Emerging Role of Gallium-68 DOTANOC PET/CT Guided Radiofrequency Ablation in the Treatment of Tumor-induced Osteomalacia.

Tumor-induced osteomalacia (TIO) is a rare acquired form of hypophosphatemia that can be cured when the tumor responsible is completely removed. These tumors can be small and located in anatomically challenging areas, rendering surgery both risky and extensive. Radiofrequency ablation (RFA) has been explored as an effective treatment option for such tumors. We present a case of a 35-year-old man exhibiting clinical and biochemical features consistent with TIO. The culprit lesion was not detectable on the whole-body computed tomography (CT) scan. Gallium (Ga-68) DOTANOC positron emission tomography (PET)/CT showed increased uptake in the left acetabulum and magnetic resonance imaging (MRI) confirmed the location of the tumor. Given the risky anatomical location, we opted for less-invasive RFA. Following an unsuccessful attempt at CT-guided RFA of the lesion, we used real-time Ga-68 DOTANOC PET/CT guidance for precise imaging during the ablation procedure. Our patient achieved complete remission both clinically and biochemically after RFA. This response was also evident by the absence of tracer uptake in follow-up imaging. In conclusion, DOTANOC PET/CT-guided RFA can serve as a safe and effective treatment for patients with tumors causing TIO. This modality proves valuable when surgical resection is not a viable option.

Extracranial Meningioma-Pelvic Bone on FDG PET/CT: A Rare of the Rarest Site.

ABSTRACT: Meningiomas are benign extra-axial tumors of the central nervous system. Extracranial meningiomas are extremely rare (2%) and can develop as a direct extension from a primary intracranial meningioma or as a true primary extracranial meningioma originating from ectopic arachnoid cells. We report an extremely unusual case of a 61-year-old woman who was diagnosed with pelvic meningioma with the help of PET/CT and PET/CT-guided biopsy. The clinicopathological features of the patient and immunoprofile of the tumor are presented.

PSMA Avidity in the Heterotropic Ossification-An Incidental Finding on PSMA PET/CT.

ABSTRACT: The upregulations of prostate-specific membrane antigen (PSMA) antigen are used for the presence of prostate cancer. However, published literature shows incidentally detected PSMA uptake in various nonprostatic benign and malignant conditions, which led to questioning the specificity of PSMA-targeted PET. In present case, we highlighted the abnormal PSMA expression in the benign bone abnormality.

FDG PET-CT in Clinical Management of a Rare Case of Primary Hepatic Lymphoma: Role and Challenges.

The common differential diagnoses for multiple space-occupying hepatic lesions (SOL) are metastases, multifocal hepatocellular carcinoma, and abscess. Primary hepatic lymphomas are rare entities that present many challenges with regard to their management. Fluorodeoxyglucose positron emission tomography-computed tomography is extensively used for the staging and response assessment of lymphomas but it can be challenging and difficult to interpret in cases with isolated liver involvement. We hereby present the case of an 82-year-old lady who presented with multiple liver SOL.

Accuracy of the Vesical Imaging-Reporting and Data System (VIRADS) for pre-treatment staging of bladder cancer in an Australian cohort.

INTRODUCTION: To evaluate the performance of the Vesical Imaging-Reporting and Data System (VIRADS) in differentiating muscle-invasive and non-muscle-invasive bladder cancer and whether this reporting system improves inter-reader agreement. METHODS: Sixty-four cases of multiparametric 3 tesla bladder MRI from January 2014 to May 2020 were reviewed retrospectively. T2-weighted, diffusion and post-contrast images were reviewed. All magnetic resonance images were reported by a radiologist with 15 years' experience (Reader 1) and a final year radiology trainee with a special interest in urogenital imaging with 3 years of experience (Reader 2). Both readers were blinded to clinical history and histopathology results when scoring each lesion. RESULTS: The sensitivity and specificity for differentiating MIBC and NMIBC were 91% and 68%, respectively, for Reader 1 and 91% and 63%, respectively, for Reader 2. The inter-reader agreement for assigning VIRADS scores was 0.79. The area under the receiver operator curve for Reader 1 and 2 were not significantly different (Reader 1 = 0.79, Reader 2 = 0.77, P = 0.83). CONCLUSIONS: Staging of bladder cancer prior to treatment can be accurately and reliably diagnosed using VIRADS, a novel, standardised reporting system for bladder MRI.

Should fluorodeoxyglucose positron emission tomography/computed tomography be the first-line imaging investigation for restaging the laryngeal carcinoma patients?

