Incidental finding of Psuedomyxoma Peritonei in Malignant Peripheral Nerve Sheath Tumour.

Psuedomyxoma peritonei is an infrequent clinical entity characterised by intraperitoneal mucinous/gelatinous ascites produced by the cancerous cells. It has been associated with gastrointestinal, gynaecological, lung and breast tumours. It is commonly asymptomatic and is most often detected incidentally on abdominopelvic imaging or laparoscopy. Higher histological grade of the tumour shows increased metabolic activity on 18F-Fluorodeoxyglucose (FDG) positron-emission tomography (PET) computed tomography (CT). It has been rarely reported in patients with sarcoma. We hereby present an interesting case of incidentally diagnosed pseudomyxoma peritonei on 18FDG PET-CT scan of a patient with soft tissue sarcoma of peripheral nerve sheath.

Arsenic Levels and Seasonal Variation in Pasture Soil, Forage and Horse Blood Plasma in Central Punjab, Pakistan.

The present study aimed to determine the accumulation levels of arsenic in pasture soil, forage and animals. An atomic absorption spectrophotometer was used to determine the concentration of metals in the samples of soil, forage and blood plasma of horses. The level of arsenic ranged between 4.26 mg/kg (summer) and 4.66 mg/kg (winter) in soil samples and 2.67 mg/kg (summer) and 2.94 mg/kg (winter) in forage samples. In blood plasma samples, the mean arsenic (As) values varied between 1.38 and 1.52 mg/L. In the blood plasma samples, the mean As values varied between 1.38 and 1.52 mg/L. No statistically significant changes were observed for arsenic concentrations in plasma samples of horses for sampling seasons (p > 0.05). A positive correlation was observed for forage and blood plasma to a certain degree for arsenic but for other media, arsenic correlations were negative and insignificant. It is therefore suggested that regular monitoring of heavy metals in soils/plants/animals is essential to prevent excessive build-up of arsenic.

Neuroendocrine liver metastases - 'doughnut box sign' on SPECT/CT.

A 76 year old patient was referred for Indium111 Octreotide scan to look for primary tumour and extent of neuroendocrine metastases. Indium 111 Octreotide scan showed a liver packed with centrally necrotic metastases like doughnuts packed in a box. No primary lesion was identified in this scan.

Accentuated 123ImIBG uptake by the left lobe of the liver - A clue to nowhere.

A 57-year-old male was imaged with 123I mIBG for left sided suprarenal mass. The planar and SPECT-CT acquisitions revealed features consistent with a left sided pheochromocytoma. There was physiological and high uptake in the hypertrophied left lobe of the liver which was normal at both MRI and non-contrast CT. Asymmetrical increased 123I mIBG uptake in the left lobe of the liver as compared to the right lobe is a known physiological finding with no obvious cause or significance.

Superscan on 18F-FDG PET-CT imaging for lymphoma: How frequent is it?

This retrospective study was conducted to evaluate the frequency of PET superscan in baseline staging scans of lymphoma patients.The study was conducted at the Shaukat Khanum Memorial Cancer Hospital, Lahore, from October 1, 2018 to August 31, 2019. A retrospective review of baseline PET-CT scans of 203 lymphoma patients, performed during the period of October 1, 2017 to August31,2018, was done from the institutional database. Out of these 203 patients, PET superscan pattern was observed in 13 (6.4%) patients, 08 (61.5%) males and 05 (38.5%) females. Eight (61.5%) patients had Non-Hodgkin's lymphoma, while 05 (38.5%)had Hodgkin's lymphoma. Based on TNM staging 10 (76.9%) patients had stage IV disease, 01 (07.6%) had stage III disease, and 2 (15.4%) had stage II disease. PET-CT superscan pattern is uncommon and is not dependent on the stage of the disease. It should be recognised in clinical practice as it suggests a poor prognosis.

Complete splenic vein tumour thrombus in primary gastric malignancy on F18-fluorodeoxyglucose positron emission tomography-computed tomography.

Tumour thrombus is an uncommon complication with ominous outcomes. F18 FDG PET-CT scan helps in differentiating tumour thrombus from venous thrombus owing to its metabolic uptake similar to the tumour. We discuss an interesting case of gastric malignancy with complete splenic vein tumour thrombosis on initial presentation.

Lymphoma involving the brain and adrenals: A chicken and egg situation.

