ram Manohar, Tanveer Ahmed Rather, Shoukat H Khan
July-September 2020, 19(3):255-259
Radionuclide whole-body bone scan is a useful investigation of choice to detect the skeletal metastases in prostate cancer. It is indicated in patients having elevated serum prostate-specific antigen (Sr. PSA) or patients with bone pain. Elevated Sr. PSA levels have high predictive value for skeletal metastases; however, there is no consensus regarding cut-off value of Sr. PSA above which bone scan is indicated. This study was performed to find out the accuracy of Sr. PSA test and to know the optimal cut-off value of Sr. PSA with high sensitivity and specificity in the prediction of skeletal metastases on bone scan in prostate cancer patients. A retrospective analysis of medical records of 307 prostate cancer patients referred to the department of nuclear medicine for bone scan between June 2009 and June 2014 was done. Of 307 patients, 15 cases were excluded due to nonavailability of Sr. PSA. Bone scan was performed 3 h after administration of 20 mCi Tc-99m methylene diphosphonate intravenously. Whole-body sweep imaging was performed and spot views were taken wherever required. Of 292 cases, 174 (59.58%) patients had positive bone scan for metastases and 118 (40.41%) patients had negative bone scan for metastases. Maximum and minimum Sr. PSA levels in positive and negative bone scan patients were 1260 and 0.02 ng/ml and 198.34 ng/ml and 0.01 ng/ml, respectively. On comparison of the mean Sr. PSA levels between positive and negative groups, we found significant Sr. PSA levels (P < 0.05). We used receiver operating characteristic (ROC) curve analyses to find out the accuracy of Sr. PSA test and to know the optimal cut-off value of Sr. PSA with maximum sensitivity and specificity in the prediction of skeletal metastases on bone scan. Area under ROC curve was 0.878 (87%). This indicates that the accuracy of Sr. PSA test in the prediction of skeletal metastases on bone scan was good. The optimal cut-off value of Sr. PSA in the prediction of positive bone scan for skeletal metastases in the management of prostate cancer was 29.16 ng/ml, with sensitivity and specificity of 89.0% and 74.6%, respectively. In this study, we conclude that the accuracy of Sr. PSA test in the prediction of skeletal metastases is good. ROC-derived optimal cut-off value of Sr. PSA for positive skeletal metastases on bone scan is >29.16 ng/ml; thus, the chances of getting positive bone scan for skeletal metastasis are less in prostate cancer patients with Sr. PSA <29.16 ng/ml. ROC-derived sensitivity and specificity of different possible cut-off points of Sr. PSA help reduce the false positive results and increase the diagnostic accuracy of bone scan in the detection of skeletal metastases in prostate cancer patients.
  1 831 128
An overview on prostate-specific membrane antigen uptake in malignancies other than prostate cancer: A pictorial essay
Esmail Jafari, Hojjat Ahmadzadehfar, Habibollah Dadgar, Majid Assadi
July-September 2020, 19(3):260-265
Prostate-specific membrane antigen (PSMA) is a Type II transmembrane glycoprotein which is extremely overexpressed in prostate cancer epithelial cells. Recently, PSMA-targeted small molecule labeled with68Ga and99mTc allowed precise molecular imaging of prostate cancer and PSMA-targeted small molecule labeled with 177Lu leads to the development of radionuclide-targeted therapy of prostate cancer. Despite its name, it has been shown that PSMA has been expressed in several malignancies which can be due to significant neovascularization. Present pictorial assay reports the nonspecific tracer uptake in some malignancies during68Ga-PSMA positron-emission tomography/computed tomography imaging and99mTc-PSMA scintigraphy.