Posttreatment detection of residual/recurrence disease in the head and neck cancers is not an easy task. Treatment induces changes create difficulties in diagnosis on conventional imaging (computed tomography [CT], magnetic resonance imaging) as well as macroscopic inspection (direct laryngoscopy). Hence, we evaluate the diagnostic performance of contract-enhanced F-18 fluorodeoxyglucose positron emission tomography (FDG PET)/CT in restaging of laryngeal carcinoma Postchemotherapy-surgery and/or radiation therapy. We retrospectively analyzed patients of carcinoma larynx (n = 100) who has completed treatment and were referred for FDG PET/CT. Two reviewers performed image analysis to determine recurrence at primary site and/lymph nodes and distant metastases. Receiver operating characteristic (ROC) was used to determine the maximum standardized uptake value (SUVmax) cut off for disease detection. Histopathological examination and clinical or imaging follow-up were taken as gold standard for recurrence. One hundred laryngeal carcinoma patients with mean age of 57.2 years (range of 40-76) were included in the present study. Among the 100 patients, 96 were male and remaining 4 were female. The average interval between completion of treatment and FDG PET/CT scan was 8.5 months (minimum 6 months). Of the 100 patients, FDG PET/CT detected FDG avid lesions in 66 patients. Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of FDG PET/CT for residual/recurrence disease detection was 90.3%, 73.7%, 84.8%, 82.3%, and 84.0%, respectively (P < 0.05). In addition, in 10 patients, metachronous primaries were detected (lung-4, thyroid-2, tongue, colon, esophagus, and lymphoma-one each). On ROC curve analysis, SUVmax >6.1 had sensitivity and specificity of 80.6% and 94.7% respectively for detection of recurrent/metastatic disease. FDG PET/CT demonstrates high diagnostic accuracy for detection of residual/recurrent disease in treated laryngeal cancer patients and our findings suggest that this imaging modality should be the first-line diagnostic investigation in this cohort of patients.

Characterization of polycystic ovary syndrome among Flo app users around the world.

BACKGROUND: Polycystic ovary syndrome (PCOS) is a complex and multi-faceted endocrine disorder that affects 5-20% of women. Literature is limited regarding potentially differing PCOS phenotypes among women around the world. OBJECTIVE: To use Flo app technology to understand the multifaceted characteristics of PCOS across several countries and identify contributing risk factors to the development of this condition. STUDY DESIGN: Flo is a widely used female health and wellbeing app with period tracking functionality that provides a globally representative and medically unbiased perspective on PCOS symptomatology. A chatbot dialog on PCOS was subsequently administered on the Flo application (app) to users from 142 countries (with at least 100 respondents) who have the app running in English during September-October 2019. RESULTS: For analyses, we selected the five countries with the greatest number of respondents: US (n = 243,238), UK (n = 68,325), India (n = 40,092), Philippines (n = 35,131), and Australia (n = 29,926). Bloating was the most frequently reported symptom among PCOS-positive women and appeared to be the main predictor of PCOS in our model (odds ratio 3·76 [95% CI 3·60-3·94]; p < 0·0001). Additional top predictors of PCOS are high blood cholesterol and glucose levels. As BMI increased, the percentage of women who reported a physician-confirmed PCOS diagnosis also increased. However, women in India did not follow this trend. CONCLUSION: Our findings are based on the largest known PCOS dataset and indicate that symptoms are more complex than previously understood. The most frequently reported symptoms (bloating, facial hirsutism, irregular cycles, hyperpigmentation, and baldness) are broader than those included in the Rotterdam criteria. Future work should reevaluate and refine the criteria utilized in PCOS diagnosis.

Follicular Thyroid Carcinoma with Unusual Radioiodine-Refractory Breast Metastasis Mimicking Primary Breast Malignancy.

The breast is an unusual site for metastasis from malignant tumors, although it may be the first manifestation of an extramammary primary malignancy typically arising in the lung, skin (melanoma), ovary, or lymph nodes (lymphoma). Breast metastasis from thyroid carcinoma is extremely rare and may take years to develop, as differentiated thyroid carcinoma is usually indolent and slow-growing and metastasizes to the lymph nodes, lungs, and bones. Here, we present the case of a middle-aged woman (after subtotal thyroidectomy for multinodular goiter 24 y previously) showing discordant 18F-FDG and iodine avidity in proven metastatic disease involving the lymph nodes, bones, spleen, and breast on whole-body 131I and 18F-FDG scans due to tumor heterogeneity.

