Uptake in sympathetic ganglia on 68 Ga-PSMA-HBED PET/CT: A potential pitfall in scan interpretation.

INTRODUCTION: The aim of this study was to assess the frequency of PSMA-HBED uptake in coeliac and stellate ganglia in patients presenting for PSMA-HBED PET/CT scan. METHODS: Prostate-specific membrane antigen-HBED PET/CT scans of 100 consecutive patients were analysed. Coeliac and stellate ganglia were identified by their anatomical location. PSMA-HBED uptake in these ganglia was recorded as either present or absent. If present, the SUVmax value for each ganglion was measured and compared to SUVmax of mediastinal blood pool. RESULTS: Of the 100 patients, 45 had PSMA-HBED uptake in the right coeliac ganglion and 81 had PSMA-HBED uptake in the left coeliac ganglion. The mean SUVmax for the right coeliac ganglion was 2.6 (range 1.2-4.0) and for the left, 2.7 (range 1.2-6.5). An SUVmax 1.5 times greater than that of mediastinal blood pool activity was found in 25 of right and 47 of left coeliac ganglia. Stellate ganglion uptake of PSMA-HBED was identified in 54 of right and 74 of left stellate ganglia. The mean SUVmax for the right and left stellate ganglia were 2.2 (range 1.6-3.6) and 2.4 (range 1.4-4.2) respectively. An SUVmax 1.5 times greater than that of mediastinal blood pool activity was found in 12 of right and 32 of left coeliac ganglia. CONCLUSION: Uptake in coeliac and stellate ganglia is a frequent finding on PSMA-HBED PET/CT imaging. Often this uptake can be sufficiently high to cause potential diagnostic confusion. It is important to be aware of this physiologic uptake to avoid incorrect diagnosis of metastatic prostate carcinoma.

Schwannoma Showing Avid Uptake on 68Ga-PSMA-HBED-CC PET/CT.

Ga prostate-specific membrane antigen (PSMA) PET/CT is a relatively new and highly sensitive imaging modality used in staging metastatic prostate cancer. We report a case of a 65-year-old man with newly diagnosed prostate carcinoma who had a PSMA PET/CT scan for staging of his disease. A PSMA-avid right pelvic mass was identified anterior to the sacrum. Surgical removal and histopathological examination of this lesion revealed the diagnosis of schwannoma. It is important to be aware that schwannoma may also show avid uptake on PSMA PET/CT scan and may potentially lead to an incorrect diagnosis of metastatic prostate carcinoma.

68Ga-DOTATATE Breast Uptake and Expression in Breast Milk.

The excretion of Ga-DOTA-Octreotate (DOTATATE) and related somatostatin analogues in breast milk has not been demonstrated. We report a case of a 34-year-old woman, 7 months postpartum and breastfeeding, who was referred for DOTATATE imaging after the diagnosis of appendiceal carcinoid and subsequent appendectomy. Prominent breast uptake was noted. A breast milk sample from the patient at 90 minutes postinjection was assayed in a gamma counter and shown to have a concentration of 5.6 Bq/g per MBq administered. The excretion of DOTATATE in breast milk is important to consider when providing radiation safety advice to breastfeeding patients.

Metastatic Renal Cell Carcinoma in the Thyroid Gland and Pancreas Showing Uptake on 68Ga DOTATATE PET/CT Scan.

Ga DOTATATE PET/CT is an imaging technique used in the diagnosis of neuroendocrine tumors. We report a case of 66-year-old woman with a history of surgically removed renal cell carcinoma who presented for a DOTATATE PET/CT scan to characterize a newly diagnosed pancreatic lesion. DOTATATE-avid lesions were identified in the thyroid gland and pancreas. Subsequent biopsy confirmed the diagnosis of metastatic renal cell carcinoma at both sites. It is important to be aware that tumors other than neuroendocrine tumors may also show uptake on DOTATATE PET/CT scan. A biopsy may be required if lesions are identified at atypical sites.

