Metastatic Superscan in 18F PSMA PET/CT of a Patient with Prostate Carcinoma.

A biopsy-proven patient with prostate carcinoma aged 70 years was referred to the department of nuclear medicine for radionuclide-based therapy. His prostate-specific antigen levels were >1000 ng/mL, and prostatic magnetic resonance imaging showed an enlarged prostate with a heterogeneous signal and size 3.8x3.7x3.5 cm with few small heterogeneous nodular signals in the transition zone. He was scheduled for 18F prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) scan before therapy. 18F PSMA PET/CT revealed PSMA-expressing prostate lesions (maximum standardized uptake value ~10.2) with extension into the urinary bladder along with bilateral supraclavicular, mediastinal, retrocrural, retroperitoneal, and pelvic lymph nodes and sclerotic lesions in the entire axial and appendicular skeleton.

Primary malignant melanoma of the small bowel: A case report.

Malignant melanoma comprises 1%-3% of all malignant tumors of the gastrointestinal tract. The small bowel melanoma is an extremely rare malignancy. Very few cases have been reported in the literature. The small intestine is mostly affected by the metastatic tumors of the primary lesions especially cutaneous. This malignancy is diagnosed at the late stages as the patient remains asymptomatic. In this report we present a case of malignant melanoma arising from the small bowel in a 58-year-old male. There was no primary lesion in the eye, skin, anus, rectum or elsewhere in the body. The patient was treated with surgery. Afterward the patient presented to the emergency room with respiratory distress for which he was on ventilator support, sadly the patient died after 10 days. Malignant melanoma is an aggressive tumor and does not respond well to chemotherapy or radiotherapy.

Addition of bioimpedance-derived body cell mass improves performance of serum creatinine-based GFR estimation in a chronic kidney disease cohort.

PURPOSE: Serum creatinine-based glomerular filtration rate (GFR) estimating equations are imprecise and systemic overestimate GFR in chronic kidney disease (CKD) populations with low muscle mass. Bioimpedance devices can measure body cell mass (BCM), a surrogate for muscle mass which has been included in a published GFR estimating equation. This BCM GFR equation is validated and compared with MDRD and CKD-EPI 2021 equations in an Indian CKD population. METHODS: Patients with stable CKD stages 1-5 and voluntary kidney donors underwent measurement of serum creatinine, DTPA GFR and bioimpedance on the same day. BCM GFR was tested for consistency, agreement and performance with respect to DTPA GFR. RESULTS: A total of 125 study participants were enrolled, including 106 patients with CKD (Stage 1: 8; stage 2: 32, stage 3: 42, stage 4: 20 and stage 5: 4 patients) and 19 voluntary kidney donors, with 66% males, and a mean age of 43.3 (± 16.5) years. The median bias of BCM GFR was 5.45 ml/min/1.73 m2 [95% confidence interval (CI) 4.2-8.3], absolute precision was 10.16 ml/min/1.73 m2 [95% CI 4.5-12.6], P30 was 59.1% [95% CI 50.0-67.7] and accuracy was 8.62% [95% CI 6.4-20.0]. Kappa measurement of agreement was the highest for BCM GFR-based staging (0.628 vs 0.545 for MDRD and 0.487 for CKD-EPI). CONCLUSION: BCM-based GFR estimating equation performed better than MDRD and CKD-EPI equations in this Indian CKD population, and BCM GFR-based KDIGO staging was associated with lesser misclassification than the MDRD and CKD-EPI equations. TRIAL REGISTRATION (PROSPECTIVE): Clinical Trials Registry of India (CTRI/2019/11/021850).

Analysis of the Efficacy of Elastography in Comparison with Dynamic Renal Nuclear Scintigraphy in the Evaluation of Unilateral Pelvi-Ureteric Junction Obstruction.

