Suspecting and diagnosing transthyretin amyloid cardiomyopathy (ATTR-CM) in India: An Indian expert consensus.

Transthyretin cardiac amyloidosis (ATTR-CM) is a rare and under-recognized disorder characterized by the aggregation of transthyretin-derived insoluble amyloid fibrils in the myocardium. Heterogeneity of symptoms at presentation, makes its diagnosis often delayed. An expert panel gathered on a virtual platform across India to conduct a meeting for developing a guiding tool for ATTR-CM diagnosis. The panel recommended younger age (≥40 years) for suspecting ATTR-CM and thick-walled non-dilated hypokinetic ventricle was considered as one of the important red flags. Electrocardiogram (ECG) and echocardiography (ECHO) findings were recommended as primary tests to raise the suspicion while nuclear scintigraphy and hematological tests were recommended to confirm the diagnosis and rule out amyloid light-chain (AL) amyloidosis. Cardiac magnetic resonance (CMR) and biopsy were recommended in case of ambiguity in the presence of red flags. Considering the lack of expert guidelines in the Indian scenario, a standardized diagnostic algorithm was also proposed.

Nuclear Medicine in India: A Historical Journey.

Evidence-based historical accounts of critical events, which shaped nuclear medicine in India today, are presented in this article. There was parallel activity happening in the northern and western region of India in the early 60s. Radiation Medicine Center (RMC) at Mumbai inaugurated in September 1963 by Dr. Bhabha; and Institute of Nuclear Medicine and Allied Sciences, Delhi dedicated to the nation in February 1964. The isotope division of Bhabha Atomic Research Center endured as the backbone in the supply of indigenously produced medical radioisotopes in research reactors APSARA (1958) and CIRUS (1960). Design and dispatch of economical generators (loaded with low specific activity 99Mo) with indigenously designed solvent extraction (Methyl Ethyl Ketone) technique had led to rapid growth of nuclear medicine facilities in the country. As per recently released list (July 2018) of the Atomic Energy Regulatory Board, there are 293 nuclear medicine departments in the country. Of which 14% are in the government sector, and the remaining 86% are under private ownership. There are currently 233 functioning gamma cameras (Single-photon emission computed tomography [SPECT]/SPECT-computed tomography [CT]) units in India since 1969 when the first gamma camera was commissioned at RMC. The first medical cyclotron (2002) and first positron emission tomography (PET) (2002) and first PET-CT (2004) in Mumbai had triggered revolution of molecular imaging in India. There are 222 PET-CT, 3 PET-magnetic resonance imaging scanners, and 19 cyclotrons operating currently. India has witnessed relatively slower headways in terms of high dose radionuclide therapy facilities. After first indoor facility at RMC in 1964, only 92 radionuclide therapy (isolation) wards have come up with no more than 200 beds for the entire country in the last 54 years. India started Delhi university approved structured postgraduate diploma in nuclear medicine in 1963 at the Institute of Nuclear Medicine and Allied Sciences (INMAS), first of its kind course in the world at that time. RMC started Mumbai University recognized diploma courses for physicians (Diploma in Radiation Medicine) and technologists (Diploma in Medical Radioisotope Techniques) in 1973. National Board of Examination (Government of India) recognized nuclear medicine as a broad specialty in 1982 and accredited RMC for training for Diplomate of National Board. Doctor of Medicine (MD) started first time in India and Asia at Sanjay Gandhi Postgraduate Institute, Lucknow in 1990. Doctorate of Therapeutic Nuclear Medicine commenced at All India Institute of Medical Sciences Delhi in 2015. There are 18 teaching hospitals currently imparting MD/DNB nuclear medicine residency for physicians with annual intake of 50. Eighteen institutions are offering bachelors and masters programs for nuclear medicine technology with an average annual intake of 110-120 students. Society of Nuclear Medicine, India (SNMI) is the oldest and largest professional body with total life membership of 1425 nuclear medicine professionals. SNMI was established in 1967 and hosted the first Annual Conference at RMC, Mumbai in 1968. Since then, SNMI is organizing its Annual Conferences in various parts of the country with the objective of scientific exchange and popularizing the modality amongst clinicians. Postgraduate Institute of Medical Education Research is hosting the 50th Annual Conference of SNMI (SNMICON-18) as mark of golden jubilee celebration.

Fluorodeoxyglucose positron emission tomography-computed tomography in evaluation of pelvic and para-aortic nodal involvement in early stage and operable cervical cancer: Comparison with surgicopathological findings.