Follicular Lymphoma Showing Avid Uptake on 68Ga PSMA-HBED-CC PET/CT.

Ga prostate-specific membrane antigen (PSMA) PET/CT is a new imaging technique that is significantly more sensitive to prostate cancer lesions than other conventional imaging modalities. Various other benign and malignant neoplasms may also express PSMA and show uptake on PSMA PET/CT scan. We report a case of 66-year-old man who had a PSMA PET/CT scan for restaging of prostate carcinoma. A PSMA-avid left femoral lymph node was identified. Subsequent biopsy confirmed the diagnosis of follicular lymphoma. It is important to be aware of this possibility to avoid scan misinterpretation. Biopsy of any atypical or clinically unexpected lesions should be considered.

Desmoid Tumor Showing Intense Uptake on 68Ga PSMA-HBED-CC PET/CT.

Ga-PSMA PET/CT is a new imaging technique that is highly sensitive to metastatic prostate cancer lesions compared with other conventional imaging modalities. We report a case of a 77-year-old man with newly diagnosed prostate carcinoma who had a PSMA PET/CT scan for staging of his disease. An intensely PSMA-avid right pelvic mass was identified abutting the cecum and terminal ileum. Surgical removal and histopathologic examination of this lesion revealed the diagnosis of a desmoid tumor. It is important to be aware that many tumors other than prostate carcinoma may also show avid uptake on PSMA PET/CT scan.

Follicular Thyroid Adenoma Showing Avid Uptake on 68Ga PSMA-HBED-CC PET/CT.

68Ga-prostate-specific membrane antigen (PSMA) PET/CT imaging is a relatively new imaging technique used to evaluate the extent of disease in prostate carcinoma. Various other neoplasms may also express PSMA and show uptake on PSMA PET/CT scan. We report a case of a 62-year-old man who had a PSMA PET/CT scan for restaging of prostate carcinoma. A PSMA-avid thyroid lesion was identified, and subsequent tissue sampling confirmed the diagnosis of follicular thyroid adenoma. It is important to be aware of this possibility to avoid scan misinterpretation. Tissue biopsy of PSMA-avid thyroid lesions should be considered to exclude a primary thyroid neoplasm.

Myopia and the long-term incidence of cataract and cataract surgery: the Blue Mountains Eye Study.

BACKGROUND: To assess the association between refractive errors and the 10-year incidence of cataract and cataract surgery. DESIGN: Population-based prospective study. PARTICIPANTS: Three thousand six hundred fifty-four persons aged 49+ years living in a well-defined geographical region were examined at baseline; 2564 were re-examined after 5 and/or 10 years. METHODS: Baseline refractive error was measured using autorefraction with subjective refinement. Lens photographs were taken at each visit and assessed using the Wisconsin Cataract Grading System. MAIN OUTCOME MEASURES: Long-term incidence of cataract and cataract surgery. RESULTS: Compared with emmetropia, high myopia was associated with increased incidence of nuclear cataract (adjusted odds ratio 3.01, 95% confidence intervals 1.35-6.71). Low (odds ratio 1.86, confidence interval 1.03-3.35) and high myopia (odds ratio 7.80, confidence interval 3.51-17.35) were significantly associated with higher incidence of posterior subcapsular cataract. Low, moderate and high myopia were associated with increased incidence of cataract surgery (odds ratio 2.54, confidence interval 1.76-3.68; odds ratio 2.61, confidence interval 1.45-4.69; and odds ratio 4.81, confidence interval 2.33-9.93, respectively). Either any (odds ratio 1.35, confidence interval 1.08-1.69) or moderate hyperopia (odds ratio 1.76, confidence interval 1.32-2.34) was associated with increased incidence of nuclear cataract. CONCLUSION: Our longitudinal study confirms the association between myopia and an increased risk of nuclear and posterior subcapsular cataract. It also suggests that hyperopia may increase the risk of nuclear cataract.

Pseudoexfoliation syndrome and the long-term incidence of cataract and cataract surgery: the blue mountains eye study.

