Lung carcinoma presenting as monocular painless blindness.

To discuss a very rare presentation of lung malignancy which results in visual disturbance as first and only clinical manifestation. Case report. We report a case of otherwise asymptomatic 32-year-old, nonsmoker female presenting with painless loss of vision in the right eye and photophobia in the left eye, owing to secondaries in choroid from lung carcinoma. Patient was worked up after admission in our hospital to ascertain the cause of blindness and subsequently revealed lung malignancy with widespread metastasis involving multiple organ systems. Despite widespread malignant involvement patient was completely asymptomatic and active except for visual disturbances. This case further emphasized the necessity of prompt and priority-based evaluation of patients for lung carcinoma whenever doubtful intraocular lesions are noted, regardless of age or smoking status. It seems that these cases represent a distinct subset of lung malignancy.

Role of Ga-68 DOTANOC Positron Emission Tomography/ Computed Tomography Scan in Clinical Management of Patients with Neuroendocrine Tumors and its Correlation with Conventional Imaging- Experience in a Tertiary Care Center in India.

Purpose of Study: Aim of the study was to evaluate the role of 68Gallium-DOTANOC positron emission tomography/computed tomography (68Ga-DOTANOC PET/CT), a pan somatostatin receptor (SSTR) analog in the clinical management of patients with neuroendocrine tumors (NETs) and its correlation with conventional imaging. Materials and Methods: We retrospectively evaluated 69 patients of known/suspected NETs who underwent 68Ga-DOTANOC PET/CT scan for tumor localization (n = 15), stage modification (primary staging, n = 26 and restaging, n = 25) and therapy monitoring (n = 3). We also compared PET scan with conventional imaging as reference standard and evaluated the impact of PET/CT in the clinical management of patients. Results: The concordant findings on 68Ga-DOTANOC PET/CT and conventional imaging seen in 33 and discordant in 36 patients. Among discordant group, disease was upstaged in 32 patients; down staged in 3 patients; no stage change in one patient. PET/CT localized primary tumor in 4 patients. Among patients with raised tumor markers (39/69), PET was positive in 29 and negative in 10 patients. Patients were followed for mean duration of 27 months to assess management. We found strong agreement between positive PET and raised tumor markers (Kappa value = 0.8). Sensitivity and specificity of PET/CT for primary tumor localization, stage modification, and therapy monitoring was >90% (P < 0.05). Conclusions: Study shows that DOTANOC, a broad spectrum SSTRs binding peptide labeled with Ga-68 in PET/CT scan is an excellent modality in the management of NETs patients.

Long-term performance of untreated fresh autologous pericardium as a valve substitute in pulmonary position.

Background: Pulmonary regurgitation is imminent after transannular patch (TAP). We analyze the long-term performance of untreated autologous pericardium (UAP) as valve substitute at pulmonary position in patients requiring TAP. Material and Methods: This cross-sectional study include patients operated between 2007 and 2012 (n = 92). A sample of 19 patients was selected for this study which had a follow-up of more than 3 years. This includes patients with no TAP (n = 4) and with TAP and valve substitute, a monocusp (n = 11) or a tricuspid valve (n = 4) at neopulmonary annulus. Patients underwent echocardiography for assessment of right ventricle function and 18 fluoro-deoxyglucose PET CT scan for measurements of valve substitute at neopulmonary annulus. The target to blood ratio (TBR) of uptake of glucose by monocusp was measured at the cooptation edge of the neopulmonary valve. Results: The median age of the patients is 14 (9 - 37). RV function is preserved (TAPSE 18.9 (10.6 - 22.8)) at a mean follow-up of 4 years (3-9). The measurements of monocusp shows a shrinkage in height of the cusp by 35.5% (70% - 1.0%) and length by 7% (-44% - +104%). There was less shrinkage observed in patients below 15 years of age. The TBR of monocusp was 0.945 (0.17 - 3.35) with a strong correlation between the TBR values of aortic valve leaflet and monocusp leaflet of same patient. Conclusion: The UAP is functional and successful as a valve substitute at neo pulmonary annulus at long-term follow-up. It has resisted calcification and has shown uptake of glucose in physiological limits.

The obstructive index in antenatal unilateral pelviureteric junction obstruction: A novel predictor of the failure of conservative management.

