Non-Cutaneous Melanoma, Findings and Prognostic Value of FDG PET/CT: A Case Series of 23 patients and review of the literature.

Objectives: Non-cutaneous malignant melanomas (NCM) are rare malignancies. Due to their nonspecific symptoms, they present later in life. The value of FDG PET/CT in this group of patients is not clear. The aim of this study is to assess the role of FDG PET/CT in the management of NCM and its prognostic implication. Methods: We retrospectively selected twenty-three patients with a diagnosis of NCM evaluated with FDG PET/CT in Shariati hospital between 2019 and 2021. The PET/CT data were reviewed and compared with available conventional imaging findings. Five patients died within five months. The surviving patients were followed within a time interval of 7 to 27.5 months after their PET/CT study, regarding their disease status. Results: Among 23 patients (8 ocular, 5 sinonasal, 3 pharyngeal, 2 anorectal, 2 vulvovaginal, and 3 unknown primaries), PET/CT was able to detect residual primary disease, assess treatment response, and reveal or exclude metastases. Additional lesions compared to conventional imaging were found in five, while in one with brain metastases PET/CT was unable to detect lesions on MRI. Thirteen patients had negative PET/CT finding of which 11 (85%) did not have remarkable finding on follow-up. Metastatic disease was recognized in eight. Patients with extensive metastases on FDG PET/CT had a poorer outcome. Conclusion: Similar to cutaneous melanoma, PET/CT is valuable in the management of NCM patients and is superior to conventional imaging modalities, with the exception of brain metastases. Patients with negative PET/CT findings have a better outcome as opposed to patients with significant positive PET/CT findings.

68Ga-DOTATATE Uptake in an Intraosseous Hemangioma, as a Potential Cause of False-Positive PET/CT Finding, Simulating Tumoral Involvement.

ABSTRACT: We present the case of a 32-year-old man with a history of hypophosphatemia and multiple bone fractures, being evaluated at our center for a potential mesenchymal tumor. 68Ga-DOTATATE PET/CT revealed a highly 68Ga-DOTATATE-avid lesion in the ethmoidal sinus extending to the nasal cavity. Following resection, histologic examination of the specimen confirmed the diagnosis of "intraosseous hemangioma," a potential cause of false-positive finding of 68Ga-DOTATATE PET/CT imaging in patients being evaluated for occult malignancies, especially at the traumatic/fractured sites.

Factors predicting biochemical response and survival benefits following radioligand therapy with [177Lu]Lu-PSMA in metastatic castrate-resistant prostate cancer: a review.

BACKGROUND: Prostate cancer (PC) is one of the most common cancers in men. Although the overall prognosis is favorable, the management of metastatic castration-resistant prostate cancer (mCRPC) patients is challenging. Usually, mCRPC patients with progressive disease are considered for radioligand therapy (RLT) after exhaustion of other standard treatments. The prostate-specific membrane antigen (PSMA) labeled with Lutetium-177 ([177Lu]Lu-PSMA) has been widely used, showing favorable and successful results in reducing prostate-specific antigen (PSA) levels, increasing quality of life, and decreasing pain, in a multitude of studies. Nevertheless, approximately thirty percent of patients do not respond to [177Lu]Lu-PSMA RLT. Here, we only reviewed and reported the evaluated factors and their impact on survival or biochemical response to treatment to have an overview of the potentialprognostic parameters in [177Lu]Lu-PSMA RLT. METHODS: Studies were retrieved by searching MEDLINE/PubMed and GoogleScholar. The search keywords were as follows: {("177Lu-PSMA") AND ("radioligand") AND ("prognosis") OR ("predict")}. Studies discussing one or more factors which may be prognostic or predictive of response to [177Lu]Lu-PSMA RLT, that is PSA response and survival parameters, were included. RESULTS: Several demographic, histological, biochemical, and imaging factors have been assessed as predictive parameters for the response to thistreatment; however, the evaluated factors were diverse, and the results mostly were divergent, except for the PSA level reduction after treatment, which unanimously predicted prolonged survival. CONCLUSION: Several studies have investigated a multitude of factors to detect those predicting response to [177Lu]Lu-PSMA RLT. The results wereinconsistent regarding some factors, and some were evaluated in only a few studies. Future prospective randomized trials are required to detect theindependent prognostic factors, and to further determine the clinical and survival benefits of [177Lu]Lu-PSMA RLT.

