A Rare Case of Neuroendocrine Prostate Cancer Detected on 68Ga - DOTANOC Positron Emission Tomography/Computed Tomography (PET/CT).

Prostate cancer is one of the most common malignancies affecting elderly men worldwide and the fifth leading cause of cancer death in men. Prostate cancer includes many histological variants with the prostatic acinar adenocarcinoma variant accounting for the majority of the diagnosed cases. Other less common histological variants are broadly classified as non-acinar carcinomas. One of the non-acinar carcinoma variants is neuroendocrine prostate cancer (NEPC). NEPC can emerge as a mechanism of treatment resistance in castration-resistant conventional prostate cancer and can also rarely be seen as a primary histological form at the time of initial diagnosis. Like other non-acinar carcinoma variants of prostate cancer, NEPC is also an aggressive variant with associated poor prognosis. Neuroendocrine tumors (NETs) are characterized by the expression of somatostatin receptors (SSTRs). Positron emission tomography/computed tomography (PET/CT) using radiolabeled somatostatin analogs like DOTANOC have been used to detect and stage these NETs. These radiolabeled somatostatin analogs also provide the option of treatment of these tumors and have been used in peptide receptor radionuclide therapy of these tumors. NEPC being a neuroendocrine malignancy also expresses SSTRs and hence can be detected with PET/CT radiotracers like 68Gallium-labeled somatostatin analogs. We here report a case of metastatic treatment-emergent NEPC detected on 68Ga - DOTANOC PET/CT.

Gallium68-Labeled Fibroblast Activation Protein Inhibitor (68Ga-FAPI) PET/CT as an Alternative to Fluoro18-Fluorodeoxyglucose (18F-FDG) PET/CT: Discussion in a Case of Metastatic Adenocarcinoma of Pancreas.

Positron emission tomography (PET) is an integral part of the imaging of solid tumors in today's oncology practice. The most commonly used PET radiotracer is 18F-Fluorodeoxyglucose (18F-FDG). FDG PET has imaging characteristics of a high tumor-to-background uptake ratio and is used in the detection of primary as well as metastatic sites. However, a significant pitfall is its inability to differentiate between neoplastic and infective lesions. To address this concern, many PET radiotracers have been developed and tried over time, a promising one being radiolabelled fibroblast activation protein inhibitor (FAPI). Fibroblast-activated protein (FAP) is a type II transmembrane glycoprotein expressed by cancer-associated fibroblasts (CAFs); it forms a significant component of the tumor stroma. Since there is over-expression of CAF in the majority of malignancies, it is a potential target for molecular imaging using PET. Several radiolabeled FAP inhibitors have been developed for PET imaging of malignancies and have also been used in theranostic applications.

68Ga-DOTANOC PET/CT Detects a Rare Case of Metastatic Neuroendocrine Neoplasm of the Gallbladder.

ABSTRACT: Gallbladder neuroendocrine neoplasms (NENs) are rare tumors of the biliary system. These neoplasms express somatostatin receptors, and hence radiolabeled somatostatin analog 68Ga-DOTANOC is used as a PET radiotracer in detection and staging. Gallbladder NEN cannot be differentiated from an adenocarcinoma of the gallbladder based on clinical symptoms or routine radiological imaging such as ultrasound or CT. These are either diagnosed postcholecystectomy or after biopsy from primary or metastatic sites. We present a rare case of gallbladder NEN detected on 68Ga-DOTANOC PET/CT.

A Rare Case of Splenic Metastasis From Squamous Cell Carcinoma of the Cervix Detected on 18F-Fluorodeoxyglucose PET/CT.

