Herpetic Eye Disease Study: A Controlled Trial of Topical Corticosteroids for Herpes Simplex Stromal Keratitis.

PURPOSE: To evaluate the efficacy of topical corticosteroids in treating herpes simplex stromal keratitis. METHODS: The authors performed a randomized, double-masked, placebo-con- trolled, multicenter clinical trial of 106 patients with active herpes simplex stromal keratitis who had not received any corticosteroids for at least 10 days before study enrollment. Patients were assigned to the placebo group (n = 49) or the steroid group (topical prednisolone phosphate; n = 57); both regimens were tapered over 10 weeks. Both groups received topical trifluridine. Visual acuity assessment and slit-lamp biomicroscopy were performed weekly for 10 weeks, every other week for an additional 6 weeks or until removal from the trial, and at 6 months after randomization. RESULTS: The time to treatment failure (defined by specific criteria as persistent or progressive stromal keratouveitis or an adverse event) was significantly longer in the steroid group compared with the placebo group. Compared with placebo, corticosteroid therapy reduced the risk of persistent or progressive stromal keratouveitis by 68%. The time from randomization to resolution of stromal keratitis and uveitis was significantly shorter in the steroid group compared with the placebo group even though both groups included patients who were removed from the study and treated with topical corticosteroids according to best medical judgment. Nineteen (33%) of the steroid-treated patients and 11 (22%) of the placebo-treated patients completed the 10 weeks of protocol therapy and had stable, noninflamed corneas after 16 weeks. At 6 months after randomization, no clinically or statistically significant differences in visual outcome or recurrent herpetic eye disease were identified between the steroid and placebo groups. CONCLUSIONS: The topical corticosteroid regimen used in this study was significantly better than placebo in reducing persistence or progression of stromal inflammation and in shortening the duration of herpes simplex stromal keratitis. Postponing steroids during careful observation for a few weeks delayed resolution of stromal keratitis but had no detrimental effect as assessed by visual outcome at 6 months.

Characteristics and Limitations of FDG PET/CT for Imaging of Squamous Cell Carcinoma of the Head and Neck: A Comprehensive Review of Anatomy, Metastatic Pathways, and Image Findings.

OBJECTIVE: This image-based article illustrates the anatomic regions of squamous cell carcinomas of the head and neck and describes the metastatic pathways in and TNM staging for each region. Both the role and limitations of FDG PET/CT in imaging such cancers are discussed, and cases exemplifying these issues are reported. Also included is a discussion of the use of FDG PET/CT to monitor the response of squamous cell carcinomas of the head and neck to therapy, in addition to a brief comparison of PET/CT with such traditional imaging modalities as CT, MRI, and ultrasound. CONCLUSION: Understanding the characteristics of squamous cell carcinoma of the head and neck, as imaged by FDG PET/CT, is crucial for determining treatment strategy, because it helps to avoid incorrect staging and also provides an accurate assessment of treatment response.

Quantitative dosimetry for yttrium-90 radionuclide therapy: tumor dose predicts fluorodeoxyglucose positron emission tomography response in hepatic metastatic melanoma.

PURPOSE: To assess a new method for generating patient-specific volumetric dose calculations and analyze the relationship between tumor dose and positron emission tomography (PET) response after radioembolization of hepatic melanoma metastases. METHODS AND MATERIALS: Yttrium-90 ((90)Y) bremsstrahlung single photon emission computed tomography (SPECT)/computed tomography (CT) acquired after (90)Y radioembolization was convolved with published (90)Y Monte Carlo estimated dose deposition kernels to create a three-dimensional dose distribution. Dose-volume histograms were calculated for tumor volumes manually defined from magnetic resonance imaging or PET/CT imaging. Tumor response was assessed by absolute reduction in maximum standardized uptake value (SUV(max)) and total lesion glycolysis (TLG). RESULTS: Seven patients with 30 tumors treated with (90)Y for hepatic metastatic melanoma with available (90)Y SPECT/CT and PET/CT before and after treatment were identified for analysis. The median (range) for minimum, mean, and maximum dose per tumor volume was 16.9 Gy (5.7-43.5 Gy), 28.6 Gy (13.8-65.6 Gy) and 36.6 Gy (20-124 Gy), respectively. Response was assessed by fluorodeoxyglucose PET/CT at a median time after treatment of 2.8 months (range, 1.2-7.9 months). Mean tumor dose (P = .03) and the percentage of tumor volume receiving ≥ 50 Gy (P < .01) significantly predicted for decrease in tumor SUV(max), whereas maximum tumor dose predicted for decrease in tumor TLG (P < .01). CONCLUSIONS: Volumetric dose calculations showed a statistically significant association with metabolic tumor response. The significant dose-response relationship points to the clinical utility of patient-specific absorbed dose calculations for radionuclide therapy.

