Τετάρτη, 20 Μαρτίου 2019

Clinical Nuclear Medicine,https://journals.lww.com/nuclearmed/pages/default.aspx



Editor's Note

In "Predicting Response to Immunotherapy by Evaluating Tumors, Lymphoid Cell-Rich Organs, and Immune-Related Adverse Events Using FDG-PET/CT", Nobashi and colleagues retrospectively investigate whether the evaluation of tumors, lymphoid cell rich organs, and immune-related adverse events (IRAE) with 18F-FDG PET/CT can predict the efficacy and outcome of immunotherapy in 40 patients (malignant melanoma, n = 21; malignant lymphoma, n = 11; renal cell carcinoma, n = 8) who underwent 18F-FDG-PET/CT  before and after therapy with immune checkpoint inhibitors.  Baseline and first restaging SUVmax for tumors, spleen, bone marrow, thyroid and pituitary glands were correlated with best overall response in the first year after therapy. Interval change between the baseline and first restaging PET showed that patients with a clinical benefit had a significant decrease in tumor parameters (P < 0.001). All patients with an increase of SUVmax in the thyroid of more than 1.5 (n = 5) on the first restaging scan had a complete response (CR) in 1 year. Patients with CR within 1 year (n = 22) were significantly associated with a favorable long-term outcome (P = 0.002). Nine patients with IRAE findings had CR at final evaluation. Among IRAE, thyroiditis was seen significantly earlier than arthritis (P = 0.040). Authors concluded that decrease of tumor parameters at early time-point PET was associated with favorable outcomes. Early development of thyroiditis is associated with a favorable early response indicator to immunotherapy.

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Pattern of FDG and MET Distribution in High- and Low-Grade Gliomas on PET Images
Takahashi, Miwako; Soma, Tsutomu; Mukasa, Akitake; More
Clinical Nuclear Medicine. 44(4):265-271, April 2019.

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Purpose of the Report
This study aimed to determine the most effective metabolic index of FDG-PET and MET-PET to differentiate high- and low-grade gliomas, and then to characterize tumor metabolism according to the 2016 WHO classification. We also developed a new calculation method of potential infiltrative tumor volume to overcome the current limitations of tumor evaluation according to metabolic index, which focuses solely on tumor core area.

Materials and Methods
Patients who underwent both FDG-PET and MET-PET, as well as surgical treatment, were retrospectively identified. All tumors were diagnosed histologically and included 44 high-grade and 19 low-grade gliomas. Metabolic indices of tumor-to-normal (T/N) ratio and maximum value within the tumor itself were compared between high- and low-grade tumors. A calculation method for potential infiltrative tumor volume was developed and compared between these 2 grades.

Results
T/N, calculated as tumor value divided by normal cortex value, was the most effective (area under the curve, 0.800 for FDG-PET; area under the curve, 0.773 for MET-PET) for differentiating high- and low-grade gliomas. Potential infiltrative volume effectively distinguished between high- and low-grade glioma (43.8 ± 30.2 mL vs 14.0 ± 12.6 mL; P = 0.005 [ t test]). A combination of T/N, with a cutoff value of 0.9 or higher on FDG-PET and/or 3.0 or higher on MET-PET, and potential infiltrative volume, with a cutoff value of 20.0 mL or higher, provided a diagnostic accuracy of 89% in distinguishing high- from low-grade gliomas.

Conclusions
Evaluation of potential infiltrative volume surrounding the tumor core area, in addition to the T/N ratio of the tumor core, may help distinguish between high- and low-grade gliomas.

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Fast-track Radioiodine Ablation Therapy After Thyroidectomy Reduces Sick Leave in Patients With Differentiated Thyroid Cancer (FASTHYNA Trial)
Waissi, Farahnaz; Kist, Jakob W.; Lodewijk, Lutske; More
Clinical Nuclear Medicine. 44(4):272-275, April 2019.

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Background
Recombinant human thyroid stimulating hormone (RhTSH) aided radioiodine ablative therapy (RIT) is current-day practice in the treatment of differentiated thyroid cancer (DTC). It is often planned 4 to 6 weeks after surgery or sometimes even longer (standard protocol). The RhTSH-aided RIT, however, has the advantage that it can be planned shortly after thyroidectomy. The FASTHYNA trial was designed to test the hypothesis that RIT 1 week after thyroidectomy (fast-track protocol) results in a significant reduction of sick leave with lower societal costs and with a better quality of life (QOL) compared with the current standard treatment.

Methods
In a randomized, multicenter trial, we included patients with differentiated thyroid cancer, stage T1–3 N0–1 M0-x, who were treated with a total or completion thyroidectomy, with a paid job of at least 12 hours per week. The primary study end point was days of sick leave reported from time of surgery. Secondary end points were QOL and societal costs associated with absence from work.

Results
Twenty patients were eligible for inclusion between November 2013 and May 2016. Significant decreases in mean duration of sick leave in the fast-track group versus the standard care group (115 and 280 hours, respectively, P = 0.02) and in costs associated with productivity losses (€4070.77 vs €9202.90, P = 0.02) were found. There were no significant differences in QOL between both groups.