  1 993 146
30 mCi exploratory scan for two-step dosimetric131I therapy in differentiated thyroid cancer patients: A novel approach and case report
Di Wu, Cristiane Jeyce Gomes-Lima, Kanchan Kulkarni, Kenneth D Burman, Leonard Wartofsky, Douglas Van Nostrand
July-September 2020, 19(3):266-270
Differentiated thyroid cancer patients with significantly elevated or rapidly rising serum thyroglobulin (Tg) levels and negative diagnostic radioiodine scans (DxScan) often present a therapeutic dilemma in deciding whether or not to administer an131I treatment. In this report, we describe a novel two-step approach of a 30 mCi131I exploratory scan before a dosimetric131I therapy to help “un-blind” the treating physician of the benefit/risk ratio of a further “blind”131I treatment. A 51-year-old man presented with rising Tg levels, a negative DxScan, and a history of widely metastatic follicular thyroid cancer. He had undergone total thyroidectomy, remnant ablation with 3.8 GBq (103.5 mCi) of131I, Gammaknife®, and treatment with 12.1 GBq (326 mCi) of131I for multiple metastases. However, at 19 months after the treatments, his Tg levels continued to rise, and scans demonstrated no evidence of radioiodine-avid metastatic disease. In anticipation of a “blind”131I treatment, the medical team and the patient opted for a 30 mCi exploratory scan. The total dosimetrically guided prescribed activity (DGPA) was decided based on the whole-body dosimetry. The patient was first given 30 mCi of131I, and the exploratory scan was performed 22 h later, which demonstrated131I uptake in the left lung, left humeral head, T10, and right proximal thigh muscle. Based on the positive exploratory scan, the remainder of the DGPA was administered within several hours after the scan. On the post-DGPA treatment scan performed at 5–7 days, the lesions seen on the ~ 22 h exploratory scan were confirmed, and an additional lesion was observed in the left kidney. The 30 mCi exploratory scan suggested the potential for a response in the radioiodine-avid lesions despite a negative diagnostic scan. This method allows131I treatment to be administered to patients who may have a greater potential for a therapeutic response while avoiding unwarranted side effects in those patients with nonavid disease.
  - 1,050 223
Vertebral uptake of99mTc-macroaggregated albumin during lung perfusion scanning
Philippe DAbadie, Benoit Ghaye, François Jamar
July-September 2020, 19(3):271-272
A 53-year-old female underwent a lung ventilation/perfusion scintigraphy (V/Q scan) in the workup of extensive thrombosis of the left subclavian and internal jugular veins. The perfusion lung scan visualized an atypical uptake in the thoracic vertebrae. A chest Computed Tomography (CT) scan demonstrated unusual tortuous and opacified thoracic superficial veins, collaterals of the lateral thoracic vein. Many venous collateral pathways can be developed in the case of superior vena cava syndrome.99mTc-macroaggregated albumin particles may pass through the lateral thoracic vein and eventually through the vertebral venous plexus before being finally trapped by the vertebral capillaries. Besides right-to-left shunting, extrapulmonary uptake in the lung perfusion scintigraphy is very rare and may be used by collateral venous pathways.
  - 805 227
Cutaneous malignant melanoma with rarest combination of prostatic and splenic metastases on fluorodeoxyglucose (FDG) positron emission tomography–computed tomography scan
Digish Shah, Prakash Odedara
July-September 2020, 19(3):273-276
Cutaneous malignant melanoma (MM) metastases to prostate and spleen are very rarely experienced in clinical setting. As per our knowledge, coexistence of prostate and splenic metastatic MM is not reported worldwide. We are presenting a case of 70-year-old male patients with biopsy and clinically proven case of multifocal cutaneous malignant melanomatous lesions having multiple metastatic lymph nodes and systemic metastases, including prostate and spleen. This is the first case reported worldwide having a combination of prostate and splenic metastases.
  - 864 174
Unusual location of recurrent mantle cell lymphoma on fluorodeoxyglucose-positron emission tomography despite complete metabolic resolution of previous sites of disease
Benjamin M. W. Froitzheim, Raef R Boktor, Eddie Lau, Sze Ting Lee
July-September 2020, 19(3):277-280
This case report presents a patient with recurrent pleomorphic mantle cell lymphoma (MCL), which is a relatively rare but aggressive type of lymphoma. A positron emission tomography/computed tomography scan performed to assess treatment response demonstrated a complete metabolic response in the sites of primary disease while also revealing new subcutaneous lesions, which were biopsy-proven recurrent disease. This case illustrates the importance of the different biological behavior of MCL, whereby new sites of metabolically active lesions can represent recurrent disease, even though there is a complete metabolic response at sites of primary disease.