INTRODUCTION: In hydronephrosis due to pelviureteric junction obstruction (PUJO), an obstruction to urine flow may lead to increased pelvic pressure, which may cause interstitial fibrosis and renal impairment. Recently, there have been reports on renal pelvic assessment using ultrasound elastography (USE). This study was conducted to see if USE can evaluate PUJO and if it can be correlated to the findings of the dynamic renal nuclear scan. MATERIAL AND METHODS: In this observational study, only patients with unilateral PUJO underwent acoustic radiation force impulse (ARFI) elastography. A rectangular region of interest (ROI) measuring 5 × 10 mm was positioned on the cortex region of the upper, mid, and lower poles of the affected kidney. Three valid measurements were obtained, from which a mean value was calculated. A dynamic renal nuclear scan using Technetium-99m ethylene dicysteine (EC or TC99 m EC) was obtained and split renal function (SRF) was used for comparison. RESULTS: In the group of 20 patients, the mean age was 3.37 years. The mean SRF of the affected kidney was 26.65 %, and the corresponding USE value was 0.45 kpa. The Spearman's rho correlation coefficient for SRF and USE was 1 and 0.672, respectively (p = 0.001). Elastography was not feasible if SRF was less than 20 %. CONCLUSION: USE may be able to comment on the renal functional status of hydronephrosis. If USE is reported as non-feasible, it may suggest that renal function is grossly compromised. It may serve as an alternative diagnostic modality for renal functional evaluation. LEVEL OF EVIDENCE: Level II, Prospective Cohort Study.

Endobronchial Squamous Cell Carcinoma Presenting as Long Continuous Bronchial Thickening on 18Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

A 67-year-old man is presented with complaints of chest pain and productive cough for 1½ years. Chest X-ray was suggestive of right upper lobe Koch's lesion. Sputum was positive for mycobacterium tuberculosis. His symptoms got relieved partially by antitubercular treatment but the patient had an aggravation of symptoms for which he was evaluated. Computed tomography (CT) thorax revealed an endobronchial lesion in the right upper lobe bronchus. Bronchoscopy showed a mass in the right main bronchus and biopsy was suggestive of moderately differentiated squamous cell carcinoma (SCC). 18Fluoro-deoxy-glucose positron emission tomography/CT was performed for staging. There would have been chances of coexisting tuberculosis with SCC.

Follicular carcinoma of the thyroid presenting as metastasis in the wall of an arachnoid cyst.

The brain is an uncommon site for metastases of differentiated thyroid carcinoma with the most common location being cerebral hemispheres, followed by cerebellum and pituitary gland. Metastasis in the wall of an arachnoid cyst is exceedingly rare with single case report available in the published literature. Arachnoid cyst metastasis from an extraneuraxial malignancy has not been published until. We present a unique case of thyroid carcinoma metastasizing to the wall of an intracranial arachnoid cyst and the most interesting fact is that it was the first clinical manifestation of her malignancy.

Primary hepatic epithelioid hemangioendothelioma masquerading as metastases: A rare case report.

Epithelioid hemangioendothelioma (EHE) of the liver is an extremely rare malignant tumor of vascular origin, representing less than 1 % of all vascular tumors. Nearly 260 cases have been reported in English literature. Radiologically it is seen as multifocal lesions. It can be seen at different sites like lungs, bones, lymph nodes, breasts, and soft tissue. Often it is misdiagnosed with metastases, cholangiocarcinoma, or angiosarcoma. No definite treatment protocol is available due to its rarity, however, these malignancies are treated by radical resection of the tumor or liver transplant and/or chemotherapy. Here we present a primary hepatic epithelioid hemangioendothelioma (HEHE) which was mimicking metastases in a 42-year-old male who was treated with chemotherapy and radiotherapy. Sadly the patient expired after 1 year of complete course of treatment. Imaging features can help to improve the diagnostic accuracy of this tumor.