Primary cerebellar diffuse large B-cell lymphoma (DLBCL) is a rare entity, which manifests with neurological symptoms. It is aggressive in nature with high rate of recurrence and short survival period. It commonly presents with local invasion and rarely spreads outside the central nervous system. Chemotherapy with radiation is the preferred treatment; however, surgery can be done for solitary lesions. Likewise, adrenal lymphoma as primary site of disease is rare but can present as extra-nodal disease. We present an unusual case of cerebellar DLBCL with bilateral adrenal involvement detected incidentally on 18-Fluorodeoxyglucose positron emission tomography (18F FDG PET-CT) scan.

Effect of Organic Manure and Mineral Fertilizers on Bioaccumulation and Translocation of Trace Metals in Maize.

Mineral fertilizers and organic manure are used as soil amender to enhance the mineral status of the soil. These fertilizers contain trace metals besides providing macro and micronutrients. The present study was performed to observe the effect of mineral fertilizers, poultry manure and cow manure on trace metal content of soil and various parts (root, shoot, and grains) of maize plant (Zea mays L.). The analysis of metals was performed by atomic absorption spectrophotometer (AA-6300 Shimadzu Japan). The highest level of Pb, Fe, Ni and Cu was observed in the root as 0.36-0.55, 70.41-83.03, 4.98-7.44 and 2.94-4.43 mg kg- 1, respectively. The highest level of Cd, Zn and Mn was determined in grains as 0.44-1.59, 28.05-46.39 and 26.24-46.57 mg kg- 1, respectively. The values of all metals were found within their permissible limit given by FAO/WHO except for the Cd. The interactive use of mineral and organic fertilizers enhanced the level of trace metals in maize as compared to their sole application. In the present findings, the health risk index for all metals was less than 1 in all treatments. So, it was concluded that the level of metals in poultry manure, cow manure and mineral fertilizer treated maize did not pose any potential threat to the consumers.

Targeting the neighbour: Primary gastric lymphoma with concealed splenic perforation.

Primary gastric lymphoma is a rare entity which manifests with vague abdominal symptoms and occasionally presents as complications including perforation and haemorrhage requiring urgent management. Chemotherapy has surpassed surgery with advancing medical era. We hereby present an unusual case of primary gastric lymphoma with splenic involvement complicated by localized perforation.

Hypermetabolic Sister Mary Joseph's nodule in pancreatic carcinoma.

Metastasis to umbilicus is often defined as Sister Mary Joseph's (SMJ) nodule. These nodules may be a manifestation of various underlying malignancies, about 50% arising from abdominopelvic cavity most frequently from the gastrointestinal tract. Pancreatic cancer is the predisposing cause in only about 6% of cases and the most common histopathology is adenocarcinomas. We present the case of a 64-year-old male who was found to have a SMJ nodule on staging F18 FDG PETCT scan.

Trace Metal Accumulation in Trigonella foenum-graecum Irrigated with Wastewater and Human Health Risk of Metal Access Through the Consumption.

The aim of the present research was to determine the trace metal accumulations in Trigonella foenum-graecum irrigated with three different water regimes (ground water, canal water and sugar mill water). Also, transfer factors, pollution load indices, and health risk indices were assessed to evaluate metal transport and accumulation through the food chain. The analysis was conducted by Atomic Absorption Spectrophotometer (Shimadzu model AA-6300) to evaluate the concentration of metals in water, soil and vegetables. Trace metal concentrations in water samples ranged from 0.84 to 1.67, 0.42 to 0.72, 0.45 to 0.85, 2.51 to 9.99, 1.21 to 1.92, 1.82 to 9.98 and 0.64 to 0.91 mg/kg for Cd, Cr, Cu, Fe, Ni, Zn and Mn, respectively. The mean metal concentrations in soil samples were determined as 0.25, 0.86, 0.96, 3.37, 0.4, 0.44 and 2.31 mg/kg for Cd, Cr, Cu, Fe, Ni, Zn and Mn, respectively. Trace metal accumulations in T. foenum-graecum samples gathered from where soil samples were taken are as follows: The contents of Cd, Cr, Cu, Fe, Ni, Zn and Mn ranged from 0.48 to 1.06, 0.11 to 0.35, 0.15 to 0.29, 1.43 to 8.39, 0.39 to 0.54, 2.1 to 3.05 and 0.42 to 0.47 mg/kg, respectively. Statistical analyses showed that the treatments have non-significant effect (p > 0.05) on concentrations of metals in T. foenum-graecum samples collected from three sites for Ni, Cr, Cu, Zn and Mn and significant effect on Fe and Cd.

Evaluation of Potential Toxic Metals Accumulation in Wheat Irrigated with Wastewater.

