Discordant Molecular Imaging Findings with 2-[18F]FDG and [68Ga]Ga-PSMA PET/CT in a Patient with Both Bladder and Prostate Cancer.

The prevalence of double primary prostate and bladder cancer is not uncommon. Though both share a common pathway of malignant transformation, they bear to differ in the case of 2-[18F]FDG PET/CT and [68Ga]Ga-PSMA uptake. We present a case of double primary cancer involving the bladder and prostate, where the prostatic primary showed intense [68Ga]Ga-PSMA uptake with non-avid skeletal and pulmonary metastases, which showed intense 2-[18F]FDG uptake, thus showing discordance due to different clonal origins.

Pulmonary Mucoepidermoid Carcinoma Mimicking Carcinoid Lung on 18 F-FDG and 68 Ga-DOTANOC PET/CT.

ABSTRACT: Pulmonary mucoepidermoid carcinoma (PMEC) is a rare pulmonary neoplasm. Although 18 F-FDG PET/CT has been shown to present with increased metabolic activity in PMEC, literature does not report increased somatostatin receptor expression in these tumors. We present the case of a 15-year-old boy where PMEC mimicked a typical carcinoid of the lung on DOTANOC PET/CT by showing significant uptake on 68 Ga-DOTANOC.

Role of FDG PET/CT in definitive and presumed autoimmune encephalitis.

OBJECTIVE: F-18 Fluorodeoxyglucose PET/CT (FDG-PET) is emerging as a useful imaging adjunct to MRI in the initial diagnostic evaluation of autoimmune encephalitis (AIE)-though presently it is not included in the diagnostic criteria. MATERIALS AND METHODS: In this prospective study we enrolled a total of 52 patients with clinically diagnosed and treated AIE. MRI evaluation was done in each case along with CSF and EEG where feasible. FDG-PET was done for all and images were interpreted visually and using SPM. RESULTS: The mean age group of patients included was 38.5 ± 22.6 years with 31 females and 21 males. 23 antibody-positive cases underwent PET, the most common antibody detected was anti-NMDAR type followed by anti-LGI 1. Most common metabolic pattern in NMDARE was hypermetabolism in basal ganglia and hypometabolism in parieto-occipital cortices and ovarian teratoma was detected in two of these patients on whole-body PET. A metabolic pattern consistent with AIE was demonstrated in 22/29 (75.8%) antibody-negative patients with hypermetabolism in basal ganglia and mesial temporal cortices. The overall sensitivity of FDG PET was 86% (45/52). MRI abnormalities were detected in 22/52 (42%) cases, 10/23 antibody positive and 12/29 antibody negative cases. PET was positive in 23/30 (76%) MRI negative cases. CONCLUSION: Sensitivity of FDG PET for supporting a diagnosis of AIE was higher compared to MRI in both antibody-positive (definitive) and antibody-negative (presumed) AIE. Specific metabolic patterns can be demonstrated on FDG PET in AIE, prompting an early diagnosis so that timely treatment can be instituted.

Near-lossless Compression of Tc-99 m DMSA Scan Images Using Discrete Cosine Transformation.

Aim and Objective: The objective of this study was to optimize the threshold for discrete cosine transform (DCT) coefficients for near-lossless compression of Tc-99 m Dimercaptosuccinic acid (DMSA) scan images using discrete cosine transformation. Materials and Methods: Two nuclear medicine (NM) Physicians after reviewing several Tc-99 m DMSA scan images provided 242 Tc-99 m DMSA scan images that had scar. These Digital imaging and communication in medicine (DICOM) images were converted in the Portable Network Graphics (PNG) format. DCT was applied on these PNG images, which resulted in DCT coefficients corresponding to each pixel of the image. Four different thresholds equal to 5, 10, 15, and 20 were applied and then inverse discrete cosine transformation was applied to get the compressed Tc-99 m DMSA scan images. Compression factor was calculated as the ratio of the number of nonzero elements after thresholding DCT coefficients to the number of nonzero elements before thresholding DCT coefficients. Two NM physicians who had provided the input images visually compared the compressed images with its input image, and categorized the compressed images as either acceptable or unacceptable. The quality of compressed images was also assessed objectively using the following eight image quality metrics: perception-based image quality evaluator, structural similarity index measure (SSIM), multiSSIM, feature similarity indexing method, blur, global contrast factor, contrast per pixel, and brightness. Pairwise Wilcoxon signed-rank sum tests were applied to find the statistically significant difference between the value of image quality metrics of the compressed images obtained at different thresholds and the value of the image quality metrics of its input images at the level of significance = 0.05. Results: At threshold 5, (1) all compressed images (242 out of 242 Tc-99 m DMSA scan images) were acceptable to both the NM Physicians, (2) Compressed image looks identical to its original image and no loss of clinical details was noticed in compressed images, (3) Up to 96.65% compression (average compression: 82.92%) was observed, and (4) Result of objective assessment supported the visual assessment. The quality of compressed images at thresholds 10, 15, and 20 was significantly better than that of input images at P < 0.0001. However, the number of unacceptable compressed images at thresholds 10, 15, and 20 was 6, 38, and 70, respectively. Conclusions: Up to 96.65%, near-losses compression of Tc-99 m DMSA images was found using DCT by thresholding DCT coefficients at a threshold value equal to 5.