PURPOSE: To assess whether the pseudoexfoliation syndrome (PXS) is associated with the long-term incidence of cataract or cataract surgery. DESIGN: Population-based cohort study. METHODS: The Blue Mountains Eye Study examined 3654 persons 49 years of age and older at baseline; 2564 were re-examined after 5 or 10 years, or both. PXS was recorded at the baseline eye examination by an ophthalmologist. Masked graders assessed lens photographs using the Wisconsin Cataract Grading System. Generalized estimating equation regression models were used to examine the association between PXS and cataract by eye. RESULTS: Eyes with PXS had a significantly greater prevalence of cortical cataract (P=.02) and nuclear cataract (P < .0001) than eyes without PXS. The association between PXS and cortical cataract, however, did not persist after further adjustment for age, gender, smoking, diabetes, steroid use, myopia, socioeconomic status, and open-angle glaucoma (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.53 to 1.46), whereas the association between PXS and nuclear cataract persisted after adjustment for the above confounders (OR, 1.90; 95% CI, 1.04 to 3.48). In addition, significant associations were found between the presence of PXS at baseline and the 10-year incidence of either nuclear cataract (P < .0001) or cataract surgery (P < .0001). These associations persisted after adjustment for the potential confounders listed above (OR, 3.25; 95% CI, 1.38 to 7.65; and OR, 4.09; 95% CI, 2.25 to 7.44; respectively). No significant cross-sectional or longitudinal associations were found between PXS and posterior subcapsular cataract. CONCLUSIONS: Long-term follow-up data from this population-based older cohort suggest that the presence of PXS is associated with an increased risk of nuclear cataract and cataract surgery.

Fasting blood glucose levels and the long-term incidence and progression of cataract -- the Blue Mountains Eye Study.

PURPOSE: To assess the associations between fasting blood glucose and the long-term incidence and progression of cataract. METHODS: A total of 3654 persons aged 49+ years were examined at baseline with fasting blood glucose measured, and 2454 re-examined after 5 and/or 10 years. Lens photographs from each visit were used to assess cataract incidence and progression. Associations between baseline fasting blood glucose and incidence and progression of cortical, nuclear and posterior subcapsular (PSC) cataract were assessed using discrete logistic regression and change-point models. RESULTS: After adjusting for potential confounders, baseline fasting blood glucose was associated with the 10-year incidence of cortical cataract with a threshold at blood glucose level of 6.0 mm (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.25-2.57 for fasting glucose ≥6.0 mm compared to fasting glucose <6.0 mm). Each 1.0 mm increase in fasting glucose was also associated with higher 5-year progression of PSC (OR 1.25, 95% CI: 1.15-1.35), 10-year progression of cortical (OR 1.14, 95% CI: 1.01-1.27) and nuclear (OR 1.20, 95% CI: 1.01-1.43) cataract, with no thresholds detected. CONCLUSIONS: In this primarily nondiabetic older population, baseline fasting blood glucose was associated with the long-term incidence of cortical cataract and long-term progression of all three cataract subtypes.

Intermediate- and longer-term visual outcomes after cataract surgery: the Blue Mountains Eye Study.

BACKGROUND: Limited data are available on long-term cataract surgical outcomes. We aimed to compare intermediate-term (up to 5 years) and longer-term (5-10 years) post-surgery visual outcomes in an older Australian population. DESIGN: Population-based cohort. PARTICIPANTS: Persons aged 49+ years, living in the Blue Mountains area, west of Sydney. METHODS: Of 3654 baseline participants of Blue Mountains Eye Study, 75% of survivors were seen at each of the 5- and 10-year follow-up visits; 90 participants (130 eyes) underwent incident cataract surgery during the first 5 years and returned to both follow-up visits. MAIN OUTCOME MEASURES: Changes in visual acuity over time, and ocular conditions affecting visual acuity. RESULTS: After the first (intermediate-term) follow-up period, 33/128 eyes (26%) had presenting visual acuity <6/12. Similarly, after the second (longer-term) period, 27/119 eyes (23%) had presenting visual acuity <6/12. Uncorrected refractive error accounted for 22/33 eyes (66%) with reduced presenting visual acuity at the intermediate term and for 16/27 eyes (59%) at the longer-term follow-up visits. Of 10 eyes with reduced best-corrected visual acuity after longer term, five (50%) were attributed to posterior capsular opacification. Of 115 eyes with refractive error data, 82 (71%) and 70 (61%) were emmetropic, at the intermediate-term and longer-term visits, respectively. CONCLUSION: Over a longer term post cataract surgery, three quarters of eyes achieved presenting visual acuity ≥6/12 and nearly two-thirds achieved emmetropia. Uncorrected refractive error and posterior capsular opacification were the main causes of poor vision in operated eyes, a finding emphasizing the need for ongoing eye care services post cataract surgery.

