Global Impact of COVID-19 on Nuclear Medicine Departments: An International Survey in April 2020.

The coronavirus disease 2019 (COVID-19) pandemic has placed significant challenges on health-care systems worldwide, whether in the preparation, response, or recovery phase of the pandemic. This has been primarily managed by dramatically reducing in- and outpatient services for other diseases and implementing infection prevention and control measures. The impact of the pandemic on nuclear medicine departments and their services has not yet been established. The aim of this online survey was to evaluate the impact of COVID-19 on nuclear medicine departments. Methods: A web-based questionnaire, made available from April 16 to May 3, 2020, was designed to determine the impact of the pandemic on in- and outpatient nuclear medicine departments, including the number of procedures, employee health, availability of radiotracers and other essential supplies, and availability of personal protective equipment. The survey also inquired about operational aspects and types of facilities as well as other challenges. Results: A total of 434 responses from 72 countries were registered and analyzed. Respondents reported an average decline of 54% in diagnostic procedures. PET/CT scans decreased by an average of 36%, whereas sentinel lymph-node procedures decreased by 45%, lung scans by 56%, bone scans by 60%, myocardial studies by 66%, and thyroid studies by 67%. Of all participating centers, 81% performed radionuclide therapies, and they reported a reduction of 45% on average in the last 4 wk, ranging from over 76% in Latin America and South East Asia to 16% in South Korea and Singapore. Survey results showed that 52% of participating sites limited their 99mTc/99Mo generator purchases, and 12% of them temporarily cancelled orders. Insufficient supplies of essential materials (radioisotopes, generators, and kits) were reported, especially for 99mTc/99Mo generators and 131I, particularly in Africa, Asia, and Latin America. Conclusion: Both diagnostic and therapeutic nuclear medicine procedures declined precipitously, with countries worldwide being affected by the pandemic to a similar degree. Countries that were in the postpeak phase of the pandemic when they responded to the survey, such as South Korea and Singapore, reported a less pronounced impact on nuclear medicine services; however, the overall results of the survey showed that nuclear medicine services worldwide had been significantly impacted. In relation to staff health, 15% of respondents experienced COVID-19 infections within their own departments.

Renal osteodystrophy presenting as a metabolic superscan on F-18 FDG PET/CT: A case report.

RATIONALE: F-18 Fluoro Deoxyglucose positron emission tomography and computed tomography (F-18 FDG PET/CT) is a useful modality in the evaluation of patients with malignancies. Increased incidence of lympho-proliferative disorders has been reported in individuals with long-standing end-stage renal disorders treated with renal replacement therapy. PATIENT CONCERNS: A 30-year-old male on peritoneal dialysis on account of end-stage renal disease. He had acute rejection of an earlier transplanted renal allograft. He was referred for an F-18 FDG PET/CT based on a clinical suspicion of lymphoma on account of bilateral inguinal lymphadenopathy associated with bilateral pedal swelling. DIAGNOSIS: Renal osteodystrophy was diagnosed based on diffusely intense F-18 FDG uptake in the axial skeleton, focal uptake in the costochondrial junctions and linear cortical uptake in the appendicular skeleton. No findings suggestive of lymphoma was seen. INTERVENTIONS: A diagnosis of renal osteodystrophy with no evidence of a lymphoma prevented futile biopsy of inguinal lymphadenopathy. Patient continued with peritoneal dialysis with no further intervention OUTCOMES:: Regular follow-up of patient to monitor calcium, phosphate and parathyroid hormone levels. Treatment will be indicated when laboratory results as well as clinical signs and symptoms are suggestive. LESSON: Metabolic bone disorder such as is seen in renal osteodystrophy should be considered in the differential diagnoses in patients with diffusely increased bone uptake on F-18 FDG PET/CT scan.

68Gallium-Arginine-Glycine-Aspartic Acid and 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Chondroblastic Osteosarcoma of the Skull.

We report the case of a 32 year-old male with Chondroblastic Osteosarcoma of the skull, which was imaged with both 18[F]fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) and 68Gallium-arginine-glycine-aspartic acid (68Ga-RGD) PET/CT. The 18F-FDG PET/CT did not demonstrate the tumour, whereas the 68Ga-RGD PET/CT clearly depicted a left-sided frontal tumour. 68Ga-RGD PET/CT may be a clinically useful imaging modality for early detection of recurrent osteosarcoma, considering the limitations of 18F-FDG PET in a setting of low glycolytic activity.

