High-Output Heart Failure in Multiple Myeloma: Novel Application of Tc-99m MAA to Identify Intramedullary Shunting.

We introduce the innovative use of technetium-99m-labeled macroaggregated albumin to diagnose high-output heart failure in a patient with multiple myeloma with persistent congestion symptoms. Symptom resolution occurred with lenalidomide and steroids. This marks the first clinical use of technetium-99m-labeled macroaggregated albumin for clarifying high-output heart failure etiology.

Joint EANM/SNMMI/IHPBA procedure guideline for [99mTc]Tc-mebrofenin hepatobiliary scintigraphy SPECT/CT in the quantitative assessment of the future liver remnant function.

PURPOSE: The aim of this joint EANM/SNMMI/IHPBA procedure guideline is to provide general information and specific recommendations and considerations on the use of [99mTc]Tc-mebrofenin hepatobiliary scintigraphy (HBS) in the quantitative assessment and risk analysis before surgical intervention, selective internal radiation therapy (SIRT) or before and after liver regenerative procedures. Although the gold standard to estimate future liver remnant (FLR) function remains volumetry, the increasing interest in HBS and the continuous request for implementation in major liver centers worldwide, demands standardization. METHODS: This guideline concentrates on the endorsement of a standardized protocol for HBS elaborates on the clinical indications and implications, considerations, clinical appliance, cut-off values, interactions, acquisition, post-processing analysis and interpretation. Referral to the practical guidelines for additional post-processing manual instructions is provided. CONCLUSION: The increasing interest of major liver centers worldwide in HBS requires guidance for implementation. Standardization facilitates applicability of HBS and promotes global implementation. Inclusion of HBS in standard care is not meant as substitute for volumetry, but rather to complement risk evaluation by identifying suspected and unsuspected high-risk patients prone to develop post-hepatectomy liver failure (PHLF) and post-SIRT liver failure.

Experience with a Perfusion-Only Screening Protocol for Evaluation of Pulmonary Embolism During the COVID-19 Pandemic Surge.

The purpose of this study was to evaluate a pulmonary embolism (PE) perfusion-only screening (POS) protocol introduced during the coronavirus disease 2019 (COVID-19) pandemic surge. Subjects without dense parenchymal lung opacities were studied; those with less than 1 segmental perfusion defect were considered to have no PE, whereas those exhibiting 1 or more defects were indeterminate, mandating additional examinations to determine the final diagnosis. Methods: We analyzed demographic information, clinical data, imaging findings, and follow-up data from the electronic records of COVID-19 patients who underwent lung scintigraphy during the 60-d study period. Results: In total, 53 studies were performed on 17 COVID-19-positive and 36 COVID-19-negative patients. The POS protocol efficiently excluded PE in 79% of cases; the remaining 21%, indeterminate for PE, were generally referred for alternative testing or were directly anticoagulated. In patients with negative POS results, there was a very low mortality before hospital discharge (1/42) and normal results on follow-up studies (6/6). Conclusion: The POS protocol, implemented during the COVID-19 surge, efficiently and safely excluded PE in 79% of patients.

Remote Reading and Teaching of Nuclear Medicine in the Era of COVID-19.

Community SARS-CoV-2 has profoundly affected traditional elements of learning and teaching in nuclear medicine and diagnostic radiology departments. The response of the nuclear medicine community to the challenges imposed by the COVID-19 pandemic can be described in 3 phases: accommodation, consolidation and optimization, and a return towards normalcy. Adoption of virtual communication platforms has emerged as the crucial interim tool for preservation of trainee supervision and diagnostic imaging education. Development of supplemental teaching materials, refocusing research interests, and relaxation of requirements have all contributed toward stabilization of the residency programs. As we embark on a gradual return to normalcy, many of the virtual solutions that were employed have gained a degree of enduring popularity and may find a place in the postpandemic period.

Diagnostic Performance of Pulmonary Embolism Imaging in Patients with History of Asthma.