A simple method for estimating dose delivered to hepatocellular carcinoma after yttrium-90 glass-based radioembolization therapy: preliminary results of a proof of concept study.

PURPOSE: To investigate a simple semiquantitative method to estimate yttrium-90 ((90)Y) dose delivered with radioembolization to infiltrative hepatocellular carcinoma (HCC). MATERIALS AND METHODS: In a prospective study, patients with infiltrative HCC and portal vein thrombosis (PVT) underwent glass-based (90)Y radioembolization including technetium-99m macroaggregated albumin ((99m)Tc-MAA) hepatopulmonary shunt study before therapy and bremsstrahlung single photon emission computed tomography (SPECT)/computed tomography (CT) after (90)Y radioembolization. Baseline magnetic resonance imaging was coregistered with (99m)Tc-MAA and bremsstrahlung SPECT/CT imaging separately. Unit tumor activity ((90)Y radioactivity delivered to each cubic centimeter of tumor) was estimated based on a lobar infusion approach. Correlation between proportions of (99m)Tc-MAA and (90)Y delivered to the tumor was investigated. Survival analysis was performed using Kaplan-Meier estimations. RESULTS: (90)Y therapy was administered in 18 consecutive patients (median age, 55.3 y; mean tumor volume, 588 cm(3)). Higher intratumoral (90)Y dose predicted prolonged survival, with 13.2-month median survival in patients with HCC and mean (90)Y dose of ≥ 100 Gy versus 4.6-month median survival for other patients (P < .001). Of administered (90)Y dose, 51.9% was delivered to the targeted tumors compared with 74.1% of (99m)Tc-MAA with linear correlation between biodistribution of (99m)Tc-MAA and (90)Y observed (Pearson r = 0.774, P < .001). CONCLUSIONS: The findings in this study suggest that approximately 50% of administered (90)Y dose is taken up by targeted infiltrative HCC with PVT. Intratumoral (90)Y dose ≥ 100 Gy in unresectable infiltrative HCC via a lobar intraarterial approach is a positive prognostic factor for survival.

Radiologic reporting: the ethical obligation of the interpreting physician to provide an accurate report.

OBJECTIVE: This article focuses on the radiology report and examines how related errors can affect patient care even though the radiologist might resist disclosing or discussing reporting errors in a patient-centered way. By using scenarios involving issues in reporting, we hope to show how various ethical theories support the obligation of a radiologist to provide an honest, complete report and to ensure that errors are disclosed to patients. CONCLUSION: Radiologists should be willing to make corrections when necessary and ethical theories and principles are available to guide them in their duty to care for their patients. Physicians owe it to their patients, their patients' families, and the medical profession to produce an honest and truthful report. Despite temptations to deviate from ethically appropriate action, physicians must make honesty to their patients and reporting of errors a priority. Few patients expect absolute perfection from their physicians, but honesty and truthfulness in reporting will advance physician-patient and physician-physician relationships and can foster optimal patient care.

Central Retinal Artery Occlusion with Concomitant Intracranial Hemorrhage Secondary to Streptococcus Gordonii Endocarditis.