Cervical cancer is one of the common gynaecological malignancies seen in women. As per the World Health Organization (WHO), cervical cancer is the fourth most common malignancy encountered in women worldwide. Squamous cell carcinoma followed by adenocarcinoma is the most common histological subtype of cervical cancer. Apart from nodal metastases, the usual sites of metastases are the lungs, bones, and liver. Spleen, breast, and skin have been reported as rare sites of metastasis in cases of cervical cancer. Spleen is a rare site of metastasis not only in cases of carcinoma cervix but also in various other solid tumour malignancies. Splenic metastases being uncommon are difficult to characterise using routine imaging modalities. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) evaluation helps to detect these rare sites of metastasis.

High Glucose Metabolism in the Right Ventricular Myocardium Due to Extrinsic Pulmonary Stenosis by Mediastinal Lymphoma.

Acquired pulmonary stenosis in adults is rare and is usually caused by extrinsic compression from a mediastinal tumor. We present a case of anterior mediastinal Hodgkin lymphoma, who presented with cough and hemoptysis. Compression of the bilateral pulmonary arteries by the mediastinal mass was demonstrated by transthoracic echocardiography and CT pulmonary angiography. FDG PET/CT showed diffusely increased FDG uptake in right ventricular myocardium in addition to lymphomatous involvement of the lymph nodes and spleen.

Physiologic Testicular Uptake of 18-F Fluorodeoxyglucose in the Indian Population.

OBJECTIVE: The objective of the study is to assess the physiologic uptake of testes in patients undergoing 18F-fluoro-2-deoxyglucose (FDG) position emission tomography/computed tomography (PET/CT) scans for various malignancies other than testicular malignancy. MATERIALS AND METHODS: The testicular uptake of 18F-FDG expressed as the standardized uptake value (T) was measured on PET/CT images in 320 men with no known testicular pathology from July 2019 to March 2020 at Tata Main Hospital, Jamshedpur. The ratio of maximum standardized uptake value (SUVmax) of the testis (T) to SUVmax of muscle (M) T/M ratio and to SUVmax of the liver (L) T/L ratio was calculated using SUVmax of right adductor muscle and liver, respectively. Testicular volume was calculated with the measurements taken from the axial, coronal, and sagittal slices of CT images. The correlation of testicular uptake with age, blood serum glucose level, and testicular volume was also analyzed. RESULTS: The mean age of 320 men was 57 ± 15 years (range: 10-94) and the mean blood glucose level was 107.7 ± 23.5 mg/dl (range: 64-175). Mean testicular SUVmax in 320 men was 2.48 ± 0.80 (range: 0.67-5.5). The mean testicular volume of 640 testes of 320 men was 18.80 ± 4.83 cm3 (range: 3.85-33.56 cm3). The mean values of (T/M) and (T/L) ratios in the studied population were 3.64 ± 1.21 (range: 1.08-5.58) and 0.97 ± 0.251 (range: 0.34-1.88), respectively. The laterality index (L - R/(L + R) ×2) in 320 men was 0.074 ± 0.050 (0.000-0.308). There was a minimal negative correlation between testicular SUVmax and age (r = -0.136, P = 0.15). Mild negative correlation was noted between T/M ratio and age (r = -0.291, P < 0.0001) and between T/L ratio and age (r = -0.182, P = 0.001) in the studied population. CONCLUSION: The physiological testicular FDG uptake (SUVmax) of testes was 2.48 ± 0.80 (0.67-5.5) among the Indian population in this study, which has a mild negative correlation with age.

Prolonged Oxygen Therapy Post COVID-19 Infection: Factors Leading to the Risk of Poor Outcome.