FDG PET/CT of an Advanced Case of Malignant Nerve Sheath Tumor of Pleura.

ABSTRACT: We present a rare case of malignant nerve sheath tumor of pleura referred for the evaluation of metastases and local invasion. FDG PET/CT demonstrated a hypermetabolic tumoral lesion extensively involving the right pleura with no involvement of mediastinal structures or pulmonary parenchyma and no clear evidence of distant metastasis. Malignant nerve sheath tumor of pleura is an extremely rare entity, and FDG PET/CT is valuable in demonstrating the extent of disease and can have potential role for postsurgical as well as postchemotherapy assessment of possible residual disease.

Potential role of 18F-FDG PET/CT in a case of progressive Rosai Dorfman disease.

Rosai Dorfman disease is a rare form of nonlangerhans cell histiocytosis, presenting with extensive lymphadenopathies. Treatment in most cases of nodal disease, involves close observation; however, extranodal involvement requires a more definitive treatment strategy. Herein, we report a case of extensive Rosai Dorfman disease in a 43-year-old woman presenting for evaluation of treatment response by 18F-FDG PET/CT after frequent relapses and disease progression. In addition to extensive lymphadenothapies in cervical, supraclavicular, superior mediastinum, axillary, abdominopelvic and inguinofemoral regions, the patient had metabolically active bone and subcutaneous lesions which were not previously recognized. Following this 18F-FDG PET/CT study, the patient management was changed to sirolimus and prednisolone. To choose the best treatment option for Rosai Dorfman patients, knowledge of the full extent of disease is important. Compared with conventional imaging, 18F-FDG PET/CT has the advantage of being a whole-body imaging modality and can recognize disease involvement prior to any anatomical changes.

Targeted Palliative Radionuclide Therapy for Metastatic Bone Pain.

Bone metastasis develops in multiple malignancies with a wide range of incidence. The presence of multiple bone metastases, leading to a multitude of complications and poorer prognosis. The corresponding refractory bone pain is still a challenging issue managed through multidisciplinary approaches to enhance the quality of life. Radiopharmaceuticals are mainly used in the latest courses of the disease. Bone-pain palliation with easy-to-administer radionuclides offers advantages, including simultaneous treatment of multiple metastatic foci, the repeatability and also the combination with other therapies. Several ߯- and α-emitters as well as pharmaceuticals, from the very first [89Sr]strontium-dichloride to recently introduced [223Ra]radium-dichloride, are investigated to identify an optimum agent. In addition, the combination of bone-seeking radiopharmaceuticals with chemotherapy or radiotherapy has been employed to enhance the outcome. Radiopharmaceuticals demonstrate an acceptable response rate in pain relief. Nevertheless, survival benefits have been documented in only a limited number of studies. In this review, we provide an overview of bone-seeking radiopharmaceuticals used for bone-pain palliation, their effectiveness and toxicity, as well as the results of the combination with other therapies. Bone-pain palliation with radiopharmaceuticals has been employed for eight decades. However, there are still new aspects yet to be established.

The role of FDG PET/CT in the evaluation of treatment response in a case of calcified ovarian metastases.

Evaluation of calcified metastatic lesions by conventional imaging can be challenging. Ovarian cancer metastases can present with calcification which might increase in size and number following therapy. It is not entirely clear whether these calcifications are associated with tumor response or disease progression. Calcified lesions which do not change in size or configuration are particularly problematic when assessed by RECIST criteria. Positron emission tomography (PET)/computed tomography (CT) is of particular value as it demonstrates the metabolic activity of the calcified lesions, in addition, it might reveal metastases in unexpected sites. We report a case of serous papillary ovarian cancer with extensive abdomino-pelvic calcified metastases referred for evaluation of therapy response. Despite being reported as stable disease on CT evaluation, we observed increased metabolic activity in the calcified lesions both on CT-attenuation corrected and non-attenuation corrected images, which was indicative of inadequate response to therapy. PET/CT is an ideal modality in follow-up of patients with ovarian cancer presenting with calcified metastatic tumoral deposits.