Purpose: To report a case of central retinal artery occlusion (CRAO) associated with subacute Streptococcus gordonii endocarditis secondary to a dental infection. Observations. A 27-year-old male presented with acute monocular vision loss in the setting of a stroke and seizure. A fundus exam revealed macular whitening and a cherry-red spot. Edema of the inner retinal layers was confirmed on macular optical coherence tomography, consistent with CRAO. Initial imaging (carotid Doppler, EKG, and transthoracic echocardiography) and a comprehensive laboratory workup did not reveal an etiology for the stroke or vision loss. Brain magnetic resonance imaging showed T1 hyperintensity with surrounding edema, which prompted a workup for possible septic emboli versus occult malignancy. Subsequent blood cultures led to the detection and diagnosis of Streptococcus gordonii endocarditis. It was subsequently revealed that the patient had self-extracted his molar two months prior to the onset of symptoms. Conclusions: Endocarditis has been associated with Roth spots and inflammatory findings in the posterior segment. However, CRAO caused by vegetal septic embolism is rare. To our knowledge, this represents the first reported case of endocarditic CRAO with Streptococcus gordonii confirmed as the causative microbe. Retinal vascular occlusion in a young patient with no distinct risk factors should prompt a comprehensive dental history and infectious workup, with consideration given to early transesophageal echocardiography.

Prognostic value of 18f-fluorodeoxyglucose positron emission tomography-computed tomography in predicting survival in patients with unresectable metastatic melanoma to the liver undergoing yttrium-90 radioembolization.

PURPOSE: To investigate the prognostic value of (18)F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) in predicting survival in patients with unresectable metastatic melanoma to the liver undergoing yttrium-90 ((90)Y) radioembolization. MATERIALS AND METHODS: A retrospective review of 12 patients with unresectable hepatic melanoma metastases (5 patients with cutaneous metastases, 7 patients with ocular metastases) who underwent (18)F-FDG PET-CT before (90)Y was performed. Metabolically significant tumors, defined as having a long-axis diameter ≥ 1 cm and maximum standardized uptake value (SUV(max)) ≥ 2.5, were identified on (18)F-FDG PET-CT. SUV(max), glycolytic activity, and volume were determined for each tumor. Overall SUV(max), total tumor glycolytic activity (TGA), total metabolic tumor volume (MTV), and metabolic tumor burden (MTB) based on percentage of liver involvement (MTV/total liver volume) were calculated. Kaplan-Meier method, life-table analysis, and Cox proportional hazards model were used for statistical analysis. RESULTS: Median SUV(max) was 10.9 (range, 4.6-15.3), median TGA was 377.0 SUV/cm(3) (range, 53.6-20,393.4 SUV/cm(3)), median MTV was 85.4 cm(3) (range, 11.5-2,504.1 cm(3)), and median MTB was 5.5% (range, 0.1%-54.0%). MTB was found to be a significant negative prognostic marker of survival on univariate (P = .020) and multivariate (P = .018) analyses accounting for age and duration from metastatic diagnosis to first (90)Y treatment. A 60th percentile MTB of 7.0% (hazard ratio, 5.704; P = .040) was a statistically significant cutoff. Median survivals from first (90)Y treatment in patients with MTB < 7.0% and ≥ 7.0% were 10.8 months (95% confidence interval [CI], 6.8-14.8) and 4.7 months (95% CI, 1.6-7.8), respectively. SUV(max) (P = .422), TGA (P = .064), and MTV (P = .065) were not found to be statistically significant. CONCLUSIONS: MTB based on (18)F-FDG PET-CT performed before treatment was found to be a negative prognostic factor for patient survival after (90)Y radioembolization for unresectable metastatic melanoma to liver.

Yttrium-90 dosimetry and implications on tumour response and survival after radioembolisation of chemo-refractory hepatic metastases from breast cancer.

PURPOSE: The aim of the study was to evaluate the effects of tumour dose on tumour response and overall survival (OS) in patients with chemo-refractory metastatic breast cancer (MBC) to the liver undergoing yttrium-90 radioembolisation (Y90 RE). MATERIALS AND METHODS: In 20 consecutive patients with chemo-refractory MBC to the liver undergoing 33 total Y90 RE resin treatments, volumes of interest were drawn around the five largest tumours of the targeted liver lobe on post-Y90 RE Bremsstrahlung single-photon emission computed tomography/computed tomography using MIM software v.6.9 (MIM Software, Cleveland, Ohio, USA) and dose-volume histograms were calculated. Response Evaluation Criteria in Solid Tumours (RECIST) was used to determine tumour response at 3 months. Receiver operating characteristics (ROC) curves were used to determine thresholds for various dosimetry parameters. Kaplan-Meier estimation was used to determine OS. RESULTS: Overall, 11 of 33 (33%) Y90 RE treatments resulted in complete or partial response according to RECIST criteria with a median OS of 20.97 months compared to 11.73 months for nonresponders (P = 0.003). Mean tumour dose, defined as the aggregate tumour dose of up to the five largest tumours in the targeted lobe, was the most predictive of tumour response with the highest area under the ROC curve of 0.967. Mean tumour dose >70 Gy had 91% sensitivity and 100% specificity for predicting tumour response. Patients with mean tumour dose >70 Gy experienced a median OS of 16.1 months vs. 12.8 months for those who did not (P = 0.008). CONCLUSION: For patients with chemo-refractory breast cancer with liver metastases, achieving a mean tumour dose >70 Gy is a significant predictor of tumour response and prolonged OS.