The present study was carried out to ascertain the level of various metals in wheat variety (Chagi-4) irrigated with diverse doses of wastewater. The concentration of metals in soil, water and wheat grain samples was examined through an atomic absorption spectrophotometer. In wheat grains, the mean values of metals (mg/kg) varied from 0.06 to 0.2 for Pb, 1.2 to 1.6 for Cd, 0.6 to 0.9 for Ni, 0.8 to 1.6 for Fe, 0.4 to 1.0 for Mn, 0.7 to 1.4 for Cu, 0.3 to 0.5 for Cr, 0.1 to 0.9 for Zn and 0.03 to 0.2 for Co, correspondingly. Measured concentrations were found within the permissible limit given by FAO/WHO except for cadmium whose concentration exceeded an acceptable limit 0.2 mg/kg suggested by FAO/WHO. It might be due to high soil pH, which hinders the efficient transfer of metals between different mediums. Wastewater irrigated soil, wheat and water had high metal values, but the low rate of transfer was noticed from soil to grains. Higher bioconcentration factor was obtained for manganese and cadmium; cadmium had even higher pollution load index, which could indicate the contamination status of soil. Therefore, regular monitoring of wastewater is necessary to prevent the excessive build-up of metals.

Potential Toxic Metal Accumulation in Soil, Forage and Blood Plasma of Buffaloes Sampled from Jhang, Pakistan.

This study was conducted to determine the concentration of toxic metals in soil, forage and blood plasma of lactating and non-lactating buffaloes in the district Jhang, Punjab, Pakistan. Soil samples were collected from varying distances from the road side. Plasma separation was achieved by centrifugation. The concentration of arsenic (As), selenium (Se), cadmium (Cd), chromium (Cr), iron (Fe), zinc (Zn), copper (Cu) and cobalt (Co) were determined by using Atomic Absorption Spectrophotometer. The results of the study showed that the mean As, Se and Cd concentrations in soil samples were lower while Cr, Fe, Zn, Cu and Co were higher than the official guidelines. In plasma samples, mean concentration values of Co, Zn, Fe, Cd, Se and As were lower while Cu and Cr were higher than the recommended concentrations. According to the results of the study there was no potential exposure of toxicity in buffaloes of the study area.

Kohler disease: Imaging King Tut's foot in 21st century.

Kohler disease refers to childhood onset avascular necrosis of the navicular bone. Hybrid SPECT-CT bone scintigraphy offers both functional and anatomic details in a single acquisition if radiography is non-diagnostic in a limping child. We present the case of a 7 year-old child with persistent post-traumatic left foot pain. Tc99m MDP bone SPECT-CT scan demonstrated characteristic anatomic features of left navicular avascular necrosis.

False positive finding of F18-FDG in non-Hodgkins lymphoma; an inflamed appendix.

Although PET-CT scanning is a tremendous advancement in oncology; for accurate interpretation, it is important to understand its limitations. Not all PET-positive lesions are cancerous. Both activated macrophages and metabolically active carcinomas will accumulate F18-FDG. Due to limited specificity of FDG-PET/CT, histologic assessment may be required to establish correct diagnosis. We describe a case of 37-year-old man with non-Hodgkin's lymphoma, who underwent F18-FDG PET/CT at the completion of chemotherapy. Imaging showed metabolically active right pelvic soft tissue. Surgical resection confirmed appendicitis.

18F-FDG PET-CT imaging versus bone marrow biopsy in pediatric Hodgkin's lymphoma: a quantitative assessment of marrow uptake and novel insights into clinical implications of marrow involvement.

OBJECTIVE: To evaluate whether positron emission tomography/computed tomography using fluorine-18 fluoro-deoxyglucose (18F-FDG PET-CT) predicts bone marrow involvement (BMI) in pediatric Hodgkin's lymphoma (pHL) with sufficient accuracy to supplant routine staging bone marrow biopsy (BMB), and to assess the clinical importance of marrow disease by comparing the prognosis of stage IV HL with BMI versus that without BMI. METHODS: Data were retrospectively analyzed for all cases of pHL between July 2010 and June 2015 referred for staging 18F-FDG PET-CT scan and BMB. The reference standard was BMB. Stage IV patients were divided into three groups to compare their progression-free and overall survival: PET+ BMB-, PET+ BMB+, and PET- BMB-. RESULTS: Of the 784 patients, 83.3% were male and 16.7% female, with age ranging from 2 to 18 years (mean 10.3 years). Among the total cases, 104 (13.3%) had BMI; of these, 100 were detected by PET imaging and 58 by BMB. BMB and 18F-FDG PET/CT scans were concordant for BMI detection in 728 patients (93%): positive concordance in 54 and negative in 674. Of the 56 discordant cases, four had a false-negative PET scans and were upstaged by BMB, 46 with focal uptake were PET/CT-positive and BMB-negative (not obtained from active sites), and six with diffuse uptake were false-positive on PET due to paraneoplastic marrow activation. The sensitivity, specificity, PPV, and NPV of PET for identifying BMI was 93.6, 94, 53, and 99.4% respectively. On quantitative assessment, mean iBM-SUVmax of bilateral iliac crests was significantly higher in those with BMI versus those without (p < 0.05). CONCLUSIONS: 18F-FDG PET-CT imaging is more sensitive than BMB for BMI detection in pHL staging. BMB should be limited to those with normal marrow uptake in the presence of poor risk factors or those with diffusely increased uptake to exclude marrow involvement in the background of reactive marrow.