Asthma and pulmonary embolism (PE) can present with overlapping symptoms, and distinguishing between these 2 conditions can be challenging. Asthma may limit imaging for PE because of either worsened ventilation defects on ventilation-perfusion scanning (VQ) or increased motion artifacts on CT pulmonary angiography (CTPA). Methods: We identified adults evaluated for PE with VQ or CTPA from 2012 to 2016. Patients with chronic lung disease (other than asthma) were excluded. Studies were classified as negative, positive, or nondiagnostic. Follow-up of negative cases was reviewed to determine the rate of repeat exams (within 1 wk) and the false-negative rate (defined as diagnosis of venous thromboembolism within 90 d). Results: We reviewed 19,412 adults (aged 52 ± 18 y, 70% women) evaluated for PE (60% with VQ, 40% with CTPA); 23% had a history of asthma. Nondiagnostic results were comparable for those with and without asthma for both VQ (asthma, 3.3%; nonasthma, 3.8%; P = 0.223) and CTPA (asthma, 1.6%; nonasthma, 1.5%; P = 0.891). A history of asthma was not associated with a higher rate of repeat exams after negative imaging for VQ (asthma, 1.9%; nonasthma, 2.1%; P = 0.547) or CTPA (asthma, 0.6%; nonasthma, 0.6%; P = 0.796), nor was a history of asthma associated with a higher false-negative rate for VQ (asthma, 0.4%; nonasthma, 0.9%; P = 0.015) or CTPA (asthma, 1.9%; nonasthma 1.5%; P = 0.347). Conclusion: A history of asthma in the preceding 10 y was not associated with impaired diagnostic performance of PE imaging for either VQ or CTPA.

Gallium-67 Single-Photon Emission Computed Tomography Affects Management of Infections of Left Ventricular Assist Devices.

Our institution employs gallium-67 single-photon emission computed tomography low-dose CT (Ga-SPECT-CT) to determine the presence and extent of left ventricular assist device (LVAD) infections. We present a retrospective single-center study of 41 LVAD recipients who underwent Ga-SPECT-CT from January 2011 to June 2018 to determine whether Ga-SPECT-CT led to changes in antimicrobial therapy, LVAD revision or exchange, or application for 1A exception. The average age was 56.6 years, predominantly male (80.5%) and diabetic (68.3%), divided between ischemic (48.8%) and nonischemic (51.2%) cardiomyopathy. The majority had HeartMate II devices (82.9%). Device-related infections were classified as possible (12.2%), probable (36.6%), proven (36.6%), or rejected (14.6%). Sensitivity was 68.6% and specificity was 100%. Most VAD-specific infections were percutaneous deep driveline infections (DRIs) (34.1%), and VAD-related infections were primarily bloodstream infections (31.7%). Staphylococcus aureus was the major pathogen isolated. Gallium-67 single-photon emission computed tomography low-dose CT resulted in changes in management in more than half (53.7%) of patients: starting (24.4%) or stopping (17.1%) antimicrobial therapy, LVAD revision (22.0%) or exchange (12.2%), and the application for 1A exception for transplant listing (17.1%). We conclude that Ga-SPECT-CT is an effective modality for determining the presence and extent of LVAD DRIs, and contributed to a change in management in more than half of cases.

The Utility of 18FDG PET/CT Versus Bone Scan for Identification of Bone Metastases in a Pediatric Sarcoma Population and a Review of the Literature.

BACKGROUND: Outcome of patients with osteosarcoma (OS) and Ewing sarcoma (EWS) is dependent on presence of metastases. Imaging guidelines for OS and EWS include radiographs, computed tomography (CT), and magnetic resonance imaging for primary tumor evaluation and CT chest and bone scintigraphy (BS) for metastatic detection. 18Fluorodeoxyglucose (18FDG) positron emission tomography (PET)/CT has become more common for disease evaluation, yet there is no consensus for its use in this population. OBJECTIVE: We aimed to compare identification of osseous metastases using BS versus 18FDG PET/CT in our patient population. We hypothesized that 18FDG PET/CT is more likely to detect osseous metastases both at diagnosis and relapse. MATERIALS AND METHODS: We performed retrospective chart reviews of pediatric sarcoma patients treated at our institution from 2008 to 2019. Paired BS and 18FDG PET/CT scans were reviewed. Review of the literature was also performed. RESULTS: Thirty-three patients had paired BS and 18FDG PET/CT during diagnosis or treatment. Fifteen patients had distant osseous metastases. In the OS cohort, 8/16 patients had osseous metastases; 100% of these patients were detected on 18FDG PET/CT and 75% on BS. Thirty-one bony lesions were seen on imaging in OS patients; 100% of these were identified on 18FDG PET/CT but only 29% on BS. In the EWS cohort, 6/15 patients had osseous metastases; 100% of these patients were detected on 18FDG PET/CT and 50% on BS. Eighteen bony lesions were seen on imaging in EWS patients; 94% of these were identified on 18FDG PET/CT, but only 28% on BS. CONCLUSION: For patients in our institution with OS or EWS, osseous metastases were more likely detected using 18FDG PET/CT.