Alcohol consumption and the long-term incidence of cataract and cataract surgery: the Blue Mountains Eye Study.

PURPOSE: To assess whether alcohol consumption is associated with the long-term incidence of cataract or cataract surgery. DESIGN: Population-based prospective cohort study. METHODS: A total of 3654 persons aged 49+ years were examined at baseline and 2564 were re-examined after 5 and/or 10 years. Lens photographs were taken at each visit and assessed using the Wisconsin Cataract Grading System by masked graders. An interviewer-administered questionnaire was used to collect information on alcohol consumption. RESULTS: No significant associations were observed between alcohol consumption and long-term risk of nuclear, cortical, and posterior subcapsular cataract. However, after adjusting for age, gender, smoking, diabetes, myopia, socioeconomic status, and steroid use, total alcohol consumption of over 2 standard drinks per day was associated with a significantly increased likelihood of cataract surgery, when compared to total daily alcohol consumption of 1 to 2 standard drinks (adjusted odds ratio [OR] 2.10, 95% confidence interval [CI] 1.16-3.81). Abstinence from alcohol was also associated with increased likelihood of cataract surgery when compared to a total alcohol consumption of 1 to 2 standard drinks per day (adjusted OR 2.36, 95% CI 1.25-4.46). CONCLUSION: A U-shaped association of alcohol consumption with the long-term risk of cataract surgery was found in this older cohort: moderate consumption was associated with 50% lower cataract surgery incidence, compared either to abstinence or heavy alcohol consumption.

Exogenous oestrogen exposure, female reproductive factors and the long-term incidence of cataract: the Blue Mountains Eye Study.

PURPOSE: To assess the association between exogenous oestrogen exposure, female reproductive factors and the long-term incidence of cataract. METHODS: People aged 49+ years living in a defined geographic region were invited to participate in this prospective population-based survey. Of 2072 women (83% of those eligible) who were examined during 1992-1994 at baseline, around 75% of survivors were re-examined at 5- and 10-year follow-up visits. Lens photographs were assessed using the Wisconsin Cataract Grading System by masked graders. An interviewer-administered questionnaire was used at each visit to collect information on female reproductive factors and the use of the oral contraceptive pill and postmenopausal hormone replacement therapy. RESULTS: After adjusting for age, smoking, socioeconomic status, steroid use, hypertension and diabetes, ever having used the oral contraceptive pill had a mild protective effect against incident cortical cataract (odds ratio 0.70, 95% confidence interval 0.50-0.98). However, hormone replacement therapy, age at menarche, age at menopause, duration of exposure to endogenous oestrogen, parity and type of menopause were not found to have significant associations with the incidence of any type of cataract or cataract surgery. CONCLUSION: Apart from a weak protective association of oral contraceptive pill use and the development of cortical cataract, we found no significant longitudinal associations between exogenous oestrogen exposure, female reproductive factors and the long-term incidence of cataract in this older population-based cohort.

Paediatric uveal melanoma.

Uveal melanoma is extremely rare in the paediatric population and can be associated with various pre-existing conditions. We report the case of a 9-year-old girl with no predisposing factor who presented with choroidal melanoma. A review of the literature is presented and various clinical, histopathological and prognostic features of paediatric uveal melanoma are discussed.