BACKGROUND: To find the impact of the obstructive index (OI) as a predictor of management in antenatal pelviureteric junction obstruction. METHODS: Records of 135 cases of antenatally detected unilateral pelviureteric junction obstruction, selected for initial observation were retrospectively analyzed. All patients who underwent pyeloplasty on follow up were assigned to Group A. Those patients who were still on conservative management were assigned to Group B. The pelvic anteroposterior diameters of the affected (PAPD[A]) and normal kidney (PAPD[N]) of the same patient, along with the cortical thickness of the affected kidneys (CT[A]) and normal kidneys (CT[N]) on postnatal ultrasound scan, the T1/2 of the affected (T1/2 [A]) and normal kidneys (T1/2 [N]), the differential renal function (DRF), and the shape of the curve on a diuretic renogram were noted for each patient at 6 weeks. The OI was defined as (PAPD[A] × T1/2 [A]) / (PAPD[N] × T1/2 [N]). RESULTS: The median duration of follow up was 55 months (36-110). Median age at surgery was 12 months (4-80). Group A had 30 patients with 105 in Group B. On multivariate analysis, OI and shape of curve predicted need for surgery with statistical significance. Median OI in Group A was 18.9 compared to 4.82 in Group B (P < 0.001, Mann-Whitney). Using receiver operating characteristic analysis, the area under curve for the OI was 0.95. A level of 12.2 could predict failure of conservative management with a sensitivity of 93.3% and a specificity of 92.4%. CONCLUSIONS: The OI can reliably predict the need for surgery at a very early stage, thus avoiding repeated tests and saving time.

F-18 Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in a Case of Subcutaneous T-cell Lymphoma Presenting as Breast Mass and Panniculitis-Like Features: A Rare Entity.

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is an unusual subtype of cutaneous lymphoma and clinically appears as erythematous, subcutaneous infiltrates, and recurrent papulonodules. It is defined as a rare cytotoxic a/b T-cell lymphoma characterized by primary involvement of subcutaneous tissue-mimicking panniculitis and a predominant CD3+/CD4/CD8+ phenotype in (2005) the World Health Organization-European Organization for Research and Treatment of Cancer classification for cutaneous lymphomas. On metabolic imaging, these lesions are invariably fluorodeoxyglucose (FDG) avid. SPTCL which presents as a breast mass is a rare entity. Here, we present a case of SPTCL presents as FDG avid breast mass and subcutaneous nodules.

Factors predicting the risk of biochemical incomplete response in well-differentiated thyroid cancer after total thyroidectomy.

BACKGROUND: Differentiated thyroid cancer (DTC) is the most common endocrine carcinoma with an overall good prognosis. However, persistent or recurrent disease (P/R disease) and incomplete biochemical response (BIR) are causes of morbidity. Histopathology and TNM stage may not predict P/R disease and BIR in all patients. Various clinical parameters, histopathological features and preablative-stimulated thyroglobulin (presTg) have been proposed to predicts P/R disease. However, there is uncertainty for presTg cutoff and diagnostic accuracy. The study's objective was to predict the BIR before radioiodine ablation from available clinical, histopathological and biochemical parameters. METHODS: A retrospective, single-center study, including DTC patients, was done. Demography and factors predicting BIR evaluated. RESULT: In comparison to the patients in remission, patients with BIR were older (P = 0.042), had higher presTg (P < 0.001), and lymph nodes (LN) metastases [central or lateral compartment (P < 0.001)]. Visualization of LN on whole-body scan (P = 0.014), higher TNM stage (P = 0.001) and distance metastasis (P < 0.001) were also associated with BIR. On multivariate analysis, high presTg (P < 0.001) and LN metastases (LNscan and histopathologically proven LN involvement, P < 0.001) were associated with BIR. A presTg level ≥12.30 ng/ml has high sensitivity (90.6%) and specificity (80.6%) to predict the BIR (odds ratio 39.90). CONCLUSIONS: The presTg and LN involvement are robust markers that predict BIR. A raised presTg level with LN metastases and nonvisualization of the LN on the whole-body scan is a worrying feature for the future BIR. We propose the inclusion of high presTg as a high-risk factor in DTC.

Clinical outcome of patients with differentiated thyroid cancer and raised antithyroglobulin antibody levels: a retrospective study.

