Left ventricular thrombus with normal systolic function secondary to the novel prothrombotic association of acute on chronic calcific pancreatitis and COVID-19.

In the presence of normal left ventricular systolic function, the development of left ventricular thrombus has seldom been documented in hypercoagulable conditions. Echocardiographic results of left ventricular thrombi can be differentiated from those found in cardiac tumors such as myxoma. Many other organs, including the central and peripheral nervous systems, as well as the cardiac and vascular systems, have recently been linked to thromboembolic events in coronavirus disease 2019 (COVID-19). It not only exacerbates acute pancreatitis but often predisposes, in fact, to a novel prothrombotic state in patients with pre-existing comorbid conditions such as chronic calcific pancreatitis. We report an unusual correlation of two prothrombotic disorders - COVID-19 and acute on chronic pancreatitis contributing to the development of thrombus in a normal left ventricle. .

Synchronous bilateral renal cell carcinomas in "Asynchrony of metabolism".

Here, we present a case of bilateral synchronous renal cell carcinoma in a 52-year-old male patient, who underwent fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) scan followed by surgical removal of both tumors. On PET scan, left renal mass showed intense FDG uptake while uptake in the right renal mass was minimal. Histopathologically, both tumors were conventional clear cell carcinoma (Fuhrman Grade III). Only the FDG-avid tumor in the left kidney had lymphovascular invasion and necrosis, which are markers of aggressive form of any tumor. FDG PET-CT can act as strong and noninvasive prognostic parameter that could help to identify patients with aggressive disease before treatment.

Serial FDG-PET scans help to identify steroid resistance in cardiac sarcoidosis.

BACKGROUND: Cardiac sarcoidosis (CS) is increasingly being recognized. Immunosuppression with corticosteroids is the mainstay of therapy. But the optimal dose of steroids and how to assess response to therapy is not known. Prognosis is poor if these patients are untreated or undertreated. Fluorine-18-flurodeoxyglucose positron emission computed tomography (18FDG-PET CT) is a sensitive tool in diagnosing CS. It correlates closely with the level of granulomatous inflammation and can be used to monitor response to therapy. METHODS: We identified 15 patients (6 women; mean age, 42.9±12.5years) based on histopathological diagnosis. All had a baseline and follow-up fasting 18FDG-PET CT scans before and after steroid therapy. Non-responders were defined as those in whom ventricular arrhythmias, symptoms of HF and left ventricular systolic function and/or ventricular arrhythmias did not improve or worsened despite steroid therapy. FDG uptake of involved myocardium and lymph nodes (LN) was compared in clinical responders and non-responders on follow-up. RESULTS: Of the 15 patients, 4 were clinical non-responders to steroid therapy. Follow-up 18FDG-PET CT was performed at 125.8±54.2days after the initiation of steroid therapy. Myocardial maximum standardized uptake of FDG (SUVmax) value decreased significantly in responders (p=0.004) while there was an increase in non-responders (p<0.05) on follow-up. Number of left ventricle (LV) segments with FDG uptake significantly decreased in responders (p=0.007), and on increasing trend in non-responders (p=0.465). Heterogeneous FDG uptake on baseline PET scan, increase in intensity as well as area of myocardial inflammation on follow-up PET scan was associated with poor clinical outcome despite steroid therapy. CONCLUSIONS: Serial 18FDG-PET CT scans can be used to monitor steroid therapy in active CS. Increase in PET uptake after steroid therapy correlates with poor clinical outcome. Repeat PET scan may help to predict steroid-resistant CS and the need for up-titration of immunosuppressive therapy among poor responders to initial therapy.

Unusual metastatic sites from renal cell carcinoma detected by 18F-FDG PET/CT scan.

Here we describe 2 cases of renal cell carcinoma where we found the unusual metastatic sites from renal cell carcinoma on 18F-FDG PET/CT scans in post-radical nephrectomy status. The first case resolves the venous migration of the tumor as a malignant thrombus arising from a remnant stump of the left renal vein, passing through hemiazygos vein further into the azygos vein and finally into the superior vena cava just before entering into the right atrium. The second case demonstrated extensive skeletal muscle deposits involving the muscles of the trunk as well as upper and lower extremities.