Utility of 99mTc-Sulfur Colloid Lymphoscintigraphy and SPECT/CT in Chylothorax and Chylous Ascites.

Purpose: To assess the diagnostic efficacy of 99mTc-sulfur colloid lymphoscintigraphy in chylothorax and chylous ascites, and the utility of single-photon emission computed tomography-computed tomography (SPECT/CT) in localizing the sites of leaks. Methods: Data from patients who underwent lymphoscintigraphy for clinical suspicion of chylothorax or chylous ascites were retrospectively analyzed. Biochemical fluid analysis was taken as the reference standard. Pleural fluid triglyceride level > 110 mg/dL (with pleural fluid/serum ratio > 1) and a cholesterol level < 200 mg/dL (with pleural fluid/serum ratio < 1) were considered confirmatory for chylothorax. Ascitic fluid triglyceride level > 200 mg/dL with a low cholesterol level (ascites fluid/serum ratio < 1) was considered confirmatory for chylous ascites. Results: 26 patients (15 males, 57.7%) aged 9 months to 68 years were enrolled in the study. Based on the reference standard, 17 had chylothorax or chylous ascites (9 with surgical history). Lymphoscintigraphy was positive in 16 (with 1 false positive) and negative in 10 (with 2 false negatives). The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of lymphoscintigraphy were 88.2% (63.6-98.5%), 88.9% (51.8-99.7%), 80.0% (51.6-93.8%), 93.8% (70.1-99.0%), and 88.5% (69.9-97.6%), respectively. SPECT/CT could localize sites of leaks in 61.5% (8/13) with a localization rate of 77.8% (7/9) and 25.0% (1/4) in patients with surgical and nonsurgical causes, respectively. Conclusion: 99mTc-sulfur colloid lymphoscintigraphy is a highly efficacious noninvasive modality to diagnose chylothorax or chylous ascites with a high positive predictive value. SPECT/CT could localize the sites of leaks more frequently in patients with surgical causes.

Utility of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Cardiac Infections.

Diagnosis of cardiac infections, which includes infective endocarditis (IE) and cardiac device infections, despite having a high death rate, is still challenging. Frequently used modalities such as echocardiography, computed tomography (CT), and magnetic resonance imaging cannot confirm the presence of an active infection or extracardiac findings. Taking these things to consideration, newer guidelines have suggested the inclusion of 18F fluorodeoxyglucose positron emission tomography/CT (18F FDG PET/CT) in the workup of patients with suspected prosthetic valve IE. In this pictorial essay, we are demonstrating the utility of 18F-FDG PET/CT in varied cases of IE, cardiac implantable electronic devices, and coronary stent infection and how they helped in solving diagnostic dilemmas.

99m-Tc MDP Bone Scan Image Enhancement using Pipeline Application of Dynamic Stochastic Resonance Algorithm and Block-Matching 3D Filter.