Multi-detector computed tomography demonstration of double-lumen aortic arch--persistent fifth arch--as an isolated anomaly in an adult.

Persistent fifth - double-lumen - aortic arch is a rarely seen entity, which is usually associated with other cardiac anomalies; it has been previously reported only in children. We report a new case of double-lumen aortic arch with a systemic-to-systemic connection diagnosed incidentally during cardiac multi-detector computer tomography evaluation of coronary artery bypass grafts in an adult.

Anomalous origin of posterior descending artery from left anterior descending in the presence of a diminutive right coronary artery: diagnosed by ECG gated multi-detector CT.

Coronary anomalies are easily detected on ECG gated multi-detector CT which has shown to be superior to conventional angiography is demonstrating their origin and course. We present an unusual case of posterior descending artery arising as the continuation of the left anterior descending artery (LAD) in the presence of a diminutive right coronary artery (RCA). The LAD crossed over the apex and continued its course to the base of the heart in the posterior interventricular groove as PDA. The RCA, although normal in origin, was diminutive and terminated on the lateral wall of the right ventricle. This anomaly has been rarely reported and the previous cases have all been conventional angiographic findings.

Long-term effect of papillary muscle approximation combined with ventriculoplasty on left ventricle function in patients with ischemic cardiomyopathy and functional mitral regurgitation.

OBJECTIVE: One of the mechanisms of development of functional mitral regurgitation after myocardial infarction is the increased papillary muscle distance which results due to ventricle remodeling. The aim of this study was to investigate the long-term effect of papillary muscle approximation (PMA) on the cardiac function of patients with ischemic cardiomyopathy and increased papillary muscle distance. METHODS: Thirty patients (22 males; mean age: 57.0 ± 7.4 years) selected for coronary artery bypass grafting (CABG) underwent ventriculoplasty. Additionally, 50% of the study population also underwent PMA (group 1). All the patients had preoperative grade 3 or 4 mitral regurgitation with an inter-papillary muscle distance > 2.5 cm. In group 1, the papillary muscles were drawn together using an encircling loop. Mitral annuloplasty and the Dor procedure were performed in all the patients. Follow-up time was 41.5 ± 5.8 months and 42.7 ± 3.3 months in groups 1 and 2, respectively (p-value=0.49). RESULTS: The two groups had no significant difference regarding the annulus diameter, ring size, number of grafts, and concavity area. There was one case of in-hospital mortality in each group, and one patient in group 2 had expired by the last follow-up. Postoperative echocardiography revealed significant changes in the concavity area, ejection fraction, and sphericity index in the PMA group by comparison to group 2 (p-value < 0.05). CONCLUSIONS: In patients with ischemic mitral regurgitation and increased papillary muscle distance, PMA as an adjunct to CABG results in better left ventricle function and shape, even at long-term follow-up.

Scoring system for predicting saphenous vein graft patency in coronary artery bypass grafting.

The initial and long-term benefits of coronary artery bypass grafting depend upon maintaining the coronary blood flow supplied by the graft. In order to devise a scoring system for predicting graft patency, we evaluated presumptive correlations between saphenous vein graft patency and the characteristics of saphenous veins that were used as conduits in coronary revascularization.We prospectively evaluated 1,000 saphenous vein segments that were implanted in 403 consecutive patients who underwent on-pump coronary artery bypass grafting at our hospital from January 2006 through February 2009. Branches, varicosity, diameter, and wall thickness were evaluated, and a scoring system was created in order to obtain a value for each characteristic. The patients were postoperatively monitored for 1 year, and graft patency was then evaluated with the use of 64-slice multidetector computed tomography.Lesions were found in 12.3% of the grafts. All of the evaluated characteristics of the grafts had a significant correlation with saphenous vein graft flow (P <0.0001). Using the venous characteristics in our statistical analysis, we devised a formula to obtain a score (range, 4-12) to predict the patency of each graft. A cutoff score of 7 yielded 87.8% sensitivity and 82.8% specificity.Our scoring system has good prognostic value. We believe that it can assist surgeons in choosing the most appropriate conduit and target vessel for coronary artery bypass grafting, especially in high-risk patients who are particularly dependent on blood flow through saphenous vein grafts.