R2 and R2* MRI assessment of liver iron content in an undifferentiated diagnostic population with hyperferritinaemia, and impact on clinical decision making.

PURPOSE: To confirm the linear correlation between Ferriscan® R2 (1/T2 Relaxomatry) and R2* (1/T2* Relaxometry) derived 3D Gradient echo (GRE) mDIXON-Quant sequence (Philips) with simultaneous production of a proton density fat fraction (PDFF) in undifferentiated patients with hyperferritinaemia, and to prospectively determine the clinical utility of this tool in these patients by recording the impact on clinical decision-making. MATERIALS AND METHODS: Participants referred to a hospital haematology outpatient clinic for investigation and management of elevated serum ferritin (two serum ferritin levels > 500 µg/L 4 weeks apart) were included in the study. EXCLUSION CRITERIA: contraindications to MRI; clinically relevant investigations for alternative causes of hyperferritinaemia pending; and terminal illness. Thirty-two participants were recruited: 27 men, 5 women. All MRIs performed at 1.5 T. For R2* quantification, 3D six echo GRE sequence (mDIXON-Quant) was acquired. R2 images were acquired over 20 min as dictated and reported by the licensee (Ferriscan®). Clinician interpretation and patient management based on R2* and liver iron content derived from R2 (LICR2) was recorded. Pearson's correlations, linear regression analyses, and ROC curves were calculated. P value <0.05 was considered significant. RESULTS: A high degree of correlation between mean R2* and LICR2 was observed in this novel patient population (slope ±â€¯SE of 43.35 ±â€¯1.88 s-1 permg/g; 95 % CI 39.5-47.2; P < 0.001; R2 = 0.87). Clinical decision making was amended in 14/32 (44 %) patients with hyperferritinaemia following the disclosure of R2* results to clinicians, compared with serum ferritin alone. Liver biopsy was avoided in one patient based on LICR2 and R2*. Unrecognised hepatic steatosis was diagnosed in one patient from the PDFF map. CONCLUSION: We have confirmed the linear correlation between R2 and R2* in a real-world diagnostic population with hyperferritinaemia. Non-invasive assessment of liver iron content (LIC) by R2 and R2* MRI is a useful clinical tool and alters management in these patients.

Isolated Malignant Portal Vein Thrombus in Colon Carcinoma: A Rare Finding on 18F-FDG PET/CECT.

In the absence of hepatic metastasis in abdominal cancers, an isolated malignant portal vein thrombus is very rare. The presence of a malignant thrombus has clinical significance for determining the stage, treatment, and prognosis. 18F-FDG PET/CECT is a noninvasive modality for discriminating between malignant and benign thrombi. We present a case of primary sigmoid colon carcinoma for which 18F-FDG PET/CT showed, in addition to the 18F-FDG-avid primary lesion, an 18F-FDG-avid filling defect in the portal vein, likely malignant thrombus.

Is F-18 FDG PET/computed tomography a useful tool to restage the patients with tongue carcinoma?

OBJECTIVE: The aim of this study was to evaluate the diagnostic performance of contrast-enhanced F-18 fluoro-2-deoxyglucose (F-18 FDG) PET/computed tomography (CT) in restaging of tongue carcinoma. MATERIAL AND METHODS: Retrospectively analysis of carcinoma tongue patients (n = 110) who were treated and referred for FDG PET/CT. Histopathological examination and clinical or imaging follow-up were taken as gold standard. RESULTS: Of 110 patients, FDG PET/CT detected FDG avid lesions in 69 (62.7%) patients. Sensitivity, specificity and diagnostic accuracy of FDG PET/CT were 92.9%, 90.0% and 91.8%, respectively, for residual/recurrence disease detection (P < 0.05). Additionally, in six patients, metachronous primaries were also detected [lung (4), esophagus and lymphoma (1) each]. The mean maximum standardized uptake value (SUVmax) with 95% confidence interval for primary site recurrence, regional lymph nodes and metastatic lesions was 11.51 (9.53-13.48), 69 (62.7%) (7.88-11.48) and 8.94 (3.11-14.76), respectively. CONCLUSION: FDG PET/CT demonstrates high diagnostic accuracy for detection of residual/recurrent disease in treated tongue cancer patients and PET/CT should be considered as first-line diagnostic investigation in these patients.

Real Time F-18 FDG PET-CT-Guided Metabolic Biopsy Targeting Differential FDG Avidity in a Pulmonary Blastoma.