Introduction: In this pilot study, we have proposed and evaluated pipelined application of the dynamic stochastic resonance (DSR) algorithm and block-matching 3D (BM3D) filter for the enhancement of nuclear medicine images. The enhanced images out of the pipeline were compared with the corresponding enhanced images obtained using individual applications of DSR and BM3D algorithm. Materials and Methods: Twenty 99m-Tc MDP bone scan images acquired on SymbiaT6 SPECT/CT gamma camera system fitted with low-energy high-resolution collimators were exported in DICOM format to a personal computer and converted into PNG format. These PNG images were processed using the proposed algorithm in MATLAB. Two nuclear medicine physicians visually compared each input and its corresponding three enhanced images to select the best-enhanced image. The image quality metrics (Brightness, Global Contrast Factor (GCF), Contrast per pixel (CPP), and Blur) were used to assess the image quality objectively. The Wilcoxon signed test was applied to find a statistically significant difference in Brightness, GCF, CPP, and Blur of enhanced and its input images at a level of significance. Results: Images enhanced using the pipelined application of SR and BM3D were selected as the best images by both nuclear medicine physicians. Based on Brightness, Global Contrast Factor (GCF), CPP, and Blur, the image quality of our proposed pipeline was significantly better than enhanced images obtained using individual applications of DSR and BM3D algorithm. The proposed method was found to be very successful in enhancing details in the low count region of input images. The enhanced images were bright, smooth, and had better target-to-background ratio compared to input images. Conclusion: The pipelined application of DSR and BM3D algorithm produced enhancement in nuclear medicine images having following characteristics: bright, smooth, better target-to-background ratio, and improved visibility of details in the low count regions of the input image, as compared to individual enhancements by application of DSR or BM3D algorithm.

Incidentally Detected Gastrointestinal Stromal Tumor in a Patient with Carcinoma Prostate: 68Ga-Prostate-Specific Membrane Antigen Versus 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography.

Uptake of 68Ga-prostate-specific membrane antigen (PSMA) in various nonprostatic tumors is well documented in the literature. We present a case of a gastrointestinal stromal tumor, incidentally detected on 68Ga-PSMA positron emission tomography/computed tomography imaging in a patient who underwent imaging for a suspected recurrence of carcinoma prostate.

Imaging Acute Myocarditis with 68Ga-DOTANOC PET/CT.

Somatostatin receptor (SSTR) imaging is a useful method in the diagnosis of acute myocarditis. We present a case of a 54-year-old male with a clinical diagnosis of acute myocarditis in whom, 68Ga-DOTANOC positron emission tomography/computed tomography PET/CT showed diffuse left ventricular myocardial uptake. SSTR imaging can act as a surrogate marker of active inflammation. SSTR imaging is useful in deciding site of biopsy, assessing response to therapy and for prognostication.

Utility of 68Ga-DOTANOC PET/CT in therapeutic monitoring of cardiac sarcoidosis.

Cardiac sarcoidosis usually occurs as a manifestation of systemic sarcoidosis, even though isolated cardiac involvement is not uncommon. The usefulness of 68Ga-DOTANOC PET/CT in the diagnosis of CS has been previously documented in the literature. We present a case of cardiac sarcoidosis, where 68Ga-DOTANOC PET/CT was used for monitoring response to therapy.

Serendipitous Diagnosis of Tertiary Hyperparathyroidism in a Case Purportedly thought to have Skeletal Metastases.

Tertiary hyperparathyroidism (THPT) is characterized by over secretion of parathyroid hormone caused by long-standing secondary hyperparathyroidism. THPT can affect the bones as well as cause extraskeletal calcifications. The bony lesions often mimic multiple skeletal metastases or multiple myeloma. We report a case of a 48-year-old man with chronic kidney disease on dialysis, who presented with chief complaints of low back ache and swelling over the left clavicle. In view of clinical suspicion of malignancy with bony metastases, he underwent 18F-fluorodeoxyglucose positron emission tomography/computed tomography and was subsequently found to have parathyroid adenomas, which were confirmed on 99mTc-methoxy-isobutyl-isonitrile scintigraphy.

Near-lossless compression of PET/CT images using singular value decomposition.