BACKGROUND: Coronavirus disease 2019 (COVID-19) infection is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a single-stranded ribonucleic acid (RNA) ß-coronavirus. Prolonged duration of symptoms, ill health, disability, and need for hospitalisation are all well-known features of severe COVID-19 disease. OBJECTIVE: To describe the epidemiological, clinical and imaging characteristics of hospitalised patients of COVID-19 who required prolonged oxygen therapy after testing negative for SARS-CoV-2 and attempt to determine the associated factors leading to delayed recovery, failure to wean, and mortality. MATERIAL AND METHOD: Prospective observational study from 9th September to 6th November 2020 in a tertiary care COVID hospital of Jharkhand. Included COVID-19-infected patients requiring oxygen to maintain a saturation of ≥95% after testing reverse transcription polymerase chain reaction (RT-PCR) negative. Patients were classified as Group I, those who could be weaned off oxygen, and Group II, those who could not be weaned off oxygen during their stay in the isolation ward. A detailed assessment for outcome in these two groups related to age, gender, presence or absence of co-morbidities, nature of co-morbidities and findings of high-resolution CT (HRCT) thorax was done to ascertain risk factors for failure to wean and adverse outcomes. RESULTS: During the study period, 93 patients suffering from moderate to severe COVID-19 infection, could not be discharged from the hospital and were admitted to the post-COVID isolation ward after testing RT-PCR negative, due to breathlessness and need for oxygen therapy, with a male predominance, M:F ratio of 2.2:1. Of these 93 patients, 51 could be weaned off oxygen in the isolation ward. The mean and median age of patients who could be successfully weaned was 58.5±14.3 years and 60 years respectively, compared to a mean age of 64±12.4 years and a median age of 67 years for patients who could not be weaned off oxygen during the isolation period. Patients aged ≥60 years were at risk for prolonged requirement of oxygen compared to those <50 years of age, relative risk (RR) 1.43 (95%CI 0.9-2, p=0.051). Failure to wean in <50 years was noted in presence of co-morbidities, RR 4 (95%CI 1.5-10.6, p=0.005). Multivariable logistic regression analysis calculated an odds ratio (OR) of 12.22 (95%CI 2.4-61.5, p<0.002) in patients of coronary artery disease (CAD), and 3.34 (95%CI 1.01-10.9, p<0.046) in patients of diabetes, for failure to wean with delayed recovery in patients aged 50 years and more, having multiple co-morbidities. Presence of ≥three co-morbid conditions was associated with increased risk of critical care unit (CCU) admissions (RR 2.1, p=0.02), failure to wean (RR 1.79, p<0.006), and death (p=0.02). Elderly male patients (mean age of 81.3±7.2years) with CAD and multiple comorbidities were at a high risk of mortality (p=0.01). CONCLUSION:  Patients ≥50 years of age having ≥three co-morbidities are at increased risk of prolonged hospitalisation and oxygen therapy in moderate to severe COVID-19 infection, precluding their discharge even after they test negative for SARS-CoV-2. Elderly male patients of COVID-19 with CAD and multiple comorbidities are at a high risk of mortality.

Rare Case of Diffuse Splenic Uptake on Methylene Diphosphonate Bone Scan in a Patient with Sickle Cell Disease.

Extraskeletal tracer uptake in methylene diphosphonate (MDP) bone scan is not a common finding. There have been several case reports in the literature showing diffuse splenic uptake in MDP bone scan. We present a case of sickle cell disease, which showed diffuse splenic uptake on MDP whole-body bone scan.

Rare Case of Docetaxel-Induced Myositis Detected on Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in a Patient with Carcinoma Breast.

We report an extremely rare case of acute inflammatory myopathy during combination chemotherapy with docetaxel and transtuzumab for metastatic breast carcinoma in a 44-year-old female patient. Despite the significant response in the follow-up fluorodeoxyglucose (FDG) positron emission tomography/computed tomography, of the underlying malignancy to the chemotherapeutic regimen, there was diffusely increased FDG uptake in the upper and lower limb muscles with associated painful, proximal muscle weakness. These symptoms regressed after the discontinuation of docetaxel and the administration of corticosteroids, suggesting it to be the drug-induced myositis.

Rare Case of Cardiac Metastasis in a Patient with Cutaneous Squamous Cell Carcinoma of Foot Detected on 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography.