A Rare Case of Thyroid Cartilage Metastases Detected on 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

The thyroid cartilage metastatic involvement is an extremely rare entity. It can be asymptomatic at the earlier stage and can become symptomatic later on. Involvement of thyroid cartilage is frequent in melanoma and renal and rarely reported in an advanced stage of carcinoma prostate, breast, and lung. These cases were usually reported on positron emission tomography/computed tomography (PET/CT) as can often easily be missed on computed tomography scan alone. We present a case report of metastatic involvement of thyroid cartilage in squamous cell carcinoma of buccal mucosa detected on the whole-body 18F-fluorodeoxyglucose PET/CT.

Management of non-functioning kidney due to pelvi-ureteric junction obstruction in pediatric age group: an observational study.

INTRODUCTION: A non-functional kidney (NFK) has been defined as one having paper-thin parenchyma, and split renal function (SRF) of < 10% on a nuclear scan. There are differences of opinion about nephrectomy or pyeloplasty in these patients. The present study was conducted to assess our management strategy of renal salvage for NFK. MATERIALS AND METHODS: It was a retrospective cohort study from January 2015 to July 2022, patients having SRF < 10% were included. These patients underwent ultrasound-guided percutaneous nephrostomy (PCN). A repeat nuclear scan was performed after 3 months. If SRF increased to > 10%, pyeloplasty was performed. RESULTS: Fifteen patients were managed. The mean age was 24.67 ± 23.61 months. Male to female ratio was 4:1. The initial mean SRF was 6.67 ± 2.85, which improved to 16.80 ± 4.69 after 3 months of placing the PCN (p < 0.001). The corresponding changes in the mean effective renal plasma flow (ERPF) were 60.13 ± 24.08 to 106.53 ± 24.61 (p < 0.001). There was no complaint after the placement of PCN. All patients underwent dismembered pyeloplasty. CONCLUSION: In NFK due to PUJO, expectant treatment in form of PCN followed by pyeloplasty appears to be the primary treatment modality, and nephrectomy may not be needed in any of them.

To evaluate the minimum number of renal scans required to follow pediatric patient postpyeloplasty.

The aim of the study is to evaluate the minimum number of renal scans required to follow pediatric patients postpyeloplasty. We prospectively reviewed the renal scans of 145 children with unilateral pelvi-ureteric junction obstruction who underwent dismembered pyeloplasty. Patients were then divided into four groups based on preoperative split renal function. All patients were followed with renal scan and ultrasound for minimum of 4 years. Renal scan and ultrasound were done after stent removal at 3, 6, and 12 months and then yearly after surgery. Drainage pattern (T1/2) was seen in all groups, except in patients where there was no comment on drainage pattern. Statistical analysis was performed using the Friedman ANOVA and Wilcoxon signed-ranks test as a post hoc test with Bonferroni correction and Kruskal-Wallis test with Mann-Whitney U-test as a post hoc test with Bonferroni correction. On comparison of the pattern of drainage with time in Groups 1-4, it was found that there was no significant difference with time in Group 1. Then, further, using Wilcoxon signed-rank test as post hoc test for Friedman ANOVA, Group 2 showed statistically significant difference in drainage pattern in scans between 6 months and 1 year, Group 3 showed statistically significant difference in drainage pattern in scans between 3 months and 1 year, and Group 4 showed statistically significant difference in drainage pattern in scans done between 3 and 6 months (P < 0.05). Minimum of three renal scans were required for paediatric patients post pyeloplasty at 3 months, 6 months and 1 year in the follow up period.

Contamination, a Major Problem in Nuclear Medicine Imaging: How to Investigate, Handle, and Avoid It.

We present a case study in which artifacts from collimator contamination and patient motion were seen on a bone scan. Any identified artifact must be further investigated and documented so as to detect its source and thus prevent its future occurrence.

Extraosseous 99mTc-methylene diphosphonate uptake on bone scan: Unusual scenario.