Impact of Patient-Centered Care on the Patient Experience in Nuclear Medicine.

OBJECTIVE: To quantify the impact of direct patient-physician interaction within a nuclear medicine pretherapy consultation clinic on the patient experience. METHODS: Patients were asked to complete a survey before and after meeting with the nuclear medicine physician. During each visit, the physician provided disease-specific information, discussed the planned therapy, answered questions, and provided tip sheets and checklists to prepare the patient for therapy. RESULTS: Thirty-eight patients were included in the analysis. Before consultation, 17 patients (44.7%) were "somewhat" or "extremely" familiar with the term "nuclear medicine doctor," whereas after the consultation, 33 patients (86.8%) were "somewhat" or "extremely" familiar with the term "nuclear medicine doctor" (P < 0.001). Thirteen patients (37.1%) felt they had either no understanding or a vague understanding of the therapy and no understanding of the plan for follow-up before the consultation, whereas 2 patients (5.4%) chose this response after the consultation (P < 0.001). More patients responded that they felt "generally" or "perfectly calm" toward the therapy overall after their consultation: 26 patients (68.4%) before vs 34 patients (91.9%) after consultation (P < 0.001). DISCUSSION: Patient- and family-centered care in radiology includes direct physician participation in care delivery. In this report, we evaluate and measure the impact of our nuclear medicine pretherapy consultation clinic on the patient experience. We demonstrate significant impact of direct patient-physician encounters on patient anxiety, patient knowledge of the role of the nuclear medicine physician, and overall patient understanding of their treatment plan.

Unilateral Absence of the Basal Ganglia on 123I-Ioflupane DaTScan.

This 33-year-old man presented with hemorrhagic stroke manifesting with left hemiparesis and right ptosis. Angiography revealed no patent carotids. The anterior and middle cerebral arteries were filling collaterally through the posterior vertebrobasilar pathway. The presumptive diagnosis was moyamoya disease. The etiology of the bleeding was right basilar tip aneurysm that subsequently had partial coil placement. Months later, the neck of the aneurysm perforated and second coiling was performed. Later on follow-up, patient developed left hand tremor. A radionuclide DATscan revealed total absence of right-sided basal ganglia activity. A possible etiology was occlusion of the middle cerebral artery's lenticulostriate branches.

Centers with more therapeutic modalities are associated with improved outcomes for patients with hepatocellular carcinoma.

BACKGROUND: Higher facility volume is correlated to better overall survival (OS), but there is little knowledge on the effect of facility treatment modality number on OS in hepatocellular carcinoma (HCC). METHODS: This is a retrospective analysis of data from the National Cancer Database (NCDB) from 2004-2014 on patients with non-metastatic HCC. Treatment modalities assessed were surgical resection, transplantation, ablation, radioembolization, stereotactic body radiation therapy (SBRT), single-agent chemotherapy, and multi-agent chemotherapy. Facilities were dichotomized at the median of the listed treatment modalities. RESULTS: There were a total of 112,512 patients with non-metastatic HCC. Of a total of 1,230 sites, 830 (67.5%) used four or fewer modalities. Average survival for patients treated at facilities using fewer modalities was 12.0 and 23.5 months for those treated at facilities with more modalities [hazard ratio (HR) =0.52, 95% confidence interval (CI): 0.51-0.53, P<0.001]. After adjusting for facility volume, liver function, tumor and patient characteristics and other prognostic factors in a multivariable Cox model, treatment at a multi-modality facility still provided a survival advantage (HR =0.60, 95% CI: 0.52-0.70, P<0.001). This benefit also persisted after propensity score matching. Sensitivity analysis varying the cut point from 2 to 6 modalities for dichotomization showed that the benefit persisted. Subgroup stratified analyses based on stage showed that the benefit in OS was highest for patients with stage I and II (P≤0.002) but was not significant for stage III or IVa. CONCLUSIONS: Institutions that offered more treatment modalities had improved OS for patients with non-metastatic HCC, especially for those with stage I and II.