Comparison of Tc-99m MAA Planar Versus SPECT/CT Imaging for Lung Shunt Fraction Evaluation Prior to Y-90 Radioembolization: Are We Overestimating Lung Shunt Fraction?

PURPOSE: To compare lung shunt fraction (LSF) prior to Y-90 radioembolization calculated using planar imaging versus SPECT/CT in patients with hepatocellular carcinoma (HCC). METHODS: A single institution retrospective analysis of technetium-99m macroaggregated albumin (Tc-99m MAA) LSF studies for 293 consecutive patients with HCC between 2013 and 2018 was performed. LSF using planar imaging (PLSF) was compared to retrospectively calculated LSF using SPECT/CT (SLSF) via semiautomated segmentation using MIM v.6.9. Sub-analyses of patients were performed based on PLSF range, tumor size, BCLC stage, and Child-Pugh (C-P) score. Mean LSF absolute discrepancy between sub-groups was analyzed. Comparisons were performed using paired t tests and linear regression analysis. RESULTS: Mean PLSF, 8.27%, was greater than mean SLSF, 3.27% (p < 0.001). When categorizing patients by PLSF ranges of < 10%, 10-19.9%, and ≥ 20%, PLSF remained greater than SLSF in all subgroups (p's < 0.001). Patients with PLSF ≥ 20% had a greater absolute discrepancy with SLSF (13.31%) compared to patients with PLSF < 20% (4.74%; p < 0.0001). LSF absolute discrepancy was greater for patients with a maximum liver tumor size ≥ 5.0 cm (5.59%) compared to a liver tumor size < 5.0 cm (4.40%; p = 0.0076). For all BCLC grades and C-P scores, PLSF was greater than SLSF. A greater LSF discrepancy existed for patients with a worse C-P score (C-P A: 4.78%, C-P B/C: 6.12%; p = 0.0081), but not BCLC stage (0/A/B: 4.87%, C: 4.56%; p = 0.5993). CONCLUSION: In patients with HCC, SLSF is significantly lower compared to PLSF, with a greater discrepancy among patients with a PLSF ≥ 20%, tumor size ≥ 5 cm, and worse C-P score. LEVEL OF EVIDENCE: Level 3, Retrospective Study.

Graft-Versus-Host Disease Presenting as a Myositis and Myonecrosis.

Graft-versus-host disease (GVHD) is a major complication of bone marrow transplantation. Polymyositis with myonecrosis is a rare manifestation of GVHD. Here, we report the case of a 32-year-old man with acute myeloid leukemia who developed GVHD after transplant. He subsequently developed polymyositis, which was diagnosed on PET/CT and confirmed on pathology. Treatment with corticosteroids resulted in the resolution of the symptoms. Abnormal muscular FDG uptake resolved on the follow-up PET/CT.

Does colon cancer ever metastasize to bone first? a temporal analysis of colorectal cancer progression.

BACKGROUND: It is well recognized that colorectal cancer does not frequently metastasize to bone. The aim of this retrospective study was to establish whether colorectal cancer ever bypasses other organs and metastasizes directly to bone and whether the presence of lung lesions is superior to liver as a better predictor of the likelihood and timing of bone metastasis. METHODS: We performed a retrospective analysis on patients with a clinical diagnosis of colon cancer referred for staging using whole-body 18F-FDG PET and CT or PET/CT. We combined PET and CT reports from 252 individuals with information concerning patient history, other imaging modalities, and treatments to analyze disease progression. RESULTS: No patient had isolated osseous metastasis at the time of diagnosis, and none developed isolated bone metastasis without other organ involvement during our survey period. It took significantly longer for colorectal cancer patients to develop metastasis to the lungs (23.3 months) or to bone (21.2 months) than to the liver (9.8 months). CONCLUSION: Metastasis only to bone without other organ involvement in colorectal cancer patients is extremely rare, perhaps more rare than we previously thought. Our findings suggest that resistant metastasis to the lungs predicts potential disease progression to bone in the colorectal cancer population better than liver metastasis does.