Pulmonary blastoma (PB) is a rare thoracic malignancy and preoperative diagnosis is challenging. A young man presented with dyspnea and chest pain for 3-4 months and chest-computed tomography (CT) revealed large mass in the left lung upper lobe and pleural effusion. Repeated CT-guided fine-needle aspiration cytology from the lesion and pleural fluid aspiration was negative for malignancy. F-18-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) revealed heterogeneous tracer avidity in left lung mass with areas of necrosis. Real-time PET-CT-guided biopsy from metabolically active component of the lesion revealed biphasic PB on histopathology.

Increased Risk of Perioperative Ischemic Stroke in Patients Who Undergo Noncardiac Surgery with Preexisting Atrial Septal Defect or Patent Foramen Ovale.

OBJECTIVES: To evaluate whether a preoperative diagnosis of atrial septal defect (ASD) or patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery and their outcomes. DESIGN: Retrospective cohort analysis. SETTING: United States hospitals. PARTICIPANTS: Adults patients (≥18 years old) who underwent major noncardiac surgery from 2010 to 2015 were identified using the Healthcare Cost and Utilization Project's National Readmission Database. INTERVENTIONS: Preoperative diagnosis of ASD or patent foramen ovale. MEASUREMENTS AND MAIN RESULTS: Among the 19,659,161 hospitalizations for major noncardiac surgery analyzed, 12,248 (0.06%) had a preoperative diagnosis of ASD/PFO. Perioperative ischemic stroke occurred in 723 (5.9%) of patients with ASD/PFO and 373,291 (0.02%) of those without ASD/PFO (adjusted odds ratio [aOR], 16.7; 95% confidence interval [CI]: 13.9-20.0). Amongst the different types of noncardiac surgeries, obstetric, endocrine, and skin and burn surgery were associated with higher risk of stroke in patients with pre-existing ASD/PFO. Moreover, patients with ASD/PFO also had an increased in-hospital mortality (aOR, 4.6, 95% CI: 3.6-6.0), 30-day readmission (aOR, 1.2, 95% CI: 1.04-1.38), and 30-day stroke (aOR, 7.2, 95% CI: 3.1-16.6). After adjusting for atrial fibrillation, ischemic stroke remained significantly high in the ASD/PFO group (aOR: 23.7, 95%CI 19.4-28.9), as well as in-hospital mortality (aOR: 5.6, 95% CI 4.1-7.7), 30-day readmission (aOR: 1.19, 95%CI 1.0-1.4), and 30-day stroke (aOR: 9.3, 95% CI 3.7-23.6). CONCLUSIONS: Among adult patients undergoing major noncardiac surgery, pre-existing ASD/PFO is associated with increased risk of perioperative ischemic stroke, in-hospital mortality, 30-day stroke, and 30-day readmission after surgery.

Network meta-analysis to compare VenaSeal with other superficial venous therapies for chronic venous insufficiency.

OBJECTIVE: Several randomized controlled trials (RCTs) have compared different interventions for chronic venous insufficiency (CVI) management, but mixed comparison of these interventions is lacking. The aim of this network meta-analysis was to compare VenaSeal closure system (Medtronic, Minneapolis, Minn) with endovenous laser ablation (EVLA), radiofrequency ablation (RFA), mechanochemical ablation, sclerotherapy, and surgery for management of CVI to achieve anatomic success (complete closure of treated vein within 6 months after intervention) as the primary outcome and health-related quality of life (HRQoL; EuroQol-5 Dimension, Aberdeen Varicose Vein Questionnaire), Venous Clinical Severity Score (VCSS), pain scores, and adverse events as secondary outcomes. METHODS: A systematic review of journal databases was undertaken, and RCTs between January 1996 and September 2018 comparing different treatment options were included. Risk of bias and quality of publications were assessed using the Cochrane bias tool; Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study selection and reporting. Twenty RCTs comprising 4570 patients were analyzed. Data for anatomic success, VCSS, HRQoL, pain score, and adverse events were extracted and analyzed using mixed treatment comparison in a network meta-analysis. A Bayesian fixed or random effects model was selected for analysis. Rank probability graphs were generated for various treatments and corresponding ranks obtained to estimate their probability of being best. Relative treatment effects were calculated in terms of log odds ratios for anatomic success and adverse events. Mean difference was calculated for VCSS, HRQoL, and pain score. RESULTS: For the primary outcome measure (anatomic success), VenaSeal system had the highest probability of being ranked first (P = .980); RFA was ranked second (P = .365), EVLA third (P = .397), surgery fourth (P = .290), mechanochemical ablation fifth (P = .695), and sclerotherapy sixth (P = .982). For secondary outcome measures, VenaSeal system ranked third for VCSS (P = .332), fifth for EuroQol-5 Dimension (P = .420), and third for Aberdeen Varicose Vein Questionnaire (P = .300). Although, VenaSeal system was slightly inferior to some of the other interventions for HRQoL, the 95% credible interval of log odds ratio indicated insufficient evidence for any concrete conclusion to be drawn. VenaSeal system ranked first in reduction of postoperative pain score from baseline (P = .690) and was lowest in occurrence of adverse events (P = .650). Odds of occurrence of adverse events was 3.3 times in the sclerotherapy arm, 2.7 times in the EVLA arm, 1.6 times with surgery, and 1.1 times with RFA vs VenaSeal system arm. CONCLUSIONS: VenaSeal system is a promising therapeutic option for anatomic success at 6 months, with fewer occurrences of adverse events (wound and groin infection, pulmonary embolism) in CVI patients compared with other interventions in this study. Additional economic analysis including cost-effectiveness analysis would provide interesting perspectives on real-world insights to patients, payers, and providers.