In nuclear medicine, 99mTc-methylene diphosphonate. (MDP) bone scan is one of the most commonly performed procedures. MDP uptake in nonosseous tissues is occasionally found in bone scan, and the knowledge of these kinds of extraosseous uptakes is of much clinical relevance. We report here two cases where bone scan showed extraosseous MDP uptake either hepatic or splenic apart from the physiological skeletal uptake.

Benefits of adopting good radiation practices in reducing the whole body radiation dose to the nuclear medicine personnel during (18)F-fluorodeoxyglucose positron emission tomography/computed tomography imaging.

INTRODUCTION: Positron emission tomography has been established as an important imaging modality in the management of patients, especially in oncology. The higher gamma radiation energy of positron-emitting isotopes poses an additional radiation safety problem. Those working with this modality may likely to receive higher whole body doses than those working only in conventional nuclear medicine. The radiation exposure to the personnel occurs in dispensing the dose, administration of activity, patient positioning, and while removing the intravenous (i.v.) cannula. The estimation of radiation dose to Nuclear Medicine Physician (NMP) involved during administration of activity to the patient and technical staff assisting in these procedures in a positron emission tomography/computed tomography (PET/CT) facility was carried out. MATERIALS AND METHODS: An i.v access was secured for the patient by putting the cannula and blood sugar was monitored. The activity was then dispensed and measured in the dose calibrator and administered to the patient by NMP. Personnel doses received by NMP and technical staff were measured using electronic pocket dosimeter. The radiation exposure levels at various working locations were assessed with the help of gamma survey meter. RESULTS AND DISCUSSION: The radiation level at working distance while administering the radioactivity was found to be 106-170 µSv/h with a mean value of 126.5 ± 14.88 µSv/h which was reduced to 4.2-14.2 µSv/h with a mean value of 7.16 ± 2.29 µSv/h with introduction of L-bench for administration of radioactivity. This shows a mean exposure level reduction of 94.45 ± 1.03%. The radiation level at working distance, while removing the i.v. cannula postscanning was found to be 25-70 µSv/h with a mean value of 37.4 ± 13.16 µSv/h which was reduced to 1.0-5.0 µSv/h with a mean value of 2.77 ± 1.3 µSv/h with introduction of L-bench for removal of i.v cannula. This shows a mean exposure level reduction of 92.85 ± 1.78%. CONCLUSION: This study shows that good radiation practices are very helpful in reducing the personnel radiation doses. Use of radiation protection devices such as L-bench reduces exposure significantly. PET/CT staff members must use their personnel monitors diligently and should do so in a consistent manner so that comparisons of their doses are meaningful from one monitoring period to the next.

SPECT in asymptomatic diabetics with and without microalbuminuria.

OBJECTIVE: To identify coronary artery disease (CAD) in asymptomatic diabetics with the help of myocardial perfusion single photon emission computed tomography (MPS), a non-invasive imaging modality and its correlation in diabetics with or without microalbuminuria. METHODS: This study included 99 patients in the age group of 30 to 80 years who were asymptomatic but possessed one or more risk factors for CAD. These patients were divided into two groups, diabetics with and without microalbuminuria (Micral). Thirty eight patients were Micral positive and 61 were Micral negative. Ischemia was detected by MPS and compared with coronary angiographic findings in both the groups. RESULTS: Amongst the 99 diabetic patients, MPS was positive in 39 patients. Out of 39 MPS positive patients, 31(79.5%) were micral positive and 8 (20.5%) were micral negative. Out of 38 micral positive patients, 31 patients were positive on MPS and 27 had significant angiographic (CAG) findings. Those with micral positive and MPS positive had multivessel CAD by CAG. It was seen that MPS status was 91.4% sensitive, 74.1% specific and had 82.1% positive predictive values (PPV) and 87.0% negative predictive value (NPV) for detection of significant CAD. CONCLUSION: Microalbuminuria is an inexpensive screening tool and a powerful independent predictor for major cardiovascular events in patients with type 2 diabetes mellitus. MPS is a sensitive, non invasive diagnostic test for identification of CAD in asymptomatic diabetic patients.