  - 537 83
Rapidly lethal secondary hemophagocytic lymphohistiocytosis predicted by fluorodeoxyglucose positron-emission tomography/computed tomography
Lovemore Peter Makusha, Darko Pucar, Colin R Young
July-September 2020, 19(3):281-283
Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare disease with either an indolent or aggressive course. A 29-year-old male presented with fever, polyarthralgias, splenomegaly, retroperitoneal adenopathy, and laboratory findings consistent with Epstein–Barr-mediated sHLH. Consistent with a prior survival analysis by Kim et al., splenic maximum standardized uptake value (SUVmax) >2.52 and bone marrow SUVmax>3.13 on18F-fuorodeoxyglucose positron emission tomography/computed tomography (18FDG-PET/CT) predicted an aggressive disease with poor treatment response. Despite optimal treatment, the patient rapidly progressed to death within 3 months of symptom onset. This case underscores the potential lethal nature of sHLH, and the evolving role of18FDG-PET/CT in predicting disease severity and treatment response.
  - 720 81
Precise localization of biliary leak post laparoscopic cholecystectomy with hepatobiliary scintigraphy and adjunct single-photon emission tomography/computed tomography fusion imaging
Shekhar Vinod Shikare, Ahmed El Hakeem
July-September 2020, 19(3):284-287
Laparoscopic cholecystectomy is commonly performed as the treatment of choice for symptomatic gallstone diseases. Bile leak is a potential complication of this procedure and the cystic duct stump is the most common site of leakage. Early diagnosis and treatment of bile leak is crucial in decreasing the morbidity and mortality related to this complication. We present a case of biliary leak following laparoscopic cholecystectomy, diagnosis of active biliary leak, and accurate localization of the site of biliary leak on hepatobiliary scintigraphy and adjunct single-photon emission computed tomography/computed tomography fusion imaging.
  - 529 111
Benign uptake of18F-fluorodeoxyglucose in the gallbladder on positron emission tomography-computed tomography
Riffat Parveen Hussain, Sadaf Nausheen, Naveed Ahmed, Tariq Mahmood
July-September 2020, 19(3):288-290
18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has been established as the indisputable tool in the oncological arena to diagnose, stage/restage, and report treatment response for various tumor malignancies. FDG uptake mostly identifies pathological uptake in oncological scans with the tracer on PET studies; however, benign uptakes are also commonly seen. Reported here is a benign case of increased uptake of the FDG on a PET with computed tomography scan in the gallbladder (GB) of a patient being screened for a known carcinoma breast. The benign accumulation of the tracer is seen in the GB to various degrees and this phenomenon may occur as a result of FDG excretion into the bile. When interpreting clinical PET images, recognition of this phenomenon is important to avoid misdiagnosing physiological GB FDG uptake as pathological so as to avoid misinterpretations of the findings.
  - 739 89
Solitary metastatic deposit in the mandible from follicular thyroid carcinoma
Nevena Manevska, Tanja Makazlieva, Sinisa Stojanoski, Ilir Vela, Selim Komina
July-September 2020, 19(3):291-295
Follicular thyroid carcinoma (FTC) is the second most common cancer of the thyroid, after papillary carcinoma. Oral metastasis arising from FTC is very rare. Mandible is more commonly affected than maxilla, with the premolar–molar region being the most frequent site of metastasis. We present the case of a 68yearold female, with swelling in the region of the parotid gland, complaining of periodic rightsided pain in the temporomandibular joint, which occurred most often in the morning with numbness and pain, and difficulty in opening the mouth. After ultrasound and X-ray, the patient was operated and the pathohistological finding was in favor of metastasis of FTC. After 3 months, a total thyroidectomy was performed, and FTC was detected in the right thyroid lobe. Laboratory results were as follows: FT4 = 9.92 pmol/L, thyroid-stimulating hormone = 9.9 mIU/L, and hTG >300 μg/L. Bone scan showed no bone metastasis. Radioablation with131I of 150 mCi was given to the patient, followed by substitutional therapy with levothyroxine. Mandible metastasis as a single skeletal deposit from follicular thyroid carcinomas is a rare clinical finding. Maxillofacial surgeons should consider and rule out thyroid pathology before performing operation of tumor formation in the mandible region. If feasible, surgical-based treatment options offer the best survival outcomes.