Conclusions
The trial showed a significant reduction in sick leave and in societal costs in the fast-track group without a deterioration of QOL. Therefore, fast-track ablation is desirable.

Trial Registration: Netherlands trial register: NTR 3933.

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Tumor Identification of Less Aggressive or Indolent Lymphoma With Whole-Body 11C-Acetate PET/CT
Tsuchiya, Junichi; Yamamoto, Masahide; Bae, Hyeyeol; More
Clinical Nuclear Medicine. 44(4):276-281, April 2019.

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Purpose
The aim of this study was to investigate the diagnostic performance of whole-body [ 11 C]acetate PET/CT in less aggressive or indolent lymphomas, wherein [ 18 F]FDG PET/CT would exhibit limited sensitivity.

Methods
Between September 2016 and May 2018, we prospectively evaluated 17 patients (9 men, 8 women; mean age [range], 71 [45–87] years) with pathologically proven less aggressive or indolent lymphomas according to Non-Hodgkin's Lymphoma Classification Project, using both [ 18 F]FDG PET/CT and [ 11 C]acetate PET/CT (performed on the same day). Detected nodal lesions were recorded according to the Ann Arbor classification. Extranodal (EN) lesions were also evaluated. We compared whole-body lesion detection between [ 18 F] FDG PET/CT and [ 11 C]acetate PET/CT using the McNemar test.

Results
In all patients, significantly more nodal and EN lesions were detected using [ 11 C]acetate PET/CT than [ 18 F]FDG PET/CT (nodal: 84 vs 64 regions; P < 0.001; EN: 26 vs 19 regions, P = 0.039). Bone lesions were detected in 8 and 5 patients using [ 11 C]acetate PET/CT and [ 18 F]FDG PET/CT, respectively ( P = 0.25). Among the 14 patients (82.4%) who underwent bone marrow biopsy, bone marrow involvement was detected with sensitivities of 100% (6/6 patients) and 80% (5/6 patients) using [ 11 C]acetate PET/CT and [ 18 F]FDG PET/CT, respectively. Multiple areas of focal uptake in the spleen of 1 patient were exhibited on [ 18 F]FDG PET/CT but not [ 11 C]acetate PET/CT.

Conclusions
[ 11 C]acetate PET/CT exhibited greater sensitivity than [ 18 F]FDG PET/CT for lesion detection in patients with less aggressive or indolent lymphomas, thus promising applicability as a physiological tracer in the study of such lesions.

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Initial Versus Follow-up Sequential Myocardial 123I-MIBG Scintigraphy to Discriminate Parkinson Disease From Atypical Parkinsonian Syndromes
Ryu, Dong-Woo; Kim, Joong-Seok; Lee, Jee-Eun; More
Clinical Nuclear Medicine. 44(4):282-288, April 2019.

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Purpose
Previous single-center or meta-analysis studies analyzed myocardial 123 I-metaiodobenzylguanidine ( 123 I-MIBG) scintigraphy in a single image session and demonstrated low sensitivity and high specificity for discriminating Parkinson disease (PD) from atypical Parkinsonian syndromes (APS). This study aimed to assess diagnostic ability of myocardial 123 I-MIBG scintigraphy at 2 phases to discriminate PD from APS.

Patients and Methods
This hospital-based prospective study enrolled 162 PD and 26 APS patients who underwent 2 sequential 123 I-MIBG scintigraphy evaluations. Patients were stratified into normal and decreased 123 I-MIBG groups according to early and delayed heart-to-mediastinum (H/M) ratios. Patients with PD and normal 123 I-MIBG uptake (initial delayed H/M ratio, ≥1.78) were considered scans without evidence of cardiac norepinephrine deficit (SWEND). Early and delayed H/M ratios on the initial and 2-year follow-up scintigraphs were studied. The diagnostic sensitivity and specificity were calculated from these confusion matrices and were analyzed according to receiver-operating characteristic curve analysis. A repeated-measures general linear model was used to investigate differences among groups over time in H/M ratio changes and washout rates.

Results
Follow-up 123 I-MIBG scintigraphy analysis had a higher diagnostic sensitivity (89.5%) than the initial imaging (72.2%). The improved sensitivity was associated with a steeper decrease in H/M ratio in the SWEND group than in the APS group.

Conclusions
Follow-up 123 I-MIBG scintigraphy can identify cardiac sympathetic denervation and its progression in patients with PD and may be effective in discriminating PD from APS. A later decrease in myocardial 123 I-MIBG uptake in the group with SWEND meets the Braak staging threshold hypothesis for synucleinopathy.

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Predicting Response to Immunotherapy by Evaluating Tumors, Lymphoid Cell-Rich Organs, and Immune-Related Adverse Events Using FDG-PET/CT
Nobashi, Tomomi; Baratto, Lucia; Reddy, Sunil A.; More
Clinical Nuclear Medicine. 44(4):e272-e279, April 2019.

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Purpose
To investigate whether the evaluation of tumors, lymphoid cell-rich organs, and immune-related adverse events (IRAE) with 18 F-FDG PET/CT can predict the efficacy and outcome of immunotherapy.