Ten-year incidence of age-related cataract and cataract surgery in an older Australian population. The Blue Mountains Eye Study.

PURPOSE: To estimate the 10-year incidence of cataract and cataract surgery in an older Australian population. DESIGN: Prospective population-based study. PARTICIPANTS: Persons at least 49 years old living in 2 postcode areas west of Sydney, Australia. METHODS: Eye examinations were performed at baseline and at 5- and 10-year follow-up visits. Lens photographs were taken and graded by masked graders using the Wisconsin Cataract Grading System. MAIN OUTCOME MEASURES: Incidences of nuclear cataract, cortical cataract, posterior subcapsular cataract (PSC), and cataract surgery. RESULTS: Ten-year person-specific incidences were 36.0% for nuclear cataract, 28.0% for cortical cataract, 9.1% for PSC, and 17.8% for cataract surgery. Corresponding rates were 31.7%, 24.4%, 8.2%, and 14.4%, respectively, in men and 39.3%, 30.8%, 9.8%, and 20.1%, respectively, in women. The incidence for each type of cataract and cataract surgery was positively associated with age (P<0.0001). Women had a significantly higher incidence than men for nuclear cataract (P = 0.04), cortical cataract (P = 0.007), any cataract (P = 0.0006), and cataract surgery (P = 0.03) after adjusting for age. There was no significant gender difference for PSC. The mean age at cataract surgery was 75.8 years, and there was no significant gender difference (P = 0.9). Among persons who developed any cataract, 22% had more than one type and 1.3% had all 3 types present. Nuclear cataract and PSC were significantly associated with visual impairment (visual acuity worse than 20/40). CONCLUSION: Age- and gender-specific cataract incidences in this study were similar to those reported from the U.S. Beaver Dam Eye Study. In this study, 72% of the participants were affected by cataract or had had cataract surgery over the 10-year follow-up period.

Management of metastatic carcinoma of the uveal tract: an evidence-based analysis.

Uveal metastasis from carcinoma is the most common cause of ocular malignancy in adults and represents an increasing problem in the context of an ageing population and enhanced survival of stage IV cancer patients. The reported prevalence of clinically evident uveal metastases in carcinoma patients ranges from 2% to 9%, with breast and lung cancer together accounting for between 71% and 92% of cases. Most patients (66-97%) have a known history of cancer and, although the majority have metastatic lesions elsewhere, up to 33% may present with an isolated ocular metastasis. These lesions may progress rapidly and are potentially sight-threatening. Early diagnosis and appropriate timely treatment are therefore of paramount importance to maintain patients' quality of life. The diagnosis is usually clinical and detailed descriptions of symptomatology and physical characteristics are provided. In 21-50% of patients, involvement is bilateral. External beam radiotherapy (EBRT), chemotherapy, hormone and biological therapies, brachytherapy, transpupillary thermotherapy, laser photocoagulation/photodynamic therapy and enucleation are therapeutic modalities described in the literature for the management of uveal metastases. The strongest evidence favours timely EBRT for the management of sight-threatening uveal metastases. The published evidence supporting EBRT for sight-threatening uveal metastases was given a grade B (strong support for recommendation). Newer alternative therapies are emerging and may have a role in selected patients; however, there are unfortunately few large studies examining such treatments for carcinoma metastatic to the eye. The role of these modalities will be further clarified with the results of larger comparative trials.

Disseminated mucormycosis and orbital ischaemia in combination immunosuppression with a tumour necrosis factor alpha inhibitor.

Disseminated mucormycosis, with pulmonary and cerebral angioinvasive disease, developed in a 65-year-old woman with rheumatoid arthritis being treated with combination immunosuppression including adalimumab. Clinical presentation included progressive orbital ischaemia. To the best of the authors' knowledge, this is the first reported case of disseminated mucormycosis in a patient treated with a tumour necrosis factor inhibitor. Important pathophysiological factors are considered.