  - 714 135
Diagnosis of portal vein tumor thrombosis in colorectal carcinoma in fluorodeoxyglucose positron emission tomography–computed tomography scan and its clinical implication
Digish Shah
July-September 2020, 19(3):296-300
Hypercoagulable state is seldom associated with colorectal carcinoma either in the form of bland thrombosis or tumor thrombosis (TT). Venous TT should not be overlooked while deciding treatment of colorectal cancer due to its propensity to complicate the disease in terms of morbidity and mortality even in favorable prognostic case of colorectal cancer. Fluorodeoxyglucose positron emission tomography–contrast-enhanced computed tomography (FDG PET-CECT) scan has proven its role in staging of colorectal cancer and also to diagnose tumor venous thrombosis. Here, we are presenting a case of a 61-year-old male patient having adenocarcinoma of rectosigmoid colon, and on pretherapy FDG PET-CECT scan, he was found with portal vein TT and its related complication which is helpful for staging, treatment planning, and prognostication.
  - 662 100
18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography for preoperative planning in a rare case of hyperfunctional bilateral adrenocortical carcinoma and review of literatures
Apichaya Claimon, Ngoentra Tantranont, Torpong Claimon
July-September 2020, 19(3):301-305
Adrenal cortical carcinoma (ACC) is a rare aggressive endocrine tumor with poor prognosis. About 60% of ACC are functional tumors. Bilateral ACC is extremely rare, roughly 2%–10% of cases. Diagnosis and staging of ACC by imaging modalities are crucial for preoperative planning and prognostication. Detection of hyperfunctional bilateral adrenocortical carcinoma by 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F- FDG PET/CT) has never been reported. Herein, we report a male patient who presented with Cushing's syndrome, type II diabetes mellitus due to Cushing's syndrome, and hypogonadism with biopsy confirmed left ACC. He underwent18F-FDG PET/CT to evaluate the contralateral adrenal mass and to plan for laparoscopic adrenalectomy, which subsequently confirmed bilateral ACC. Furthermore,18F-FDG PET/CT was useful in staging, which revealed paraaortic lymph node and lung metastasis.
  - 622 120
Diffuse pleural metastases of osteosarcoma detected by bone scan
André Marcondes Braga Ribeiro, Eduardo Nobrega Pereira Lima, Daniel Habib Issa Lima
July-September 2020, 19(3):310-312
Osteosarcoma (OS) is a fast-growing tumor, with a high risk of local recurrence and distant metastases, with the lung and bone being the most common sites of dissemination occurring in approximately 80% of cases. Pleural metastases rarely occurs and the appearance of diffuse pleural thickening with ossification is not usual, with few such cases reported due to the current state-of-art treatment protocols. A 29-year-old woman, diagnosed with a proximal left tibial OS underwent planar and single-photon emission computed tomography/computed tomography bone scan scintigraphy with99mtechnetium methylene diphosphonate showing bilateral pleural uptake, corresponding to multiple calcified foci of thickening and nodules.
  - 597 101
Isolated aplasia of submandibular salivary gland and contralateral prominence of submandibular and sublingual salivary glands incidentally found on68Ga-prostate-specific membrane antigen positron emission tomography–computed tomography
Abbas Yousefi-Koma, Reyhane Ahmadi, Saba Karami Gorzi, Yaser Shiravand, Mohsen Qutbi
July-September 2020, 19(3):322-323
Prostate-specific membrane antigen (PSMA)-targeted imaging is now an effective tool for the evaluation of prostate cancer patients. Although salivary glands take up68Ga-PSMA avidly, pathologies of these glands may be readily noticeable. Herein, we present a case of prostate cancer referred for68Ga-PSMA positron emission tomography–computed tomography in whom an isolated aplasia of the submandibular salivary gland was incidentally found.