Performance of Low-Dose Perfusion Scintigraphy and CT Pulmonary Angiography for Pulmonary Embolism in Pregnancy.

BACKGROUND: The symptoms of normal pregnancy overlap those of pulmonary embolism (PE). Limited literature suggests that low-dose perfusion scanning (LDQ), which yields lower maternal-fetal radiation exposure than CT pulmonary angiography (CTPA), performs well in excluding PE in pregnant patients. METHODS: We performed a retrospective cohort study of sequential pregnant women who underwent imaging for PE with LDQ or CTPA between 2008 and 2013 at Montefiore Medical Center. Our practice recommends LDQ for patients with negative results on chest radiographs. Patients were categorized according to initial imaging modality, and a subgroup analysis was performed in patients with asthma. The primary outcome was the negative predictive value (NPV) of imaging determined by VTE diagnosis within 90 days. RESULTS: Of 322 pregnant women (mean age, 27.3 ± 6.3 years), initial imaging was positive for PE in 2.7% (6 of 225) of LDQs and 4.1% (4 of 97) of CTPAs, negative in 88.0% (198 of 225) of LDQs and 86.6% (84 of 97) of CTPAs, and indeterminate/nondiagnostic in 9.3% (21 of 225) of LDQs and 9.3% (9 of 97) of CTPAs (P = .79). Ten patients (3.1%) were treated for PE. The NPV was 100% for LDQ and 97.5% for CTPA. Subgroup analysis of patients with asthma (23.9% of this population) revealed a high likelihood of a negative study in the LDQ and CTPA groups (74.1% and 87.0%, respectively) and 100% NPV for both modalities. CONCLUSIONS: PE is an uncommon diagnosis in pregnancy. LDQ and CTPA perform well, with less maternal-fetal radiation exposure with LDQ. Therefore, when available, LDQ is a reasonable first-choice modality for suspected PE in pregnant women with a negative result on chest radiograph.

Preoperative 18F-FDG-PET/CT vs Contrast-Enhanced CT to Identify Regional Nodal Metastasis among Patients with Head and Neck Squamous Cell Carcinoma.

Objective Our objective was to compare the accuracy of preoperative positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) in detecting cervical nodal metastases in patients treated with neck dissection and to scrutinize the ability of each modality to determine nodal stage. Study Design Case series with chart review. Setting Montefiore Medical Center, Bronx, New York. Subjects and Methods Patients who underwent neck dissection at our institution for primary treatment of head and neck squamous cell carcinoma (HNSCC) and had received preoperative PET/CT and CECT were included in this study. Imaging studies were reinterpreted by 3 specialists within the field and compared for interreader agreement. Concordance between radiology and histopathology was measured using neck levels and sides, along with patient nodal stage. Sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and agreement coefficients were calculated. Results Seventy-three patients were included in the study. Sensitivity was 0.69 and 0.94 (level and side) for PET/CT vs 0.53 and 0.66 for CECT ( P = .056, P = .001). Specificity was 0.86 and 0.56 for PET/CT vs 0.91 and 0.76 for CECT ( P = .014, P = .024). No significant difference was found in overall accuracy ( P = .33, P = .88). The overall agreement percentages between N stage called by imaging modality and pathology were 52% and 55% for PET/CT and CECT, respectively. Conclusion No significant difference in sensitivity was found between PET/CT and CECT. CECT was found to have superior specificity compared with PET/CT. The information gleaned from each modality in the pretreatment evaluation of HNSCC appears to be complementary.