Methods
Forty patients who underwent 18 F-FDG-PET/CT scans before and after therapy with immune checkpoint inhibitors from December 2013 to December 2016 were retrospectively enrolled (malignant melanoma, n = 21; malignant lymphoma, n = 11; renal cell carcinoma, n = 8). SUVmax of the baseline and first restaging scans were evaluated in tumors, spleen, bone marrow, thyroid and pituitary glands, and were correlated to best overall response in the first year after therapy; IRAE-affected areas were also evaluated.

Results
Interval change between the baseline and first restaging scans showed that patients with a clinical benefit had a significant decrease in tumor parameters ( P < 0.001). All patients with an increase of SUVmax in the thyroid of more than 1.5 (n = 5) on the first restaging scan had a complete response (CR) in 1 year. Patients with CR within 1 year (n = 22) were significantly associated with a favorable long-term outcome ( P = 0.002). Nine patients with IRAE findings had CR at final evaluation. Among IRAE, thyroiditis was seen significantly earlier than arthritis ( P = 0.040).

Conclusions
The decrease of tumor parameters at early time-point PET scans was seen in patients with immunotherapy who had clinical benefit within 1 year. PET-detectable IRAE was useful for prediction of a favorable outcome. Early development of thyroiditis may particularly represent an early response indicator to immunotherapy.

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Point Spread Function Reconstruction for Integrated 18F-FET PET/MRI in Patients With Glioma: Does It Affect SUVs and Respective Tumor-to-Background Ratios?
Rogasch, Julian Manuel Michael; Albers, Josefine; Steinkrüger, Ferdinand L.; More
Clinical Nuclear Medicine. 44(4):e280-e285, April 2019.

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Purpose
Semiquantitative 18 F-FET PET assessment using the tumor's SUV or tumor-to-background ratios (TBRs) can separate gliomas from peritumoral tissue or progression from pseudoprogression. This study investigated if point spread function (PSF) reconstruction of 18 F-FET PET data affects SUV-based dignity assessment.

Materials and Methods
This study is a retrospective analysis of 87 glioma patients (female, 36; male, 51; age, 48 [13–81] years) undergoing 18 F-FET PET/MRI for staging (n = 17) or restaging (n = 70). PET was reconstructed using ordered-subset expectation maximization with and without PSF. Lesions were delineated with semiautomated background-adapted thresholding relative to SUV max ; background was delineated contralaterally. Comparative measurements with a National Electrical Manufacturers Association International Electrotechnical Commission PET body phantom (sphere-to-background ratios, 8:1 and 4:1) were performed.

Results
PSF showed significantly higher tumor SUV max (median difference, +0.1; interquartile range, 0.04–0.18), SUV mean (+0.05; 0.03–0.08), TBR max|mean (+0.1; 0.04–0.2), and TBR mean|mean (+0.06; 0.03–0.09) than non-PSF ( P < 0.001). Background SUV mean was unaffected. In patients and phantom, differences between PSF and non-PSF increased with TBR and decreased with lesion's PET volume. Differences only exceeded 0.2 SUV for SUV max or 0.1 SUV for SUV mean if TBR was greater than 3 and lesion's PET volume was less than 10 mL (d = 27 mm). Dignity assessment by PSF and non-PSF was concordant in all patients examined for staging (cutoff, TBR mean|mean > 1.6; positive, 14; negative, 3) and restaging (cutoff, TBR max|mean > 2.0; positive, 67; negative, 3).

Conclusions
PSF increased tumor SUV max and SUV mean compared with non-PSF 18 F-FET PET/MRI data, especially in small lesions with high TBR (>3). However, dignity assessment using established TBR cutoffs was not affected.

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Quality and Safety in Health Care, Part XLVI: Mindfulness, Meditation, and Burnout
Harolds, Jay A.
Clinical Nuclear Medicine. 44(4):289-291, April 2019.

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Some of the approaches to prevent and recover from burnout focus on the individual, and others focus on organizational initiatives. A common recommendation for the individual with burnout is to practice meditation and mindfulness. Mindfulness may be defined as focused awareness without judgment regarding the current instance in time. The practice of mindfulness and the outcome of various mindfulness courses will be discussed in this article. Other approaches on the subject of burnout regarding individual efforts and organizational changes will be discussed in subsequent articles in this series.

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Baseline Pancreatic Beta Cell Imaging After Pancreatic Transplantation Using Whole-Body 68Ga-DOTA-Exendin-4 PET/CT: A Spectrum of 2 Cases of Diabetes Mellitus
Gambhir, Aashish; Jain, Avani; Elangovan, Indirani; More
Clinical Nuclear Medicine. 44(4):292-294, April 2019.

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Whole pancreatic transplant and islet cells transplantation are currently available strategies aiming toward diabetes cure. Beta cell specific noninvasive functional imaging using novel PET radiotracers are now available and can be used for beta cell imaging and quantification. Herein we describe a spectrum of 2 cases demonstrating beta cell targeted imaging using 68 Ga-DOTA-exendin-4 PET/CT in patients with diabetes after simultaneous pancreas-kidney transplantation.