BACKGROUND: Thyroglobulin (Tg) is a specific tumor marker for differentiated thyroid cancer (DTC). However, in the presence of an antithyroglobulin antibody (TgAb), it becomes unreliable. The purpose of the study was to assess the long-term outcome of DTC patients with raised TgAb. METHOD: In a retrospective study, we included patients with DTC who had raised TgAb following total thyroidectomy. We excluded patients with persistently raised Tg (≥ 1 ng/ml) or radioiodine avid disease. Serial TgAb levels, excellent response (ER), incomplete response (IR), and anatomical recurrence were evaluated. RESULTS: A total of seventy-six patients were included in the study. Patients with IR had higher baseline TgAb (1071.27 ± 1216.17 vs. 99.61 ± 91.29 IU/ml, p < 0.001) and central compartment lymph node metastases (70.8% vs. 46.4%, p = 0.035) in comparison to those in the ER group. In the first follow-up, 64 (84.2%) patients had a stable or fall in the TgAb (0 to - 98.3%). Sixty-eight patients received high-dose radioiodine therapy (RIT). Out of these, 59 (86.5%) had transient, and 51 (75%) had a long-term fall in TgAb. After a follow-up period of 58.74 ± 26.26 months, 63.2% (48 out of 76) patients had IR. Nine (11.8%) patients had a rising TgAb level (3.7-170.9%) from baseline. Eleven patients underwent 18F-FDG PET/CT, and five of them demonstrated metabolically active recurrent disease. Three patients underwent cervical lymph nodes dissection. None of the patients died during the follow-up period. CONCLUSION: High post-operative TgAb levels and central compartment lymph nodal metastases are risk factors for IR. RIT leads to a significant fall in the TgAb in these patients. The low level of raised TgAb is associated with an excellent outcome. Patients with recurrences had very high baseline TgAb > 1000 IU/ml. Raised TgAb was associated with good clinical outcomes and not associated with increased mortality.

The Utility of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Differentiated Thyroid Cancer Patients with Biochemical Recurrence and Negative Whole-Body Radioiodine Scintigraphy and Evaluation of the Possible Role of a Limited Regional Scan.

PURPOSE OF THE STUDY: 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) is used in the management of recurrent differentiated thyroid cancer (DTC) patients presented with rising thyroglobulin (Tg) or anti-Tg antibody (Atg) levels and negative whole-body I-131 scan (WBS). We aimed to evaluate the utility of regional or limited PET/CT in a large population preset with variable Tg/(ATg) levels. MATERIALS AND METHODS: In a retrospective study, we analyzed 137 PET/CT done on DTC patients presented with raised Tg/Atg and negative WBS. Retrospective evaluation of other available clinical information was done. RESULTS: One hundred and thirty-seven patients aged 8-72 years (41 ± 17.7 years) were included in the study. Eighty-nine (64.9%) patients had positive findings on 18F-FDG PET-CT. It included thyroid bed recurrence, cervical, mediastinal lymphadenopathy, lung, and bone lesions. In addition, 36 patients had metabolically inactive lung nodules detected on CT. Serum Tg and female sex were the only predictors for a positive PET scan. In most (97.1%) of the patients, the disease was limited to the neck and thoracic region. CONCLUSIONS: PET/CT is an excellent imaging modality for evaluating DTC patients presented with biochemical recurrence. It not only finds the disease in more than 80% of the patients but also detects distant metastatic disease, which precludes regional therapies. Lesions were noted mostly in the neck and thoracic region with very few distant skeletal metastases (4/137 patients). In most of the patients, routine vertex to mid-thigh imaging could be avoided.

Assessment of untreated fresh autologous pericardium as material for construction of heart valve: Result at 5 years.

Introduction: Tetralogy of Fallot requiring transannular repair of the right ventricular outflow tract (RVOT) are exposed to free pulmonary insufficiency and hence inevitable right ventricular dysfunction. This study analyzes the function and structure of untreated autologous pericardium monocusp used to create a competent pulmonary valve. Materials and Methods: This is a retrospective analysis of 52 cases operated between December 2006 and December 2012. Untreated autologous pericardium was used for creating a competent pulmonary valve following a transannular patch. They are followed for functional and structural assessment of the pulmonary valve by echocardiography. Positron emission tomography (PET) with 18 fluorodeoxyglucose was performed in two cases for profiling the pulmonary valve. Results: Median age was 10.5 years (1-38). The follow-up was complete for 42 (80.76%) patients for 3 years and 25 (48.07%) patients for 5 years. The RVOT gradient was 42 mmHg (16-96) in the year of surgery, which reduced to 26 mmHg (10-58) and pulmonary insufficiency that was present in 8.3% of patients in 1st year was witnessed in 22.7% in the 5th year of follow-up. The monocusp patch was successful in creating a competent valve while maintaining its structure at 3 years; however, it became distorted and retracted at 5 years of follow-up. There was no calcification in any of the patients. PET-computed tomography confirmed the uptake of glucose by monocusp at 1 year of follow-up. Conclusion: The untreated autologous pericardium functioned well when it was used to create a competent pulmonary valve at short term and midterm. Although it changed in its structure; there was no calcification at 5 years of follow-up.