  - 573 98
Inferior vena cava syndrome on skeletal scintigraphy secondary to metastatic prostate cancer
Lovemore Peter Makusha, Michal Kulon, Darko Pucar, Colin Raymond Young
July-September 2020, 19(3):324-326
This interesting image illustrates an unusual case of inferior vena cava (IVC) syndrome from prostate cancer retroperitoneal adenopathy initially identified with skeletal scintigraphy. IVC syndrome is an infrequent occurrence resulting from extrinsic compression or intraluminal occlusion of the vessel. Whole-body planar skeletal scintigraphy showed a stable left sacroiliac metastasis and increased soft tissue uptake throughout the lower hemibody up to the lower chest level. Computed tomography (CT) demonstrated extrinsic compression of the IVC from metastatic retroperitoneal adenopathy. This represents a rare presentation of IVC syndrome in prostate cancer with characteristic appearance on skeletal scintigraphy of Fisherman's Wader's sign, that should prompt confirmatory anatomic imaging.
  - 809 112
Potential diagnostic pitfalls of bone scintigraphy in transthyretin-related amyloidosis
Georgios Meristoudis, Ioannis Ilias, Georgia Keramida
July-September 2020, 19(3):313-314
  - 1,111 229
Covid-19: Lessons from hospital preparedness for radiation accidents
Saeid Keshmiri, Iraj Nabipour, Majid Assadi
July-September 2020, 19(3):315-316
  - 565 104
Follow-up of incidental findings on positron emission tomography
Joseph C Lee, Fiona L Britten, Gemma F Hartnett
July-September 2020, 19(3):317-318
  - 463 77
Reply to follow-up of incidental findings on positron emission tomography
Arvind Krishnamurthy
July-September 2020, 19(3):319-320
  - 447 64
Uptake of prostate-specific membrane antigen-targeted18F-DCFPyL in avascular necrosis of the femoral head
Selim Safali, Bahattin Kerem Aydin, Mehmet Kaynar
July-September 2020, 19(3):321-321
  - 455 88
Attenuation correction in single-photon emission computed tomography for NURBS-based cardiac-torso phantom using dual-energy acquisition
Hossein Rajabi, Hadi Taleshi Ahangari, Iraj Mohammadi, Alireza Mohammadkarim, Mohammad Ali Tajik-Mansoury
July-September 2020, 19(3):211-219
Single photon emission tomography is widely used to detect photons emitted from the patient. Some of these emitted photons suffer from scattering and absorption because of the attenuation occurred through their path in patient's body. Therefore, the attenuation is the most important problem in single-photon emission computed tomography (SPECT) imaging. Some of the radioisotopes emit gamma rays in different energy levels, and consequently, they have different counts and attenuation coefficients. Calculation of the parameters used in the attenuation equation Nout=αNin= eμl Ninby mathematical methods is useful for the attenuation correction. Nurbs-based cardiac-torso (NCAT) phantom with an adequate attenuation coefficient and activity distribution is used in this study. Simulations were done using SimSET in 20–70 and 20–167 keV. A total of 128 projections were acquired over 360°. The corrected and reference images were compared using a universal image quality index (UIQI). The simulation repeated using NCAT phantom by SimSET. In the first group, no attenuation correction was used, but the Zubal coefficients were used for attenuation correction in the second image group. After the image reconstruction, a comparison between image groups was done using optimized UIQI to determine the quality of used reconstruction methods. Similarities of images were investigated by considering the average sinogram for every block size. The results showed that the proposed method improved the image quality. This study showed that simulation studies are useful tools in the investigation of nuclear medicine researches. We produced a nonattenuated model using Monte Carlo simulation method and compared it with an attenuated model. The proposed reconstruction method improved image resolution and contrast. Regional and general similarities of images could be determined, respectively, from acquired UIQI of small and large block sizes. Resulted curves from both small and large block sizes showed a good similarity between reconstructed and ideal images.