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Resolution of Hypoxic Tissue in Cerebellar Hemispheres After Arterial Bypass Surgery in a Patient With Symptomatic Bilateral Vertebral Artery Occlusion: A 18F-FRP170 PET Study
Oikawa, Kohki; Kobayashi, Masakazu; Beppu, Takaaki; More
Clinical Nuclear Medicine. 44(4):295-296, April 2019.

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A 48-year-old man experienced recurrent vertigo refractory to antiplatelet medications. Cerebral angiography showed occlusion of bilateral vertebral arteries with poor collateral circulation. PET using 15 O 2 gas showed reduced blood flow and metabolic rate of oxygen and elevated oxygen extraction fraction in bilateral cerebellar hemispheres. Subsequent 18 F-FRP170 (1-(2- 18 F-fluoro-1-[hydroxymethyl]ethoxy)methyl-2-nitroimidazole) PET, which depicts hypoxic but viable tissue, revealed elevated tracer uptake in the same regions. After superficial temporal artery-posterior cerebral artery anastomosis, 15 O-gas PET showed normalization of blood flow, metabolic rate of oxygen, and oxygen extraction fraction in bilateral cerebellar hemispheres. Abnormally elevated 18 F-FRP-170 uptake was also resolved in those regions.

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Multiple Myeloma of Testes and Spermatic Cord on 18F-FDG PET/CT
Velaga, Jyothirmayi; Liang, Huang Hian; Gopalakrishnan, Sathish Kumar
Clinical Nuclear Medicine. 44(4):297-298, April 2019.

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Extramedullary multiple myeloma (EM) has negative prognostic implications on the overall survival as well as progression-free survival. Testis is a rare site of EM, which can be a part of diffuse involvement in multiple myeloma or a site of recurrence in patients with remission. We present a case of EM of testes and left spermatic cord in an 80-year-old man who presented with painless progressive enlargement of the scrotum. 18 F-FDG PET/CT revealed tracer avidity of both testes and left spermatic cord. Bilateral radical orchidectomy was subsequently performed, and the diagnosis of multiple myeloma was confirmed on histopathology.

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Lymphadenopathy Due to Kimura's Disease Mimicking Lymphoma on FDG PET/CT
Yu, MingMing; Wang, ZhenGuang; Zhao, Jing; More
Clinical Nuclear Medicine. 44(4):299-300, April 2019.

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Kimura's disease is a clinically rare, chronic, benign lymphoproliferative disorder of unknown etiology. A 36-year-old man presented with painless axillary swelling, which was suspected as lymphoma. PET/CT was performed for staging. The images showed multiple foci of increased activity in bilateral axillary and right inguinal lymph nodes. Laboratory tests revealed an increased eosinophil ratio and eosinophil count. Pathological examination from dissected axillary lymph nodes was consistent with Kimura's disease.

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High-Resolution Brain 18F-FDG Images Provided by Fully Digital PET
Salvadori, Julien; Perrin, Mathieu; Marie, Pierre-Yves; More
Clinical Nuclear Medicine. 44(4):301-302, April 2019.

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Normal brain 18 F-FDG PET images, consecutively recorded on analog and fully digital PET cameras in an 85-year-old woman, are depicted herein with the reconstruction methods recommended for a 2-mm voxel size on each camera and with a high-resolution reconstruction additionally developed for digital PET with a 1-mm voxel size. An enhanced gray-to-white matter contrast was consistently documented for digital PET when compared with analog PET, and was associated with a further enhancement in spatial resolution at 1-mm voxel size, as evidenced by a much clearer delineation of cortical gyri. These high-resolution images could favor the identification of brain abnormalities.

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Dynamic Renal Ptosis Demonstrated on 18F-FDG PET/CT
Taylor, Justin; Prasad, Kalpna; Rohrer, Rebecca
Clinical Nuclear Medicine. 44(4):303-304, April 2019.

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Renal ptosis, otherwise known as nephroptosis or "floating kidney," is a condition of abnormal descent of the kidney, often asymptomatic with controversy over its clinical and therapeutic significance. The aberrant location of renal and renal collecting system activity associated with this condition may serve as a diagnostic pitfall in PET/CT interpretation. We report a case of dynamic renal ptosis demonstrated on 18 F-FDG PET/CT, identified as right kidney migration from an ectopic location on attenuation correction CT images, obtained immediately after upright positioning, to the right renal fossa on subsequent PET images, obtained after approximately 10 min of supine positioning.

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Pachymeningitis Demonstrated on Gallium SPECT/CT Scan
Wong, Veronica C.; Yung, Grace; Russo, Robert; More
Clinical Nuclear Medicine. 44(4):305-309, April 2019.

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A 34-year-old woman presented with a 3-month history of right-sided headaches associated with photophobia and pulsatile tinnitus. Investigations including lumbar puncture revealed elevated opening CSF pressure, increased protein, and presence of monocytosis consistent with an inflammatory/infective process. Brain MRI showed an area of thickened enhancing dura around the venous sinus posteriorly. 67 Ga scintigraphy demonstrated focal intracranial uptake in the posterior occipital region, and biopsy confirmed a chronic inflammatory infiltrate with no granulomas.

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Diffuse-Type Tenosynovial Giant Cell Tumor of the Shoulder Evaluated by FDG PET/CT
Tang, Kun; Zheng, Xiangwu; Lin, Jie; More
Clinical Nuclear Medicine. 44(4):310-312, April 2019.