Cutaneous squamous cell carcinoma (SCC) metastasizes most commonly to the regional lymph nodes and lungs. Metastasis to heart, although described in literature, is a very rare phenomenon. We present the 18F-fluorodeoxyglucose positron emission tomography-computed tomography findings in a 50-year-old woman who was a biopsy-proven case of SCC left foot, showing cardiac metastasis in addition to lymph nodes, lungs, and skeletal metastases.

Rare Presentation of Isolated Scar Site Recurrence in a Case of Carcinoma Cervix.

Scar site recurrence is a rare phenomenon and is even rarer in squamous cell carcinoma. We present a special case of isolated scar site recurrence in a patient with carcinoma cervix detected on fluorodeoxyglucose positron emission tomography-computed tomography, 2 years after hysterectomy and radiotherapy.

Rare Case of Testicular Sarcoidosis Detected on FDG PET/CT in a Patient With PUO.

Genitourinary sarcoidosis is an uncommon entity, and testicular sarcoidosis is even rarer. We present a case of 66-year-old man who presented to our hospital as PUO (pyrexia of unknown origin) and later diagnosed as testicular sarcoidosis with the help of FDG PET/CT.

Reduction in relapse rate of radioiodine therapy in patients of toxic multinodular goiter: A quality improvement project.

INTRODUCTION: Radioiodine (I-131) therapy is the definitive treatment of toxic multinodular goiter (TMNG). Treatment failure may result in relapse after I-131 therapy. The present study was undertaken to reduce treatment failure rate of I-131 therapy in TMNG patients. MATERIALS AND METHODS: Multiple causes may have lead to treatment failure of I-131 in TMNG patients making it difficult to establish a direct cause-effect relationship and take corrective action. Therefore, the JURAN methodology of quality improvement was applied. The treatment failure rate in 80 TMNG patients treated with I-131 in the period 2003-06 was 29%. The root cause analysis identified delay in decision to radioablate and concomitant antithyroid drugs (ATD) with I-131 therapy as factors leading to relapse. In 2007, a change in management was introduced with decision to radioablate all TMNG patients not remitting at 1 year of ATD and to withdraw ATD for 2 weeks prior to I-131 therapy. A total of 63 patients of TMNG followed the changed protocol between 2007 and 2009. Further analysis showed that one of the factors identified in the initial brainstorming (high iodide pool in the patient) had not been addressed in the protocol currently followed. The protocol was modified to include patient preparation and implemented after standardization. RESULTS: The post-I-131 relapse rate in patients treated after implementation of the new protocol from 2007 to 2009 was 18% which further reduced to 16% in 2011 after modification of the protocol. CONCLUSION: The failure rate of I-131 therapy in TMNG reduced from 29% to 16% through standardization of the treatment procedure achieved by the use of Juran Methodology that helped to identify process-related defects.

Does thyroxine suppression therapy help to rationalize surgery in benign euthyroid nodules?

BACKGROUND: Nodular thyroid disease is a common endocrine problem. Most thyroid nodules are benign hyperplastic lesions, but 5-20% may be a true neoplasm. It is important to differentiate a benign from a malignant nodule early as the approach to treatment in the two is radically different. Early institution of medical management in a benign nodule may obviate the need for surgery. PURPOSE OF THE STUDY: The present work aims to study the efficacy of thyroxine suppression in the management of benign thyroid nodules. MATERIALS AND METHODS: A prospective study on patients presenting with thyroid nodule was undertaken. The diagnostic work-up included a clinical evaluation, thyroid function tests, thyroid scintigraphy and fine needle aspiration cytology. Based on the investigations, patients were segregated in Group A (toxic nodular goiter), Group B (benign euthyroid nodule) and Group C (malignant nodule). Group A patients were managed with antithyroid drugs and radioiodine and Group C patients were managed surgically. Group B patients were put on thyroxine suppression. Patients who failed to show reduction in size of the nodule at 18 months were treated surgically. CONCLUSION: The response rate of benign euthyroid nodule to thyroxine suppression was 76% in the present study.