The role of F-18 FDG PET/CT in evaluating the impact of HIV infection on tumor burden and therapy outcome in patients with Hodgkin lymphoma.

BACKGROUND: To evaluate the impact of HIV infection on tumor burden and therapy outcome following treatment with chemotherapy in patients with Hodgkin lymphoma. METHODS: A total of 136 patients with classical Hodgkin lymphoma were studied (mean age ± SD = 32.31 ± 1.39 years, male = 86, female = 50). Advanced disease (stage III and IV) was present in 64% of patients. HIV infection was present in 57 patients while 79 patients were HIV-negative. Baseline F-18 FDG PET/CT was obtained in all patients. SUVmax, MTV and TLG were determined on the baseline scan to evaluate for tumor burden. All patients completed a standard regimen of adriamycin, bleomycin, vinblastine and dacarbazine (ABVD). After a median period of 8 weeks (range = 6 to 17 weeks), a repeat F-18 FDG PET/CT scan was obtained to evaluate response to therapy using Deauville 5-point scoring system. RESULTS: The HIV-positive and HIV-negative groups were similar with regards to age and disease stage. The groups were heterogeneous with respect to gender (p = 0.029). The SUVmax, MTV and TLG of lesions were not significant different between the two groups. Complete response was seen in 72.8% of the study population. Presence of HIV infection was associated with higher rate of treatment failure with 40.4% of the HIV-positive patients having treatment failure while only 17.7% of the HIV-negative patients had treatment failure (p = 0.0034). HIV infection was a significant predictor of response to chemotherapy. Effects of SUVmax, MTV, TLG and Ann Arbor stage of the disease were not statistically significant as predictors of therapy outcome. In a multiple logistic regression, presence of HIV infection still remained an independent predictor of therapy outcome in the presence of other factors such as SUVmax, MTV, TLG and the Ann Arbor stage of the disease. CONCLUSIONS: HIV infection is not associated with a higher tumor burden in patients with Hodgkin lymphoma. HIV infection is, however, a strong predictor of poor therapy outcome in patients treated with standard regimen of ABVD.

18F-FDG PET/CT in the detection of asymptomatic malignant melanoma recurrence.

AIM: To evaluate the diagnostic accuracy of FDG PET/CT in the detection of asymptomatic recurrence in patients with malignant melanoma who have had resection of their primary lesion. We also aimed to determine the pattern and factors predisposing to disease recurrence. METHODS: Patients with malignant melanoma who have had surgical resection of their disease and without any clinical evidence of disease recurrence were followed-up with FDG PET/CT. The diagnostic accuracy of FDG PET/CT, pattern of recurrence and factors predictive of disease recurrence were determined. RESULTS: A total of 144 patients were followed-up for a median period of 50.50 months. Asymptomatic recurrence was seen in 37 patients (25.7 %) with a median time to recurrence of 20 months. Lymph node was the commonest site of asymptomatic recurrence. Sex, tumour depth, histology type and presence of nodal metastasis were significant predictors of tumour recurrence. Age, race, site of primary lesion, type of lymph node resection were not significant predictors of disease recurrence. Race has a significant effect on the histological subtype of tumour (nodular maligna was more common in Caucasian while acral lentiginous was more prevalent in the Blacks) and the site of the primary lesion (lower limb in Blacks and trunk in Caucasians). Sensitivity, specificity and accuracy of FDG PET/CT for the detection of disease recurrence were 94.5 %, 87.6 % and 89.6 % respectively. CONCLUSION: FDG PET/CT is a suitable modality for early detection of asymptomatic recurrence of malignant melanoma. Asymptomatic recurrence most commonly occurs in lymph nodes. Sex, nodal metastasis and tumour pathologic features are predictors of recurrence.

68Ga-PSMA-HBED-CC PET imaging in breast carcinoma patients.