Interim18 F-FLUORO-2-deoxy-d-glucose positron emission tomography scan/computed tomography scan in diffuse large B cell lymphoma-as a prognostic tool.

OBJECTIVE: To assess the role of interim [18F]-Fluoro-2-deoxy-d-glucose positron emission tomography scan/computed tomography scan in the management of diffuse large B-cell lymphoma in terms of progression-free survival and overall survival prediction. METHODS: The retrospective study was conducted at the Shaukat Khanum Memorial Cancer Hospital, Lahore, and comprised data of newly diagnosed patients of diffuse large B-cell lymphoma treated between January 2010 and June 2013.Baseline characteristics of patients were documented and compared. Response on interim positron emission tomography/computed tomography and end of treatment scan was taken a look at, and .progression-free survival and overall survival for positive/negative scans were calculated. Data was also reviewed for sensitivity, specificity, positive predictive value and negative predictive value for relapse. SPSS 19 was used for statistical analysis. RESULTS: Data of 119 patients was reviewed, and 87(73%) of them were males. Overall median age was 33 years (range 18-50). Interim scan was positive for 63(53%) patients and negative for 53(47%), and showed positive predictive value, negative predictive value, sensitivity and specificity for relapse of 35%, 89%, 79% and 55% respectively. Two-years progression-free survival and overall survival for scan-positive patients was 66% and 72% compared to 88% (p=0.002) and 92% (p=0.005) for scan-negative patients. Corresponding values at 2 years for patients having positive end-of-treatment scan were 35% and 44% against 94% (p< 0.001) and 96%(p< 0.001) for patients with negative scan. CONCLUSIONS: Interim positron emission tomography/computed tomography had high sensitivity and negative predictive value for relapse in diffuse large B-cell lymphoma. Both interim and end-of-treatment scans were predictors of progression-free survival and overall survival.

Musculoskeletal Spect-Ct: A Pictorial Review.

SPECT-CT being a hybrid imaging scanner provides molecular and anatomical imaging in one go as a one stop shop. The addition of correlative CT scan to the planar skeletal scintigraphy gives better localization of the lesion, its characterization and attenuation correction as well. We present a brief overview of our institutional experience with hybrid SPECT-CT, as an adjunct to planar skeletal scintigraphy. SPECT-CT imaging improves the diagnostic yield and specificity of planar skeletal scintigraphy.

METASTATIC RADIOIODINE AVID STRUMA OVARII ASSOCIATED WITH PSEUDO-MEIGS' SYNDROME.

We report a case of 21 years old lady who presented with ascites, left adnexal mass and elevated CA-125. With suspicion of ovarian malignancy, she underwent left salpingo-oophorectomy with omental biopsy. Histopathology revealed: 'follicular variant of papillary thyroid carcinoma arising in struma ovarii' with metastatic papillary thyroid carcinoma in omental and peritoneal nodules. Patient underwent total thyroidectomy followed by radioactive iodine therapy for metastatic omental and peritoneal disease. Post-therapy whole body scan, revealed extensive I-131 avid disease metastatic disease involving the chest, abdomen, pelvis and the musculoskeletal system. Patient was treated with multiple doses of high dose radioactive iodine. She became symptom free on supra-physiologic doses of oral thyroxin however her high thyroglobulin levels and residual radioiodine avid metastatic disease required further treatment. In literature a few cases of struma ovarii have been reported with elevated CA-125 and associated pseudo-Meigs' syndrome. The treatment for this rare disease is still not standardized and poses a therapeutic challenge. Our case emphasizes the need for a multidisciplinary approach for managing struma ovarii.