INTRODUCTION: Nodal metastases in cervical cancer have prognostic implications. Imaging is used as an adjunct to clinical staging for evaluation of nodal metastases. Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) has an advantage of superior resolution of its CT component and detecting nodal disease based on increased glycolytic activity rather than node size. But there are limited studies describing its limitations in early stage cervical cancers. OBJECTIVE: We have done meta-analysis with an objective to evaluate the efficacy of FDG PET/CT and its current clinical role in early stage and operable cervical cancer. MATERIALS AND METHODS: Studies in which FDG PET/CT was performed before surgery in patients with early stage cervical cancers were included for analysis. PET findings were confirmed with histopathological diagnosis rather than clinical follow-up. FDG PET/CT showed lower sensitivity and clinically unacceptable negative predictive value in detecting nodal metastases in early stage cervical cancer and therefore, can not replace surgicopathological staging. False negative results in presence of microscopic disease and sub-centimeter diseased nodes are still the area of concern for metabolic imaging. However, these studies are single institutional and performed in a small group of patients. There is enough available evidence of clinical utility of FDG PET/CT in locally advanced cervical cancer. But these results can not be extrapolated for early stage disease. CONCLUSION: The current data suggest that FDG PET/CT is suboptimal in nodal staging in early stage cervical cancer.

Efficacy of SPECT over planar bone scan in the diagnosis of solitary vertebral lesions in patients with low back pain.

BACKGROUND: The purpose of our study has been to evaluate the efficacy of single photon emission computed tomography (SPECT) over planar bone scan in identifying solitary vertebral lesions in patients with low backache and its ability to differentiate various pathologies according to the uptake pattern. MATERIALS AND METHODS: The study included twenty patients out of whom six patients presented with known carcinoma and fourteen patients with low back pain. SPECT was done in all following planar skeletal survey. Benign and malignant lesions were identified according to the uptake pattern in vertebral elements, based on Gary F. Gates observations. Final diagnosis was obtained by means of biopsy or correlation with radiograph or computed tomography (CT) or magnetic resonance imaging (MRI), and / or follow up. RESULTS: SPECT detected additional 30% of solitary vertebral lesions that were obscured on planar scan. Seven out of twenty were localized in anterior vertebral body and were diagnosed as benign ostophytes in six and osteoma in one substantiating the previous observations. Out of six cases of known carcinoma, three were having solitary metastases and showed posterior vertebral body uptake with pedicle involvement. SPECT could localize specific lesions as source of pain in eleven patients with low back pain (78%) and identified various etiologies including benign tumors (osteoid osteoma and osteoma), facet arthritis, discitis, transverse process fractures and spondylolysis. CONCLUSION: Our study highlighted the higher diagnostic value of SPECT over planar skeletal scintigraphy in localizing solitary vertebral lesions in low backache patients. Based on SPECT pattern, malignant and benign lesions could be differentiated in the given clinical context.

Integrated PET/CT in evaluating sarcomatous transformation in osteochondromas.

AIM: To study the role of PET-CT in evaluating sarcomatous transformation in osteochondromas. MATERIALS AND METHODS: This was a retrospective analysis of a prospective data base of 12 patients from 2005 to 2007 with a clinical diagnosis of an osteocartilaginous lesion who were referred for a FDG PET-CT study to evaluate for possible malignant transformation. Imaging was performed on a GE Discovery ST PET-CT system after intravenous injection of 370 MBq (10 mCi) of F-18 FDG. RESULTS: Seven patients with histopathological evidence of a sarcomatous transformation to grade II chondrosarcoma showed moderate to high FDG uptake (SUV 3.3-6.9), whereas 1 patient with a dedifferentiated chondrosarcoma showed a focus of very intense uptake (SUV 11.4). Four patients with histopathological and/or clinical or follow-up diagnosis of a benign osteocartilaginous lesion showed low grade FDG uptake (SUV 0.8-1.3). FDG uptake was also noted in an asymptomatic osteochondroma which on histopathology revealed a grade II chondrosarcoma. CONCLUSIONS: Whole body FDG PET-CT is an important adjunct to conventional morphologic imaging in evaluating suspected malignant transformation in osteochondromas. Increased glucose metabolism can help diagnose sarcomatous transformation at the suspected sites as well as detect early malignant change at clinically unsuspected sites. Moreover, its ability to detect a focus of dedifferentiation can be useful for prognostication and to plan adjuvant treatment. A small cohort limits statistically sound conclusions to be drawn from this study, however further prospective trials based on these findings can help explore the potential application of FDG PET-CT in this clinical condition.