AIMS AND OBJECTIVES: The aim of the study is to compare the single matrix approach and slice-by-slice approach for computing singular value decomposition (SVD) to achieve near-lossless compression of PET/CT images. MATERIALS AND METHODS: The parameters used for comparison were SVD computation time, percentage compression and percentage difference between ROI counts on compressed and original images. SVD of 49 F-18-FDG PET/CT studies (33 370 PET/CT images) was computed using both approaches. The smaller singular values contributing insignificant information to the image were truncated, and then, the compressed image was reconstructed. A mask (101 × 101pixels) was used to extract the ROI counts from compressed and original images. Two nuclear medicine physicians compared compressed images with their corresponding original images for loss of clinical details and the presence of generated artifacts. Structural Similarity Index Measure, blur, brightness, contrast per pixel and global contrast factor were used for objective assessment of image quality. Wilcoxon test was applied to find a statistically significant difference between the parameters used for comparison at alpha = 0.05. RESULTS: Nuclear medicine physicians found compressed image identical to the corresponding original image. The values of comparation parameters were significantly larger for the single matrix approach in comparison with the slice-by-slice approach. The maximum percentage error between the compressed image and original image was less than 5%. CONCLUSIONS: Up to 64 % and 44% near-lossless compression of PET and CT images were achieved, respectively using the slice-by-slice approach, and up to 58 and 53% near-lossless compression of PET and CT images were achieved respectively using the single matrix approach.

Utility of PET/Computed Tomography in Infection and Inflammation Imaging.

The role of nuclear medicine for noninvasive assessment of infection and inflammation is well established. The role of nuclear medicine is limited to initial diagnosis, recurrence, and response assessment of infections and inflammations such as tuberculosis, sarcoidosis, vasculitis, osteomyelitis, immunoglobulin G4-related diseases, and coronavirus disease 2019, as the specificity is affected by false positivity due to physiologic fluorodeoxyglucose uptake in specific organ and nonspecific uptake in postoperative cases. PET with fludeoxyglucose F 18/CT is a well-established modality for diagnosis of fever of unknown origin helping in optimized management of the patient.

Restoration of Tc-99m methyl diphosphonate bone scan image using Richardson-Lucy algorithm.

INTRODUCTION: In this study, the optimal input parameters point spread function (PSF) and the number of iterations of the Richardson-Lucy algorithm were experimentally determined to restore Tc-99 m methyl diphosphonate (MDP) whole-body bone scan images. MATERIALS AND METHODS: The experiment was performed on 60 anonymized Tc-99 m MDP whole-body bone scan images. Ten images were used for estimating the optimum value of PSF and the number of iterations to restore scintigraphic images. The remaining 50 images were used for validation of estimated parameters. The image quality of observed and restored images was assessed objectively using blind/referenceless image spatial quality evaluator (BRISQUE), mean brightness (MB), discrete entropy (DE), and edge-based contrast measure (EBCM) image quality metrics. Image quality was subjectively assessed by two nuclear medicine physicians (NMPs) by comparing the restored image quality with observed image quality and assigning a score to each image on the scale of 0-5. RESULTS: Based on BRISQUE, MB, DE, and EBCM scores, the restored images were significantly sharper, less bright, had more detailed information, and had less contrast around edges compared to the input images. The restored images had improved resolution based on visual assessment as well; NMPs assigned an average image quality score of 4.00 to restored images. Maximum resolution enhancement was noticed at PSF (size: 11 pixels, sigma: 1.75 pixels) and the number of iterations = 10. With the increase in the number of iterations, noise also gets amplified along with resolution enhancement and affects the detectability of small lesions; in the case of relatively low noisy input images, the number of iterations = 5 gave better results. CONCLUSION: Tc-99 m MDP bone scan images were restored to improve image quality using the Richardson-Lucy algorithm. The optimum value of the PSF parameter was found to be of size = 11 pixels and sigma = 1.75 pixels.

Lower Gastrointestinal Bleed Playing Hide and Seek.

A 13-year-old adolescent male presented with an episode of rectal bleed. He has had five such episodes in the past year where he witnessed black tarry stools mixed with fresh blood, painless, not associated with fever or hematemesis. Clinical examination revealed pallor and a soft, non-tender abdomen. Vitals were stable. Blood investigations revealed haemoglobin of 102g/L, WBC count of 10 X 109/L and platelet count of 165 × 109/L. The clotting screen was normal. Upper GI endoscopy and colonoscopy revealed no abnormality. The patient underwent Tc-99m pertechnetate scintigraphy to look for Meckel's Diverticulum in view of painless lower GI bleed.

Compression of 99mTc Methylene Diphosphonate Bone Scan Images using Discrete Cosine Transformation.