Tumor blood flow measured by perfusion computed tomography and 15O-labeled water positron emission tomography: a comparison study.

OBJECTIVES: To compare blood flow measurements of tumors assessed by perfusion computed tomography (pCT) and the clinical gold standard of 15O-labeled water positron emission tomography (15O-PET). METHODS: Blood flows were estimated by pCT (4-row multidetector, CT Perfusion 3.1) and 15O-PET (Posicam, first-pass model) in 14 patients with solid tumors, totaling 22 index tumors and 57 matched pairs of examinations. Blood flow estimates were compared using t test, Bland-Altman, and linear mixed regression analyses. RESULTS: There was no significant difference between the mean (SD) blood flow values measured by pCT and 15O-PET: 25.9 +/- 15.4 and 27.8 +/- 14.0 mL/min per 100 g, respectively. CONCLUSIONS: The demonstration of a good correlation between pCT and 15O-PET potentially enables the use of pCT, which is more widely available than 15O-PET, when tumor blood flow estimates are required, particularly in the context of clinical studies.

Uptake of 18F-Fluciclovine in Paget Disease.

Since its recent approval by the United States Food and Drug Administration, fluciclovine PET-CT has gained widespread use for imaging of recurrent prostate cancer patients. As an amino acid-based radiotracer transported by LAT-1 and ASCT-2 transporters, fluciclovine exploits the up-regulation of amino acid transporters in malignant cells. We present a rare case of fluciclovine uptake in Paget disease in a 58-year-old man with suspected recurrent prostate cancer and asymmetric increased left hemipelvic uptake on imaging.

Tumor blood flow measured by PET dynamic imaging of first-pass 18F-FDG uptake: a comparison with 15O-labeled water-measured blood flow.

UNLABELLED: PET molecular imaging of 15O-labeled water is the gold standard for measuring blood flow in humans. However, this requires an on-site cyclotron to produce the short-lived 15O tracer, which is cost-prohibitive for most clinical PET centers. The purpose of this study was to determine if the early uptake of 18F-FDG could be used to measure regional blood flow in tumors in the absence of 15O-water. METHODS: PET scans were obtained in patients being evaluated for tumor perfusion and glucose metabolism in a phase I dose-escalating protocol for endostatin, a novel antiangiogenic agent. A 2-min perfusion scan was performed with a bolus injection of 2,220 MBq (60 mCi) of 15O-water, which was followed by a 370-MBq (10 mCi) dose of 18F-FDG. Four sequential scans of 18F-FDG uptake were acquired, consisting of an early 2-min uptake scan-or first-pass scan-and 3 sequential 15-min late 18F-FDG uptake scans. Regions of interest (ROIs) were drawn on 2 or more tumor sites and on back muscle, as a control ROI, for each patient. Arterial blood concentration was derived from the PET scans by drawing an ROI over a large artery in the field of view. Blood flow was computed with a simple 1-compartment blood flow model using the first 2 min of data after injection. RESULTS: Blood flow estimated from the early uptake of 18F-FDG was linearly correlated with 15O-measured blood flow, with an intercept of 0.01, a slope of 0.86, and an R2 regression coefficient of 0.74 (r = 0.86). The 18F-FDG tumor extraction fraction relative to 15O-water averaged 0.86. A preliminary case study of a patient with prostate cancer confirms the utility of the first-pass 18F-FDG blood flow analysis in tumor diagnosis. CONCLUSION: These results suggest that the first-pass uptake of 18F-FDG may provide an estimate of perfusion in a tumor within the limitations of incomplete extraction of 18F-FDG compared with 15O-water.

Effects of the New York State Workers Compensation Board Medical Treatment Guidelines on Return to Work.