Tumour thrombosis and patterns of fluorine-18 fluorodeoxyglucose uptake: a pictorial review.

Tumour thrombosis (TT) is a very rare but serious complication in oncologic patients. The presence of TT has a significant impact on tumour staging, treatment decisions and prognosis in many malignancies. Current diagnostic techniques show poor ability to differentiate between bland and malignant thrombi; tumour thrombi are also usually inaccessible for biopsies, making their diagnosis difficult. In recent times, fluorine-18 fluorodeoxyglucose PET/computed tomography (F-FDG PET/CT) has well established its role in oncological imaging because of the high metabolic contrast of F-FDG between malignant and normal tissue. Patients with tumour thrombi may benefit from F-FDG PET/CT imaging when TT cannot be diagnosed precisely by other conventional imaging modalities. Here we provide a pictorial review of a few common and unusual sites of tumour thrombus in different malignancies and their patterns of F-FDG uptake.

Potential of (18)F-FDG-PET as a valuable adjunct to clinical and response assessment in rheumatoid arthritis and seronegative spondyloarthropathies.

AIM: To evaluate the role of fluorine-18-labeled fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) in various rheumatic diseases and its potential in the early assessment of treatment response in a limited number of patients. METHODS: This study involved 28 newly diagnosed patients, of these 17 had rheumatoid arthritis (RA) and 11 had seronegative spondyloarthropathy (SSA). In the SSA group, 7 patients had ankylosing spondylitis, 3 had psoriatic arthritis, and one had non-specific SSA. Patients with RA were selected as per the American College of Rheumatology criteria. One hour after FDG injection, a whole body PET scan was performed from the skull vertex to below the knee joints using a GE Advance dedicated PET scanner. Separate scans were acquired for both upper and lower limbs. Post-treatment scans were performed in 9 patients in the RA group (at 6-9 wk from baseline) and in 1 patient with psoriatic arthropathy. The pattern of FDG uptake was analysed visually and quantified as maximum standardized uptake value (SUVmax) in a standard region of interest. Metabolic response on the scan was assessed qualitatively and quantitatively and was correlated with clinical assessment. RESULTS: The qualitative FDG uptake was in agreement with the clinically involved joints, erythrocyte sedimentation rate, C-reactive protein values and the clinical assessment by the rheumatologist. All 17 patients in the RA group showed the highest FDG avidity in painful/swollen/tender joints. The uptake pattern was homogeneous, intense and poly-articular in distribution. Hypermetabolism in the regional nodes (axillary nodes in the case of upper limb joint involvement and inguinal nodes in lower limb joints) was a constant feature in patients with RA. Multiple other extra-articular lesions were also observed including thyroid glands (in associated thyroiditis) and in the subcutaneous nodules. Treatment response was better appreciated using SUVmax values than visual interpretation, when compared with clinical evaluation. Four patients showed a favourable response, while 3 had stable disease and 2 showed disease progression. The resolution of regional nodal uptake (axillary or inguinal nodes based on site of joint involvement) in RA following disease modifying anti-rheumatoid drugs was noteworthy, which could be regarded as an additional parameter for identifying responding patients. In the SSA group, uptake in the affected joint was heterogeneous, low grade and non-symmetrical. In particular, there was intense tendon and muscular uptake corresponding to symptomatic joints. The patients with psoriatic arthritis showed intense FDG uptake in the joints and soft tissue. CONCLUSION: (18)F-FDG PET accurately delineates the ongoing inflammatory activity in various rheumatic diseases (both at articular and extra-articular sites) and relates well to clinical symptoms. Different metabolic patterns on FDG-PET scanning in RA and SSA can have important implications for their diagnosis and management in the future with the support of larger studies. FDG-PET molecular imaging is also a sensitive tool in the early assessment of treatment response, especially when using quantitative information. With these benefits, FDG-PET could play a pivotal clinical role in the management of inflammatory joint disorders in the future.