  - 1,101 180
Improving technetium-99m methylene diphosphonate bone scan images using histogram specification technique
Anil Kumar Pandey, Param Dev Sharma, Akshima Sharma, Ashish Negi, Girish Kumar Parida, Harish Goyal, Chandra Sekhar Bal, Rakesh Kumar
July-September 2020, 19(3):224-232
In this study, we have proposed and validated that histogram of a good-quality bone scan image can enhance a poor-quality bone scan image. The histograms of two good-quality technetium-99m methyl diphosphonate bone scan images IAand IBrecommended by nuclear medicine physicians (NMPs) were used to enhance 87 poor-quality bone scan images. Processed images and their corresponding input images were compared visually by two NMPs with scoring and also quantitatively using entropy, Structural similarity index measure, edge-based contrast measure, and absolute brightness mean error. Barnard's unconditional test was applied with a null hypothesis that the histogram of both IAand IBproduces similar output image at α =0.05. The mean values of quantitative metrices of the processed images obtained using IAand IBwere compared using Kolmogorov–Smirnov test. Histogram of a good-quality bone scan image can enhance a poor-quality bone scan image. Visually, histogram of IBimproved statistically significantly higher proportion (P < 0.0001) of images (86/87) as compared to histogram of IA(51/87). Quantitatively, IBperformed better than IA,and the Chi-square distance of input and IBwas smaller than that of IA. In addition, a statistically significant (P < 0.05) difference in all the quantitative metrics among the outputs obtained using IAand IBwas observed. In our study, reference histogram of good-quality bone scan images transformed the majority of poor-quality bone scan images (98.85%) into visually good-quality images acceptable by NMPs.
  - 741 179
Diagnostic value of sentinel lymph node scintigraphy and 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in the detection of metastatic lymph nodes in patients with early-stage cervical cancer
Florette Reyneke, Leon Cornelius Snyman, Ismaheel Lawal, Thabo Lengana, Mariza Vorster, Mike Sathekge
July-September 2020, 19(3):240-245
Cervical cancer is staged clinically using the International Federation of Gynaecology and Obstetrics staging system. Although lymph node status does not form part of the staging, it has important prognostic and potential therapeutic implications. The aim of the study was to evaluate the role of sentinel lymph node (SLN) scintigraphy and 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (18F-FDG PET/CT) in detecting lymph node metastases in patients with early-stage cervical cancer. Thirty-six patients with early-stage cervical cancer underwent SLN detection during primary operation. Of the 36 patients, 28 patients underwent18F-FDG PET/CT before surgery. The18F-FDG PET/CT images were analyzed with the histopathological findings as the reference standard. The diagnostic performance of18F-FDG PET/CT in the detection of nodal disease was reported in terms of accuracy value. The SLN detection rate was the highest (91.7%) using the combined method (lymphoscintigraphy, intraoperative gamma probe, and blue dye). Seven of the thirty-six patients had lymph node involvement (19.4%), of which five had preoperative18F-FDG PET/CT imaging. On overall patient-based analysis, the sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of18F-FDG PET/CT were 40.0%, 78.3%, 28.6%, 85.7%, and 71.4%, respectively. The combination of radiolabeled nanocolloid with blue dye is safe and reliable and allows successful detection of SLNs in patients with early-stage cervical cancer in a population with high prevalence of human immunodeficiency virus. The specificity and NPV of18F-FDG PET/CT are high and can be used in conjunction with SLN biopsy.
  - 603 94
Clinical value of perilesional perfusion deficit measured by Technetium-99m-ECD single-photon emission computed tomography in hypertensive intracerebral hemorrhage
Mayur Deepak Thakkar, Abdul Qavi, Ajai Kumar Singh, Pradeep Kumar Maurya, Dinkar Kulshreshtha, Anup Kumar Thacker, Satyawati Deswal
July-September 2020, 19(3):246-254
Pathological and experimental studies indicate the existence of a “penumbra” of progressive tissue damage and edema in regions immediately surrounding a hematoma in patients of intracerebral hemorrhage (ICH). This zone of oligemia surrounding ICH has a potential for perfusion recovery. Improved understanding of the pathophysiology of perilesional blood flow changes and brain injury after ICH may result in improved treatment strategies. The aim was to study perilesional blood flow changes in ICH by perfusion deficit (PD) measured by single-photon emission computed tomography (SPECT) and to correlate it with the severity of ICH and outcome. Forty-four patients of computed tomography (CT) documented nonlobar deep ICH suggestive of hypertensive hematoma of <7 days duration were subjected to99mTc-ethylene diacetate SPECT scans of the brain. Patients with significant midline