Pericardial tamponade and right-to-left shunt through patent foramen ovale after epicardial pacing-wire removal.

After cardiac operations, careful management substantially reduces the risks of negative complications during or after the removal of temporary epicardial pacing wires. Herein, we report the case of a 58-year-old man who, 4 days after undergoing aortic root replacement, developed pericardial tamponade after the removal of temporary epicardial pacing wires. Consequent to the tamponade, a right-to-left shunt developed through a previously undiagnosed patent foramen ovale. The patient underwent emergency surgery to repair myocardium that had ruptured due to the removal of the wires, and he recovered uneventfully.

Papillary muscle repositioning in valve replacement for left ventricular dysfunction: ischemic mitral regurgitation.

BACKGROUND: The aim of this study was to investigate the feasibility of performing papillary muscle repositioning (PMR) for subvalvular-sparing mitral valve replacement procedures in patients with ischemic mitral regurgitation and to determine the early and late effects of this procedure on the clinical outcome and left ventricular mechanics. METHODS: We prospectively randomly allocated 50 patients with severe ischemic mitral regurgitation and left ventricle dysfunction who were candidates for coronary artery bypass graft surgery and mitral valve replacement into a total chordal-sparing mitral valve replacement group or a PMR group. Echocardiography was performed preoperatively, at discharge, and after 3 years to determine the left ventricular dimensions, shape, and function. RESULTS: The reduction in the left ventricle volumes and sphericity index in the PMR group was more significant than that in the other group. With regard to the left ventricular end-systolic and left ventricular end-diastolic volumes, sphericity index, and ejection fraction, the PMR group showed better results (p < 0.05), but the difference in New York Heart Association functional class after 3 years was not statistically significant between the two groups (p > 0.05). CONCLUSIONS: The PMR technique described herein can dramatically help ischemic patients by affecting the left ventricular shape and function more efficiently compared with the complete retention of the mitral subvalvular apparatus if the mitral valve is to be replaced.

Echo rejection score: new echocardiographic approach to diagnosis of heart transplant rejection.

OBJECTIVE: The gold standard test in the diagnosis of heart transplant rejection is right ventricular (RV) myocardial biopsy, which is an invasive, time-consuming, expensive method. In an effort to find a reliable method to minimise the sequential use of myocardial biopsy, we assessed the main echocardiographic indices for the detection of allograft rejection. MATERIALS AND METHODS: Fifty myocardial specimens were examined in this prospective study, which assessed the prominent echocardiographic parameters propounded by previous studies as indicators of rejection. Prior to biopsy, all the patients underwent preoperative transthoracic echocardiography. The accuracy of the echocardiographic indices was compared with that of myocardial biopsy indices as the gold standard. At three myocardial segments, namely, RV base, interventricular septal (Sep) base and lateral left ventricular (Lat) base, peak systolic strain (RV-S, Lat-S and Sep-S) was measured. In addition, time to systole (TS) was measured at the same three segments, yielding the three variables of RV-TS, Sep-TS and Lat-TS. RESULTS: Our logistic regression model revealed that the four factors of Lat-S (%), Sep-TS (ms), posterior wall thickness (PWT; mm) and left ventricular mass index (LVMI; g m(-2)) could denote heart transplant rejection. We devised a new index, the echo rejection score, using the following formula: [(PWT+LVMI)-(Lat-S+Sep-TS)]. This new formula has an area under a curve of 0.932 and a cut-off point of 0; it yields a sensitivity of 100.0%, specificity of 71.0%, positive predictive value of 67.9% and a negative predictive value of 100.0%. If the echo rejection score is >0, there is a 67.9% possibility that a cardiac transplant patient is presenting with allograft rejection, while a score < or =0 denotes a 100% improbability of rejection. CONCLUSION: Our proposed method for screening patients at risk of acute cardiac rejection with echo rejection score showed a good sensitivity in detection of graft rejection. However, further study is required to determine if it can be used as an adjunct to the myocardial biopsy.