Trends and Outcomes of Intravascular Imaging-guided Percutaneous Coronary Intervention in the United States.

INTRODUCTION: Intravascular imaging-guided percutaneous coronary intervention (PCI) has shown to improve outcomes in randomized controlled trials. However, there are little real-world data about intravascular imaging utilization during PCI and its outcomes in the United States. METHODS: We conducted an observational analysis on the use of intravascular imaging (Intravascular Ultrasound or Optical Coherence Tomography)-guided PCI in 2,425,036 patients undergoing PCI between January 2010 and December 2014 from the Nationwide Inpatient Sample database. Utilizing propensity score matching, 83,988 matched pairs were identified. The primary outcome was in-hospital mortality. The secondary outcomes included cardiogenic shock and acute kidney injury. RESULTS: Among the 2,425,036 patients, 161,808 (6.7%) underwent imaging-guided PCI. Use of imaging-guidance increased from 6% in 2010 to 6.6% in 2014 (Ptrend < 0.001). The in-hospital mortality was significantly different between imaging-guided PCI and angiography-guided PCI [1.0% vs. 1.5%; adjusted OR: 0.67; 95% confidence interval (CI): 0.54-0.83, P < 0.001]. The rates of cardiogenic shock (2.5% vs. 3.1%; adjusted OR: 0.78; 95% CI: 0.66-0.93; P = 0.005) were significantly lower in imaging-guided PCI group and acute kidney injury rates (7.0% vs. 7.1%; adjusted OR: 0.99; 95% CI: 0.89-1.12; P = 0.919) were not significantly different. CONCLUSIONS: Imaging-guided PCI is associated with lower in-hospital mortality. Yet, a small proportion of patients undergoing PCI have imaging-guidance.

Calcific tendinosis of rotator cuff with intraosseous extension.

Calcific tendinosis is characterized by macroscopic deposits of hydroxyapatite within the tendon. Commonest location is rotator cuff of shoulder. Cortical erosion with intraosseous migration of calcium deposits is rare complication of this condition. It may be confused with neoplasm or infection, resulting in unnecessary biopsies or interventions. The knowledge of this uncommon complication and its appearance should enable its detection by imaging and lead to specific treatment.

Metastasis in mixed epithelial stromal tumour of the kidney: a rare presentation.

Mixed epithelial stromal tumour of the kidney (MESTK) is a rare genitourinary tract tumour. MESTK is typically seen in perimenopausal women and rarely reported in men and children. MESTK has been included in the WHO renal tumour classification since 2004. Here, we present a case of 50-year-old female patient who underwent left radical nephrectomy for left renal mass. Postoperative positron emission tomography (PET) scan also showed nodal metastasis, for which, she was started on chemotherapy.

Tuberculosis Presenting as Cutaneous Erythema Nodosum on 18F-FDG PET/CT.

The present article presented a 47-year-old woman with areas of nodular swelling and discoloration involving bilateral lower limbs since 12 months. Biopsy from skin lesions revealed erythema nodosum. As erythema nodosum can be secondary to multiple etiologies, whole-body F-FDG PET/CT was performed to assess the disease distribution and guide the site of biopsy. F-FDG PET/CT revealed metabolically active mediastinal lymphadenopathy in addition to the skin lesions. Endobronchial ultrasound-guided biopsy from subcarinal lymph node revealed tuberculosis.