shift (0.5 cm) or global blood flow reduction were excluded from the analysis. SPECT scan of the brain was analyzed by segmental analysis, a semi-quantitative method of cerebral blood flow. A difference of radiotracer uptake of >10% between the region of interest of ICH cases and the ratio between the two ROI below 0.9 was taken as a significant PD. A correlation of PD was analyzed with that of various parameters such as the severity of stroke, duration from onset of ictus, and imaging including CT scan of the brain and SPECT scan. A statistically significant difference in the percentage of radiotracer uptake on comparison of ipsilateral and contralateral to ICH (P < 0.001) was observed, suggesting a significant hypoperfusion in the perilesional area in patients with ICH. A statistically significant correlation was noted between the severity of stroke and PD indicated by various parameters such as the National Institutes of Health Stroke Scale (NIHSS) score at admission (r = 0.328, P = 0.016), Glasgow Coma Scale (GCS) score at admission (r = −0.388, P = 0.005), and ICH score at admission (r = 0.314, P = 0.020). This study demonstrated more severe hypoperfusion in clinically severe ICH which is a possible explanation of poor outcomes in severe ICH cases. We observed hypoperfusion on SPECT study in 25 of 34 (73.5%) patients with subacute ICH and 5 of 10 patients (50%) with acute ICH. The mean time from the onset of ictus to SPECT scan done was 5.04 ± 1.75 days with a range of 1–7 days, suggesting the persistence of hypoperfusion in subacute stages too. This finding may be of clinical importance for identifying the salvageable area surrounding ICH for any possible intervention in future to improve the outcome. This study demonstrates that perilesional PD occurs in acute and subacute cases of ICH. This hypoperfusion is possibly time related and appears to be more severe in patients having major ICH with poor clinical and imaging parameters. This area of hypoperfusion or ischemic penumbra is a potential site for perfusion recovery to improve clinical outcomes and to reduce long-term neurological deficits.
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Role of18F-fluorodeoxyglucose positron emission tomography/computed tomography in the evaluation of breast carcinoma: Indications and pitfalls with illustrative case examples
Moheieldin M Abouzied, Ahmed Fathala, Ahmad AlMuhaideb, Mohammed H Al Qahtani
July-September 2020, 19(3):187-196
Whole-body18F-fluorodeoxyglucose positron emission tomography (PET) has been used extensively in the last decade for the primary staging and restaging and to assess response to therapy in these patients. We aim to discuss the diagnostic performance of PET/computed tomography in the initial staging of breast carcinoma including the locally advanced disease and to illustrate its role in restaging the disease and in the assessment of response to therapy, particularly after the neoadjuvant chemotherapy. Causes of common pitfalls during image interpretations will be also discussed.
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Precision Radiotherapy:18F-FDG PET-based radiotherapy planning in Head and Neck cancers
Padma Subramanyam, Shanmuga Sundaram Palaniswamy, Shah Pervez Numani
July-September 2020, 19(3):197-204
Precision medicine is gaining importance in this era of molecular imaging where the molecular features of a disease can be noninvasively assessed and treated with personalized medicine. This is especially suited for head and neck cancers (HNCa). Early stage HNCa are ideally managed with radiotherapy (RT) or surgery. Head and neck (HN) is a complex region and its tumors respond to RT differently due to dissimilar structures and moving organs such as tongue. Radiation oncologists are always in the process of trying and investigating newer RT techniques in order to achieve precise and targetted therapy to tumour/s. One such innovation is Intensity modulated RT (IMRT) using 3 Dimensional conformal RT (3DCRT). This 3DCRT resizes the radiation beams to match the shape of the tumor. Such focused dose escalation may improve local control in HNCa. Image guided RT in conjunction with IMRT is the most advanced form of RT planning being used these days. Simulation computerized tomography (CT) images are usually incorporated into RT planning module. But limitations of CT such as poor soft tissue contrast than magnetic resonance imaging and inability to clearly define solid / cystic / necrotic areas and viable tumour exist. Functional imaging such as Positron Emission Tomography (PET) has established its superiority over CT in delineating the actual site and extent of HN tumors. A combination of IMRT with BTV (Biological Tumour Volume) may be the most ideal technique to deliver a homogeneous radiation boost to tumour. This review shall discuss PET based RT planning, challenges, practical tips, and how to optimize therapy with the least side effects to the normal surrounding tissues.
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