BACKGROUND: To report on imaging findings using 68Ga-PSMA-HBED-CC PET in a series of 19 breast carcinoma patients. METHODS: 68Ga-PSMA-HBED-CC PET imaging results obtained were compared to routinely performed staging examinations and analyzed as to lesion location and progesterone receptor status. RESULTS: Out of 81 tumor lesions identified, 84% were identified on 68Ga-PSMA-HBED-CC PET. 68Ga-PSMA-HBED-CC SUVmean values of distant metastases proved significantly higher (mean, 6.86, SD, 5.68) when compared to those of primary or local recurrences (mean, 2.45, SD, 2.55, p = 0.04) or involved lymph nodes (mean, 3.18, SD, 1.79, p = 0.011). SUVmean values of progesterone receptor-positive lesions proved not significantly different from progesterone receptor-negative lesions. SUV values derived from FDG PET/CT, available in seven patients, and 68Ga-PSMA-HBED-CC PET/CT imaging proved weakly correlated (r = 0.407, p = 0.015). CONCLUSIONS: 68Ga-PSMA-HBED-CC PET/CT imaging in breast carcinoma confirms the reported considerable variation of PSMA expression on human solid tumors using immunohistochemistry.

Development of a Single Vial Kit Solution for Radiolabeling of 68Ga-DKFZ-PSMA-11 and Its Performance in Prostate Cancer Patients.

Prostate-specific membrane antigen (PSMA), a type II glycoprotein, is highly expressed in almost all prostate cancers. By playing such a universal role in the disease, PSMA provides a target for diagnostic imaging of prostate cancer using positron emission tomography/computed tomography (PET/CT). The PSMA-targeting ligand Glu-NH-CO-NH-Lys-(Ahx)-HBED-CC (DKFZ-PSMA-11) has superior imaging properties and allows for highly-specific complexation of the generator-based radioisotope Gallium-68 ((68)Ga). However, only module-based radiolabeling procedures are currently available. This study intended to develop a single vial kit solution to radiolabel buffered DKFZ-PSMA-11 with (68)Ga. A (68)Ge/(68)Ga-generator was utilized to yield (68)GaCl3 and major aspects of the kit development were assessed, such as radiolabeling performance, quality assurance, and stability. The final product was injected into patients with prostate cancer for PET/CT imaging and the kit performance was evaluated on the basis of the expected biodistribution, lesion detection, and dose optimization. Kits containing 5 nmol DKFZ-PSMA-11 showed rapid, quantitative (68)Ga-complexation and all quality measurements met the release criteria for human application. The increased precursor content did not compromise the ability of (68)Ga-DKFZ-PSMA-11 PET/CT to detect primary prostate cancer and its advanced lymphatic- and metastatic lesions. The (68)Ga-DKFZ-PSMA-11 kit is a robust, ready-to-use diagnostic agent in prostate cancer with high diagnostic performance.

Fluorine-18-fluoroethylcholine PET/CT in the detection of prostate cancer: a South African experience.

OBJECTIVE: Imaging with fluorine-18-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) has, until recently provided disappointing results with low sensitivity ranging from 31%-64% in patients with well-differentiated prostate cancer (PC) at all prostatic specific antigen (PSA) levels while fluorine-18-fluoroethylcholine ((18)F-FECh) PET/CT showed about 85% sensitivity in restaging patients after relapse. We present our experience of the sensitivity of (18)F-FECh PET/CT in the early stages of PC. SUBJECT AND METHODS: Fifty patients were prospectively recruited and imaged, of which 40 fulfilled all inclusion criteria. Our patients had an average age of 65.5 years. Fifteen patients were referred for initial staging, with the remaining 25 referred for restaging and all patients had histologically confirmed adenocarcinoma. Patients were imaged by (18)F-FECh PET/CT. Findings were evaluated qualitatively and quantitatively and compared to the results of histology, PSA, Gleason score and bone scintigraphy. The prostate SUVmax was also used. RESULTS: Thirty-one patients demonstrated abnormal pelvic- and or extra- pelvic findings on (18)F-FECh PET/CT, which was consistent with malignant or metastatic involvement. The prostate SUVmax could not be used to predict the presence or absence of metastatic disease. CONCLUSION: Findings of this paper suggest that (18)F-FECh PET/CT in 30/40 cases (estimated as 75%) was helpful in the initial staging, restaging and lymph node detection of patients with PC. The SUVmax was not helpful. We diagnosed more PC cases in our African-American patients as compared to the Caucasian patients.