OBJECTIVE: Examine the association between New York State Workers' Compensation Medical Treatment Guidelines (Guidelines) adherence and return-to-work after occupational low back injuries. Assess adherence to Guidelines by examining diagnostic and treatment utilization. METHOD: Retrospective chart review of cases. Outcomes of interest were lost time duration and diagnostic/treatment utilization rates. Time to event analyses performed using Kaplan-Meier plots and Cox proportional hazard model. RESULTS: Care received after implementation of Guidelines resulted in decreased lost time. Treatment rates were consistent, while diagnostic imaging use was inconsistent with Guidelines recommendations. CONCLUSIONS: Guidelines use positively influenced return-to-work after acute occupational low back injuries. Inconsistencies in following Guidelines were observed for diagnostic tests, having a potential paradoxical effect on lost time. Further studies are necessary to test for additional hypotheses.

Oncologic 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography: What All Physicians Need to Know.

Fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) hybrid examinations (PET/computed tomography, PET/magnetic resonance imaging) have become the most common PET imaging tools in the evaluation of the oncologic patient. Therefore it is of paramount importance that physicians who take care of oncology patients in any capacity are familiar with the basics of when these examinations are indicated, know how to best prepare the patients, and understand the benefits and limitations of the procedure. Additionally, it is important to understand which medical conditions and medications need to be controlled to maintain the diagnostic accuracy of these tests. In this article we aim to explain what 18F-FDG is, how to best prepare our patients, what PET is, and how these examinations are interpreted. Finally, we discuss some of the limitations of these examinations.

(18)F-Fluorodeoxy glucose (FDG) uptake in nontraumatic bilateral adrenal hemorrhage secondary to heparin-associated thrombocytopenia syndrome (HATS) - a case report.

(18)F-Fluorodeoxy glucose (FDG) activity reflects tissue glucose metabolism; malignancies, metastases, and acute infections have relatively increased FDG activity reflecting increased glucose metabolism. Benign adrenal disease demonstrating mild FDG uptake can be worrisome for metastasis in patients with a history of malignancy. Our patient with breast and colon cancer developed gastrointestinal bleeding on heparin therapy, enlarged adrenals with heterogeneous attenuation consistent with hemorrhage and blood clots as seen on abdominal computed tomography scan, and as abnormal intense FDG activity in the bilateral adrenal glands on positron emission tomography scan.

99mTc-Sestamibi Avid Soft Tissue Lesions in Rosai-Dorfman Disease.

Langerhan's histiocytosis is a not uncommon disease, but a related disorder, Rosai-Dorfman (RDD) with extensive or exclusive extranodal distribution, is relatively rare. Ga and PET/CT imaging have typically been used for diagnosis and tracking response to treatment. The authors present a very unusual case wherein lesions of RDD actively accumulated Tc-sestamibi, which was injected as part of a scan to localize a parathyroid adenoma.

Clinical activities in an academic hospital-based occupational medicine program.

OBJECTIVES: The objectives of this article are to characterize the clinical activities encountered by a large academic hospital-based occupational medicine program and to discuss their implications for occupational medicine residency training and the training of practicing physicians. METHODS: Clinical activities from July 1, 1996, to December 31, 2004, were retrieved from computerized databases and categorized. All morbidity coding was performed using the same classification scheme and resource. RESULTS: The largest volume of clinical activities included patients seen for physical examinations, work-related injury and illness care, and substance abuse testing. The most frequently encountered workers' compensation cases were musculoskeletal. CONCLUSIONS: Although medical surveillance examinations, toxic exposure assessments, and other specialty services were available, the demand for such services was relatively low.

Rim sign in Tc-99m sulfur colloid hepatic scintigraphy.

A case of pericholecystic hyperperfusion on Tc-99m sulfur colloid (SC) flow images with a pericholecystic rim of increased activity (PCHA) on delayed planar and single-photon emission computed tomography images of the liver was seen in a patient with a history of multiple renal transplants admitted with cramping right lower quadrant abdominal pain. Laparotomy performed 5 days after the scan revealed an acutely perforated gangrenous gallbladder and occluded cystic duct. The secondary findings of gallbladder hyperperfusion and PCHA or "rim sign" have been frequently reported with Tc-99m IDA hepatobiliary imaging. These secondary findings in conjunction with a nonvisualized gallbladder on an IDA scan suggest a complicated or advanced stage of acute cholecystitis and usually require urgent surgical intervention. The rim sign on Tc-99m SC scintigraphy also likely indicates the same grave diagnosis.