Semi-quantitative assessment of diffuse hepatic uptake seen in I-131 scans - an indicator of functioning thyroid tissue and disease burden in differentiated thyroid cancer.

BACKGROUND: To semi-quantitatively analyze liver uptake of I-131 in diagnostic and post-therapy scans by calculating hepatic to thigh ratios (HTR) and evaluate its clinical significance in management of differentiated thyroid cancer. METHOD: Two hundred forty-nine patients were included in the study. Hepatic to thigh ratio (HTR) of counts were calculated for 249 diagnostic and 104 post-therapy scans. Patients were divided into six study groups based on their disease status:1-Serum thyroglobulin (serum Tg) negative (serum Tg ≤ 4 ng/dl) and scan negative; 2-Thyroid remnant only; 3-Thyroid remnant and lymph node metastasis; 4- Tg positive (serum Tg > 4 ng/dl) and scan negative; 5-Bone or/and lung metastasis, and 6-Only lymph node metastasis. Comparison of HTR between these groups was done using one-way ANOVA test. Correlation of HTR with serum Tg, serum thyroid stimulating hormone (TSH), anti-thyroglobulin antibody (ATg) titer and therapeutic dose of I-131 was also assessed. RESULTS: Comparison of HTR between different study groups (1 to 6) showed significant difference in HTR (p = .001). Study group 5 (bone or/and lung metastasis) showed significantly higher mean HTR compared to other groups (p = 0.001). There was only a weak correlation between serum Tg and HTR (r = 0.395). Dose of I-131 administered also had a weak correlation with HTR (r = 0.207). CONCLUSION: HTR has good correlation with functional status of tumor cells, while it has weak correlation to therapeutic dose of I-131 administered and serum Tg. Increased HTR predicts significant disease burden in the form of distant bone and lung metastasis and may potentially be used as a second prognostic factor apart from serum Tg.

Comparison of SPECT/CT and MRI in diagnosing symptomatic lesions in ankle and foot pain patients: diagnostic performance and relation to lesion type.

PURPOSE: The purpose of this study was to compare the diagnostic performance of SPECT/CT and MRI in patients with ankle and foot pain, with regard to the lesion types. MATERIALS AND METHODS: Fifty consecutive patients with ankle and foot pain, who underwent 99mTc-MDP SPECT/CT and MRI, were retrospectively enrolled in this study. Symptomatic lesions were determined based on clinical examination and response to treatment. On MRI and SPECT/CT, detected lesions were classified as bone, ligament/tendon, and joint lesions. Uptake on SPECT/CT was assessed using a 4-grade system. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of SPECT/CT and MRI were evaluated in all detected lesions and each lesion type. Diagnostic value of uptake grade was analyzed using receiver-operating characteristics (ROC) curve analysis, and diagnostic performance was compared using Chi-square or McNemar tests. RESULTS: In overall lesions, the sensitivity, PPV and NPV of SPECT/CT for symptomatic lesions were 93%, 56%, 91%, and they were 98%, 48%, 95% for MRI. There was no significant difference between SPECT/CT and MRI. However, the specificity of SPECT/CT was significantly higher than that of MRI (48% versus 24%, P = 0.016). Uptake grade on SPECT/CT was significantly higher in symptomatic lesions (P < 0.001), and its area under curve on ROC analysis was 0.787. In the analysis of each lesion type, the specificity of SPECT/CT was poor in joint lesions compared with other lesion types and MRI (P < 0.001, respectively). MRI exhibited lower specificity than SPECT/CT in bone lesions (P = 0.004) and ligament/tendon lesions (P < 0.001). CONCLUSIONS: SPECT/CT has MRI-comparable diagnostic performance for symptomatic lesions in ankle and foot pain patients. SPECT/CT and MRI exhibit different diagnostic specificity in different lesion types. SPECT/CT may be used as a complementary imaging method to MRI for enhancing diagnostic specificity.