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Diffuse-type tenosynovial giant cell tumor is a locally aggressive neoplasm that typically involves the knee and hip but rarely involves the shoulder. In this case, a 74-year-old woman presented a painless mass in the right shoulder. FDG PET/CT demonstrated intense FDG uptake with an SUVmax of 19.2 in the lesion. The mass was dissected and confirmed as diffuse-type tenosynovial giant cell tumor by pathology. Follow-up FDG PET/CT assessment revealed more extensive soft tissue infiltration and adjacent bone erosion 3 years after surgery. Thus, FDG PET/CT well demonstrated the hypermetabolic and local aggressive characteristics of the lesion.

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Gummatous Syphilis Mimicking Malignant Bone Tumor on FDG PET/CT
Wang, Li-juan; Wu, Hu-bing; Zhou, Wen-lan; More
Clinical Nuclear Medicine. 44(4):313-316, April 2019.

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A 47-year-old woman suffered worsening pain in the waist and numbness in the right thigh for 1 month. MRI was performed to determine the cause, which detected an osteolytic lesion in the T12 vertebral body, suggestive of possible bone metastasis. FDG PET/CT scan was undertaken to detect the primary tumor, which only showed the same isolated lesion in the T12 without any other abnormal hypermetabolic lesion. The pathology following vertebrectomy revealed granulomatous infection. The diagnosis of osseous syphilis was eventually made following a subsequent positive Treponema pallidum serological test.

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A Case of Radioactive Iodine Uptake Found in Artificial Eye
Kim, Il-Hyun; Yoon, Joon-Kee; Lee, Su Jin; More
Clinical Nuclear Medicine. 44(4):317-318, April 2019.

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Radioactive iodine (RAI) therapy is widely used as an adjunctive treatment in patients with differentiated thyroid cancer. Although 131 I has high avidity in the functioning thyroid, and in differentiated thyroid cancer lesions, physiological and nonspecific uptake of 131 I in healthy or benign tissue may contribute to false-positive findings on an 131 I scan. Here, we present an interesting image of RAI uptake in the eye region post-RAI treatment, which has been identified as tear contamination in the artificial eye.

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Identification of Heterotopic Ossification Using 18F-NaF PET/CT
Seraj, Siavash Mehdizadeh; Al-Zaghal, Abdullah; Østergaard, Brian; More
Clinical Nuclear Medicine. 44(4):319-320, April 2019.

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Heterotopic ossification (HO) is a benign condition characterized by the abnormal formation of mature lamellar bone in extraskeletal soft tissues. Most frequently, HO is observed around the hip joint after fractures or surgical procedures such as open reduction internal fixation or total hip arthroplasties. We are presenting a case of HO as detected by 18 F-NaF PET/CT in a 68-year-old woman with multiple myeloma and a history of internal fixation of the right hip. Many previous publications have reported 18 F-NaF uptake portraying calcification in soft tissue; the present report demonstrates the feasibility of 18 F-NaF PET/CT to assess extraosseous calcification.

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Spontaneous Regression of Clinically Indolent Lymphomas Revealed by 18F-FDG PET/CT
Pan, Qingqing; Luo, Yaping; Cao, Xinxin; More
Clinical Nuclear Medicine. 44(4):321-323, April 2019.

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A 48-year-old man and a 55-year-old woman, who were diagnosed with follicular lymphoma and small B lymphocytic cell lymphoma, respectively, underwent initial "watch-and-wait" approach against lymphoma. The initial 18 F-FDG PET/CT of both patients showed multiple FDG-avid lymph nodes in the neck, mediastinum, abdomen, and inguinal regions. During their active surveillance, the follow-up PET/CT of both patients revealed spontaneous regression of lymphoma.

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Variable 131I Activity in Multiple Hepatic Cysts in a Patient With Thyroid Cancer
Shao, Fuqiang; Tang, Jiali; Lan, Xiaoli
Clinical Nuclear Medicine. 44(4):324-326, April 2019.

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Various etiologies could cause focal 131 I accumulation. Hepatic cyst is one of these etiologies. Here we present a 59-year-old man with a history of papillary thyroid cancer resection who received radioiodine therapy for three times. The images after the 131 I therapy of the second and third time showed variable activity uptake in the same hepatic cysts.

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Remarkable Response of Pulmonary Metastases Rather Than Remnant Thyroid in 131I Therapy of Follicular Thyroid Cancer
Tian, Tian; Chen, Yu; Xiang, Yongzhao; More
Clinical Nuclear Medicine. 44(4):327-329, April 2019.

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A 66-year-old man with follicular thyroid cancer after total thyroidectomy was referred for 131 I therapy. Thyroid function tests before 131 I administration exhibited severe thyrotoxicosis although the patient did not take levothyroxine after thyroidectomy. A 185 MBq 131 I whole-body scintigraphy and SPECT/CT revealed multiple iodine-avid pulmonary metastases with the largest tumor diameter of 1.4 cm and remnant thyroid. A diagnosis of thyrotoxicosis caused by hyperfunctioning pulmonary metastases was then made. The patient was administered 7.4 GBq of 131 I. Six months after 131 I therapy, a significant reduction of the pulmonary metastatic disease and thyroglobulin level was observed. However, the remnant thyroid was still visualized.