Aims and Objectives: The objective of this study was to find the optimum value of threshold for compression of 99mTc-methylene diphosphonate (MDP) bone scan images using discrete cosine transformation (DCT). Materials and Methods: DCT was applied to 51 99mTc-MDP bone scan images and then the image of logarithmic value of DCT coefficients was inspected to determine the threshold. After inspecting the number of images of DCT coefficients, we estimated the appropriate value of the threshold to be 10. After the application of threshold = 10, compressed image was reconstructed by applying the inverse DCT. Compression factor was calculated by dividing the nonzero element after thresholding to the nonzero element before thresholding DCT coefficients. Nuclear medicine physicians compared the compressed images with its input images and labeled them as acceptable or unacceptable. During comparison of input and compressed images, we considered points such as smoothening, blocking artifacts, body contour, gap between closely placed lesions, and detectability of lesion. Results: Forty-four compressed images (out of 51 images) obtained at threshold 10 were acceptable to Nuclear Medicine Physician (NMP). Compressed images were less noisy compared to its input image. Compression factor was found to be 13.03 ± (minimum = 2.71, maximum = 42.92). Conclusion: The optimum value of threshold for compression of 99mTc-MDP bone scan images was found to be 10, and the average compression factor achieved was equal to 13.03 (92.30%).

Contrast Enhancement of Scintigraphic Image Using Fuzzy Intensification.

Introduction: The objective of this study was to see the effect of fuzzy intensification (INT) operator on enhancement of scintigraphic image. Materials and Methods: Nuclear medicine physician (NMP) provided 25 scintigraphic images that required enhancement. The image pixels value was converted into fuzzy plane and was subjected to contrast INT operator with parameters of INT operator i.e., cross-over = 0.5 and number of iterations = 1 and 2. The enhanced image was again brought back into spatial domain (de-fuzzification) whose intensity value was in the range 0-255. NMP compared the enhanced image with its input image and labeled it as acceptable or unacceptable. The quality of enhanced image was also accessed objectively using four different image metrics namely: Entropy, edge content, absolute mean brightness error and saturation metrics. Results: Most of the enhanced images (18 out of 25 images) obtained at cross-over = 0.5 and number of iterations = 1 are acceptable and found to have overall better contrast compared to the corresponding input image. Four images (two brain positron emission tomography scan and two I-131 scan) obtained at cross-over = 0.5 and with iteration = 2 are acceptable. Three input images (one dimercaptosuccinic acid (DMSA), one I-131 and one I-131- metaiodo-benzyl-guanidine (MIBG) scan) were better than their enhanced images. Conclusions: The enhancement produced by fuzzy INT operator was encouraging. Majority of enhanced images were acceptable at cross-over = 0.5 and number iterations = 1.

F-18 ML-104 tau PET imaging in mild cognitive impairment.

OBJECTIVE: This study was undertaken to evaluate the tau distribution patterns in patients with amnestic mild cognitive impairment (aMCI) using PET radiotracer F-18 ML-104. MATERIALS AND METHODS: Thirty patients, clinically diagnosed as aMCI [mini mental state evaluation ≥24] in the neurology or geriatric memory clinics, were included in the study. Each aMCI patient underwent F-18 fluorodeoxyglucose and F-18 ML-104 tau PET. Standardized uptake value ratios for cortical gray matter regions were evaluated for F-18 ML-104 tau PET and compared with normal controls and with early Alzheimer's disease (AD) patients (used from a previous study). RESULTS: aMCI revealed significantly higher standardized uptake value ratios in both medial temporal cortices, precuneus and posterior cingulate cortices in comparison to normal controls and a significantly lesser binding in bilateral medial and lateral temporal, precuneus and posterior cingulate cortices in comparison to early AD. A negative correlation was noted between F-18 fluorodeoxyglucose uptake and F-18 ML-104 retention in the precuneus and posterior cingulate cortices in aMCI, while F-18 ML-104 retention and mini mental state evaluation scores revealed a moderate negative correlation in the posterior cingulate cortices. CONCLUSION: We could demonstrate a significant increase in cortical tau deposition in aMCI patients in comparison to normal controls, thus providing in vivo evidence of the underlying pathological process in this subgroup of patients with high probability of conversion to AD.