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Hepatocellular Carcinoma Mimicking Neuroendocrine Tumor Metastasis on 68Ga-DOTATATE PET/CT
Ulaner, Gary A.; Bodei, Lisa
Clinical Nuclear Medicine. 44(4):330-331, April 2019.

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68 Ga-DOTATATE is a radiolabeled somatostatin analog used for the detection and characterization of somatostatin receptor (SSR)–overexpressing tumors, particularly well-differentiated neuroendocrine tumors. We present a case of a 65-year-old man with well-differentiated pancreatic neuroendocrine tumor post–Whipple surgery and a new liver lesion on CT. 68 Ga-DOTATATE PET/CT was performed for SSR characterization and restaging, which demonstrated the lesion to be intensely SSR positive and interpreted as a neuroendocrine metastasis. However, subsequent pathology proved the lesion to be a hepatocellular carcinoma. This case adds hepatocellular carcinoma as a potentially DOTATATE-avid malignancy to be considered in the differential diagnoses of SSR-positive liver lesions.

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Diagnosis of Primary Clear Cell Carcinoma of the Vagina by 18F-FDG PET/CT
Fu, Zhanli; Chen, Xueqi; Yang, Xing; More
Clinical Nuclear Medicine. 44(4):332-333, April 2019.

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A 41-year-old woman presented with irregular vaginal bleeding, and a vaginal tumor was found and proved to be a clear cell carcinoma by biopsy. An 18 F-FDG PET/CT was performed to exclude its metastatic possibility, which showed the vaginal tumor was the only lesion with 18 F-FDG avidity. The vaginectomy and hysterectomy were performed to resect the lesion, and primary clear cell carcinoma of the vagina was finally diagnosed.

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Acral Involvement of Lymphoblastic Lymphoma Revealed on FDG PET/CT
Wen, Zhe; Zhuang, Hongming
Clinical Nuclear Medicine. 44(4):334-336, April 2019.

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Lymphoma rarely involves hand or foot. We presented the FDG PET/CT findings of lymphoblastic lymphoma in a 28-year-old man who had recurrent disease in many bones, including those of the hand and foot without any lymph node involvement 17 years after initial diagnosis.

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Superscan 18F-Fluciclovine PET/CT of PSA-Negative Prostate Cancer Bone Metastases
Chen, Bo; Macapinlac, Homer A.; Lu, Yang
Clinical Nuclear Medicine. 44(4):337-338, April 2019.

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A 76-year-old man presented with recently diagnosed prostate adenocarcinoma, Gleason score of 4 + 4, and a Super bone scan with concurrent PSA of 1.7 ng/mL. Approximately 3.5 months later, an 18 F-fluciclovine PET/CT was performed despite of a decreased PSA of 0.3 ng/mL. A Superscan fluciclovine PET/CT was identified, and bone metastasis were later confirmed at biopsy.

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Pericholecystic Rim Sign and Gallbladder Nonvisualization Indicating Acute Gangrenous Cholecystitis on 99mTc-MIBI Myocardial Perfusion SPECT
Qutbi, Mohsen; Ahmadi, Reyhana
Clinical Nuclear Medicine. 44(4):339-340, April 2019.

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Rim sign is assumed as an ominous sign of gangrenous cholecystitis and mandates an urgent surgery. The main mechanism by which this phenomenon arises is increased regional blood flow as a result of an inflammatory process. Therefore, it is expected that this finding be visualized in varieties of scans with various radiopharmaceuticals, including myocardial perfusion scan with 99m Tc-MIBI as an extracardiac finding. Herein, we present a case of acute cholecystitis with a rim sign on preoperative myocardial perfusion SPECT using 99m Tc-MIBI, which posed the possibility of gangrene and perforation and thus the need for urgent surgical intervention.

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Safety and Efficacy of Combined Peptide Receptor Radionuclide Therapy and Liver Selective Internal Radiation Therapy in a Patient With Metastatic Neuroendocrine Tumor
Maccauro, Marco; Follacchio, Giulia Anna; Spreafico, Carlo; More
Clinical Nuclear Medicine. 44(4):e286-e288, April 2019.

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Nuclear medicine treatments of well-differentiated neuroendocrine tumors (NETs) are gaining increasing acceptance among clinicians. Peptide receptor radionuclide therapy (PRRT) is an effective systemic treatment, providing a significant survival benefit and improving patients' quality of life. Locoregional selective internal radiation therapy (SIRT) is a safe and effective treatment for unresectable NET liver metastases, providing good local tumor control and symptomatic relief. Few reports in literature examine the sequential use of PRRT and SIRT in metastatic NET. We report the case of a metastatic NET patient treated with sequential PRRT-SIRT achieving a long disease control interval without cumulative toxicity issues.

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Inflammatory Activity of Tumoral Calcinosis in a Patient With Fever of Unknown Origin
Gühne, Falk; Drescher, Robert; Seifert, Philipp; More
Clinical Nuclear Medicine. 44(4):e289-e290, April 2019.

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Unexpected inflammatory activity of tumoral calcinosis periarticular to the shoulders and hips in a man with recurrent fever of unknown origin and dialysis-dependent kidney insufficiency was revealed by FDG PET/CT. In absence of other pathologies, the calcinosis was deemed to be the cause of the fever. An infectious or malignant disease could be ruled out, so further therapeutic steps were enabled.

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68Ga-PSMA-11 PET/MR Can Be False Positive in Normal Prostatic Tissue
Ferraro, Daniela A.; Rupp, Niels J.; Donati, Olivio F.; More
Clinical Nuclear Medicine. 44(4):e291-e293, April 2019.

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Prostate-specific membrane antigen (PSMA) is a transmembrane glycoprotein expressed in the cytosol of normal prostate tissue and highly overexpressed on the membrane of prostate cancer, therefore increasingly used to image prostate cancer. We report a case of a 65-year-old man with two focal PSMA-positive areas on a 68 Ga-PSMA-11 PET/MR, one corresponding to a prostate carcinoma (Gleason score 4 + 3) and another region without any evidence of malignancy, but with corresponding high PSMA-expression on immunohistochemistry.

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18F-FDG PET/CT Demonstrates Renal Cell Cancer in a Transplant With Synchronous Intestinal Infection
Kavanal, Anwin Joseph; Bharati, Joyita; Vadi, Shelvin Kumar; More
Clinical Nuclear Medicine. 44(4):e294-e295, April 2019.

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We present a case of a 22-year-old man with history of allogenic renal transplantation on immunosuppression, who underwent 18 F-FDG-PET/CT to characterize a lesion in the transplanted kidney on ultrasonogram and contrast-enhanced computed tomography imaging. PET/CT revealed FDG avid lesion in the transplanted kidney and mural thickening involving the distal ileum, ileocecal junction, and ileocolic lymph nodes. Subsequent histopathological examination from the renal lesion revealed renal cell carcinoma in the transplanted kidney. Additionally, endoscopic biopsy from the ileal thickening revealed granulomatous inflammation, suggesting tuberculosis, which was missed on both ultrasonogram and contrast-enhanced CT imaging.

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Atypical Presentation of T-Cell Large Granular Lymphocytic Leukemia Mimicking Pleural Malignancy on 18F-FDG PET/CT
Senthil, Raja; Visakh R., Arun; Pratap, Thara; More
Clinical Nuclear Medicine. 44(4):e296-e297, April 2019.

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T-cell large granular lymphocytic leukemia is a rare form of leukemia, caused by clonal proliferation of cytotoxic T-cells, characterized by modest lymphocytosis and cytopenias of other lineage with hepatosplenomegaly and relatively rare lymph nodal involvement. Involvement of other organs is extremely rare. It is predominantly an indolent disease and most of patients remain asymptomatic for a long period. We present a rare case of aggressive form (CD56 positive) of large granular lymphocytic leukemia with atypical presentations mimicking pleural malignancy on 18 F-FDG PET/CT.

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18F-FDG PET/CT in Intramuscular Mantle Cell Lymphoma With Elongated Lymphomatous Neurovascular Extension
Hod, Nir; Levin, Daniel; Anconina, Reut; More
Clinical Nuclear Medicine. 44(4):e298-e300, April 2019.

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Skeletal muscle involvement by lymphoma is rare, particularly for mantle cell lymphoma. We describe a 65-year-old man who presented with a rapidly growing left thigh mass. FDG PET/CT characterized the mass as malignant. Interestingly, an unusual hypermetabolic elongated tumorous extension was demonstrated arising from the intramuscular mass disseminating alongside the neurovascular bundle of the thigh up to the groin. Histopathology revealed intramuscular mantle cell lymphoma. In this case, we aim to highlight this interesting FDG PET/CT imaging finding, which can serve as a clue allowing one to strongly suggest lymphoma as the leading diagnosis.

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68Ga-PSMA Uptake in Prostate Cancer Sciatic Nerve Metastasis
Gouveia, Patrícia Barros; Violante, Liliana Catarina Sobral; Teixeira, Ricardo Jorge Valpaços; More
Clinical Nuclear Medicine. 44(4):e301-e302, April 2019.

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Most prostate cancers spread to regional lymph nodes, axial skeleton and lungs. Perineural malignant involvement is very rare. We present a 68 Ga-PSMA PET/CT image of a sciatic nerve metastasis in a 65-year-old man with recurrent prostate cancer.

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Incidental 18F-NaF Uptake in Drug-Induced Gynecomastia
Kothekar, Esha; Raynor, William Y.; Al-Zaghal, Abdullah; More
Clinical Nuclear Medicine. 44(4):e303-e304, April 2019.

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Gynecomastia is not uncommon in men older than 50 years of age and is characterized by glandular proliferation of breast tissue. Non-physiologic gynecomastia is mostly caused by a variety of external medical interventions. Medications that belong to classes of antiandrogens, antipsychotics, or antibiotics alter the levels of estrogen and testosterone and are commonly implicated in patients with gynecomastia. We are presenting a case of bilateral 18 F-NaF uptake in the breast tissue of a 56-year-old man with known history of prostate cancer.

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18F-Choline PET/CT Imaging for Intracranial Hemangiopericytoma Recurrence
Jehanno, Nina; Cassou-Mounat, Thibaut; Mammar, Hamid; More
Clinical Nuclear Medicine. 44(4):e305-e307, April 2019.

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We report the case of a 50-year-old man, with previous history of grade 3 intracranial hemangiopericytoma with initial complete surgical resection, addressed for local recurrence. Surgical revision performed 18 months after initial surgery allowed only partial resection, leaving residual disease along the optic nerve. Complementary radiotherapy with proton was decided. 18 F-FDG PET/CT and 18 F-choline PET/CT were both performed for treatment planning. 18 F-FDG PET showed no uptake of the residual tumor, whereas 18 F-choline depicted highly metabolic residual disease uptake with excellent delineation of local recurrence. 18 F-choline PET/CT appears as a useful PET tracer for hemagiopericytoma imaging.

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Multifocal Small Bowel Carcinoid: Evaluation by 68Ga-DOTATATE PET
Clark, Michael; Nathan, Mark; Broski, Stephen
Clinical Nuclear Medicine. 44(4):e308-e310, April 2019.

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Carcinoid is a subtype of neuroendocrine tumor, a rare group of tumors that are known to express somatostatin receptor 2. 68 Ga-DOTATATE is a somatostatin analog that is specific for somatostatin receptor 2 and therefore allows visualization of neuroendocrine tumors. We present 2 cases of primary multifocal small bowel carcinoid evaluated using 68 Ga-DOTATATE PET/CT, along with contrast-enhanced CT corollary findings. Given the increased sensitivity of 68 Ga-DOTATATE PET/CT compared with CT and 111 In-octreotide scintigraphy, we expect multifocal carcinoid to become increasingly recognized.

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Primary Pulmonary Paraganglioma Revealed by FDG PET/CT
Shen, Guohua; Su, Minggang; Kuang, Anren
Clinical Nuclear Medicine. 44(4):e311-e312, April 2019.

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Primary pulmonary paraganglioma is a rare type of extra-adrenal paragangliomas arising from neuroectodermal-derived paraganglionic tissue. We report herein the case of a 49-year-old woman with a round-like well-defined nodule in the right middle lobe detected by chest CT. FDG PET/CT also revealed this homogeneous nodule with increased FDG accumulation. Finally, the patient underwent right middle lobe resection, and the pathological findings demonstrated the diagnosis of pulmonary paraganglioma.

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Hereditary Spherocytosis Presenting as Diffuse Bone Marrow Activation and Splenomegaly on PSMA-Targeted 18F-DCFPyL PET/CT
Gomez, Erin; Tran, Phuoc T.; Pienta, Kenneth J.; More
Clinical Nuclear Medicine. 44(4):e313-e314, April 2019.

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We present the case of a 71-year-old man with Gleason 3 + 3 = 6 pT2N0MxR0 adenocarcinoma of the prostate who presented with rising PSA level 16 years after radical prostatectomy. PSMA-targeted 18 F-DCFPyL PET/CT was performed, which demonstrated recurrent disease in the prostatectomy bed as well as splenomegaly and mild-diffuse bone marrow activation, consistent with the patient's history of hereditary spherocytosis. We briefly review the clinical characteristics of hereditary spherocytosis, its appearance on molecular imaging studies, the normal biodistribution of 18 F-DCFPyL, and the PSMA-RADS scoring system for characterizing findings on PSMA-targeted PET imaging.

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Meningeal Metastasis Relapse With Focal Involvement of Cranial Bone Flap: A Case Resolved by 18F-DOPA PET/MRI
Louarn, Nicolas; Dauta, Aurélie; Lechapt-Zalcman, Emmanuèle; More
Clinical Nuclear Medicine. 44(4):e315-e317, April 2019.

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A 63-year-old woman was referred to our PET/MRI platform to evaluate the possible relapse of a meningeal metastasis, complicating an invasive ductal carcinoma of the left breast. This metastasis was diagnosed on a left hemiparesis and treated by surgery and radiation therapy. One year later, the same symptoms led to another brain MRI examination that found a contrast-enhanced lesion in the operating site. We decided to perform a 18 F-DOPA PET/MRI to document this lesion, which confirmed the diagnosis of a probable relapse and revealed a focal uptake on the bone flap.

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Response Assessment of 223Ra Treatment: Should a Fluorocholine PET/CT Be Performed?: Reply
García Vicente, Ana María; Soriano Castrejón, Angel
Clinical Nuclear Medicine. 44(4):341-342, April 2019.

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Re: The Prognostic Value of 18F-FDG PET/CT in Monitoring Chemotherapy in Ovarian Cancer Both at Initial Diagnosis and at Recurrent Disease
Rubello, Domenico; Marzola, Maria Cristina; Colletti, Patrick M.
Clinical Nuclear Medicine. 44(4):342-344, April 2019.

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131I and 124I Accumulation in a Thymic Cyst: Reply
Freesmeyer, Martin; Kunze, Almut; Winkens, Thomas
Clinical Nuclear Medicine. 44(4):344, April 2019.

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